Second Edition

P Prakash PhD (N), MBA (HM)

Assistant Professor
College of Nursing
Prince Sattam Bin Abdulaziz University
Al-Kharj, Kingdom of Saudi Arabia (KSA)

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 Dedicated to
My Friends, Family
and
Nursing Students
About the Author

P Prakash PhD (N), MBA (HM) is presently working as an Assistant Professor in Department of Nursing
at Prince Sattam Bin Abdulaziz University, Kingdom of Saudi Arabia (KSA), and Adjunct Teaching
Faculty cum Post-Doctorate Research Fellow in Nursing at Lincoln University College, Malaysia.
He has 11 years of experience in Nursing as a Teaching faculty, ward in-charge (Psychiatric Unit),
and Nursing Officer (Liver Transplantation Unit). He is a recognized research guide cum international
examiner for scholars pursuing a doctorate program in Nursing. He has been awarded a Doctorate in
Nursing at Meenakshi Academy of Education & Research (MAHER), Chennai. He completed Master’s
degrees in Psychiatric Nursing from Sri Ramakrishna Institute of Paramedical Sciences (SRIPMS),
Coimbatore and in Hospital Administration from Alagappa University, Karaikudi. Besides, he also
completed a diploma in Operation Theatre Techniques and yoga from Annamalai University &
Madurai Kamaraj University respectively.
The author received the prestigious Florence Nightingale Award for Best Nurse in Philanthropy in 2016 by Doctors United
Charitable Trust (DUCT). He has also been awarded a merit certificate in his post-graduation for obtaining second place in
General Proficiency. He received a gold medal from ‘His Excellency of Governorship, Surjit Singh Barnala,’ for securing State
level First rank in the conversational English program conducted at the State Bank Officers Association, Chennai. He was
awarded twice for best poster presentation in national seminars. He was also awarded gold certificate in the Yogathon Challenge
Competition for the completion of 108 rounds of Surya Namaskar on World Health Day April 7, 2012.
Dr P Prakash is a Certified Master trainer for the Promotion of Mental Health Services in collaboration with the World
Health Organization (WHO) & Ministry of Health/Family Welfare, Govt. of India. He is an American Heart Association
Certified Advance Cardiac Life Support (ACLS) Provider. He is an assessor of the Health Sector Skills Council. He worked as
a Medical Investigator at Ayu Health, Chennai. He is a content developer for ‘The CBS Nursing Next Mobile application.’ He is
a Life Member of the International Palliative Care Family Career Research Center, University of Melbourne in Australia, the
American Travel Health Nurses Association, the Indian Red Cross Society, the Trained Nurses Association of India & Senior
Member of the Asian Researchers Society.
The author is Editor-in-Chief, Editorial Board Member, and Reviewer of various Indexed International journals. He has
authored Textbook of Applied Sociology and Psychology published by CBS Publishers. Besides, he has published books titled
Pocket Clinical Guide for Nurses and Health/Nursing Informatics published by reputed medical book publishers.
Last but not least, he has presented topics as a resource person at the international conferences and has published
research articles in Scopus-indexed journals, organized workshops, and has presented scientific papers at national and
international levels.
Preface to the
Second Edition

Numerous books on psychiatry are available in the market but most of them are not appropriate and suitable from the students’
point of view. This book has been written to equip the nurses with easy understanding of subject, as I intended that each aspect
of the psychiatry should be imbibed by the students.
For this, I have tried to present the text in lucid language. This second edition of “Textbook of Mental Health/Psychiatric
Nursing” has been written based on Revised Syllabus of Indian Nursing Council. This book is equipped with the recent updates
such as ICD-11 criteria, DSM-5 criteria, Mental Healthcare Act (2017), POCSO Act (2012), Trends in Psychiatric Nursing, etc.
Each chapter is organized by following a uniform pattern as Chapter Outline, Learning Objectives, Key Terms, Description,
Summary, Probable Questions and MCQs with Answers.
‘Assess Yourself ’ at the end of every chapter includes the possible Essay Type Questions, Short Notes and Multiple-Choice
Questions (with answers) to help the students to revise the chapter easily. This book has been prepared with the selected key
points that are included in every chapter to ensure that student excels in university exams.
A number of illustrations and photographs are presented in all chapters which will help students enhance their presentation
skill in the university exams. All-important concepts have been explained with appropriate examples. “Glossary” at the end of
book will help the students to memorize important terms in Psychiatric Nursing in one go.
“Appendices” including Formats for Mental Health Assessment, Psychiatric History Collection and the Checklists will
guide the students to understand the formats followed in practice along with implementation of core concepts of Psychiatry.
“Learn the Differences” which are included in the annexure will help the students explore the differences between the important
terminologies used in Psychiatric Nursing.
Moreover, case scenarios of all the vital Psychiatric nursing topics have been covered with appropriate answers for the same.
In addition to that, viva voce questions with answers are included in the textbook.
OSCE, Abbreviations, Psychotropic Drugs and Syndromes in Psychiatry have been included in the textbook to give a concise
view of important topics.
I am confident that this book will provide adequate information to the teachers as well as students for understanding the
basic concepts of Psychiatric Nursing. Suggestions from the teachers and students are always welcome for the improvement of
the content of this textbook.

P Prakash
email: [email protected]
Preface to the First Edition

Numerous books on psychiatry are available in the market but most of them are not relevant from the students’ point of view.
This book has been written to equip the nurses with easy understanding of subject, as I intended that each aspect of the psychiatry
should be imbibed by the students.
I have tried to present the text in lucid language. “Textbook of Mental Health/Psychiatric Nursing” has been written on
the basis of Revised Syllabus of Indian Nursing Council. This book is equipped with the recent updates such as DSM-5 criteria,
Mental Healthcare Act (2017), Trends in Psychiatric Nursing, etc. Each and every chapter is organized by following a uniform
pattern as Chapter Outline, Learning Objectives, Key Terms, Description, Summary, Probable Questions and MCQs with
Answers.
‘Assess Yourself ’ at the end of every chapter includes the possible Essay Type Questions, Short Notes and Multiple Choice
Questions (with answers) to help the students to revise the chapter easily. This book has been prepared with the selected key
points that are included in each and every chapter to ensure that student excels in university exams.
A number of illustrations and photographs are presented in all chapters which will help students to enhance their presentation
skill in the university exams. All important concepts have been explained with appropriate examples. “Glossary” at the end of
book will help the students to memorize important terms in Psychiatric Nursing in one go.
“Appendices” including Formats for Mental Health Assessment, Psychiatric History Collection and the Checklists will guide
the students to understand the formats followed in practice along with implementation of core concepts of Psychiatry. “Learn
the Differences” which are included in the annexure will help the students to explore the differences between the important
terminologies used in Psychiatric Nursing.
Abbreviations, Psychotropic Drugs and Syndromes in Psychiatry have been included in the textbook to give a glimpse of
important topics.
I am pretty sure that this book will provide valuable information to the teachers as well as students for understanding the
basic concepts of Psychiatric Nursing. Suggestions from the teachers and students are always welcome for the improvement of
the content of this textbook.

P Prakash
email: [email protected]
Acknowledgments

First of all, I would like to thank the Almighty God for helping me at every step and for bestowing wisdom and patience to
achieve this grand success. My heartfelt thanks go to my parents Mr Palanivelu and Mrs Lalitha. I convey sincere thanks to my
wife Mrs Dhivya and my daughter Taeju, who kept patience and supported me. I express thanks to my sister Mrs Anitha, who
always encouraged me.
I am thankful to Dr Parthasarthy, Associate Professor at Pondicherry Institute of Medical Sciences, for his excellent guidance.
I am so thankful to all the reviewers, editors, and content designers for their remarkable contributions.
My special thanks is due to Mr Satish Kumar Jain (Chairman) and Mr Varun Jain (Managing Director), M/s CBS
Publishers and Distributors Pvt Ltd for their wholehearted support in publication of this book. I have no words to describe the
role, efforts, inputs and initiatives undertaken by Mr Bhupesh Aarora [Sr. Vice President – Publishing & Marketing (Health
Sciences Division)] for helping and motivating us.
Last but not least, I sincerely thank the entire CBS team for bringing out the book with utmost care and attractive
presentation. I would like to thank Ms Nitasha Arora (Assistant General Manager Publishing – Medical and Nursing),
Ms Daljeet Kaur (Assistant Publishing Manager) and Dr Anju Dhir (Product Manager cum Commissioning Editor – Medical)
for their editorial support. I would also extend my thanks to Mr Shivendu Bhushan Pandey (Sr. Manager and Team Lead),
Ms Surbhi Gupta (Sr. English Editor), Mr Ashutosh Pathak (Sr. Proofreader cum Team Coordinator) and all the production team
members for devoting laborious hours in designing and typesetting the book.
Contributors and
Reviewers

CONTRIBUTORS

E Elamathi Parthasarathy V
(Psychiatric Nursing) Masters at MMC, Chennai MD (Psychiatry), Gold Medal Achiever, Post
Graduation at JIPMER
Assistant Professor
Department of Psychiatric Nursing Associate Professor
Hindu Mission College of Nursing Department of Psychiatry
Chennai, Tamil Nadu Pondicherry Institute of Medical
Sciences (PIMS)
Puducherry

Hyrune Zohara Pastin Pushpa Rani P

MSc (Mental Health Nursing) Post-Graduation at CMC Vellore and PhD at INC
Consortium
Assistant Professor
Department of Psychiatric Nursing Associate Professor
Ithaya Jyothi College of Nursing College of Nursing
Tirunelveli, Tamil Nadu CMC Vellore Chittoor Campus
Andhra Pradesh

Joseph Jeganathan Sampoornam V

(Psychiatric Nursing) Masters at NIMHANS and (Psychiatric Nursing), PhD (N), MSc (C&P)
PhD at INC Consortium MSc (Psy), SEFM, GRN, OWCN, ATHNA, IFNA

Assistant Professor Professor cum Principal

Department of Psychiatric Nursing Bhavani College of Nursing
University of Bahrain Varadhanallur, Bhavani
Erode, Tamil Nadu
Nithyasree Venkitaraman
(Neuro Psychology)

Mental Health Professional

Birmingham Women’s and Children’s
NHS Foundation Trust, UK

The names of the contributors are arranged in an alphabetical order.

xvi Textbook of Psychiatric Nursing for BSc Nursing Students

REVIEWERS

Aldrin Vas Jesudian K Nath

PhD (N), MSc Nursing (Psychiatric Nursing) MSc (Mental Health Nursing)

Professor cum Principal Professor

Tejasvini Nursing Institute United Institute of Nursing and
Mangaluru, Karnataka Paramedical Sciences
Prayagraj, Uttar Pradesh

Anitha Kirandeep Dhaliwal

MSc (Mental Health Nursing) PhD (N), MSc (Mental Health Nursing)

Associate Professor Principal

Sri Vijay Vidyalaya College of Nursing MM Institute of Management
and Research Maharishi Markandeshwar (DU)
Bagur, Krishnagiri, Tamil Nadu Mullana, Ambala, Haryana

Barnali Mukherjee Lida Antony

MSc (Psychiatric Nursing) PhD (N), MSc (N)

Professor Vice Principal

Government College of Nursing Dr Moopen’s Nursing College
Burdwan Medical College and Hospital Meppadi, Wayanad, Kerala
Purba Bardhaman, West Bengal

Baskar Manisha Gupta

PhD (N), MSc (Mental Health Nursing) PhD (N), MA (Sociology), RM, RN

Professor Dean and Principal

Department of Mental Health Nursing Rabindranath Tagore University Institute
PSG College of Nursing of Nursing
Coimbatore, Tamil Nadu Bhopal, Madhya Pradesh

Gomathi M Moushumi Purkayastha

PhD (N) Scholar Mukherjee
MSc (Mental Health Nursing) (Psychiatrist) MBBS, DPM (NIMHANS),
DNB (GMCH, Chandigarh)
JIPMER, Puducherry
Professor
Department of Psychiatry
JIPMER, Puducherry

The names of the reviewers are arranged in an alphabetical order.

 Contributors and Reviewers xvii

Narendra Kumar Sharma Ruba A

MSc (Mental Health Nursing) PhD (N), MSc (N)

Principal Professor cum Principal

Chitrini Nursing College Mariamman Nursing College
Prantij, Gujarat Tiruchirappalli, Tamil Nadu

Neetu Bhatnagar Sadhya Ghai

MSc (Applied Psychology and Psychiatric Nursing) PhD (Psychiatric Nursing)
Diploma in Nursing Administration
Consultant/Senior Advisor
Principal JHPIEGO, Lucknow, Uttar Pradesh
Bee Enn Nursing Institute
Former Principal
Chak Bhalwal
PGININE, Chandigarh
Jammu and Kashmir

Nuziba Begum Sangeetha P

MSc (Mental Health Nursing) MSc (Mental Health Nursing)

Professor Professor and Head

Department of Mental Health Nursing Department of Psychiatric Nursing
Sri Ramakrishna Institute of Adhiparasakthi College of Nursing
Paramedical Sciences (SRIPMS)— Melmaruvathur, Chennai, Tamil Nadu
College of Nursing
Coimbatore, Tamil Nadu

P Jamunarani Sathish Rajamani

MSc (Mental Health Nursing) MSc (Psychiatric Nursing)

Professor Professor
Department of Mental Health Nursing DRIEMS School and College of Nursing
KMCH College of Nursing Cuttack, Odisha
Coimbatore, Tamil Nadu

R Sridevi Sibin K Dummini

PhD (N), MSc (N) BSc (N)

Professor cum Principal Principal

EGS Pillay College of Nursing Jeevandeep School of Nursing
Nagapattinam, Tamil Nadu UP State Medical Faculty
Lucknow, Uttar Pradesh

The names of the reviewers are arranged in an alphabetical order.

xviii Textbook of Psychiatric Nursing for BSc Nursing Students

Smitha P M Varun Toshniwal

MSc (Mental Health Nursing) PhD (N)

Professor/HOD Professor cum Head

Department of Mental Health Nursing College of Nursing
Narayana College of Nursing IIMT University
Vellore, Andhra Pradesh Meerut, Uttar Pradesh

Sonia Nanda Vinodh Selvan Vincent

MSc Nursing (Psychiatric Nursing) MSc (Mental Health Nursing)

Associate Professor Assistant Professor

Rajiv Gandhi College of Nursing Department of Psychiatric Nursing
Chak Bhalwal College of Nursing
Jammu and Kashmir Pondicherry Institute of Medical Sciences
Puducherry

V Nirosha
MSc (N)

Professor
Vivekanandha College of Nursing
Elayampalayam, Tamil Nadu
 From the Publisher’s Desk

Dear Reader,
Nursing Education has a rich history, often characterized by traditional teaching techniques
that have evolved over time. Primarily, teaching took place within classroom settings. Lectures,
textbooks, and clinical rotations were the core teaching tools; and students majorly relied on
textbooks by local or foreign publishers for quality education. However, today, technology
has completely transformed the field of nursing education, making it an integral part of the
curriculum. It has evolved to include a range of technological tools that enhance the learning
experience and better prepare students for clinical practice.
As publishers, we’ve been contributing to the field of Medical Science, Nursing and Allied Sciences and earned the trust of many.
By supporting Indian authors, coupled with nursing webinars and conferences, we have paved an easier path for aspiring
nurses, empowering them to excel in national and state level exams. With this, we’re not only enhancing the quality of patient
care but also enabling future nurses to adapt to new challenges and innovations in the rapidly evolving world of healthcare.
Following the ideology of Bringing learning to people instead of people going for learning, so far, we’ve been doing our part by
• Developing quality content by qualified and well-versed authors
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Innovative teaching methodologies, such as modern-age Phygital Books, have sparked the interest of the Next-Gen students in
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At Nursing Next Live, a sister concern of CBS Publishers & Distributors, we have long recognized the immense potential within
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With the vision of strengthening learning at every stage, we have introduced several plans that cater to the specific needs of the
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Additionally, we have successfully completed seven series of our Target High Book in a very short period, setting a milestone
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We take immense pride in our achievements and eagerly look forward to the future, brimming with new opportunities for
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in a technology-driven healthcare system.

Mr. Bhupesh Aarora

(Sr. Vice President- Publishing & Marketing)
[email protected]| +91 95553 53330
Special Features of
the Book

LEARNING OBJECTIVES

Learning Objectives in the beginning of After studying this chapter, the student will be able to understand
every Chapter help readers understand the basic concepts of psychiatric nursing.
the purpose of the chapter.

CHAPTER OUTLINE
• Perspectives of Mental Health and Mental Health Nursing Chapter Outline gives a glimpse of the
• Mental Health Team or Multidisciplinary Team content covered in the chapter.
• Nature/Philosophy of Psychiatric Nursing

KEY TERMS

Key Terms are added in each chapter Mental health nursing, Mental health, Mental health policy, Mental
to help understand difficult scientific health team, Normal behavior, Abnormal behavior, Evolution of
terms in easy language. mental health services, Functions of psychiatric nurse.

Table 3.14: Drug levels in blood

Name of the drug Blood therapeutic value

Numerous Tables have been used in
Lithium 0.6–1.8 mEq/L the chapters to facilitate learning in a
Carbamazepine 6–12 mg/mL quick way.
Sodium valproate 50–100 mg/mL

The book is well illustrated with

relevant colorful Figures, etc.

Figure 3.7: Assessment of triceps reflex

xxii Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 3.2: Classification of reflexes

Flow Diagrams are used in-between

the text to enhance students’ learning
experience in one go.

CLINICAL IMPLICATION
Evolving conceptual details for
Frontal Lobe Syndrome
application in clinical situations are
depicted in Clinical Implication boxes. Damage to the dorsolateral (upper and outer) areas of the frontal
lobes may cause symptoms such as lack of drive and spontaneity.
Damage to the anterior aspects of frontal lobes might lead the
changes in mood or affect, which in turn exhibits the impulsive
and inappropriate behavior in patients.

NURSING IMPLICATION
Clinical correlations from nursing
Implications for Nursing Practice point of view have been covered
• Understanding the psychosexual stages of childhood provides under Nursing Implication or Nursing
a framework for understanding behaviors observed in adult Responsibility boxes.
patients.
• Effective parenting can be promoted by teaching parents about
the child’s needs during each psychosexual stage.

NOTE
Extra knowledge related to the
respective topic is covered under the Light therapy used for skin conditions might emit ultraviolet rays
Note boxes. that should not be used for other conditions because it might
harm the eyesight.

DO YOU KNOW
Do You Know boxes give an overview
Some Indian celebrities who spoke boldly that they were of important facts and terms of the
suffering from mood disorders were Manisha Koirala, Yo Yo concerned topic.
Honey Singh, Shahrukh Khan, Deepika Padukone, Anushka
Sharma, Varun Dhawan, Randeep Hooda and Ileana D’Cruz.
 Special Features of the Book xxiii

Mnemonic

Numerous Mnemonics have been Mnemonic to remember lithium side effects are “LITHUM”
added in whole book to help the L : Leukocytosis
students remember complex topics in I : Insipidus (Nephrogenic diabetes insipidus)
easy way.
T : Tremors (or) thirst (or) taste as metallic (or) teratogenic
(Teratogenics–Ebstein anomaly)
H : Hypothyroidism
U : Urinary (Polyuria)
M : Miscellaneous

EXTRA EDGE
Extra Edge boxes provide highly useful
Types of Schizophrenia additional information to enhance the
Paranoid Schizophrenia knowledge of the students.
It is most common type of schizophrenia. Onset is late and has
good prognosis. Personality is said to be preserved, i.e., client
is able to perform activities of daily living (ADLs) and has good
social interaction. Hallucination, delusion and thought disorders
are peculiarly seen. Examples of hallucinatory themes are
commenting, arguing, threatening, body sensations/movements.
Examples of thought disorders are irrelevant, incoherent and
neologisms in speech.

SUMMARY
Important takeaway points of • Antipsychotics are medications to treat psychotic disorder and
respective chapters have been psychosis related to other psychiatric and medical disorders.
highlighted under Summary boxes. • The other names of antipsychotics are D2 receptor blockers,
major tranquilizers, neuroleptic agents, ataractics and anti-
schizophrenic drugs.

ASSESS YOURSELF
Long Answer Questions At the end of chapters, Assess Yourself
section is given which contains
1. Explain the scope of psychiatric nursing practice. frequently asked questions in exams
Short Answer Questions and multiple choice questions to
help students attain mastery over
1. Name the members of a mental health care team. the subject.
Short Notes
Write short notes on:
1. Functions of psychiatric nurse
Multiple Choice Questions
1. Misperception of taste is _______ hallucination.
a. Auditory b. Visual
c. Functional d. Gustatory
xxiv Textbook of Psychiatric Nursing for BSc Nursing Students

CASE 2 PATIENT WITH DEPRESSIVE DISORDER

Case Study demonstrates example(s)
of specific clinical scenarios covered Mr K, 63-year-old male, unmarried, he is a carpenter, completed Higher
in separate section from clinical and Secondary Certificate (HSC). Mr K has a pervasive low mood, poor appetite,
applied aspects. decreased sleep, fearfulness, lack of interest in activities, decreased self-
care and social withdrawal.

Objective Structured Giving extra edge to book from the

Clinical Evaluation (OSCE) practical point of view OSCE station
and Viva Voce covered in a separation
section.
STATION 1–ANXIOUS PERSONALITY DISORDER

Instructions to the Examinee

Ms X aged 28 years came with complaint of avoiding social
gathering and family functions. Her mind is preoccupied with
being criticized or rejected and she also shows extreme anxiety,
nervousness and low self-esteem.
Participant number: ________ Date: ___________

Viva Voce

1. Define mental illness.

Mental illness is a maladjustment in living which produces
disharmony in life.

Important terms with their one-line Glossary

definition covered under Glossary.
Acute depression: It’s a sudden abrupt onset of depression.
Apraxia: Inability to perform learned motor activities.
Biceps reflex: Flexion of forearm occurs when arm is gently flexed
at elbow, tap the biceps brachii tendon.
Coprophilia: Sexual pleasure with feces.
Syllabus

Mental Health Nursing-I

Placement: V Semester Theory: 3 Credits (60 Hours)

Unit Time Learning Outcomes Content Teaching/Learning Assessment

(Hrs) Activities Methods
I 6 (T) • Describe the historical Introduction • Lecture discussion • Essay
development and • Perspectives of mental health and mental • Short answer
current trends in mental health nursing, evolution of mental health
health nursing services, treatments and nursing practices
• Discuss the scope of • Mental health team
mental health nursing • Nature and scope of mental health nursing
• Describe the concept of • Role and functions of mental health nurse in
normal and abnormal various settings and factors affecting the level
behavior of nursing practice
• Concepts of normal and abnormal behavior
II 10 (T) • Define the various Principles and Concepts of Mental Health • Lecture cum • Essay
terms used in mental Nursing discussion • Short answer
health nursing • Definition: Mental health nursing and • Explain using charts
• Explain the terminology used • Review of
classification of mental • Classification of mental disorders: ICD-11, personality
disorders DSM-5, Geropsychiatry manual classification development
• Explain the • Review of personality development, defense
psychodynamics of mechanisms
maladaptive behavior • Etiology biopsychosocial factors
• Discuss the • Psychopathology of mental disorders: Review
etiological factors and of structure and function of brain, limbic
psychopathology of system and abnormal neurotransmission
mental disorders • Principles of mental health nursing
• Explain the principles • Ethics and responsibilities
and standards of • Practice standards for psychiatric mental health
mental health nursing nursing (INC practice standards)
• Describe the • Conceptual models and the role of nurse:
conceptual models of ƒ Existential model
mental health nursing ƒ Psychoanalytical models
ƒ Behavioral model
ƒ Interpersonal model
• Preventive psychiatry and rehabilitation
Contd…
xxvi Textbook of Psychiatric Nursing for BSc Nursing Students

Unit Time Learning Outcomes Content Teaching/Learning Assessment

(Hrs) Activities Methods
III 6 (T) Describe nature, purpose Mental Health Assessment • Lecture cum • Essay
and process of assessment • History taking discussion • Short answer
of mental health status • Mental status examination • Demonstration • Assessment of
• Mini mental status examination • Practice session mental health
• Neurological examination • Clinical practice status
• Investigations: Related blood chemistry, EEG,
CT and MRI
• Psychological tests
IV 6 (T) • Identify therapeutic Therapeutic Communication and Nurse- • Lecture cum • Essay
communication and Patient Relationship discussion • Short answer
techniques • Therapeutic communication: Types, • Demonstration • OSCE
• Describe therapeutic techniques, characteristics and barriers • Role play
relationship • Therapeutic nurse-patient relationship • Process recording
• Describe therapeutic • Interpersonal relationship • Simulation (video)
impasses and its • Elements of nurse-patient contract,
interventions • Review of technique of IPR—Johari window
• Therapeutic impasse and its management
V 10 (T) Explain treatment Treatment Modalities and Therapies used in • Lecture cum • Essay
modalities and therapies Mental Disorders discussion • Short answer
used in mental disorders • Physical therapies: Psychopharmacology • Demonstration • Objective type
and role of the nurse • Electroconvulsive therapy • Group work
• Psychological therapies: Psychotherapy, • Practice session
behavior therapy, CBT • Clinical practice
• Psychosocial: Group therapy, family therapy,
therapeutic community, recreational therapy,
art therapy (dance, music, etc.), occupational
therapy
• Alternative and complementary: Yoga,
meditation, relaxation
• Consideration for special populations
VI 8 (T) Describe the etiology, Nursing Management of Patient with • Lecture and • Essay
psychodynamics/ Schizophrenia, and Other Psychotic Disorders discussion • Short answer
pathology, clinical • Prevalence and incidence • Case discussion • Assessment
manifestations, diagnostic • Classification • Case presentation of patient
criteria and management • Etiology, psychodynamics, clinical manifestation, • Clinical practice management
of patients with diagnostic criteria/formulations problems
schizophrenia, and other Nursing Process
psychotic disorders
• Nursing assessment: History, physical and
mental assessment
• Treatment modalities and nursing
management of patients with schizophrenia
and other psychotic disorders
• Geriatric considerations and considerations for
special populations
• Follow-up and home care and rehabilitation
VII 6 (T) Describe the etiology, Nursing Management of Patient with Mood • Lecture and • Essay
psychodynamics, clinical Disorders discussion • Short answer
manifestations, diagnostic • Prevalence and incidence • Case discussion • Assessment
criteria and management • Mood disorders: Bipolar affective disorder, • Case presentation of patient
of patients with mood mania depression and dysthymia, etc. • Clinical practice management
disorders • Etiology, psychodynamics, clinical problems
manifestation, diagnosis
• Nursing assessment history, physical and
mental assessment
Contd…
 Glossary xxvii

Unit Time Learning Outcomes Content Teaching/Learning Assessment

(Hrs) Activities Methods
• Treatment modalities and nursing
management of patients with mood disorders
• Geriatric considerations/considerations for
special populations
• Follow-up and home care and rehabilitation
VIII 8 (T) Describe the etiology, Nursing Management of Patient with Neurotic, • Lecture and • Essay
psychodynamics, clinical Stress Related and Somatization Disorders discussion • Short answer
manifestations, diagnostic • Prevalence and incidence • Case discussion • Assessment
criteria and management • Classifications • Case presentation of patient
of patients with neurotic, • Anxiety disorders—OCD, PTSD, Somatoform • Clinical practice management
stress related and disorders, phobias, Dissociative and conversion problems
somatization disorders disorders
• Etiology, psychodynamics, clinical
manifestation, diagnostic criteria/formulations
• Nursing assessment: History, physical and
mental assessment
• Treatment modalities and nursing
management of patients with neurotic and
stress related disorders
• Geriatric considerations/considerations for
special populations
• Follow-up and home care and rehabilitation

Mental Health Nursing-II

Placement: VI Semester Theory: 1 Credit (40 hours)

Unit Time Learning Outcomes Content Teaching/Learning Assessment

(Hrs) Activities Methods
I 6 (T) Describe the etiology, Nursing Management of Patients with Substance • Lecture cum • Essay
psychodynamics, clinical Use Disorders discussion • Short answer
manifestations, diagnostic • Prevalence and incidence • Case discussion • Assessment
criteria and management • Commonly used psychotropic substance: • Case presentation of patient
of patients with substance Classifications, forms, routes, action, • Clinical practice management
use disorders intoxication and withdrawal problems
• Psychodynamics/etiology of substance use
disorder (Terminologies: Substance use, abuse,
tolerance, dependence, withdrawal)
• Diagnostic criteria/formulations
• Nursing assessment: History (substance
history), Physical, mental assessment and drug
and drug assay
• Treatment (detoxification, antabuse and
narcotic antagonist therapy and harm
reduction, brief interventions, MET, refusal
skills, maintenance therapy) and nursing
management of patients with substance use
disorders
• Special considerations for vulnerable
population
• Follow-up and home care and rehabilitation
Contd…
xxviii Textbook of Psychiatric Nursing for BSc Nursing Students

Unit Time Learning Outcomes Content Teaching/Learning Assessment

(Hrs) Activities Methods
II 6 (T) Describe the etiology, Nursing Management of Patient with • Lecture cum • Essay
psychodynamics, clinical Personality and Sexual Disorders discussion • Short answer
manifestations, diagnostic • Prevalence and incidence • Case discussion • Assessment
criteria and management • Classification of disorders • Case presentation of patient
of patients with • Etiology, psychopathology, characteristics, • Clinical practice management
personality, and sexual diagnosis problems
disorders • Nursing assessment: History, physical and
mental health assessment
• Treatment modalities and nursing
management of patients with personality, and
sexual disorders
• Geriatric considerations
• Follow-up and home care and rehabilitation
III 8 (T) Describe the etiology, Nursing Management of Behavioral and • Lecture cum • Essay
psychopathology, Emotional Disorders Occurring during Childhood discussion • Short answer
clinical manifestations, and Adolescence (Intellectual disability, autism, • Case discussion • Assessment
diagnostic criteria attention deficit, hyperactive disorder, eating • Case presentation of patient
and management of disorders, learning disorder) • Clinical practice management
childhood and adolescent • Prevalence and incidence problems
disorders including mental • Classifications
deficiency • Etiology, psychodynamics, characteristics,
diagnostic criteria/formulations
• Nursing assessment: History, physical, mental
status examination and IQ assessment
• Treatment modalities and nursing
management of childhood disorders including
intellectual disability
• Follow-up and home care and rehabilitation
IV 5 (T) Describe the etiology, Nursing Management of Organic Brain Disorders • Lecture cum • Essay
psychopathology, clinical (Delirium, Dementia, Amnestic Disorders) discussion • Short answer
manifestations, diagnostic • Prevalence and incidence • Case discussion • Assessment
criteria and management • Classification • Case presentation of patient
of organic brain disorders • Etiology, psychopathology, clinical features, • Clinical practice management
diagnosis and differential diagnosis problems
• Nursing assessment: History, physical, mental
and neurological assessment
• Treatment modalities and nursing management
of organic brain disorders
• Follow-up and home care and rehabilitation
V 6 (T) Identify psychiatric Psychiatric Emergencies and Crisis • Lecture cum • Short answer
emergencies and carry out Intervention discussion • Objective type
crisis intervention • Types of psychiatric emergencies (attempted • Case discussion
suicide, violence/aggression, stupor, delirium • Case presentation
tremens and other psychiatric emergencies) and • Clinical practice
their managements
• Maladaptive behavior of individual and groups,
stress, crisis and disaster(s)
• Types of crisis
• Crisis intervention: Principles, techniques and
process
ƒ Stress reduction interventions as per stress
adaptation model
ƒ Coping enhancement
ƒ Techniques of counseling
Contd…
 Glossary xxix

Unit Time Learning Outcomes Content Teaching/Learning Assessment

(Hrs) Activities Methods
VI 4 (T) Explain legal aspects Legal Issues in Mental Health Nursing • Lecture cum • Short answer
applied in mental health • Overview of Indian Lunacy Act and The Mental discussion • Objective type
settings and role of the Health Act, 1987 • Case discussion
nurse • (Protection of Children from Sexual Offence)
POCSO Act
• Mental Health Care Act (MHCA) 2017
• Rights of mentally ill clients
• Forensic psychiatry and nursing
• Acts related to narcotic and psychotropic
substances and illegal drug trafficking
• Admission and discharge procedures as per
MHCA 2017
• Role and responsibilities of nurses in
implementing MHCA 2017
VII 5 (T) • Describe the model of Community Mental Health Nursing • Lecture cum • Short answer
preventive psychiatry • Development of Community Mental Health discussion • Objective type
• Describe community Services: • Clinical/field • Assessment of
mental health services • National Mental Health Policy viz. National practice the field visit
and role of the nurse Health Policy • Field visits to mental reports
• National Mental Health Program health service
• Institutionalization versus deinstitutionalization agencies
• Model of preventive psychiatry
• Mental health services available at the
primary, secondary, tertiary levels including
rehabilitation and nurses’ responsibilities
• Mental health agencies: Government and
Voluntary, National and International
• Mental health nursing issues for special
populations: Children, adolescence, women
elderly, victims of violence and abuse,
handicapped, HIV/AIDS, etc.
Contents

About the Author................................................................................................................................................................................................... vii

Preface to the Second Edition................................................................................................................................................................................ ix
Preface to the First Edition.................................................................................................................................................................................... xi
Acknowledgments................................................................................................................................................................................................... xiii
Contributors and Reviewers.................................................................................................................................................................................. xv
Special Features of the Book................................................................................................................................................................................... xxi
Syllabus................................................................................................................................................................................................................... xxv
Abbreviations......................................................................................................................................................................................................... xxxvii

CHAPTER 1 Introduction to Psychiatric Nursing ......................................................................... 1–14

Perspectives of Mental Health and Mental Health Nursing 1 Current Trends and Issues in Care of Mentally Ill Patients 9
Mental Health Team or Multidisciplinary Team 6 Functions of Psychiatric Nurse in Various Settings 10
Nature/Philosophy of Psychiatric Nursing 7 Factors Affecting the Level of Practice of Psychiatric Nurse 12
Scope of Psychiatric Nursing 8 Concepts of Normal and Abnormal Behavior 12

CHAPTER 2 Principles and Concepts of Mental Health Nursing ............................................... 15–68

Definitions 15 Biopsychosocial Etiology of Mental Illness 37
Terminology 16 Psychopathology of Mental Disorders: Review of
Classification of Mental Disorders 20 Structure of Brain, Functions of Brain, Limbic
Review of Personality Development 30 System and Abnormal Neurotransmission 38
Perspectives in Personality Theory 30 Principles of Psychiatric Nursing 43
Theories of Personality Development 30 Standards of Psychiatric Nursing 46
Defense Mechanisms 33 Conceptual Models in Psychiatric Nursing 51

CHAPTER 3 Assessment of Mental Health Status ..................................................................... 69–90

Psychiatric History Collection 69 Mini Mental Status Examination or Folstein Test 82
Mental Status Examination 72 Investigations in Psychiatry 84
Neurological Assessment 78 Psychological Tests 86
xxxii Textbook of Psychiatric Nursing for BSc Nursing Students

CHAPTER 4 Therapeutic Communication and Nurse-Patient Relationship ........................... 91–104

Communication 91 Ethics and Responsibilities 101
Types of Relationship 93 Dynamics of Therapeutic Nurse-Patient Relationship or
Nurse-Patient Relationship or Therapeutic Relationship 94 Therapeutic Use of Self for Gaining Self-awareness 101
Communication Process and its Barriers 96 Johari Window of Interpersonal Relationship 101
Therapeutic Impasses 97 Process Recording 102
Therapeutic Communication 98

CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders ...................... 105–185
Psychopharmacology Miscellaneous
Antipsychotics 106 Yoga 159
Antidepressants 111 Meditation 162
Antianxiety Agents (or) Anxiolytics 117 Biofeedback 163
Antiparkinson Agents 119 Alternative and Complementary Medicine
Mood Stabilizers 120 History 165
Stimulants (or) Psychostimulants 121 Definition 165
Psychological Therapies Principles of Alternative and Complementary Medicine 165
Psychotherapy 122 Major Domains of Alternative and Complementary Medicine 166
Cognitive Therapy 125 Occupational Therapy
Behavioral Therapy 127 Definitions 169
Cognitive Behavioral Therapy 130 Aims of Occupational Therapy 170
Therapeutic Community 132 Principles of Occupational Therapy 170
Milieu Therapy 134 Basic Elements of Psychiatric Occupational Therapy 170
Supportive Psychotherapy 137 Indications 170
Family Therapy 138 Settings of Occupational Therapy 170
Group Therapy 140 Occupational Therapy Activities 170
Play Therapy 144 Classification of Occupational Therapy 171
Psychodrama 146 Services Given in Occupational Therapy 171
Music Therapy 148 Occupational Therapy Process 171
Dance Therapy (or) Dance Movement Advantages of Occupational Therapy 172
Psychotherapy 150 Electroconvulsive Therapy
Recreational Therapy (or) Therapeutic Recreation 152 Historical Background 172
Light Therapy (or) Phototherapy (or) Definition 172
Heliotherapy 154 Classification of Electroconvulsive Therapy 172
Relaxation Therapy 156 Psychosurgery or Functional Neurological Surgeries
Guided Imagery or Guided Affective Imagery (or) Deep Brain Stimulation 181
Katathym—Imaginative Psychotherapy 158 Psychological Therapies 182

CHAPTER 6 Nursing Management of Patients with Schizophrenia and

Other Psychotic Disorders .................................................................................. 187–204
Introduction and Meaning 187 Other Psychotic Disorders 194
History 187 Prognosis of Schizophrenia 198
Prevalence and Incidence 188 Psychosocial Interventions 198
Etiology 189 Treatment 199
Diagnosis 191 Nursing Interventions 199
Diagnostic Criteria 191 Geriatric Considerations 201
Differential Diagnosis of Schizophrenia 192 Follow-up, Home Care and Rehabilitation of Patients with
Three Phases of Schizophrenia 192 Schizophrenia 201
Positive and Negative Symptoms of Schizophrenia 192

CHAPTER 7 Nursing Management of Patients with Mood Disorders .................................... 205–228

Introduction 205 Diagnostic Criteria for Bipolar I Disorder 209
Mood Disorders—Meaning/Definition 205 Diagnostic Criteria for Bipolar II Disorder 210
 Contents xxxiii

Diagnostic Criteria for Cyclothymic Disorder 211 Depression 215

Lithium 212 Classification of Depressive Disorders 217
Treatment of Bipolar Disorder 214 Diagnostic Criteria for Depressive Disorder 218
Nursing Management 214 Persistent Mood Disorder 224
Nursing Diagnosis and Interventions 214 Geriatric Considerations 225

CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related

and Somatoform Disorders ................................................................................ 229–257
Neurotic Disorder 229 Dissociative Disorder 246
Anxiety Disorders 229 Somotoform or Somatic Symptom and Related Disorders 249
Obsessive-Compulsive Disorder and its Related Disorders 238 Other Neurotic Disorders 254
Trauma- and Stressor-Related Disorders 240 Geriatric Considerations 254

CHAPTER 9 Nursing Management of Patients with Substance Use Disorders .................... 259–284
Common Substance Abuse in India 260 Cocaine 277
Modified Mann’s Index of Addiction 260 Nicotine Abuse 278
ICD-11 Classification of Substance Use Disorders 260 Hallucinogens 279
DSM-5 Classification of Substance Use Disorders 261 Caffeine 280
Stages of Adolescent Substance Abuse 261 Synthetic Cathinones 280
Stages of Craving 262 Disorders Due to Use of Methylenedioxymethamphetamine or
Etiology of Substance Abuse 262 Related Drugs 281
Complications of Substance Abuse 263 Disorders Due to Use of Dissociative Drugs Including Ketamine
Alcohol 263 and Phencyclidine 281
Disulfiram Ethanol Reaction 267 Inhalants (or) Volatile Solvents 281
Various Approaches to Quit Alcohol 268 Nursing Diagnosis and Interventions for Patient with
Alcohol Withdrawal Syndromes 269 Substance Abuse
Alcoholics Anonymous 270 Nursing Care in Acute Episode 281
Sedatives, Hypnotics and Antianxiety Agents Nursing Care in Withdrawal 281
Introduction 271 Nursing Diagnosis and Interventions 281
Cannabis Prevention of Substance Use Disorder 282
Introduction 273 Rehabilitation 283
Opioids 274 Geriatric Considerations 283
Central Nervous System Stimulants 276

CHAPTER 10 Nursing Management of Patients with Sexual, Personality

and Eating Disorders .......................................................................................... 285–305
Sexual Disorders Antisocial Personality Disorder 296
ICD-11 and DSM-5 Classification of Sexual Disorders 286 Borderline Personality Disorder 297
Gender Identity Disorder or Gender Dysphoria or Geriatric Considerations 298
Gender Incongruence 286 Eating Disorders
Disorders Related to Sexual Maturation and Development 287 Etiology of Eating Disorder 298
Disorders of Sex Preference/Deviation/Perversions/ Comparison of Anorexia Nervosa and
Paraphilic Disorders 287 Bulimia Nervosa 300
Sexual Dysfunction 288 Complications of Eating Disorders 300
Personality Disorders Categories of Eating Disorders 301
Introduction 291 Assessment of Eating Disorders 301
Definition of Personality Disorder 291 Nursing Diagnosis 301
Incidence and Prevalence 291 Signs and Symptoms of Eating Disorders Revealed
Significant Features of Personality Disorders 292 During Physical Assessment 301
Etiology of Personality Disorders 292 Treatment of Eating Disorders 301
Classification of Personality Disorders 292 Eating Disorders of Infancy and Childhood 302
Protective and Risk Factors of Personality Disorders 293 Obesity 302
xxxiv Textbook of Psychiatric Nursing for BSc Nursing Students

CHAPTER 11 Child Psychiatry .................................................................................................. 307–337

Introduction 308 Tic Disorder 328
Historical Perspectives/Development in Child Psychiatry 308 Sibling Rivalry 330
Mental Retardation or Intellectual Disability or Intellectual Enuresis 330
Developmental Disorder or Mentally Challenged Individuals 309 Encopresis 332
Disorders of Psychological Development School Refusal or School Phobia 333
Specific Developmental Disorders of Speech and Language 315 Sleep Disorders in Children 334
Disorders of Language or Specific Language Impairments 316 Miscellaneous Adult Psychiatric Disorders Present
Specific Developmental Disorders of Scholastic Skills 316 in Children 334
Autism Spectrum Disorder 318 Feeding Disorder of Infancy and Childhood 334
Conduct Disorder 320 Pica 334
Juvenile Delinquency 323 Stereotyped Movement Disorders 334
Separation Anxiety Disorder 324 Child Abuse or Child Battered Syndrome 334
Treatment 325 Follow-up, Home Care and Rehabilitation for
Attention Deficit Hyperactivity Disorder 325 Childhood Psychiatric Disorders 335

CHAPTER 12 Nursing Management of Patients with Organic Brain Disorders

or Neurocognitive Disorders .............................................................................. 339–362
Organic Brain Disorders or Neurocognitive Disorders 339 Amnesia 346
Delirium 341 Dementia (ICD-11) or Mild and Major Neurocognitive Disorders
Proper Communication Strategies for Patients with (DSM-5) 348
Organic Brain Disorders 345 Nursing Management of Patients with Organic Brain Disorders 358
Nursing Management 346 Geriatric Considerations 359

CHAPTER 13 Psychiatric Emergencies and Crisis Intervention ............................................... 363–398

Introduction 363 Delirium 379
Common Psychiatric Emergencies 365 Epileptic Furor 379
Aggression/Violence 371 Maladaptive Behaviors of Individuals and Groups: Crisis,
Transient Situational Disturbances 375 Stress and Disasters
Victims of Disaster 375 Adaptive Behavior 379
Catatonic Stupor 375 Maladaptive Behavior 379
Victim of Rape 376 Crisis 381
Medical Emergency in Psychiatry Grief and Bereavement 387
Neuroleptic Malignant Syndrome 376 Counseling 390
Overdose of Psychotropic Agents 377 Stress 392
Substance Intoxication and Withdrawal 377 Coping Mechanism 396
Serotonin Syndrome 377 Geriatric Considerations 397

CHAPTER 14 Legal Issues in Mental Health Nursing ............................................................... 399–413

Indian Lunacy Act (1912) 399 Forensic Psychiatry 407
Mental Health Act (1987) 400 Narcotic Drugs and Psychotropic Substance Act (1985) 408
Protection of Child from Sexual Offences (POCSO) Act (2012) 402 Role of Mental Health Nurse as per the
Offences Covered as per the Act 404 Mental Health Care Act (2017) 410
Punishment for Offences Covered Under the Act 404 Nurse’s Responsibility in Admission Procedure 411
Mental Health Care Act (2017) 404 Nurse’s Responsibility in Discharge Procedure 412
Rights of Mentally Ill Patients 405 Nurse’s Responsibility in Regard to Legal Aspects 412

CHAPTER 15 Community Mental Health Nursing ................................................................... 415–439

Introduction 415 National Mental Health Policy 419
Definition of Community Mental Health Nursing 415 National Health Policy, 2002 420
Principles of Community Mental Health Nursing 416 National Mental Health Program, 1982 421
Issues in Community Mental Health Nursing 416 District Mental Health Program, 1996 422
Development of Community Mental Health Services 416 Institutionalization versus Deinstitutionalization 423
 Contents xxxv

Preventive Psychiatry 424 Issues in Mental Health Nursing for Special

Psychiatric Rehabilitation 426 Populations 433
Mental Health Services by Various Agencies 429 Victims of Violence 436
Agencies/Organization Supporting to Psychiatric Aspects of HIV/AIDS 437
Promote Mental Health—Abroad 431

Do You Know?................................................................................................................................................................................... 441–442

Syndromes in Psychiatry................................................................................................................................................................. 443–444
Psychotropic Drugs........................................................................................................................................................................... 445–458
Know the Differences........................................................................................................................................................................ 459–470
Objective Structured Clinical Evaluation (OSCE)...................................................................................................................... 471–510
Station 1–Anxious Personality Disorder 475 Station 18–Premorbid Personality Assessment (History Taking) 494
Station 2–Suicidal Ideation 476 Station 19–CAGE Questionnaire and Psychological Test 495
Station 3–Psychoanalytical Counseling 477 Station 20–Obsessive Compulsive Disorder, Checkers 496
Station 4–Violent Behavior and Selection of Station 21–Somatoform Disorder–Therapeutic Procedure 497
Appropriate Medicine 478 Station 22–Obsessive Compulsive Disorder 498
Station 5–Premorbid Personality Assessment (History Taking) 479 Station 23–Histrionic Personality Disorder 499
Station 6–Counseling for Behavior Modification Station 24–Pica 500
(Patient with OCD Personality Disorder) 480
Station 25–Identification of Types of Delusions 501
Station 7–Diagnosis and Management of
Station 26–Identification of Therapy (Therapeutic Procedure) 502
Histrionic Personality Disorder 481
Station 27–Drug Identification (Therapeutic Procedure) 503
Station 8–Identify the Types of Narcissistic Personality 482
Station 28–Generalized Anxiety Disorder 504
Station 9–Dependent Personality Disorder 483
Station 29–Depressive Disorder 505
Station 10–Behavior Therapy-Positive Reinforcement 485
Station 30–Mania 506
Station 11–Amnesia 486
Station 31–Bipolar Mood Disorder-Virtual Sign Identification 507
Station 12–Psychometric Assessment 487
Station 32–Phobia-Diagnostic Procedure 508
Station 13–Admission Procedure 489
Station 33–Post-Traumatic Stress Disorder-Identification of
Station 14–Sexual Disorder 490
Symptoms 509
Station 15–Pervasive Developmental Disorder-Dysgraphia 491
Station 34–Schizoid Personality Disorder-Virtual Sign
Station 16–Dyscalculia 492 Identification 510
Station 17–Discharge Procedure 493

Viva-Voce .................................................................................................................................................................. 511–540

Multiple Choice Questions ......................................................................................................................................... 541–547
Appendices ................................................................................................................................................................ 549–570
Appendix 1: History Collection Format 549 Appendix 16: Group Psychotherapy Format 561
Appendix 2: History Collection Format for Patient with Alcohol Appendix 17: Family Therapy Format 561
Dependence Syndrome 551 Appendix 18: Clozapine Side Effect Chart 561
Appendix 3: History Collection Format—Children and Adolescent Appendix 19: Psychiatric Nursing Care Daily Checklist 562
with Psychiatric Disorders 552 Appendix 20: Disulfiram Consent Form 563
Appendix 4: History Collection Format—Geriatric Psychiatry 552 Appendix 21: Occupational Therapy Format 563
Appendix 5: Mental Status Examination (MSE) Format 553 Appendix 22: Recreational (or) Play Therapy Format 563
Appendix 6: Mental Status Examination of Uncooperative Patients Appendix 23: Checklist for Admission Procedure 563
(Kirby’s Method) 554
Appendix 24: Checklist for Discharge Procedure 564
Appendix 7: Hindi Mental Status Examination (HMSE) 555
Appendix 25: Format for Writing Observational Visit Report 564
Appendix 8: Mini Mental Status Examination (or) Folstein Test
Appendix 26: Psychometric Assessment Report 565
Format 556
Appendix 27: Important Days Related to Mental Health 565
Appendix 9: Neurological Assessment 556
Appendix 28: Proponents in Psychiatry 565
Appendix 10: Process Recording Format 557
Appendix 29: Therapeutic Serum Levels of Psychotropic
Appendix 11: Nursing Care Plan Format 558
Medications 566
Appendix 12: Nursing Care Study/Clinical Presentation Format 559
Appendix 30: Imbalance of Neurotrasmitters in Various Psychiatric
Appendix 13: Health Education Format 560 Disorders 566
Appendix 14: Assessment and Checklist Used for the Patient Appendix 31: ICD-11 and DSM-5 Classification of Mental
Undergoing Electroconvulsive Therapy (ECT) 560 Disorders 567
Appendix 15: Individual Psychotherapy Format 561
xxxvi Textbook of Psychiatric Nursing for BSc Nursing Students

Clinical Case Scenarios............................................................................................................................................. 571–623

Case 1–Patient with Mania 571 Case 7–Multiple Substance Abuse Disorder 622
Case 2–Patient with Depressive Disorder 583 Case 8–Major Depressive Disorder 622
Case 3–Patient with Bipolar Affective Disorder 593 Case 9–Mental Retardation 623
Case 4–Patient with Multiple Substance use Disorder 603 Case 10–Obsessive-Compulsive Disorder 623
Case 5–Patient with Undifferentiated Schizophrenia 612
Case 6–Bipolar Affective Disorder—Mania with Psychotic
Symptoms 622

Glossary ................................................................................................................................................................... 625–642

Index ........................................................................................................................................................................ 643–656

Abbreviations

A C
AA: Alcoholic Anonymous CATIE-AD: Clinical Antipsychotic Trials of Intervention
AAMR: American Association on Mental Retardation Effectiveness for Alzheimer’s Disease
AN: Anorexia Nervosa CA: Chronological Age
ABPN: American Board of Psychiatry and Neurology CAM: Complementary and Alternative Medicine
ACT: Acceptance and Commitment Therapy CAMQ: Common Mental Disorder Questionnaire
ACTH: Adrenocorticotropic Hormone CAPU: Child and Adolescent Psychiatric Unit
CAT: Cognitive Analytic Therapy
AD: Alzheimer’s Disease (or) Adjustment Disorder
CBCL: Child Behaviour Checklist
AIMS: Abnormal Involuntary Movement Scale
CBT: Cognitive Behaviour Therapy
ADD: Attention Deficit Disorder
CD: Conduct Disorder
ADHD: Attention Deficit Hyperactive Disorder
CGI: Clinical Global Impressions
APA: American Psychiatric Association
CGI-C: Clinical Global Impression of Change
ARDSI: Alzheimer’s & Related Disorders Society of India
CID: Critical Incident Debriefing
ASPD: Antisocial Personality Disorder
CIT: Crisis Intervention Team
ASD: Autism Spectrum Disorder
CIMH: Center for International Mental Health
ATS: Amphetamine-Type Stimulant
CLF: Community Living Facility
AvPD: Avoidant Personality Disorder
CMAI: Cohen-Mansfield Agitation Inventory
CMHN: Community Mental Health Nurse
B
CNS: Central Nervous System
BAI: Beck Anxiety Inventory CPRP: Community Psychiatric Rehabilitation Program
BDI: Beck Depression Inventory CRH: Corticotropin Releasing Hormone
BDRS: Bipolar Depression Rating Scale CROMP: Centre for Rehabilitation of Mental Patients
BED: Binge Eating Disorder CRSD: Circadian Rhythm Sleep Disorders
BDD: Body Dysmorphic Disorder CT: Computed Tomography
BEHAVE: AD Behavioral Pathology in Alzheimer’s Disease CVA: Cerebrovascular Accident
BHS: Beck Hopelessness Scale
BMI: Body Mass Index D
BPRS: Brief Psychiatric Rating Scale DBS: Deep Brain Stimulation
BPSD: Behavioral and Psychological Symptoms of Dementia DID: Dissociative Identity Disorder
xxxviii Textbook of Psychiatric Nursing for BSc Nursing Students

DiG: DiGeorge Syndrome G

DLB: Dementia with Lewy body
GA: Gamblers Anonymous
DBT: Dialectical Behaviour Therapy
GABA: Gamma Amino Butyric Acid
DISC: Diagnostic Interview Schedule for Children
GAD: Generalized Anxiety Disorder scale
DMHP: District Mental Health Program
GAF: Global Assessment of Functioning scale
DMHT: District Mental Health Team
GAI: Geriatric Anxiety Inventory
DOES: Disorder of Excessive Somnolence
GAS: General Adaptation Syndrome
DPN: Diploma in Psychiatric Nursing
GBL: Gamma-Butyrolactone
DSH: Deliberate Self Harm GGT: Gamma Glutamyl Transpeptidase
DSM-IV: Diagnostic and Statistical Manual of Mental GHB: Gamma Hydroxybutyric acid
Disorders, 4th Edition
GHQ-12: General Health Questionnaire, 12 item version
DSM-5: Diagnostic and Statistical Manual of Mental
GRADE: Grading of Recommendations Assessment,
Disorders, 5th Edition
Development and Evaluation
DT: Delirium Tremens
GTS: Gilles de Tourette’s Syndrome
DXM: Dextromethorphan
GIP: Global Initiative in Psychiatry
DZP: Diazepam
H
E
HADS: Hospital Anxiety and Depression Scale
ED: Emotional Disturbances HDRS: Hamilton Depression Rating Scale
EBP: Evidence-Based Practice HGH: Human Growth Hormone
ECT: Electroconvulsive Therapy HT: Healing Touch
ECG: Electrocardiogram HIV: Human Immunodeficiency Virus
EDNS: Eating Disorder Not otherwise Specified
EEG: Electroencephalogram I
EMG: Electromyogram IDEA: Individuals with Disabilities Education Act
EIT: Early Intervention Team IDS: Inventory of Depression Symptomatology
EMPS: Emergency Mobile Psychiatric Services ITP: Inferior Thalamic Peduncle
EOMI: Episodes of Mental Illness ICD-10: International Classification of Diseases, 10th Revision
EPDS: Edinburgh Postnatal Depression Scale IEC: Information Education Communication
EPQ: Eysenck Personality Questionnaire IED: Intermittent Explosive Disorder
EPS: Extrapyramidal Symptoms IOP: Intensive Outpatient Program
EQ: Emotional Quotient IPT: Interpersonal Therapy
ERP: Exposure and Response Prevention ILA: Indian Lunacy Act
EUPD: Emotionally Unstable Personality Disorder IQ: Intelligent Quotient
IR: Immediate Release
F IRF: Inpatient Rehabilitation Facility
FAS: Fetal Alcohol Syndrome IRR: Incidence Rate Ratio
FAA: Food Addicts Anonymous ISMH: Indian System of Medicine & Homeopathy
FAP: Functional Analytic Psychotherapy ISMO: International Society for Mental Health Online
FAST: Functional Assessment staging ISPN: Indian Society of Psychiatric Nurses
FGA: First-Generation Antipsychotic ITAQ: Insight and Treatment Attitude Questionnaire
FTD: Formal Thought Disorder (or) Frontotemporal  Dementia ITT: Intention to Treat
 Abbreviations xxxix

L NCMH: National Council for Mental Health (or) National

Center for Mental Health
LAAM: Levacetylmethadol
NINCDS/ADRDA: National Institute of Neurological and
LSD: Lysergic Acid Diethylamide
Communicative Diseases and Stroke/Alzheimer’s Disease and
Related Disorders Association
M
NMS: Neuroleptic Malignant Syndrome
MA: Mental Age
NMHP: National Mental Health Programme
MADRS: Montgomery-Asberg Depression Rating Scale
NPI: Neuropsychiatric Inventory
MAOIs: Monoamine Oxidase Inhibitors
NPI-NH or NPI/NH: Neuropsychiatric Inventory—Nursing
MARIs: Mono Amine Reuptake Inhibitors
Home
MBCT: Mindfulness Based Cognitive Therapy
NPI-Q: Neuropsychiatric Inventory Questionnaire
MBSR: Mindfulness Based Stress Reduction
NREM: Non-Rapid Eye Movement
MDAD: Mixed Depressive Anxiety Disorder
NQF: National Quality Forum
MDD: Major Depressive Disorder
MDE: Major Depressive Episode
O
MDMA: Methylene Dioxy Phenethylamine
MDP: Manic Depressive Psychosis OCD: Obsessive-Compulsive Disorder
MFT: Marriage and Family Therapist ODD: Oppositional Defiant Disorder
MHA: Mental Health Act ODDRS: Oppositional Defiant Disorder Rating Scale
MI: Motivational Interviewing OPQ: Occupational Personality Questionnaire
MMD: Major Mental Disorder
MMSE: Mini-Mental State Examination P
MPA: Medico Pastoral Association PCP: Phencyclidine
MR: Mental Retardation PD: Parkinson Disease
MRI: Magnetic Resonance Imaging PBD: Pediatric Bipolar Disorder
MSIR: Morphine Sulphate IR PCIT: Parent Child Interaction Therapy
MSW: Master of Social Work PCLN: Psychiatric Consultation Liaison Nurse
MHCOP: Mental Health Care of Older People PDD: Pervasive Developmental Disorder
MH Hx: Mental Health History
PDD: Persistent Depressive Disorder
MHW: Mental Health Worker
PE: Prolonged Exposure Therapy
PET: Positron Emission Tomography
N
PESU: Psychiatric Emergency Service Unit
NA: Narcotics Anonymous
PHP: Partial Hospitalization Program
NANDA: North American Nursing Diagnosis Association
PLMD: Periodic Limb Movement Disorder
NAMI: National Alliances for the Mentally Ill
PPD: Paranoid Personality Disorder
NCCAM: National Centre for Complementary and Alternative
Medicine PPP: Postpartum Psychosis
NCMH: National Council for Mental Health PRS: Psychiatric Rehabilitation Services
NE: Norepinephrine PTSD: Post-Traumatic Stress Disorder
NES: Night Eating Syndrome PSSD: Post SSRI Sexual Dysfunction (or) Post SSRI Sexual
NIA: National Institute on Aging Disorder
NIMH: National Institute of Mental Health PSW: Psychiatric Social Worker
NIMHANS: National Institute of Mental Health and PANSS-EC: Positive and Negative Symptom Scale—
Neurosciences Excitement Component
xl Textbook of Psychiatric Nursing for BSc Nursing Students

Q TD: Tardive Dyskinesia

THC: Tetrahydrocannabinol
QTc: Corrected QT interval
THP: Trihexyphenidyl
R TLE: Temporal Lobe Epilepsy
TMD: Transitory Mood Disorder
RAS: Reticular Activating System
TMS: Transcranial Magnetic Stimulation
REM: Rapid Eye Movement
TRADA: Total Response to Alcohol and Drug Abuse
REBT: Rational Emotive Behavior Therapy
TRD: Treatment-Resistant Depression
RLS: Restless Leg Syndrome
TRH: Thyrotropin Releasing Hormone
RTC: Residential Treatment Center
TS: Tourette Syndrome
TT: Therapeutic Touch
S
TIA: Transient Ischemic Attack
SAD: Seasonal Affective Disorder (or) Separation Anxiety
Disorder (or) Social Anxiety Disorder
V
SDMI: Severe Disabling Mental Illness
VCA/S: Ventral Capsule and Ventral Striatum
SCC: Subcallosal Cingulate Cortex
VNS: Vagus Nerve Stimulation
SDD: Specific Developmental Disorders
VTA: Ventral Tegmental Area
STN: Subthalamic Nucleus
VH: Visual Hallucinations
SAS: Simpson-Angus Scale
VTE: Venous Thromboembolism
SFRS: Schneider’s First Rank Symptoms of Schizophrenia
SGA: Second-Generation Antipsychotic
W
SIB: Severe Impairment Battery
SMD: Standardized Mean Difference WAIS: Wechsler Adult Intelligence Scale
SSRI: Selective Serotonin Reuptake Inhibitors WFMH: World Federation for Mental Health
SNRI: Selective Serotonin and Norepinephrine Reuptake WISC: Wechsler Intelligence Scale for Children
Inhibitor WIAT: Wechsler Individual Achievement Test
SPD: Schizoid Personality Disorder WHO: World Health Organization
SUD: Substance Use Disorder WRAT: Wide Range Achievement Test
SZA: Schizoaffective Disorder
X
T XR: Extended Release
TAT: Thematic Appreciation Test
TBI: Traumatic Brain Injury Y
TCA: Tricyclic Antidepressant YBOCS: Yale-Brown Obsessive-Compulsive Scale
TCL: Training in Community Living YGTSS: Yale Global Tic Severity Scale.
 CHAPTER
Introduction to
Psychiatric Nursing 1
LEARNING OBJECTIVE

After studying this chapter, the student will be able to understand the basic concepts of psychiatric nursing.

CHAPTER OUTLINE
• Perspectives of Mental Health and Mental Health Nursing • Current Trends and Issues in Care of Mentally Ill Patients
• Mental Health Team or Multidisciplinary Team • Functions of Psychiatric Nurse in Various Settings
• Nature/Philosophy of Psychiatric Nursing • Factors Affecting the Level of Practice of Psychiatric Nurse
• Scope of Psychiatric Nursing • Concepts of Normal and Abnormal Behavior

KEY TERMS
Mental health nursing, Mental health, Mental health policy, Mental health team, Normal behavior, Abnormal behavior, Evolution of
mental health services, Functions of psychiatric nurse.

PERSPECTIVES OF MENTAL HEALTH AND The capacity of an individual to form harmonious relationships
MENTAL HEALTH NURSING with others and to participate in or contribute constructively
to changes in social environment.
Definitions of Mental Health —World Health Organization (WHO), 1950
The adjustment of human beings to the world and to each Mental health is defined as, ‘state of well-being in which every
other with the maximum of effectiveness and happiness. person realizes one’s own potential, is able to cope with the
—Karl Menninger, 1893 normal stresses of life, able to work productively or fruitfully,
A dynamic state in which feelings and behavior are age and is able to make a valuable contribution to the community.
appropriate and congruent with the local and cultural norms.  —World Health Organization (WHO), 2014
 —Robinson, 1983
Mental health is simultaneous success at working, loving and Aspects of Mental Health
creating with the capacity for mature and flexible resolution • Individual aspect: Free from internal conflict, self-
of conflicts between instincts, conscience, other important confident, feels adequate.
people and reality. • Social aspect: Establishes a satisfactory relationship
 —American Psychiatric Association, 1980 between himself and his environment.
2 Textbook of Psychiatric Nursing for BSc Nursing Students

8. There is an inequality in the distribution of skilled human

resources in mental health.
9. There are five key barriers to increase the availability of
mental health services such as absence of mental health
from public health agenda with its implications for
funding, organization of mental health services, absence
of integration within primary care, lack of human
resources for mental health and lack of public mental
health leadership.
10. Financial resources to enhance the mental health services
are relatively small.

Indicators of Mental Health

Marie Jahoda (1958) has identified six indicators of mental
health:
Figure 1.1: Mental health continuum 1. A positive attitude toward self:
„ An objective view of self.
Knowledge and acceptance of strengths and
Mental Health Continuum
„

limitations.
Continuum of mental health ranges from low mental „ A strong sense of personal identity.
health to high mental health and high mental disorder to „ Feel of security within the environment.
low mental disorder. Component present between the high 2. Growth, development and the ability for self-
mental health and high mental disorder is diagnosed with actualization
mental illness but has a positive mental health. Component „ Successful achievement of tasks associated with each
present between the high mental health and low mental level of development.
disorder is not diagnosed with mental illness and has a positive 3. Integration
mental health. Component present between the low mental „ Ability to adaptively respond to the environment.
health and low mental disorder is not diagnosed with mental „ Development in regard with the philosophy of life.
illness but has a poor mental health. Component present 4. Autonomy
between the low mental health and high mental disorder is „ Ability to perform in an independent self-directed
diagnosed mental illness and has poor mental health (Fig. 1.1). manner.
5. Perception of reality
Ten Facts on Mental Health by World Health „ Perception of the environment without distortion.
Organization (WHO) „ Capacity for empathy and social sensitivity—a respect
1. Approximately 20% of adolescents and children have and concern for the wants and needs of others.
psychiatric illness. 6. Environmental mastery
2. Psychiatric illness and substance use disorders are the „ Ability to achieve a satisfactory role within the group/
chief cause of disability worldwide. society or environment.
3. Around eight lakh people commit suicide every year. United Nations adopted the Sustainable Development
4. War and disasters have a huge impact on psychosocial Goals (SDGs) with two mental health indicators that are
well-being and mental health. listed here:
5. Psychiatric illness is an important risk factor for other 1. Promotion of mental health: By the year 2030, one-
diseases. third of mortality of noncommunicable diseases should
6. Stigma and discrimination will prevent the people from be reduced through prevention/treatment measures and
seeking mental health treatment. mental health/well-being should be promoted.
7. Violation of human rights in regard to mental and 2. Harmful use of alcohol: Prevention and treatment
psychosocial disability was reported routinely in most of measures of substance abuse including the harmful use of
the countries. alcohol and narcotic drug abuse.
CHAPTER 1 Introduction to Psychiatric Nursing 3

Flowchart 1.1: Components of mental health according to ‘Keyes’

Principles of Mental Health Criteria for Mental Health

There are two basic principles of mental health: • Adequate contact with reality
1. Self-knowledge: Individual must be aware of himself, his • Control of thoughts and imagination
strengths and weaknesses. • Efficiency in work and play
2. Harmonious social relationship: Individual must be able • Social acceptance
to establish and maintain a harmonious relationship. • Positive self-concept
• A healthy emotional life
Components of Mental Health
Components of mental health include: Characteristics of a Mentally Healthy Person
• Ability to accept self • Has an ability to make adjustments.
• The capacity to feel right toward others • Has a sense of personal worth, feels worthwhile and
• The ability to fulfil life’s tasks
important.
According to Keyes, components of mental health were
• Solves his problems largely by his own effort and makes
classified as emotional well-being, psychological well-being
his own decisions.
and social well-being (Flowchart 1.1). Emotional well-being
• Has a sense of personal security and feels secure in a
includes having interest in life, being satisfied and stay happy
group.
with life. Psychological well-being includes, the satisfaction
• Shows understanding of others’ problems and motives.
with the most parts of one’s own personality, well in managing
the responsibilities of life and maintaining good interpersonal • Has a sense of responsibility.
relationship with others. The social well-being includes the • Can give and accept love.
social integration, social contribution, social actualization and • Lives in a world of reality rather than fantasy.
social coherence. Social integration means, ‘individual feels • Shows emotional maturity in his behavior and develops
that he/she is a part of a society.’ Social contribution means, capacity to tolerate frustration and disappointments in his
‘individual feels that he/she is having a strong contribution to daily life.
the society.’ Social actualization means, ‘individual believes • Has developed a philosophy of life that gives meaning and
that society is the best place for all people.’ Social coherence purpose to his daily activities.
means ‘individual feels that, working in the society makes a • Has a variety of interests and generally lives a well-
good sense to all.’ balanced life of work, rest and recreation.
4 Textbook of Psychiatric Nursing for BSc Nursing Students

Characteristics of a Mentally Healthy Definitions of Mental Disorder

Person According to National Mental Health • A mental disorder is a syndrome characterized by
Association (2004) clinically significant disturbance in an individual’s
• Feels good about oneself. cognition, emotional regulation, or behavior that
• Individual will not be overwhelmed by emotions, such as reflects a dysfunction in the psychological, biological, or
anger, fear, jealousy, love, guilt, anxiety, etc. development processes underlying mental functioning.
• Has a satisfying personal relationship with others.  —DSM–5
• Feels comfortable with others. • Clinically significant conditions are characterized by
• Can laugh with others. alterations in thinking, mood (emotions) or behavior
• Has self-respect and for others even with the presence of are associated with personal distress and/or impaired
differences. functioning. —WHO, 2001
• Is able to accept life’s disappointments. • In general, an individual may be considered to be mentally
• Can meet the demands of life and handle the problems. ill, if:
• Takes own decisions. „ The person’s behavior is causing distress and suffering
• Shapes the environment whenever possible and gets to self and/or others.
adjusted when required. „ The person’s behavior is causing disturbance in
his day-to-day activities, job and interpersonal
Characteristics of a Mentally Healthy Person relationships.
According to South Africa Federation
Association (2014) Features of Mental Illness
A mentally healthy person feels good about himself/herself; • Disturbances in bodily functions: Disturbed sleep,
feels comfortable with others and is able to meet the demands increased or decreased food intake, disturbances in bowel
of life as shown in Figure 1.2. and bladder functions and changes in libido.
• Disturbances in mental functions: Behavioral
disturbances, abnormal speech pattern, abnormal
thoughts, disturbed perception, impaired attention and
concentration, memory disturbances, poor judgment and
sometimes disturbed consciousness.
• Changes in individuals and their social activities:
Neglected physical care, poor social sense and strange
behavior with family members, friends, colleagues and
others.
• Somatic complaints: Aches and pains in different parts
of the body, fatigue, weakness, involuntary movements,
etc.

Evolution of Mental Health Services/Psychiatry

Developments in the field of psychiatry are discussed here in
a nutshell:
• Soul friends: In the history of psychiatry, Christian
Europe created models of care for the mentally ill which
include, partnering of the insane with “Soul friends” who
will help to reconnect with themselves and society. In
many ways, these soul friends could be seen as forerunners
of the modern psychiatric nurse.
• Exorcism: Exorcism is the religious practice of evicting
demons or other spiritual entities from a person or an
Figure 1.2: Characteristics of a mentally healthy person according area which they are believed to have possessed either by
to South Africa Federation Association commanding the spirit, or by making a hole on the skull
CHAPTER 1 Introduction to Psychiatric Nursing 5

of the affected person or torturing the spirit by beating • Schools of nursing were established in Boston and
and chaining the affected person. Philadelphia by 1872.
• The Witches’ Hammer: This was a book published in 1487. • The first American graduate nurse, Ms Linda Richards,
„ It was written by Dominican monks Jacob Sprenger graduated from the ‘New England Hospital for Women
and Heinrich Kramer. and Children’ in 1873.
„ This book rationalized mental illness in terms of • Dorothea Lynde Dix devoted time to improve the
magical explanation. conditions of mentally ill persons.
• Era of moral treatment: During this period, there was
a revolution in the model of care for the mentally ill Phase 2: Development of the Work Role of Psychiatric
persons. Many humanitarians strived to bring in a least Nurses (1882–1914)
restrictive way of caring. Few of them are as follows: • Training schools for nurses in the psychiatric setting
„ In 1974, Philippe Pinel treated inmates in the French were established at McLean Hospital in Belmont,
institutions with humanity. Massachusetts and at Buffalo State Hospital in
„ In England, William Tuke focused on “moral New York in 1882.
treatment” in a humane milieu called York Retreat. • It was a two-year program, focusing mainly on the
„ In America, Benjamin Rush focused on custodial care of the patients.
humanitarianism and moral treatment at the • Trained nurses were employed in State mental hospitals
Pennsylvania Hospital. (1890).
• Decade of the brain: • National Society for Mental Hygiene was founded in 1909.
„ The 1990s has been called the “Decade of the Brain.” • John Hopkins University started a School of Nursing and
The advent of numerous imaging techniques opened the fully developed curriculum for Psychiatric Nursing
up a new world of understanding the neurophysiology was implemented in 1913.
and neuroanatomy of the brain.
„ This knowledge leads to a revolution in the Phase 3: Development of Undergraduate Psychiatric
understanding of mental health, providing evidences Nursing Education (1915–1935)
that most serious mental disorders should be viewed • Student nurses received clinical experience in state mental
as “diseases of the brain.” hospitals.
„ Thus, there has been a major shift in the way of • Textbooks focusing on psychiatric nursing practice were
treating people suffering from mental diseases, mainly written.
through psychopharmacology. • Educational objectives for undergraduate were discussed
at National League for nursing conventions.
Development or Evolution of • Harriet Bailey wrote the first psychiatric nursing textbook
Mental Health Nursing ‘Nursing Mental Diseases’.
Psychiatric nursing is a specialized area of nursing practice • Insulin Shock Therapy, ECT and Prefrontal lobotomy
employing theories of human behavior. It is used in the were introduced in the psychiatric clinical setting.
diagnosis and treatment of human response to actual and • The National Committee for Mental Hygiene was
potential mental health problems. Evolution of psychiatric established.
nursing takes place along with the developments of psychiatry.
Phase 4: Development of Graduate Psychiatric Nursing
A record of these historic events helps us to get a vivid picture
Education (1936–1945)
of the development of psychiatric nursing.
• Clinical experiences in psychiatric hospitals were
Phase 1: The Emergence of Psychiatric/Mental Health standardized by 1937.
Nursing (1773–1881) • Approximately, half of all nursing schools provided
• Special institutions for individuals with psychiatric psychiatric nursing courses; however, participation in
disorders were built. psychiatric courses did not become a requirement for
• Benjamin Rush wrote the first American textbook on nursing licensure until 1955.
psychiatry. • The National League of Nursing education has framed
• Attendants were hired to socialize with patients. curriculum guidelines for psychiatric nursing graduate
• Philippe Pinel classified clients according to their education. By 1943, three universities were sponsored
observable behaviors. with the existing graduate program.
6 Textbook of Psychiatric Nursing for BSc Nursing Students

Phase 5: Development of Consultation and Research in Table 1.1: Development of Psychiatric Nursing in India
Psychiatric Nursing Practice (1946–1990)
Year Milestone development of psychiatric nursing in
• The Mental Health Act provides funding to graduate India
nursing programs in order to prepare psychiatric clinical 1954 Nur Manzil Mental Health Center, Lucknow introduced
nurses. 4–6 weeks’ orientation course in psychiatry for the
• Yearly grants were given to the National League for employed nurses
nursing to evaluate psychiatric programs. 1956 Health Survey Committee recommended a 1 year post
• Psychiatric nursing was added as a subject in the nursing certificate course in Psychiatric Nursing. The duration
of this course was reduced to 11 months by 1974 –77
curriculum in many schools of nursing in western
countries. 1962 Mysore Government started a 9 months’ course
in Psychiatric Nursing for male nurses in lieu of
• In 1950, National League for Nursing started the training Midwifery. In 1976, the course duration was reduced
of student nurses in psychiatric units, which was found to 6 months.
essential. 1965 Indian Nursing Council incorporated Psychiatric
• In 1950, psychiatric nurses were able to define their role as Nursing as a compulsory subject in BSc Nursing.
a scientific observer, a creator of therapeutic environment, 1966 Psychiatric Nursing was added as a compulsory subject
a socializing agent and a psychotherapeutic agent. in Diploma in General Nursing and Midwifery.
• In 1952, Hildegard Peplau developed ‘Theory related to 1975 Psychiatric Nursing was offered as an elective subject
Interpersonal relations in Psychiatric Nursing’. in MSc Nursing at RAK College of Nursing, New Delhi.
• In 1953, Maxwell Jones wrote a book on ‘Therapeutic 1988 Psychiatric Nursing was offered as a specialization in
Community’. He mentioned the therapeutic aspect of the MSc Nursing.
Nurses’ role in his book.
• In 1960, first Doctoral Program in Psychiatric Nursing • Clinical psychologist
was started in Boston. • Psychiatric social worker
• In 1960, the name ‘Psychiatric Nursing’ was changed to • Occupational therapist
‘Psychiatric Mental Health Nursing’. • Counselor
• In 1963, ‘The Journal of Psychiatric Nursing and Mental
• Pharmacist
Health Services’ was published.
Qualifications and functions of mental health team members
• In 1970, the name ‘Psychiatric Mental Health Nursing’
have been listed in Table 1.2.
was again changed to ‘Psychosocial Nursing’.
• In 1985, Standards of Psychiatric Mental Health and Psychiatric Paraprofessionals or Technical Staff
Clinical Nursing Practice were published by American
Nurses Association. • Psychiatric nursing aid:
• In 1990, integration of neurosciences into holistic „ Provides care under supervision by assisting the client
biopsychosocial practice of Psychiatric Nursing took place. in meeting daily living activities.
Development of Psychiatric Nursing in India is shown in „ Aids in maintaining therapeutic environment.
Table 1.1. • Electroconvulsive therapy (ECT) technician:
„ Prepares the ECT room, ECT machine and other
MENTAL HEALTH TEAM OR MULTIDISCIPLINARY articles required for the procedure.
TEAM „ Assists the psychiatrist in administering ECT.
„ Gives ECT under the supervision of psychiatrist or
Mental health care is a product of collaborative care rendered anesthetist.
by a team of mental health care professionals. They form a • Dietician: Plans and distributes therapeutic diet to the
multidisciplinary team named mental health team. They meet clients according to the physician’s order.
within 48 hours of admission to determine a comprehensive • Clergymen/Chaplain
treatment plan, set goals of therapy and assign responsibilities „ They visit patients once or twice a week based on
to provide intervention. All members will sign the treatment client’s faith.
plan and meet weekly to update the plan as needed. „ Identifies and attends the spiritual needs of the clients
Mental health team members: and family members.
• Psychiatrist „ Provides comfort and spiritual support through
• Psychiatric nurse counseling.
CHAPTER 1 Introduction to Psychiatric Nursing 7

Table 1.2: Qualification and functions of mental health team members

Mental health Qualification Functions

team members
Psychiatrist MBBS with diploma • Admission of patients into mental health care setting
or a postgraduation in • Formulating diagnosis and prescribing pharmacological treatment
psychiatry • Administering physical and psychological methods of treatment
• Leading the mental health team and coordinating institutional services, treatment
and rehabilitation of mentally ill patients
• Discharging the patient from hospital and extending services in the community setting
Psychiatric nurse Diploma/Basic BSc • Formulating the nursing care plans
(N), Post Basic BSc • Administering and monitoring medications ordered by psychiatrist
(N), MSc (N) or PhD • Organizing and assisting the various therapies
(specialization in • Providing Psychoeducation to the patient and patient’s family members.
psychiatric nursing) • Maintaining the patient’s records
• Creating awareness program in the community in order to promote mental health.
Clinical Postgraduate degree • Performing psychological assessment and contributing to formulation of diagnosis
psychologist or Doctoral degree in • Providing psychological therapies to the patients and families
clinical psychology
Psychiatric social Postgraduate degree or • Performing family case work by applying skills in interview techniques and group
worker Doctoral degree in social dynamics
work (specialized in • Providing social assistance to clients with mental illness
psychiatric field) • Helping the family members to understand the nature of treatment
• Working for reintegration of patients into community
• Emphasizing interventions in social environment where the patient lives
Occupational Bachelor of occupational • Conducting recreational, occupational and activity programs
therapist therapy (BOT) or • Assisting the patients to gain pre-vocational, vocational and home making skills
postgraduate in • Helping the patients to gain or retain employment
occupational therapy
(MOT)
Counselor MSc (Psychology)/ • Providing supportive counseling
MSc counseling and • Assisting in psychological therapy
Psychotherapy • Assisting in psychoeducational and recreational activities
Pharmacist D Pharm/B Pharm/M • Dispensing the psychotropic agents as per prescription
Pharm (Diploma to
masters in pharmacy)

• Speech therapist: The qualification of speech therapist is • Every individual has the potential to change.
Bachelor in Audiology and Speech Language Pathology • Each person functions as a holistic being who acts on,
(BASLP). Speech therapist will treat the patients with interacts with, and reacts to the environment as a whole
speech related problems. person.
• All people have common, basic needs such as physical
NATURE/PHILOSOPHY OF PSYCHIATRIC NURSING requirements, safety, love, belonging, esteem and self-
actualization.
Hildegard Peplau is known as the mother of psychiatric • Behavior of the individual is meaningful.
nursing. She identified that the heart of psychiatric nursing • Individuals vary in their coping capacities.
is the role of a nurse as a counselor or psychotherapist. • All people have rights to utilize the equal opportunity for
Therapeutic nurse patient relationship is a core part of this. adequate health care.
The practice of mental health nursing is based on certain • Each individual has a right to participate in decision-
philosophical beliefs: making regarding his/her health.
• The individual has intrinsic worth, dignity and respect. • The goal of nursing care is to promote wellness.
• The goal of all individuals is growth, health, autonomy • An interpersonal relationship can produce change and
and self-actualization. growth.
8 Textbook of Psychiatric Nursing for BSc Nursing Students

SCOPE OF PSYCHIATRIC NURSING „ Coordinate the nursing services with psychosocial

therapies.
The psychiatric nurse provides holistic care to the client „ Communicate the patient’s behavior to the concerned
with emphasis on the psychological component which is a personnel. (For example, intimating the abscond of
core value of essential nursing care. The scope of psychiatric patient to police).
nursing practice can be discussed at three levels: „ Share the knowledge about the community
resources with patients and their families for future
1. Basic Roles rehabilitation.
As a basic nurse, his/her functions and responsibilities can be • Role in other therapies: The nurse plays an interdependent
categorized into: role in various therapies such as pharmacological,
• Patient care psychological, social and physical therapies. The nurse has
„ Assess the patient’s needs and give individualized a key role in milieu therapy and therapeutic community.
nursing care according to their needs.
„ Develop care plans to meet long-term goals. 2. Expanded Roles
„ Assist the multidisciplinary team members in Expanded role of psychiatric nurse means enlargement of
diagnostic and therapeutic measures. nursing responsibilities within the boundaries of psychiatric
„ Provide therapeutic environment. nursing. The expanded roles in psychiatric nursing are as
„ Assist in personal hygiene and provide facilities for follows:
those who can take care of themselves. • Registered psychiatric nurse: Provides psychiatric
„ Assist patients in meeting nutritional needs and give mental health nursing care to individuals, families and
feed to those who are unable to feed themselves. groups to enable them to function at an optimal level of
„ Carry out mental status examination. psychological wellness through more effective adaptive
„ Set limits with the unacceptable patient’s behavior. behaviors and increased resilience to stress.
„ Provide activities to channelize the patient’s energy • Nurse practitioner:
with constructive work to improve their self-esteem. „ Utilizes psychological processes and phases in
• Education and supervision rendering psychological reassurance and counseling
„ Make use of opportunities to give group or individual services to the client.
health education. „ Assists the clients in meeting his/her total needs
„ Teach nursing students about Psychiatric Nursing especially emotional needs and delivers holistic care.
care and assist them to take care of the mentally ill • Clinical Nurse Specialist (CNS):
patients. „ Psychiatric clinical nurse specialist holds a master’s
„ Supervise the work of subordinates. degree in psychiatric mental health nursing.
„ Change the misconceptions of mental illness by „ CNS is an advanced practice nurse who is usually a
conducting health teaching program. primary health care provider, functions autonomously,
• Ward management often work in a semi-isolated situation.
„ Write the daily report of acutely ill patients. „ Has medication prescription privileges, manages the
„ Periodically evaluate the chronic patient’s progress overall care of people with emotional and psychiatric
and record it. problems.
„ Assess the cleanliness of ward and take steps to „ Usually has a consultative arrangement with a
improve it. psychiatrist.
„ Give a brief report about patient’s behavior changes • Nurse clinician:
while hand over the patient to another staff nurse, this „ Identifies the emotional and behavioral problems of
will help to maintain the consistency in nursing care. the clients.
„ Accompany the multidisciplinary team for clinical „ Provides comprehensive care, emotional support.
rounds and give report based on her observation. „ Makes the client to learn coping strategies and helps
• Interpersonal relationship and communication them to understand and adapt to the situations.
„ Establish and maintain cordial relationship with • Nurse counselor: Provides counseling services to both
patients, their families and team members. family and to the client whenever the need arises.
CHAPTER 1 Introduction to Psychiatric Nursing 9

• Nurse researcher: „ They provide assessment, recommendations and

„ Undertakes research projects and contributes to the supportive therapy to patients who are anxious,
evidence of psychiatric nursing. depressed or experiencing other psychological
„ Modifies the existing practice based on the current problems or emotional distress.
evidence. • Geropsychiatric nurse: Nurses provide care to
„ Communicates the research findings through aged people who have been affected by emotional
publications or paper presentations. and behavioral disorders such as dementia, chronic
• Nurse case manager: Nurse case managers act as schizophrenia, delirium, etc.
advocates for patients and their families by coordinating • Parish nurse:
care and linking the patient with the physician, other „ Parish nursing is a program that promotes health and
members of the health care team, resources and the wellness of body, mind and spirit.
payers. „ The parish nurse is a pastorally called, spiritually
mature, licensed registered nurse with a desire to serve
3. Extended Roles the members and friends of his or her congregation.
It is the responsibility assumed by the psychiatric nurse
CURRENT TRENDS AND ISSUES IN CARE OF
beyond traditional functioning of the psychiatric nurse and
MENTALLY ILL PATIENTS
it requires additional professional preparation or educational
qualification. A psychiatric nurse faces various challenges because of
• Community Mental Health Nurse: changes in the inpatient care approach. Some of these changes
„ Community mental health is the application of that affect the role are as follows:
knowledge of psychiatric nursing in preventing • Trends in health care
mental illness and promoting and maintaining mental „ Increased mental health problems
health of the people. „ Provision for quality and comprehensive services
„ It includes early diagnosis, appropriate referrals, care „ Multidisciplinary team approach
and rehabilitation of mentally ill people. „ Providing continuity of care
• Psychiatric Home Care Nurse: „ Care is provided in alternative settings
„ Provides holistic mental health care at the doorstep of • Economic issues
the people. „ Industrialization
„ Provides comprehensive care including physical „ Urbanization
assessment, mental status assessment, direct nursing „ Raised standard of living
care, behavioral management, crisis intervention, • Changes in illness orientation: Shift from illness to
psychoeducation, in-home detoxification, medication prevention (modification of style), specific to holistic,
management, case management and consultation quantity of care to quality of care.
with the colleagues. • Changes in care delivery: Care delivery is shifted from
• Forensic Psychiatric Nurse: institutional services to community services, genetic
„ Forensic psychiatric nurse works with the individuals services to counseling services, nurse-patient relationship
who have mental health needs of those who have to nurse-patient partnership.
entered the legal system. • Information technology
„ Nurses in this role perform physical and psychiatric „ Telenursing
assessment and develop plans of care for the „ Telemedicine
patients. „ Mass media
• Psychiatric Consultation—Liaison Nurse: „ Electronic systems
„ It is an advanced practice where nurses practice „ Nursing informatics
psychiatric and mental health nursing in a medical • Consumer empowerment
setting/non-psychiatric setting. „ Create awareness to the health team members in
„ They provide consultation and education to community for early detection and treatment of
patients, families and health care team and the mental illness as well as proper utilization of available
community. psychiatric hospitals.
10 Textbook of Psychiatric Nursing for BSc Nursing Students

„ Patients are health care consumers demanding • Support the individuals and family members with mental
quality health care services at affordable cost with less health problems by providing treatment.
restrictive and more humane rates. • Promote, prevent, treat and give rehabilitation to mentally
• Deinstitutionalization: Bringing mental health patients ill.
out of the hospital and shifting the nursing care at • Emphasize the need of competent workforce in all settings.
community level.
• Physician shortage and gaps in service: Physician FUNCTIONS OF PSYCHIATRIC NURSE IN VARIOUS
shortage can provide the opportunity for new roles (e.g., SETTINGS
Nurse practitioner). In respect to gaps in services, nurses
always meet the needs of people for whom services are • Psychiatric inpatient ward
not available (e.g., home visiting nurse). „ Enhancing environmental safety.
• Demographic changes: „ Performing comprehensive psychosocial assessment.
„ Increasing number of the elderly group. „ Meeting the biological and emotional needs of the
„ Type of family—increased number of nuclear families. patients.
• Change in needs of the patient: „ Administering the psychotropic agents as per order.
„ Wanting a more holistic orientation in health care. „ Assisting the psychiatrist in somatic therapies.
„ Culturally specific and sensitive nursing care. „ Organizing and assisting in psychological therapies.
„ Preventive health in the place of promotive health. „ Observing and documenting the peculiar change in
behavior of mentally ill patient.
Issues and Challenges in Psychiatric Nursing „ Providing psychoeducation to the patients and family
members.
• Misconceptions about the mental illness—stigma and „ Coordinating the mental health team.
discrimination. „ Planning discharge, community referral and follow-
• Misconceptions in mental health nursing profession. up of patients.
• Deinstitutionalization of mental illness care (Closure of „ Ward administration.
psychiatric hospitals). • Psychiatric outpatient department
• Limited access to psychiatric nurse. „ Performing clinical assessment.
• Reduction in hospital stay for patients with mental „ Assisting in psychometric assessment.
disorders. „ Assisting in psychological therapies.
• Decline in psychotherapy and more use of psycho­ „ Counseling the patients and family members.
pharmacology. „ Drug compliance counseling.
• Lack of health insurance for mentally ill. „ Conducting group therapy.
• Government initiatives to render financial help to „ Providing psychoeducation to the patients and family
mentally ill. members.
• Rapid shift toward mental health hospitals from • ECT room nurse
community based mental health services. „ Educating the family members on ECT.
• Issues related to the safety and security for the mentally ill „ Preparing the patients for ECT.
patients in ward. „ Providing nursing care during ECT.
• Lack of protocols/policies to take care of the patients with „ Providing nursing care after ECT.
psychiatric illness. „ Reassuring the patients and reducing their anxiety.
• Lack of trained psychiatric nurse in the hospitals. • Psychotherapy unit
• Resources are limited. „ Advanced practice psychiatric nurses can practice
• Uncertainty of the role specified. individual or group psychotherapy.
„ Establishing a therapeutic relationship with the patient.
Priorities of the Helsinki Declaration „ Facilitating ventilation of patient’s feelings.
(1964–2013) „ Helping the patients in gaining insight about the
• Create the awareness in regard with significance of mental problem.
health. „ Helping the patients in learning new skills.
• Tackle the stigma, inequality and discrimination „ Reinforcing desirable behaviors.
collectively. „ Providing consistent emotional assistance.
CHAPTER 1 Introduction to Psychiatric Nursing 11

• Day care centers „ Training paraprofessionals, community leaders,

„ Performing clinical assessment. school teachers and other care giving professionals in
„ Accurately observing and documenting the patient’s the community.
behaviors. „ Locating and managing resources in the community.
„ Medication management. „ Direct services, like care of families at risk for violence,
„ Social skills training. abuse and dysfunction, care of homeless mentally ill
„ Counseling the patients and family members. patients.
„ Providing psychoeducation. • Hospice care centers
„ Assisting in occupational or recreational therapy. „ Provide the cancer patients with pain relief through
„ Providing vocational assistance. psychological measures.
• Family therapy units „ Facilitate the normal grieving process.
„ Assess the conflicts existing among the family „ Provide supportive psychotherapy to patients and
members. their families.
„ Facilitation of family’s use of positive coping • Emergency department
strategies. „ Crisis intervention during natural disasters, accidents,
„ Encouraging positive family communication. unexpected illnesses causing increased anxiety, stress
„ Promoting adaptive family functioning. or immobilization.
„ Delivering psychoeducation. „ Helping the mother in labor and support them to
• Child and adolescent psychiatry units cope up with the stress during labor.
„ Psychosocial need assessment „ Providing support to bereaved parents in the event
„ Developmental assessment of fetal demise, abortion, birth of an infant with
„ Assessment of child’s strengths and abilities congenital anomalies.
„ Providing a safe environment to the child • Medical inpatient wards: Psychosocial intervention
„ Interdisciplinary care approach for chronic illnesses with major psychological effects.
„ Self-care training to the child For example, Alzheimer’s disease, HIV/AIDS, diabetes
„ Provide genetic counseling if necessary mellitus, Parkinson’s disease, multiple sclerosis,
„ Deliver psychoeducation hemophilia, colon cancer, amputation, etc.
„ Provide emotional support to the child. • Industrial medical centers
• Home setting „ Implementing or participating in industrial substance
„ Performing routine psychosocial assessment abuse programs for employees.
„ Performing physical assessment „ Providing crisis intervention during accidents (or) in
„ Supervising regularity of medications the acute onset of a physical or mental illness.
„ Providing Psychoeducation on drug compliance, diet „ Teaching stress management techniques.
and rehabilitation • Forensic psychiatry units
„ Providing family counseling „ Forensic psychiatric nurses assist patients with self-
„ Performing necessary basic investigations and nursing care, administration of medications and monitor the
procedures. effectiveness of the treatment.
• Community mental health center „ Promote coping skills.
„ Screening and identification of patients in the „ Advanced nurses are able to diagnose and treat
community. individuals with psychiatric disorders.
„ Referring the identified cases to appropriate centers „ Provide psychotherapy
of care. „ Forensic evaluation for legal sanity
„ Making home visits and providing direct care to the „ Assessment of risk for violence
patients in the community. „ Parole/probation considerations
„ Follow-up care with special emphasis on drug „ Assessment of racial/cultural factors during crime
compliance, patient prognosis, management of side „ Sexual predator screening and assessment
effects and improvement done in patient’s functional „ Submitting formal written reports to court
ability. „ Reviewing police reports
„ Conducting mental health awareness programs. „ On scene consultation to law enforcement.
12 Textbook of Psychiatric Nursing for BSc Nursing Students

FACTORS AFFECTING THE LEVEL OF PRACTICE „ Encouragement from professional activities and
OF PSYCHIATRIC NURSE organizations.
4. Personal initiative: The personal competence and
Role of the psychiatric nurses and their activities include a initiative of the psychiatric nurse will influence the
wide variation in levels of performance. Individual nurses roles and activities of the nurse. This is a very important
have primary responsibility and accountability for their own factor. Psychiatric nurse can use one strategy to enhance
practice. Four major factors play a part in the roles engaged in the personal growth and competence by joining and
by each nurse. These are as follows: participating with support groups.
1. Laws: Laws are the primary factor affecting the level of
nursing practice. Each state has its own nursing practice CONCEPTS OF NORMAL AND ABNORMAL
act, which regulates entry into the profession and defines BEHAVIOR
the legal limits of nursing practice that must be adhered
to by all nurses. Nurse practice acts also address aspects Defining the concepts of normal and abnormal behavior
of advanced practice, including prescriptive authority. is found to be difficult. Abnormality is the deviation from
Nurses must be familiar with the nursing practice act of the norms or standards or rules and regulations. When the
their state and define and limit their practice accordingly. abnormal behavior persists for longer duration, it is termed
2. Qualifications: A nurse’s qualifications include maladaptive behavior (Fig. 1.3). Several models have been
education, work experience, and certification. Two levels put forward in order to explain the concept of normal and
of psychiatric- mental health clinical nursing practice, abnormal behavior. Some of these are as follows:
basic and advanced have been identified. Basic level • Medical model: Mental health refers to a state that is
nurses work as staff nurse, case manager, nurse manager free from undue pain, discomfort and disability. Medical
and other nursing roles in psychiatric setting. The model describes mental illness as a result of organic
advanced practice psychiatric nurse focuses on clinical pathology. According to this model, abnormality is
practice which applies knowledge, skills and experience characterized by the disturbances in thought, emotions
autonomously to complex mental health problems. and behavior due to the organic pathology.
3. Practice setting: The role of a nurse in any psychiatric • Statistical model: Statistically normal mental health
mental health setting depends on the following: falls within two standard deviations (SDs) of the normal
„ Philosophy, mission, values, and goals of the treatment distribution curve. Therefore, mental illness falls outside
setting. two SDs of the normal distribution curve.
„ Definitions of mental health and mental illness that • Utopian model: Utopian model states that individual’s
ability is based on the normal mental health. Mental
prevail in the setting.
illness might interfere with the ability to function at
„ Needs of the consumers of the mental health services.
optimum level.
„ Number of clinical staff available and the services they
are able to provide.
„ Organizational structure and reporting relationships
in the setting.
„ Consensus reached by the mental health care
providers about their roles and responsibilities.
„ Resources and revenues available to offset the cost of
care needed and provided.
„ Presence of strong nursing leadership and mentorship.
A supportive environment for psychiatric nurses is
characterized by:
„ Open and honest communication among staff.
„ Interdisciplinary respect.
„ Recognition of nurses’ contributions.
„ Nursing involvement in decision making.
„ Delegation of nonessential nursing tasks.
„ Opportunities to expand into new roles and
responsibilities. Figure 1.3: Concepts of normal and abnormal behavior
CHAPTER 1 Introduction to Psychiatric Nursing 13

• Subjective model: According to this model, normality a continuum, rather than being disparate entities.
is viewed as an absence of distress, disability, or help- According to this model, level of severity (scores above the
seeking behavior resulting thereof. When there is a ‘cut-off ’) that determines whether a particular individual
subjective distress in the emotional domain, he/she is said constitutes a symptom of a disorder or falls on the healthy
to be abnormal. side of the continuum.
• Social model: Normality is defined in context with social
norms prescribed by the culture. A normal person is Some of the following traits are more commonly found in
expected to behave in a socially ‘acceptable’ way. When ‘normal’ individuals:
there is a deviation from the social norms, it is considered • Reality orientation.
an abnormal behavior. • Self-awareness and self-knowledge.
• Process model: Normal behavior is the result of • Self-esteem and self-acceptance.
interacting system. Normality is a dynamic and changing • Ability to exercise voluntary control over their behavior.
process, rather than a static process. This model focuses • Ability to form affectionate relationships.
on the need for developmental changes in the attainment • Pursuance of productive and goal-directed activities.
of mature adult functioning.
• Behavioral model: Behavior that is adaptive and socially The personal world of an individual is abnormal, when it:
acceptable is considered normal. Abnormal behavior is a • Is universally abnormal.
set of faulty behaviors acquired through learning. • Separates the individual from others emotionally.
• Continuum model: According to this model, normality • Does not provide the person with a sense of spiritual and
and mental disorder are as falling at the two ends of material security.

SUMMARY
• Mental health is defined as ‘state of well-being in which every person realizes one’s own potential, is able to cope with the normal
stressors of life, able to work productively or fruitfully, and is able to make a valuable contribution to the community. (WHO, 2014)
• Continuum of mental health ranges from low mental health to high mental health and high mental disorder to low mental disorder.
• Marie Jahoda (1958) has identified six indicators of mental health that are positive attitude toward self, growth/development and the
ability for self-actualization, integration, autonomy, perception of reality and environmental mastery.
• United Nations adopted the Sustainable Development Goals (SDGs) with two mental health indicators that are suicide mortality and
harmful use of alcohol.
• There are two basic principles of mental health that are self-knowledge and harmonious social relationship.
• According to Keyes, components of mental health were classified as emotional well-being, psychological well-being and social well-
being. Emotional well-being includes interest in life, being satisfied and happy. The psychological well-being includes that most parts of
one’s own personality is liked by self, well in managing the responsibilities of life and maintaining good interpersonal relationship with
others. The social well-being includes the social integration, social contribution, social actualization and social coherence.
• Characteristics of a mentally healthy person by South Africa Federation Association (2014) are feeling good about themselves;
feel comfortable with others and able to meet the demands of life. National Mental Health Association (2004) also suggested the
characteristics of mentally healthy person.
• Mental illness is defined as, ‘A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual which
is associated with present distress or disability or with a significant increased risk of suffering’ (DSM-IV).
• Evolution of mental health services/psychiatry discussed in the topics: Soul friends, Exorcism, Witches’ Hammer, Era of Moral
Treatment and Decade of the Brain.
• Development and evolution of mental health nursing is classified into the following phases:
„ Phase 1: The Emergence of Psychiatric Mental Health Nursing (1773–1881)

„ Phase 2: Development of the Work Role of Psychiatric nurses (1882–1914)

„ Phase 3: Development of Undergraduate Psychiatric Nursing Education (1915–1935)

„ Phase 4: Development of Graduate Psychiatric Nursing Education (1936–1945)

„ Phase 5: Development of Consultation and Research in Psychiatric Nursing Practice (1946–1990)

• Mental health team members include Psychiatrist, Psychiatric Nurse, Clinical Psychologist, Psychiatric Social Worker, Occupational
Therapist, Counselor and Pharmacist. Psychiatric Paraprofessionals or Technical Staff such as Psychiatric Nursing aid, ECT technician,
Dietician, Clergy men/Chaplain and Speech Therapist.
• The scope of psychiatric nursing practice can be discussed at three levels such as basic role, expanded roles and extended roles.
Basic roles are patient care, education, supervision, ward management, interpersonal relationship, communication and role in other
therapies. Expanded roles are registered psychiatric nurse, nurse practitioner, clinical nurse specialist, nurse clinician, nurse researcher,
nurse counselor and case manager. Extended roles are community mental health nurse, psychiatric home care nurse, forensic
psychiatric nurse, psychiatric consultation—liaison nurse, geropsychiatric nurse and parish nurse.
Contd…
14 Textbook of Psychiatric Nursing for BSc Nursing Students

• Trends in mental health are increased mental health problems, provision for quality and comprehensive services, multidisciplinary
team approach, providing continuity of care and care has to be provided in alternative settings.
• Issues in mental health are discussed in the headings: Economic issues, changes in illness orientation, changes in care delivery,
information technology, consumer empowerment, deinstitutionalization, physician shortage and gaps in service, demographic changes
and change in needs of the patient.
• Functions of psychiatric nurse in various settings were discussed in the headings: Psychiatric inpatient ward, psychiatric outpatient
department, ECT room nurse, psychotherapy unit, day care centers, family therapy units, child and adolescents’ psychiatry units, home
setting, community mental health center, hospice care centers, emergency department, medical inpatient wards, industrial medical
centers and forensic psychiatry units.
• Factors affecting the level of practice discussed as four major factors such as laws, qualifications, practice setting and personal initiative.
• Abnormality is the deviation from the norm or standard or rules and regulations. When the abnormal behavior persists for longer
duration, it is termed maladaptive behavior. Several models have explained the concept of normal and abnormal behavior that are
medical model, statistical model, utopian model, subjective model, social model, process model, behavioral model and continuum
model.

ASSESS YOURSELF

Long Answer Questions 4. National Society for Mental Hygiene was founded in:
1. Explain the scope of psychiatric nursing practice. a. 1908 b. 1909
c. 2002 d. 2005
2. Describe the characteristics of a mentally healthy
person. 5. Which of the following is emotional well-being
component of mental health according to ‘Keyes’?
Short Answer Questions a. Social integration b. Social coherence
c. Social contribution d. Being satisfied
1. What are the three levels of the scope of psychiatric
nursing practice? 6. _________ is called ‘decade of brain’.
2. Name the members of a mental health care team. a. 1980s b. 1990s
c. 2000s d. 2010s
Short Notes 7. Who wrote the first American Textbook of Psychiatry?
Write short notes on: a. Philippe Pinel b. Dorothea Lynde Dix
1. Functions of psychiatric nurse c. Sigmund Freud d. Benjamin Rush
2. Mental health team 8. In which year, Indian Nursing Council incorporated
3. Concept of normal and abnormal behavior Psychiatric Nursing as compulsory subject in BSc
4. Evolution of mental health nursing Nursing?
5. Components of mental health a. 1954 b. 1962
c. 1965 d. 1975
6. Continuum of mental health
9. Who work for the reintegration of patients into
Multiple Choice Questions community?
1. Development of the work role of Psychiatric nurses a. Psychiatrist
b. Psychiatric nurse
happened in ________.
c. Psychiatric social worker
a. 1773–1881 b. 1882–1914 d. Occupational therapist
c. 1915–1935 d. 1936–1945
10. Who conducts the recreational and activity programs
2. Mental illness interferes with the ability for optimal to the patient?
functioning explained in ______ model. a. Psychiatrist
a. Subjective b. Utopian b. Psychiatric nurse
c. Social d. Process c. Psychiatric social worker
3. Normal mental health falls within two Standard d. Occupational therapist
Deviations (SDs) of the normal distribution curve
Answer Key
explained in ______ model.
1. b 2. a 3. d 4. c 5. d
a. Subjective b. Utopian
c. Continuum d. Statistical 6. b 7. d 8. b 9. b 10. d
 CHAPTER
Principles and Concepts of
Mental Health Nursing 2
LEARNING OBJECTIVE

After studying this chapter, the student will be able to understand the basic concepts and principles of mental health nursing to take
care of the mentally ill patients.

CHAPTER OUTLINE
• Definitions • Biopsychosocial Etiology of Mental Illness
• Terminology • Psychopathology of Mental Disorders: Review of Structure
• Classification of Mental Disorders of Brain, Functions of Brain, Limbic System and Abnormal
• Review of Personality Development Neurotransmission
• Perspectives in Personality Theory • Principles of Psychiatric Nursing
• Theories of Personality Development • Standards of Psychiatric Nursing
• Defense Mechanisms • Conceptual Models in Psychiatric Nursing

KEY TERMS
Mental health nursing, Psychiatric nurse, Personality, Psychoanalytic theory, Psychosocial theory, Social learning theory, Personality
traits, Defense mechanism, Cerebral hemisphere, Limbic system, Cerebellum, Brain stem, Pineal gland, Frontal lobe syndrome,
Basal ganglia, Amygdala, Thalamus, Cingulate gyrus, Hippocampus, Medulla oblongata, Pons, Mid brain, Autonomic nervous
system, Neurons, Neurotransmitters, Action potential, Neuroplasticity, Existential model, Psychoanalytical model, Behavioral model,
Interpersonal model.

DEFINITIONS Mental health nursing is focused on prevention, treatment and

nursing care of individuals who suffer from mental illness and
Mental Health Nursing its effects. Despite continuing improvements in health care
Mental health nursing is defined as a branch of nursing which and living conditions in many countries of the world, extended
deals with the study of measures in order to: life expectancy as well as improved economic growth have
• Prevent mental illnesses brought an increase in the number of individuals who suffer
• Promote mental health from mental illness.
• Restore the patient with mental illnesses. —World Health Organization (WHO, 1998)
16 Textbook of Psychiatric Nursing for BSc Nursing Students

Psychiatric Nurse that tends to fluctuate during the course of day. It is

characterized by disorientation to time or place, reduced
Psychiatric nurse is an expert in performing mental status
ability to focus, sustain or shift attention, incoherent
assessment, crisis intervention, administering psychotropics,
speech and continual aimless physical activity.
therapies and patient assistance. Psychiatric nurses work with
• Dementia: A global impairment of intellectual (cognitive)
patients to help them in order to manage their psychiatric
functions (e.g., thinking, remembering, reasoning) that is
illness and live productive and fulfilling lives.
—American Psychiatric Nurses Association (APNA) usually progressive and of sufficient severity to interfere
with a person’s social and occupational functioning.
TERMINOLOGY • Depression: A mood disorder that is characterized by
persistent and pervasive sadness or low mood, changes
Terminology Related to States of Mind in appetite, sleep, weight, activity, libido and energy that
may or may not be accompanied by suicidal thoughts.
• Mood: The pervasive feeling tone which is sustained
• Dissociative amnesia: The inability to recall important
or lasts for some length of time and colors the total
personal information that is generally of a traumatic or
experience of the person.
stressful nature.
• Affect: The outward bodily expression of emotions that
• Dissociative fugue: A sudden or unexpected travel away
range from joy to sorrow or anger.
from one’s home or work place with an inability to recall
• Insight: The ability to perceive oneself realistically and
to understand oneself and the motives behind one’s the past.
behavior. • Dysthymia: Chronic low-level depression that lasts for
• Judgment: The ability to make logical decisions. more than two years and that may lead to more severe
depression, if left untreated.
Terminology Related to Mental Disorders • Factitious disorder: The intentional way of producing
the symptoms of illness so that one can assume a sick role.
• Alzheimer’s disease: A neurodegenerative disease that
• Hypochondriasis: Individual may have a fear or belief
is characterized by progressive, irreversible and lethal
that one has a serious illness despite medical reassurance.
structural damage to the brain that results from the
• Hypomania: A mood of elation with higher-than-usual
presence of β-amyloid proteins and that leads to a loss
activity, but not as expansive as full mania.
of cognitive functions with the symptoms of progressive
• Phobias: A group of disorders that are primarily
dementia.
characterized by the avoidance of a specific situation or
• Anorexia nervosa: An eating disorder in which one
escaping, if the situation is unexpectedly encountered.
is preoccupied with food or eating behavior which
• Psychosis: A form of serious mental illness in which the
suppresses the desire to take food. It can be achieved by
patient is unable to recognize reality, displays bizarre
compromising nutritional intake and not necessarily by a
behavior and is unable to deal with life’s demands.
loss of appetite.
• Amnestic disorders: Impairment of memory that occurs
Terminology Related to Thinking
without delirium and dementia.
• Autism: A pervasive developmental disorder that is • Autistic thinking: Disturbances in thought that
characterized by marked impairment of social and result from the intrusion of a private fantasy world that
cognitive abilities. is internally stimulated. This type of thinking results
• Body dysmorphic disorder: A somatization disorder in in abnormal responses to people and events in the real
which one becomes obsessed with an imagined defect in world.
one’s body or body parts. • Cognition: The process of being aware, thinking,
• Bulimia nervosa (Earlier known as “bulimarexia”): An knowing and reasoning.
obsession with thinness, dieting and a compulsive cycle of • Critical thinking: An intellectual and disciplined process
bingeing and purging. of actively and skillfully conceptualizing, applying,
• Conversion disorder: A disorder in which one perceives analyzing, synthesizing and evaluating information
deficits that affect sensory or motor functions that are through observation, experience, reasoning and
unrelated to a medical condition. communication as a guide for belief or action.
• Delirium: A disturbance of consciousness and a change • Intuition: Knowing or sensing without the use of rational
in cognition that develops over a short period of time processes such as reasoning.
CHAPTER 2 Principles and Concepts of Mental Health Nursing 17

Terminology Related to Substance Abuse • Cope: The ability to adapt with the situation and promote
well-being by using a variety of tools, including adaptive
• Abstinence: A voluntary act of refraining from behavior
or maladaptive maneuvers. Internal coping involves
or from the use of a substance (e.g., alcohol, drugs, food
changes in thinking and use of psychic defense; external
and gambling, spending, sex) that has caused problems
coping occurs through the actions.
in the psychosocial, physical, cognitive/perceptual or
• General adaptation syndrome (GAS): This process
spiritual/belief dimensions of an individual’s life.
was given by Hans Selye which shows the physiological
• Blackout: The loss of memory about the events that occur
changes of our body responses during stress in three
after the onset of the causative agent or condition (e.g.,
stages. The GAS occurs in three stages, i.e., alarm,
memory loss after the ingestion of alcohol or drugs).
adaptation and exhaustion.
• Alcoholic blackout: An episode of forgetting all or part of • Loss: The process of losing or being deprived of
what occurred during or after the intake of alcohol. someone or something that is characterized by a series
• Codependence: A relationship in which the actions of of overlapping stages that includes the psychological and
a family member or a close friend or a colleague of an behavioral manifestation.
alcohol or drug dependent person tend to perpetuate the • Maladaptation: A response that may result in unfavorable
person’s dependence and thereby retard the process of circumstances, situations or conditions for an individual
recovery. who is unable or unwilling to meet the standards that are
• Gateway drugs: Substances that have been implicated accepted by the medical or social community.
as forerunners to polysubstance use or drug dependence • Mourning: The social and psychological expression of
(e.g., tobacco, alcohol, marijuana). grief.
• Detoxification: It is the physiological or medicinal
removal of toxic substances from a living organism. It is Terminology Related to Mental Health Nursing
recommended for patients with substance use disorders.
• Countertransference: It is the redirection of a
This treatment assists an individual in getting rid of the
psychotherapist’s (Nurses) dependent feelings toward the
physical effects of substances.
patient.
• Intoxication: The physiologic state of being poisoned by
• Forensic nursing: A branch of nursing that focuses on
a drug or other toxic substance. the clinical observation and treatment of individuals who
are victims of crimes or who have mental health problems
Terminology Related to Crisis, Loss and Grief
or who are charged with or convicted of crimes.
• Bereavement: The objective state of grieving that occurs • Clinical pathway: A standardized format that is used to
after loss, especially of a loved one. provide and monitor patient care and progress by way
• Grief: The dynamic natural response to loss. of case management and interdisciplinary health care
• Anticipatory grief: Grief that is experienced before the delivery system. It is also known as a critical pathway, care
death or loss occurs (e.g., when loved one has a terminal path or care map.
illness). • Empathy: Projecting sensitivity and an understanding of
• Complicated grief: Grief that is expressed with a other’s feelings.
significantly greater or lesser intensity over a longer • Johari window: A model of communication that helps
or shorter period of time than is culturally expected. the nurse to look at self-awareness through interpersonal
This may manifest as serious physical or emotional learning styles.
disabilities. • Process recording: A written account of an interaction
• Crisis: An event that threatens one’s well-being (e.g., between a nurse and a patient that helps the nurse to
death of a family member in an earthquake) and that examine the relationship.
exceeds the person’s ability to cope with the threat. • Transference: The feelings or responses that a patient has
• Crisis intervention: Therapeutic techniques for helping toward the nurse that are associated with someone who is
individuals who are experiencing a crisis. significant in the patient’s life.
• Distress: A subjective response to internal or external
stimuli that are threatening or perceived as threatening Terminology Related to Psychiatric
to the self. Symptomatology
• Eustress: A nonspecific stress response associated with • Ambivalence: Simultaneously holding two different
desirable events such as marriage, the birth of a child, or attitudes, emotions, thoughts, or feelings about a person,
a job promotion. object or situation.
18 Textbook of Psychiatric Nursing for BSc Nursing Students

• Anhedonia: The loss of interest and inability to experience • Dysarthria: Difficulty with articulating words. It is more
pleasure in activities that were previously enjoyed by an commonly found in patients with vascular dementia,
individual. This state is seen in depressive disorder. stroke and major head injuries.
• Aggression: Acting out behaviors that can lead to harm • Dyspareunia: Painful sexual intercourse that does not
or injury to the self and others. result from a general medical condition.
• Agnosia: The loss of comprehension of auditory, visual or • Delusion: A false, unshakable belief which is not
other sensations although the senses are intact. amenable to reasoning, and is not in keeping with the
• Agraphia: The loss of ability to write. patient’s sociocultural and educational background.
• Akathisia: A syndrome that is caused by dopamine- • Shared delusion: A phenomenon in which a person takes
blocking drugs and is characterized by both motor on the delusion of another person and often manifests
restlessness and a subjective feeling of inner restlessness. similar characteristics of delusion. It is also known as
• Alexia: Inability to read caused by a lesion or dysfunction ‘Folie a deux’.
of the central nervous system. • Depersonalization: Feelings of unreality or personal
• Alexithymia: A condition that causes individuals to have dissociation. Individuals who are experiencing deper-
difficulty in identifying and describing their emotions. sonalization have difficulty in distinguishing themselves
Individuals with eating disorders often have a restricted from others.
emotional life and thus, exhibit this condition. • Derealization: An alteration in the perception of external
• Apathy: Indifference, disinterest or dull attitude. This world so that the feeling of the reality of external world is
manifests as a negative symptom of schizophrenia. (as if) temporarily changed or lost.
• Aphasia: The inability to speak or write (expressive
• Disorientation: A loss of familiarity with place, time,
aphasia) or the inability to comprehend what is being
person and situation.
said or written; it may progress to babbling or mutism
• Echolalia: The involuntary repetition of words spoken by
(receptive aphasia).
another person.
• Apraxia: The loss of abilities to carry out purposeful or
• Echopraxia: The spontaneous imitation of movements
complex movements and to use objects properly.
made by another person.
• Avolition: A lack of motivation or will. It is noted in
• Encopresis: The repeated passage of feces in inappro-
patients with schizophrenia or other mental illnesses.
priate places whether involuntary or intentional (most
• Battering: Physical or sexual abuse of a person by
commonly seen in children).
intimate partner or by someone with whom he/she has
• Enuresis: The repeated voiding of urine into the bed or
been intimate.
clothing, whether involuntary or intentional.
• Blunted affect: The restricted expression of emotions.
• Cataplexy: A sudden loss of muscle tone and voluntary • Euphoria: Mild elevation of mood in which an individual
muscle movement. experiences a sense of well-being and happiness, not
• Circumstantiality: A type of speech that is characterized keeping with ongoing events. This state is seen in
by unnecessary details and indirectness before the point hypomania.
or intent is reached. It may be noted in patients with • Euthymia: Normal range of mood with absence of
schizophrenia or other mental illnesses. depressed or elevated mood.
• Compulsion: An unremitting and repetitive impulse to • Ecstasy: Very severe elevation of mood in which an
perform a behavior or a mental act. The object of the individual experiences an intense sense of rapture or
compulsion is to prevent or reduce anxiety or distress. blissfulness.
Compulsive acts often occur to reduce the distress that • Flat affect: The lack of outward expression of emotions.
accompanies an obsession. • Flight of ideas: The shifting from one idea to another
• Confabulation: The fabricating of stories to fill in memory without completing the previous idea or an abrupt change
gaps. It may be an attempt to preserve self-esteem, and of topics expressed in a rapid flow of speech.
not to be mistaken for lying. It is often seen in patients • Grandiosity: A characteristic that is noted in patients
with Alzheimer’s disease or other types of dementia. with mania in which they experience a sense of inflated
• Double bind communication: A situation in which self-esteem or exaggerated confidence. It is also known as
contradictory messages are given to one person by self-aggrandizement.
another; and a response or a choice between two opposing • Hallucination: A perceptual disturbance of one or more
alternatives is demanded. of the five senses in the absence of external stimuli.
CHAPTER 2 Principles and Concepts of Mental Health Nursing 19

• Hyper-religiosity: A preoccupation or obsession with • Psychomotor agitation: Agitated motor activities such as
religion, God or another deity. restlessness, pacing and irritability.
• Hypervigilance: An excessive watchfulness and scanning • Psychomotor retardation: The slowing of physiologic
of the environment that is generally manifested in patients processes that result in slow movement, speech and
who are experiencing delusions or hallucinations and that reaction time. It is often noted in patients with depression.
may preclude acts of aggression or violence. • Residual symptoms: Minor disturbances that may
• Inappropriate affect: An affect that is not congruent with remain after an episode of schizophrenia but do not
the emotion being felt (e.g., laughing when sad). include delusions, hallucinations, incoherence or gross
• Ideas of reference: Incorrect interpretations of external disorganization.
incidents and events that have a particular or special • Secondary gain: Any benefit that results from illness,
meaning specific to the person. such as personal attention, sympathy from others, or
• Labile affect: A disorder where the patient has excessive escape from unwanted responsibilities.
display of emotion, or expresses emotions that are not • Somatization: The conversion of mental state or
congruent with the situation. Labile affect is also called experiences into bodily symptoms that are associated
pseudobulbar affect or emotional incontinence. with anxiety.
• Looseness of association: A thought disturbance in • Sundowner’s syndrome: The confusion and irritation
which the speaker rapidly shifts his/her expression of that are commonly seen in patients with dementia at the
ideas from one subject to another in an unrelated and end of the day, as a result of tiredness and inability to
fragmented manner. This is most commonly noted in mentally process any more information as they struggled
patients with schizophrenia. whole day long to understand the environmental clues.
• Negative symptoms: Symptoms that include flat affect, • Tangentiality: Responding in a manner that is irrelevant
poverty of speech, poor grooming, withdrawal and to the topic.
avolition that are seen in patients with schizophrenia. • Thought blocking: An abrupt interruption in the flow of
• Neologisms: Invented words to which meanings are thoughts or ideas that results from a disturbance in the
attached; coining of new words for which patients have speed of association.
personal meaning.
• Nihilism: The belief that existence is senseless and useless. Terminology Related to Treatment Modalities
Patients with schizophrenia may experience nihilistic
• Cognitive behavioral therapy: Therapy that is focused
delusions in which they believe the world is nonexistent.
on changing irrational or self-defeating thoughts and
• Obsessions: Persistent ideas, thoughts, impulses or
behaviors into realistic ones.
images that involve death, sexual matters, religion, or any
• Deinstitutionalization: The discharge of a patient from
themes which lead to the person’s efforts to resist them.
the psychiatric institution or hospital into the community.
It may result in marked anxiety or distress.
• Milieu therapy: A type of therapy that recreates a
• Panic: A circumscribed period of extreme anxiety.
community atmosphere in an inpatient treatment setting
During panic, one’s perceptions are distorted; and the
to facilitate interaction among patient peers to identify
ability to integrate and separate environmental stimuli is
and solve issues that occur when relating to others.
impaired.
• Perseveration: The excessive and persistent repetition of
Terminology Related to Drug Side Effects
the same ideas in response to different questions.
• Positive symptoms: Symptoms that include hallucinations, • Acute dystonia: Abnormal muscle tonicity and spasm of
delusions, increased speech production with loose the face, head, neck and back. It is a side effect of some
associations, bizarre behavior. These are often seen in antipsychotic medications.
patients with schizophrenia. • Extrapyramidal syndrome (EPS): The collective term
• Poverty of thought: A psychopathologic thought that is used to describe the troubling motor side effects
disturbance seen in patients with schizophrenia. Patient’s of dopamine blocking medications. It includes acute
inability to think logically and sequentially is reflected dystonia, akathisia, Parkinsonism and tardive dyskinesia.
in the poverty of content of his or her speech, which is • Hypertensive crisis: Any severe elevation of blood
vague, repetitious and disconnected. pressure that is a medical emergency. It may occur as a
• Pressured speech: Rapid speech with an urgent quality. result of food or drug admixtures with some psychotropic
It is often noted in patients with mania. medications.
20 Textbook of Psychiatric Nursing for BSc Nursing Students

• Neuroleptic malignant syndrome (NMS): A rare but ‘undesirable’ words. The letters ‘O’ and ‘I’ are omitted to
potentially lethal toxic reaction to dopamine-blocking prevent confusion with the numbers ‘0’ and ‘1’. Chapters are
drugs that presents with a constellation of symptoms indicated by the first character. For example, 1A00 is a code in
including fever, autonomic instability, increased muscular Chapter 1, and BA00 is a code in Chapter 11.
rigidity and altered mental status.
• Serotonin syndrome: An adverse drug reaction that 1.2.4.2 Extension codes
results in excessive production of serotonin in the brain. ICD-11 allows for adding specific detail to coded entities by
It may be life-threatening. using the following mechanisms:
• The extension codes comprise groups of codes, e.g.,
CLASSIFICATION OF MENTAL DISORDERS anatomy, agent, histopathology and other aspects that
may be used to add detail to a stem code. Extension codes
Classification of mental disorders has been illustrated in are not to be used alone but must be added to a stem code.
Flowchart 2.1. Not all extension codes can be used with every stem code.
• ‘Code also’ instructions provide additional etiological
ICD-11 Classification of Mental Disorders
information which is mandatory to code in conjunction
1.2.4.1 Coding Scheme with certain categories, because that additional
• The coding scheme always has a letter in the second information is relevant for primary tabulation. The ‘code
position to differentiate from the codes of ICD-10. also’ instruction marks the categories that must be used
• In ICD-11, the first character of the code always relates in conjunction with the indicated condition. In some
to the chapter number. It may be a number or a letter. instances, they may be a reason for treatment in their own
The code range of a single chapter always has the same right, where etiology is unknown.
character in the first position. • ICD-11 has an explicit way of marking codes that are
• In order to describe a causal relationship between post coordinated to describe one condition, called
conditions in a code title, the preferred term is ‘due to’. cluster coding. This is a notable new feature in ICD-11
• In order to indicate the concurrence of two conditions in that creates an ability to link core diagnostic concepts
a code title, the preferred term is ‘associated with’. (i.e., stem code concepts) when desired, and/or to add
The codes of ICD-11 are alphanumeric and cover the range clinical concepts captured in extension codes to primary
from 1A00.00 to ZZ9Z.ZZ. Codes starting with ‘X’ indicate stem code concepts. Either way, it should be emphasized
an extension code (see Extension codes). The inclusion of a that the clustering ability inherent to ICD-11 is one of the
forced number at the 3rd character position prevents spelling significant changes relative to ICD-10.

Flowchart 2.1: Classification of mental disorders

CHAPTER 2 Principles and Concepts of Mental Health Nursing 21

DSM-5 Classification of Mental Disorders • Feeding and eating disorders

• Elimination disorders
Diagnostic Statistical Manual (DSM) Classification of Mental
• Sleep-wake disorders
Disorders has been given by American Psychiatric Association
• Sexual dysfunctions
(APA). DSM-I was released in 1952 and various revisions have
• Gender dysphoria
been done. DSM-5 was released in 2013 which replaced the
• Disruptive, impulsive and conduct disorders
previous version of DSM-IV. This is the standard classification
• Substance-related and addictive disorders
used by mental health professionals in the United States.
• Neurocognitive disorders
DSM-5 diagnostic chapters are as follows:
• Personality disorders
• Schizophrenia spectrum and other psychotic disorders
• Paraphilic disorders
• Bipolar and related disorders
• Other mental disorders
• Depressive disorders
• Anxiety disorders
ICD-11 and DSM-5 Classification of Mental
• Obsessive-compulsive and related disorders
Disorders
• Trauma and stressor-related disorders
• Dissociative disorders Table 2.1 shows ICD-11 and DSM-5 classification of mental
• Somatic symptom and related disorders disorders.

Table 2.1: ICD-11 and DSM-5 classification of mental disorders

ICD-11 DSM-5 Classification of mental disorders

Neurodevelopmental disorders
Intellectual disability (intellectual developmental disorder)
6A00.0 — Mild intellectual disability
6A00.1 — Moderate intellectual disability
6A00.2 — Severe intellectual disability
6A00.3 — Profound intellectual disability
6A00.4 Provisional intellectual disability
— 315 Global developmental delay
6A00.Z 319 Unspecified intellectual disability (intellectual developmental disorder)
Communication disorders
6A01 315.39 Language disorder
6A01.0 315.39 Speech sound disorder
— 315.35 Childhood-onset fluency disorder (stuttering)
— 307.0 Adult-onset fluency disorder
6A01.22 315.39 Social (pragmatic) communication disorder
6A01.Z 307.9 Unspecified communication disorder
Autism spectrum disorder
6A02 299.00 Autism spectrum disorder
— 293.89 Autism spectrum disorder with catatonia
Attention-deficit/hyperactivity disorder
6A05.0 314.00 Predominantly inattentive presentation
6A05.1 314.01 Predominantly hyperactive/impulsive presentation
6A05.2 314.01 Combined presentation
6A05.Y 314.01 Other specified attention-deficit/hyperactivity disorder
6A05.Z 314.01 Unspecified attention-deficit/hyperactivity disorder
Contd…
22 Textbook of Psychiatric Nursing for BSc Nursing Students

ICD-11 DSM-5 Classification of mental disorders

Specific learning disorder
6A03.0 315.00 With impairment in reading
6A03.1 315.2 With impairment in written expression
6A03.2 315.1 With impairment in mathematics
Motor disorders
— 315.4 Developmental coordination disorder
6A06 307.3 Stereotypic movement disorder
Tic disorders
8A05.00 307.23 Tourette’s disorder
— 307.22 Persistent (chronic) motor or vocal tic disorder
— 307.21 Provisional tic disorder
— 307.20 Other specified tic disorder
— 307.19 Unspecified tic disorder
Other neurodevelopmental disorders
6A0Y 315.8 Other specified neurodevelopmental disorder
6A0Z 315.9 Unspecified neurodevelopmental disorder
Schizophrenia spectrum and other psychotic disorders
6A20 295.90 Schizophrenia
6A21 — Schizoaffective disorder
6A22 301.22 Schizotypal (personality) disorder
6A23 — Acute and transient psychotic disorder
6A24 297.1 Delusional disorder
— 298.8 Brief psychotic disorder
— 295.40 Schizophreniform disorder
— 295.70 Schizoaffective disorder (bipolar type)
— 295.70 Schizoaffective disorder (depressive type)
— 293.81 Psychotic disorder due to another medical condition (with delusions)
— 293.82 Psychotic disorder due to another medical condition (with hallucinations)
6A40 293.89 Catatonia associated with another mental disorder (catatonia specifier)
— 293.89 Catatonic disorder due to another medical condition
6A41 — Catatonia induced by psychoactive substances, including medications
6A4Z 293.89 Unspecified catatonia
— 298.8 Other specified schizophrenia spectrum and other psychotic disorder
— 298.9 Unspecified schizophrenia spectrum and other psychotic disorder
Bipolar and related disorders
Bipolar I disorder
— 296.41 Current or most recent episode manic (mild)
— 296.42 Current or most recent episode manic (moderate)
— 296.43 Current or most recent episode manic (severe)
6A60.5 296.44 Current or most recent episode manic (with psychotic features)
6A60.B 296.45 Current or most recent episode manic (in partial remission)
6A60.F 296.46 Current or most recent episode manic (in full remission)
6A60.E 296.40 Current or most recent episode manic (unspecified)
Contd…
CHAPTER 2 Principles and Concepts of Mental Health Nursing 23

ICD-11 DSM-5 Classification of mental disorders

Bipolar II disorder
6A61 296.89 Bipolar II disorder
6A62 301.13 Cyclothymic disorder
6A6Y 296.89 Other specified bipolar and related disorder
6A6Z 296.80 Unspecified bipolar and related disorder
Depressive disorders
— 296.99 Disruptive mood dysregulation disorder
6A70.0 296.21 Single episode depression (mild)
— 296.22 Single episode depression (moderate)
6A71.1 — Single episode depression (moderate without psychotic features)
6A71.2 — Single episode depression (moderate with psychotic features)
6A71.3 — Single episode depression (severe without psychotic features)
6A71.4 — Single episode depression (severe with psychotic features)
— 296.23 Single episode depression (severe)
— 296.24 Single episode depression (with psychotic features)
6A70.6 296.25 Single episode depression (in partial remission)
6A70.7 296.26 Single episode depression (in full remission)
6A70.Z 296.20 Single episode depression (unspecified)
6A71.0 296.31 Recurrent episode depression (mild)
— 296.32 Recurrent episode depression (moderate)
6A71.1 — Recurrent episode depression (moderate without psychotic features)
6A71.2 — Recurrent episode depression (moderate with psychotic features)
— 296.33 Recurrent episode depression (severe)
6A71.3 — Recurrent episode depression (severe without psychotic features)
6A71.4 — Recurrent episode depression (severe with psychotic features)
— 296.34 Recurrent episode depression (with psychotic features)
6A71.6 296.35 Recurrent episode depression (in partial remission)
6A71.7 296.36 Recurrent episode depression (in full remission)
6A71.Y 296.30 Recurrent episode depression (unspecified)
6A7Z 300.4 Persistent depressive disorder (dysthymia)
— 625.4 Premenstrual dysphoric disorder
— 293.83 Depressive disorder due to another medical condition
Anxiety disorders
6B00 300.02 Generalized anxiety disorder
6B01 300.01 Panic disorder
6B02 300.22 Agoraphobia
6B03 300.29 Specific phobia
6B04 300.23 Social anxiety disorder (social phobia)
6B05 309.21 Separation anxiety disorder
6B06 312.23 Selective mutism
— 293.84 Anxiety disorder due to another medical condition
6B0Y 300.09 Other specified anxiety disorder
6B0Z 300.00 Unspecified anxiety disorder
Contd…
24 Textbook of Psychiatric Nursing for BSc Nursing Students

ICD-11 DSM-5 Classification of mental disorders

Obsessive-compulsive and its related disorder
6B20 300.3 Obsessive-compulsive disorder
— 300.7 Body dysmorphic disorder
6B24 300.3 Hoarding disorder
6B25.0 312.39 Trichotillomania (hair-pulling disorder)
6B25.1 698.4 Excoriation (skin-picking) disorder
— 294.8 Obsessive-compulsive and related disorder due to another medical condition
— 300.3 Other specified obsessive-compulsive and related disorder
6B20.Z 300.3 Unspecified obsessive-compulsive and related disorder
Trauma- and stressor-related disorders
6B44 313.89 Reactive attachment disorder
6B45 313.89 Disinhibited social engagement disorder
6B40 309.81 Post-traumatic stress disorder
— 308.3 Acute stress disorder
6B43 — Adjustment disorders
— 309.0 Adjustment disorders (with depressed mood)
— 309.24 Adjustment disorders (with anxiety)
— 309.28 Adjustment disorders (with mixed anxiety and depressed mood)
— 309.3 Adjustment disorders (with disturbance of conduct)
— 309.4 Adjustment disorders (with mixed disturbance of emotions and conduct)
— 309.9 Adjustment disorders (unspecified)
6B4Y 309.89 Other specified trauma- and stressor-related disorder
6B4Z 309.9 Unspecified trauma- and stressor-related disorder
Dissociative disorders
6B60 — Dissociative neurological symptom disorder
6B61 300.12 Dissociative amnesia
— 300.13 Dissociative amnesia (with dissociative fugue)
6B62 — Trance disorder
6B63 — Possession trance disorder
6B64 300.14 Dissociative identity disorder
6B65 — Partial dissociative identity disorder
6B66 300.6 Depersonalization-derealization disorder
6B6Y 300.15 Other specified dissociative disorder
6B6Z 300.15 Unspecified dissociative disorder
Somatic symptom and related disorders
— 300.82 Somatic symptom disorder
— 300.7 Illness anxiety disorder
— 300.11 Conversion disorder (functional neurological symptom disorder)
— 316 Psychological factors affecting other medical conditions
— 300.19 Factitious disorder
— 300.89 Other specified somatic symptom and related disorder
— 300.82 Unspecified somatic symptom and related disorder
Contd…
CHAPTER 2 Principles and Concepts of Mental Health Nursing 25

ICD-11 DSM-5 Classification of mental disorders

Feeding and eating disorders
6B80 307.1 Anorexia nervosa
6B80.10 — Restricting type
6B80.11 — Binge eating/purging type
6B81 307.51 Bulimia nervosa
6B82 307.51 Binge eating disorder
6B83 307.59 Avoidant/Restrictive food intake disorder
6B84 307.52 Pica
6B85 307.53 Rumination disorder
6B8Y 307.59 Other specified feeding or eating disorder
6B8Z 307.50 Unspecified feeding or eating disorder
Elimination disorders
6C00 307.6 Enuresis
6C01 307.7 Encopresis
— 788.39 Other specified elimination disorder (with urinary symptoms)
— 787.60 Other specified elimination disorder (with fecal symptoms)
6C00.Z 788.30 Unspecified elimination disorder (with urinary symptoms)
6C01.Z 787.60 Unspecified elimination disorder (with fecal symptoms)
Sexual dysfunctions
HA00 302.71 Hypoactive sexual desire disorder
HA01.0 302.72 Female sexual interest/arousal disorder
HA01.1 302.72 Erectile disorder
HA02 302.73 Female orgasmic disorder
HA03.0 302.75 Premature (early) ejaculation
HA03.1 302.74 Delayed ejaculation
— 302.76 Genito-pelvic pain/penetration disorder
HA03.Y 302.79 Other specified sexual dysfunction
Gender dysphoria
— 302.6 Gender dysphoria in children
— 302.85 Gender dysphoria in adolescents and adults
— 302.6 Other specified gender dysphoria
— 302.6 Unspecified gender dysphoria
Disruptive, impulse-control and conduct disorders
6C90 313.81 Oppositional defiant disorder
6C73 312.34 Intermittent explosive disorder
6C91.0 312.81 Conduct disorder (childhood-onset type)
6C91.1 312.82 Conduct disorder (adolescent-onset type)
6C91.Z 312.83 Conduct disorder (unspecified onset)
— 301.7 Antisocial personality disorder
6C70 312.33 Pyromania
6C71 312.32 Kleptomania
6C7Y 312.89 Other specified disruptive, impulse-control, and conduct disorder
6C7Z 312.9 Unspecified disruptive, impulse-control, and conduct disorder
Contd…
26 Textbook of Psychiatric Nursing for BSc Nursing Students

ICD-11 DSM-5 Classification of mental disorders

Personality disorders
6D10 — Personality disorders
6D10.0 — Personality disorders, mild
6D10.1 — Personality disorders, moderate
6D10.2 — Personality disorders, severe
6D10.Z — Personality disorders, unspecified severity
6D11 — Predominant personality traits
6D11.0 — Negative affectivity in personality disorder
6D11.1 — Detachment in personality disorder
6D11.2 — Dissociality in personality disorder
6D11.3 — Disinhibition in personality disorder
6D11.4 — Anankastic personality disorder
6D11.5 — Borderline pattern personality disorder
Cluster A personality disorders
— 301.0 Paranoid personality disorder
— 301.20 Schizoid personality disorder
— 301.22 Schizotypal personality disorder
Cluster B personality disorders
— 301.7 Antisocial personality disorder
— 301.83 Borderline personality disorder
— 301.50 Histrionic personality disorder
— 301.81 Narcissistic personality disorder
Cluster C personality disorders
— 301.4 Obsessive-compulsive personality disorder
— 301.82 Avoidant personality disorder
— 301.6 Dependent personality disorder
Other personality disorders
310.1 Personality change due to another medical condition
301.89 Other specified personality disorder
Medication-induced movement disorders and other adverse effects of medication
— 332.1 Neuroleptic-induced parkinsonism
— 333.92 Neuroleptic malignant syndrome
— 333.72 Medication-induced acute dystonia
— 333.99 Medication-induced acute akathisia
— 333.85 Tardive dyskinesia
— 333.72 Tardive dystonia
— 333.99 Tardive akathisia
— 333.1 Medication-induced postural tremor
— 333.99 Other medication-induced movement disorder
Gender dysphoria (DSM-5) and gender incongruence (ICD-11)
HA60 302.85 Gender dysphoria in adolescents and adults
HA61 302.6 Gender dysphoria in children
Contd…
CHAPTER 2 Principles and Concepts of Mental Health Nursing 27

ICD-11 DSM-5 Classification of mental disorders

HA8Y 302.6 Other specified gender dysphoria
HA6Z 302.6 Unspecified gender dysphoria
Paraphilic disorders
6D30 302.4 Exhibitionistic disorder
6D31 302.82 Voyeuristic disorder
6D32 302.2 Pedophilic disorder
6D33 302.84 Sexual sadism disorder
6D34 302.89 Frotteuristic disorder
— 302.83 Sexual masochism disorder
F65.0 302.81 Fetishistic disorder
— 302.3 Transvestic disorder
6D35 and 302.89 Other specified paraphilic disorder
6D36
6D3Z 302.9 Unspecified paraphilic disorder

ICD-11 Classification of Amnestic Disorder • 6D81 Vascular dementia.

6D72 Amnestic Disorder • 6D82 Dementia due to Lewy body disease.
• 6D83 Frontotemporal dementia.
• 6D72.0 Amnestic disorder due to diseases classified
• 6D84 Dementia due to psychoactive substances including
elsewhere.
medications.
• 6D72.1 Amnestic disorder due to psychoactive substances
„ 6D84.0 Dementia due to use of alcohol.
including medications.
„ 6D84.1 Dementia due to use of sedatives, hypnotics
• 6D72.10 Amnestic disorder due to use of alcohol.
or anxiolytics.
• 6D72.11 Amnestic disorder due to use of sedatives,
„ 6D84.2 Dementia due to use of volatile inhalants.
hypnotics or anxiolytics.
„ 6D84.Y Dementia due to other specified psychoactive
• 6D72.12 Amnestic disorder due to other specified
substances.
psychoactive substances including medications.
• 6D85 Dementia due to diseases classified elsewhere.
• 6D72.13 Amnestic disorder due to use of volatile
„ 6D85.0 Dementia due to Parkinson’s disease.
inhalants.
„ 6D85.1 Dementia due to Huntington’s disease.
• 6D72.2 Amnestic disorder due to unknown or unspecified
„ 6D85.2 Dementia due to exposure to heavy metals
etiological factors.
and other toxins.
• 6D72.Y Other specified amnestic disorder.
„ 6D85.3 Dementia due to human immunodeficiency
• 6D72.Z Amnestic disorder, unspecified.
virus.
6D85.4 Dementia due to multiple sclerosis.
ICD-11 Classification of Dementia „

„ 6D85.5 Dementia due to prion disease.

6D80 Dementia „ 6D85.6 Dementia due to normal pressure
• 6D80 Dementia due to Alzheimer’s disease. hydrocephalus.
„ 6D80.0 Dementia due to Alzheimer’s disease with „ 6D85.7 Dementia due to injury to the head.
early onset. „ 6D85.8 Dementia due to pellagra.
„ 6D80.1 Dementia due to Alzheimer’s disease with late „ 6D85.9 Dementia due to Down syndrome.
onset. „ 6D85.Y Dementia due to other specified diseases
„ 6D80.2 Alzheimer’s disease dementia, mixed type, classified elsewhere.
with cerebrovascular disease. • 6D86 Behavioral or psychological disturbances in
„ 6D80.3 Alzheimer’s disease dementia, mixed type, dementia.
with other nonvascular etiologies. „ 6D86.0 Psychotic symptoms in dementia.
„ 6D80.Z Dementia due to Alzheimer’s disease, onset „ 6D86.1 Mood symptoms in dementia.
unknown or unspecified. „ 6D86.2 Anxiety symptoms in dementia.
28 Textbook of Psychiatric Nursing for BSc Nursing Students

„ 6D86.3 Apathy in dementia. Table 2.3 shows DSM-5 classification of major and mild
„ 6D86.4 Agitation or aggression in dementia. neurocognitive disorders (dementia).
„ 6D86.5 Disinhibition in dementia. Table 2.3: DSM-5 classification of major and mild neurocognitive
„ 6D86.6 Wandering in dementia. disorders (dementia)
„ 6D86.Y Other specified behavioral or psychological
disturbances in dementia. Major and mild neurocognitive disorders
„ 6D86.Z Behavioral or psychological disturbances in 294.11 Probable major neurocognitive disorder due to
Alzheimer’s disease with behavioral disturbance
dementia, unspecified.
• 6D8Z Dementia, unknown or unspecified cause. 294.10 Probable major neurocognitive disorder due to
Alzheimer’s disease without behavioral disturbance
• 6E0Y Other specified neurocognitive disorders.
331.9 Possible major neurocognitive disorder due to
• 6E0Z Neurocognitive disorders, unspecified.
Alzheimer’s disease

ICD-11 Classification of Substance Use Disorders 331.83 Mild neurocognitive disorder due to Alzheimer’s
disease
• 6C40 Disorders due to use of alcohol. 294.11 Major or mild frontotemporal neurocognitive
• 6C41 Disorders due to use of cannabis. disorder with behavioral disturbance
• 6C42 Disorders due to use of synthetic cannabinoids. 294.10 Major or mild frontotemporal neurocognitive
• 6C43 Disorders due to use of opioids. disorder without behavioral disturbance
• 6C44 Disorders due to use of sedatives, hypnotics or 331.9 Possible major neurocognitive disorder due to
anxiolytics. frontotemporal lobar degeneration
• 6C46 Disorders due to use of stimulants including 331.83 Mild neurocognitive disorder due to frontotemporal
amphetamines, methamphetamine or methcathinone. lobar degeneration
• 6C47 Disorders due to use of synthetic cathinones. 294.11 Major or mild neurocognitive disorder with Lewy
• 6C48 Disorders due to use of caffeine. Bodies with behavioral disturbance
• 6C49 Disorders due to use of hallucinogens. 294.10 Major or mild neurocognitive disorder with Lewy
• 6C4A Disorders due to use of nicotine. Bodies without behavioral disturbance
• 6C4B Disorders due to use of volatile inhalants. 331.9 Possible major neurocognitive disorder with Lewy
Bodies
• 6C4C Disorders due to use of MDMA or related drugs,
including MDA. 331.83 Mild neurocognitive disorder with Lewy Bodies
• 6C4D Disorders due to use of dissociative drugs including 290.40 Probable major vascular neurocognitive disorder
ketamine and phencyclidine [PCP]. with behavioral disturbance
• 6C4E Disorders due to use of other specified psychoactive 290.40 Probable major vascular neurocognitive disorder
without behavioral disturbance
substances, including medications.
• 6C4F Disorders due to use of multiple specified 331.9 Possible major vascular neurocognitive disorder
psychoactive substances, including medications. 331.83 Mild vascular neurocognitive disorder
• 6C4G Disorders due to use of unknown or unspecified 294.11 Major neurocognitive disorder due to traumatic brain
psychoactive substances. injury with behavioral disturbance
• 6C4H Disorders due to use of non-psychoactive 294.10 Major neurocognitive disorder due to traumatic brain
substances. injury without behavioral disturbance
• 6C4Y Other specified disorders due to substance use. 331.83 Mild neurocognitive disorder due to traumatic brain
injury
• 6C4Z Disorders due to substance use, unspecified.
294.11 Major neurocognitive disorder due to hiv infection
Table 2.2 shows DSM-5 classification of delirium. with behavioral disturbance
Table 2.2: DSM-5 classification of delirium 294.10 Major neurocognitive disorder due to hiv infection
without behavioral disturbance
Delirium 331.83 Mild neurocognitive disorder due to hiv infection
292.81 Medication-induced delirium 294.11 Major neurocognitive disorder due to prion disease
293.0 Delirium due to another medical condition (or) with behavioral disturbance
Delirium due to multiple etiologies 294.10 Major neurocognitive disorder due to prion disease
780.09 Other specified delirium (or) unspecified delirium without behavioral disturbance
Contd…
CHAPTER 2 Principles and Concepts of Mental Health Nursing 29

Major and mild neurocognitive disorders Inhalants

331.83 Major neurocognitive disorder due to prion disease 292.89 Inhalant intoxication
294.11 Major neurocognitive disorder probably due to 292.9 Unspecified inhalant-related disorder
Parkinson’s disease with behavioral disturbance Opioids
294.10 Major neurocognitive disorder probably due to 305.50 Opioid use disorder (mild)
Parkinson’s disease without behavioral disturbance
304.00 Opioid use disorder (moderate or severe)
331.9 Major neurocognitive disorder probably due to
Parkinson’s disease 292.89 Opioid intoxication
331.83 Mild neurocognitive disorder probably due to 292.0 Opioid withdrawal
Parkinson’s disease 292.9 Unspecified opioid-related disorder
294.11 Major neurocognitive disorder due to Huntington’s Sedative, hypnotic or anxiolytic-related disorders
disease with behavioral disturbance
305.40 Sedative, hypnotic or anxiolytic use disorder (mild)
294.10 Major neurocognitive disorder due to Huntington’s
304.10 Sedative, hypnotic or anxiolytic use disorder
disease without behavioral disturbance
(moderate or severe)
331.83 Mild neurocognitive disorder due to Huntington’s 292.89 Sedative, hypnotic or anxiolytic intoxication
disease
292.0 Sedative, hypnotic or anxiolytic withdrawal
294.11 Major neurocognitive disorder due to another
292.9 Unspecified sedative-, hypnotic- or anxiolytic-related
medical condition with behavioral disturbance
disorder
294.10 Major neurocognitive disorder due to another
Stimulant-related disorders
medical condition without behavioral disturbance
305.70 Stimulant use disorder, mild amphetamine-type
331.83 Mild neurocognitive disorder due to another medical
substance use (or) use of unspecified substances
condition
305.60 Stimulant use disorder, mild cocaine substance use
294.11 Major neurocognitive disorder due to multiple
etiologies with behavioral disturbance 304.40 Stimulant use disorder, moderate or severe
amphetamine-type substance use (or) use of
294.10 Major neurocognitive disorder due to multiple
unspecified substances
etiologies without behavioral disturbance
304.20 Stimulant use disorder, moderate cocaine substance
331.83 Mild neurocognitive disorder due to multiple
use
etiologies
292.89 Stimulant intoxication
Table 2.4 shows DSM-5 classification of substance use 292.0 Stimulant withdrawal
disorders. Tobacco
Table 2.4: DSM-5 classification of substance use disorders 305.1 Tobacco use disorder, mild
305.1 Tobacco use disorder, moderate
Alcohol
305.1 Tobacco use disorder, severe
305.00 Alcohol use disorder (mild)
292.0 Tobacco withdrawal
303.90 Alcohol use disorder (moderate or severe)
292.9 Unspecified tobacco-related disorder
303.00 Alcohol intoxication
291.81 Alcohol withdrawal Miscellaneous

291.9 Unspecified alcohol-related disorder 305.90 Other (or unknown) substance use disorder, mild

Caffeine 304.90 Other (or unknown) substance use disorder,

moderate
305.90 Caffeine intoxication
304.90 Other (or unknown) substance use disorder,
292.0 Caffeine withdrawal severe
292.9 Unspecified caffeine-related disorder 292.89 Other (or unknown) substance intoxication
Cannabis 292.0 Other (or unknown) substance withdrawal
305.20 Cannabis use disorder (mild) 292.9 Unspecified other (or unknown) substance-related
304.30 Cannabis use disorder (moderate or severe) disorder

Contd…
30 Textbook of Psychiatric Nursing for BSc Nursing Students

REVIEW OF PERSONALITY DEVELOPMENT 1. Psychoanalytic perspective: It focuses on the role of

unconscious mind in the development of personality.
The term ‘personality’ has been derived from the word 2. Behaviorist perspective: The approach focuses on the
‘persona’ which means the mask that the Roman and Greek effect of behavior on the environment.
actors used to wear in dramas, which indicated to the audience 3. Humanistic perspective: This arises as a reaction
whether they played the good or bad characters. Thus, the against the psychoanalytic and behaviorist perspectives
mask distinguished one actor from the other actor.
and focuses on the role of each person’s conscious life
experiences or the choices in personality development.
Personality
4. Trait perspective: The psychoanalytic, behavioristic and
• Personality is defined as a characteristic set of behaviors, humanistic perspectives all seek to explain the process that
cognitions and emotional patterns that evolve from causes personality to form into its unique characteristics,
biological and environmental factors. whereas trait theorists are more concerned with the end
• Personality is a characteristic way of thinking, feeling and result, ‘the characteristics’.
behaving oneself.
• Personality embraces moods, attitudes and opinions that
THEORIES OF PERSONALITY DEVELOPMENT
are most clearly expressed in interactions with other
people. Psychoanalytic Theory
• It includes behavioral characteristics, both inherent and
acquired, that distinguish one person from another, can Sigmund Freud’s psychoanalytical theory of personality has
be observed in people’s relations to the environment or been based primarily on his concept of unconscious nature of
the social group. personality. This theory assumes that man is motivated more
by unseen forces than by conscious and rational thoughts.
Related Terms He emphasized that the major force which motivates a human
being is his unconscious framework. This framework includes
• Temperament: It refers to those aspects of an individual’s
three conflicting psychoanalytic concepts, namely the id, the
personality that are often regarded as innate rather than
ego and the superego (Table 2.5).
learned. It is a natural disposition. There are three major
temperament types—Easy, difficult and slow to warm up. 1. Id is the foundation of the unconscious behavior and is the
• Character: It is the sum total of the acquired dispositions source of psychic energy and seeks immediate satisfaction
of an individual. It is a mental structure which is organized, of biological or instinctual needs.
lasting and enduring. It influences the conduct and social 2. Ego is the conscious and logical part because it is
behavior all the time. concerned about the realities of external environment.
The ego of a person keeps the id in check whenever it
PERSPECTIVES IN PERSONALITY THEORY demands immediate pleasure.
3. Superego is a higher-level force to restrain the id and
There are several ways in which the characteristic behavior of it is described as the conscience of a person. Superego
human beings can be explained. The personality is still difficult represents the norms of an individual, his family, society
to measure precisely and scientifically. Hence, there is no single and is an ethical constraint on the behavior.
explanation of personality that all can agree on. There are four
Freud believed that personality develops through a series of
main perspectives in personality theory (Fig. 2.1).
childhood stages in which the pleasure-seeking energies of the
id become focused on certain erogenous areas, an area of the
body that is particularly sensitive to stimulation. Each stage of
development is marked by conflicts that can help in growth
or self-development, depending upon how they are resolved.
If these psychosexual stages are completed successfully, they
result in the development of a healthy personality. Early
experiences play a major role in personality development and
Figure 2.1: Perspectives in personality theory continue to influence behavior later in life.
CHAPTER 2 Principles and Concepts of Mental Health Nursing 31

Table 2.5: Principles and level of consciousness involved in structure of mind

Structure of mind Description Behavior Principle Level of consciousness highly

involved
Id Needs or wishes or pleasure Animalistic Pleasure Unconscious mind
Ego Think about right and wrong; Humanistic Reality Conscious mind
Gains control over the behavior
Superego Moral concepts or ideals Spiritualistic Morality Unconscious and conscious mind

Neo-Freudian Approaches their own behavior. There is a continuous mutual interaction

between the person (P), his behavior (B) and the external
Alfred Adler, one of Freud’s earlier associates, agreed that
environment (E) (Fig. 2.2).
early childhood experiences are important to development
but believed that much of our personality is determined by Process of Social Learning
our efforts to overcome feelings of inferiority. He said that
• We learn to observe the behavior of others and we later
birth order can influence the development of personality.
reproduce it when required.
The schema that depicts the differences in personality is given
• We also create new and original behaviors.
in Table 2.6.
• Human beings can think and regulate their behavior
Table 2.6: Schematic representation showing differences in through self-observation.
personality based on the birth order (Neo-Freudian approaches) • People are more likely to engage in certain behaviors
The eldest child Set goals to get back the attention of
when they believe they are capable of implementing those
parents and others, which was lost after behaviors successfully (self-efficacy).
the birth of younger sibling
Middle children Either very social or very competitive Rogers Theory of Personality
The youngest child More secure, but generally pampered and Carl Rogers viewed personality structure in terms of ‘self-
dependent concept’. He referred to self-concept as “the organized,
consistent set of perceptions and beliefs about oneself.” Self-
Jung’s Theory concept is influenced by the actual life experiences of an
Carl Jung explained that the collective unconscious contains individual and his/her interpretation of those experiences.
more than the repressed thoughts and feelings (personal Self-concept and life experiences may or may not be
unconscious state). Collective unconscious contains memories congruent with each other which in turn determine the kind
which are shared by all mankind stored in the form of of personality developed within an individual. Being genuine,
archetypes. The aim of healthy personality is to achieve a showing acceptance and empathy are the conditions required
kind of wholeness in which all parts of personality are fully for growth-promoting climate of a child (Table 2.8).
developed and harmoniously interpreted. Congruence between self-concept and life experiences
may result in self-actualization. Such individuals are
Erikson’s Theory of Psychosocial Development well adjusted, well-balanced and interesting to know.

Erik H Erikson proposed that personality develops in a

predetermined order. In his theory, he explained how the process
of socialization affects a child’s sense of self. According to him,
personality is unfolded through eight different stages, each with
two possible outcomes. Each stage involves accomplishment of
specific developmental task that may lead to acquisition of certain
virtues or psychosocial strength. Failure to accomplish these tasks
may result in development of maladaptive behavior (Table 2.7).

Bandura’s Social Learning Theory

Albert Bandura emphasized the role of social learning in Figure 2.2: Bandura’s social learning model
personality. He said that human beings can think and regulate and development of personality
32 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 2.7: Stages of personality development

Stage Psychosocial Virtues Developmental tasks Success in Failure in

crisis tasks tasks
Infancy Basic trust vs Hope • Learn to develop trust based on their interaction Feel secure Suspiciousness
(0–1 year) mistrust with their caregivers
• Feels secure when receives consistent care from
caregivers
• Lack or inconsistent care giving process may result
in mistrust and a sense of fear in the child.
Early Autonomy vs Will • Learn to be independent Feel Low self-
Childhood shame and • Want to make their own choices independent esteem
(1–3 years) doubt • Learn motor skills
• Develop a sense of autonomy when they are
allowed to function independently
• Doubt themselves or feel shameful when they are
denied to be independent
Middle Initiative Purpose • Develop a sense of initiative and feel secure in their Self-content Being a
childhood vs guilt ability to lead others and make decisions passive
(3– 6 years) • Develop a sense of guilt when they are criticized or personality
controlled or fail to develop initiative
Late Industry vs Competence • Develop a sense of pride in their accomplishments Self- Inferiority
childhood inferiority and gain confident complex
(6–12 years) • self-confidence
• Develop a feeling of inferiority when they are
confronted with failures or negative feedbacks
Adolescence Identity Fidelity • Look at the future in terms of career and Clear Improper
(12–18 years) vs role relationships with role personal
confusion • Begin to form new identity based on exploration of performance relations
possibilities and observation of adult roles
• If development of self-identity is hindered, it results
in confusion about themselves and their role
Young Intimacy vs Love • Develop a sense of intimacy from a mutually Intimate Immature
adulthood isolation satisfying marital relationship personal behavior
(18–25 years) • Failure to develop close relationships may lead to relations and lack of
isolation, loneliness and even depression personal
relations
Middle Generativity Care • Accomplishing family commitments, work place Being a part No concern for
adulthood vs stagnation demands and sociocultural duties lead to a sense of in welfare of others
(25-45 years) generativity others
• Failure in fulfilling these tasks can result in
stagnation.
• Feelings of stagnation can lead to a feeling of being
unproductive
Old age Ego integrity Wisdom • Develop sense of ego integrity when recalling the Feeling Hopelessness
(45 years to vs Despair life’s accomplishments satisfied
death) • If one sees life as unproductive, it may bring
feelings of despair

Table 2.8: Differences between congruence and incongruence

Congruence Incongruence
• Self-concept and actual life experiences may be consistent with • Disparity between one’s self-concept and actual life experiences
each other • Distortion or denial of experiences
• Accepts and learns from the life experiences • Impaired psychological well-being
• Becomes an individual who is able to function at full extent.
CHAPTER 2 Principles and Concepts of Mental Health Nursing 33

Rogers also identified the following five characteristics of a 5. N – Neuroticism

fully functioning or self-actualizing person: People high in neuroticism worry frequently and easily slip
1. Open to experience into anxiety and depression. If all is going well, neurotic people
2. Existential living tend to find things to worry about. In contrast, people who are
3. Trust feeling low in neuroticism tend to be emotionally stable and even-
4. Creativity keeled.
5. Fulfilled life
DEFENSE MECHANISMS
Trait Approach
The following Big Five are the most widely accepted personality Definitions
traits: (Mnemonic OCEAN) • A defense mechanism is an unconscious psychological
1. O – Openness mechanism that reduces anxiety arising from unacceptable
2. C – Conscientiousness or potentially harmful stimuli.
3. E – Extraversion • Defense mechanism is defined as, ‘unconscious processes
4. A – Agreeableness which defend the individual and protect from the anxiety’.
5. N – Neuroticism  —Sigmund Freud
The Big Five are the ingredients that make up each individual’s
personality. Each individual has all these traits but in varying Psychoanalytic Basis of Defense Mechanism
degrees. In psychoanalytic theory, defense mechanisms are psychological
strategies brought into the performance by the unconscious
1. O – Openness
mind to manipulate, deny or distort reality in order to defend
Openness refers to “openness to experience”. People who against feelings of anxiety and unacceptable impulses and to
are high in openness will enjoy adventure. They are curious maintain one’s self-schema or other schemas.
and appreciate the art, imagination and novelty. People with
low openness prefer to stick to their habits and avoid new Defense Mechanism in Relation with Origin
experiences. Changing personality is usually considered
Table 2.9 shows defense mechanisms used in various age
a tough process, but openness is a personality trait which is
groups.
subjected to change in adulthood.
Table 2.9: Defense mechanisms used in various age groups
2. C – Conscientiousness
Period Age group Defense mechanisms
People who are conscientious are organized and have a
Oral 0–2 years • Fixation
strong sense of duty. They are dependable, disciplined and
• Compensation
achievement-focused. People with low conscientiousness are • Denial
more spontaneous or freewheeling and they may tend toward • Displacement
carelessness. Conscientiousness is a helpful trait as it has been Habit training 1–3 years • Conversion
linked to achievement in school and on the job. • Identification
• Sublimation
3. E – Extraversion • Reaction formation
• Introjection
Extroverts are chatty, sociable and draw energy from • Transference
crowds. They tend to be assertive and cheerful in their social
Late childhood 3–6 years • Repression
interactions. Introverts, on the other hand, prefer to spend • Rationalization
most of their time lonely, perhaps because their brains process • Regression
social interaction differently. Latency period 6–12 years • Projection

4. A – Agreeableness
Agreeableness measures the extent of a person’s warmth and
Normal and Pathological Use
kindness. If the individual is mostly agreeable, he is more Healthy persons normally use different defenses throughout
likely to be trustful, helpful and compassionate. Disagreeable life. An ego defense mechanism becomes pathological, when
people are cold, suspicious of others and they are less likely to the persistent use leads to maladaptive behavior which affects
cooperate. the physical or mental health.
34 Textbook of Psychiatric Nursing for BSc Nursing Students

Key Aspects
Defense mechanism is a false coping mechanism which is said
to be unconscious and not to be confused with usual coping
strategies. Repression is considered a base for all defense
mechanisms. The purposes of defense mechanism are as
follows:
• To protect the self, mind and ego from anxiety.
• To help in situations where coping mechanism fails.

Views of Psychologists about Defense

Mechanism
• Robert Plutchik (1979) viewed the defenses as derivatives
of basic emotions.
As per his theory:
„ Reaction formation is related to joy and manic  features. Figure 2.3: George Eman Vaillant
„ Denial is related to acceptance and histrionic features.
„ Repression is related to fear and passivity.
„ Regression is related to surprise and borderline traits.
„ Compensation is related to sadness and depression.
„ Projection is related to disgust and paranoia.
„ Displacement is related to anger and hostility.
„ Intellectualization is related to anticipation.
• Otto F Kernberg (1967) developed a theory of borderline
personality. The borderline defenses are projection,
denial, splitting, devaluation and projective identification. Figure 2.4: Vaillant’s levels of defense mechanism
• Anna Freud (1936), daughter of Sigmund Freud,
enumerated 10 defense mechanisms such as regression, • This decreases the distress and anxiety produced by the
repression, isolation, reaction formation, projection, threatening people or by an uncomfortable reality.
undoing, introjection, turning against one’s own person, • These mechanisms lead to problems in a person’s ability
sublimation and displacement. to cope effectively.
• These defenses are often seen in major depression and
Vaillant’s Categorization of Defense Mechanisms personality disorders.
George Eman Vaillant (Fig. 2.3), a psychiatrist, described four- Table 2.11 describes the immature defenses with examples.
level classification of defense mechanisms (Fig. 2.4).
3. Neurotic Defenses
1. Pathological Defenses • Neurotic defenses are quite common in adults.
• Pathological defenses are severely pathological when used • These defenses have short-term advantages in coping. But
predominantly. they can cause long-term problems in relationships and
• These defenses, in conjunction, allow an individual to work when used as one’s primary style of coping.
effectively experience and eliminate the need to cope with Table 2.12 describes the neurotic defenses with examples.
reality.
• Pathological users of these mechanisms may appear 4. Mature Defenses
“irrational” or “insane” to others. • Mature defenses are found among emotionally healthy
Table 2.10 describes the pathological defenses with examples. adults.
• These are considered mature defenses, even though many
2. Immature Defenses have their origins in an immature stage of development.
• Immature mechanisms are often present in adults. • They have been adapted in order to optimize success in
• Excessive use of such defenses is considered socially human relationships.
undesirable because they are immature, difficult to deal • These defenses help to integrate conflicting emotions and
with and out of touch with reality. thoughts.
CHAPTER 2 Principles and Concepts of Mental Health Nursing 35

Table 2.10: Description of pathological defenses with examples

Level 1 pathological Description Examples

defenses
Conversion The intrapsychic conflicts are exhibited outside as Student might get conversion fits, when the teacher
physical symptoms such as deafness, blindness, punishes him.
seizures, paralysis or numbness.
Denial Refusing to accept the external reality since it is Patient will not accept that he has been diagnosed
extremely threatening. with Human Immunodeficiency Virus (HIV) or Acquired
Immunodeficiency Syndrome (AIDS) when the western
blot test reveals the positive result.
Superiority complex Having a greater feel of superiority with Mother may feel that “I am the only person with special
extraordinary talents and feel special with talents and so the child has to obey my words” without
arrogant behavior which increases difficulties in giving any importance to the feelings of the child, which
work or relationship with others. will enhance hatred in the child.
Inferiority complex Individual will feel that he/she is having a lack Student who fails in a subject feels that, ‘I am not
of self-worth and not meeting up to the level of capable to study and I am inferior to others’.
standards when compared to others.

Table 2.11: Description of immature defenses with examples

Level 2 immature Description Examples

defenses
Acting out Direct the expression of an unconscious wish Father beats his son because he feels so angry about the
or impulse into action without the conscious behavior of his son that he is not behaving as per the
awareness of emotion which drives into the father’s expectations.
expressive behavior.
Fantasy Using fantasy in order to resolve inner conflicts. An individual has a lot of issues in a job, takes his casual
leave and thinks of his promotion or salary when he/she is
employed in other organization.
Wishful thinking Take decisions which are pleasing to imagine Decision to enjoy in a park even when there is an important
instead of giving importance to the reality. work in the office.
Idealization Perceive the other individual with more positive Father perceives his daughter as too good even after her
qualities more than the actual potential. daughter’s professor tells many complaints about her poor
academic performance.
Passive aggression Aggression expressed toward others either Teacher failed the student in the exam because the student
indirectly or passively did not join the tuition classes.
Projection Conscious or unconscious way of blaming others Student replies that I failed in the exam because the
for one’s own mistake. evaluator did not evaluate my answer script properly.
Somatization Transformation of negative feeling toward oneself Boy saying that he was having severe pain in leg because he
in terms of pain, illness and anxiety. was emotionally upset.

Table 2.12: Description of neurotic defenses with examples

Level 3 Description Examples

neurotic defenses
Displacement Unconscious manner of letting the feelings toward In a family, father scolds the mother for her mistake.
the less threatening object Mother shows the anger to the child and in turn child
beats the doll.
Dissociation Modifying one’s own identity in order to prevent Adult forgets everything about his childhood sexual
psychological distress. abuse.
Hypochondriasis An excess preoccupation or concern about health Even with insignificant symptoms, individual worries
about his illness.
Intellectualization Focus on the intellectual aspects so that one can Person shows no emotional expression in a quarrel.
prevent the anxiety-provoking emotions.
Contd…
36 Textbook of Psychiatric Nursing for BSc Nursing Students

Level 3 Description Examples

neurotic defenses
Isolation Separation of the feelings from ideas. Be lonely when you dislike an individual.
Rationalization Try to make excuses to convince self that he/she is A student came late to college, reasons out that he came
not wrong. late because his bike tyre got punctured.
Reaction formation Converting the unconscious wishes or ideas or A jealous girl who hates her elder sister might show high
impulses which are perceived as dangerous or level of respect and affection toward her.
unacceptable by their opposites.
Regression Temporary state of the ego put into the earlier stage Adult cries like a child to get the things done from his
of development instead of handling the unacceptable parents.
impulses as an adult.
Repression Unconscious way of suppressing the negative feelings Forgetting the birthday of loved one after the fight.
which is a threat
Undoing An individual tries to ‘undo’ destructive or unhealthy Giving a gift to an individual with a dislike feeling toward
thoughts in reverse of the unacceptable. him.
Withdrawal Withdraw oneself from interactions or stimuli or events Student taking leave often because he feels that his
due to the threat of painful thoughts and feelings. teacher will scold him badly in front of other students.
Upward and Will compare oneself with other person to be low and A student compares oneself with other student who
downward social find oneself comfortable with one’s performance. secures less marks than him.
comparisons

Table 2.13 describes mature defenses with examples.

Table 2.13: Description of mature defenses with examples

Level 4 mature Description Examples

defenses
Patience Being silent under difficult circumstances such as At the time of quarrel with his friend, Raja is being silent.
provocation, delay, criticism, quarrel, etc.
Acceptance Person accepts the reality of a situation. Driver accepts that the road traffic accident happened due
to his carelessness.
Mindfulness Orientation of one’s experiences in present moment. Mother making her daughter aware that the mistake has
been committed.
Humility Humility is intelligent self-respect given to oneself. Raj gives importance and respect to one’s own ideas or
thoughts
Courage Psychological willingness and ability to confirm the Boxer has physical courage to fight. A counselor has mental
pain, danger, fear, conflicts, obstacles, despair, etc. courage to give solutions to the problem.
Gratitude Feeling of thankfulness or appreciation toward the Patient says thanks to the nurse at the time of discharge for
person. efficient care.
Altruism Constructive social service to others which gives Ram is helping the orphan children, which gives personal
personal satisfaction. satisfaction to Ram.
Forgiveness Being merciful and forgiving the mistake of others. Mother forgives the mistake of children.
Anticipation Plan in a realistic way for future discomfort. A person who knows that he is going to lose his job,
psychologically prepares for that incidence.
Emotional self- Not being emotionally dependent on the approval or Wife is not happy with an encouragement from her
sufficiency disapproval of others. husband.
Humor Channeling of unacceptable impulses or thoughts Turns out the serious situation in a joyful way by cracking
into a light-hearted story or joke. jokes.
Emotional self- Individual who modifies the intensity and duration of A person who gets angry will move away from that
regulation expressing the emotions. particular place to divert oneself.
Contd…
CHAPTER 2 Principles and Concepts of Mental Health Nursing 37

Level 4 mature Description Examples

defenses
Thought The conscious way of pushing out the negative A student writing the exam keeps on thinking about the
suppression thoughts or feelings. quarrels with his friend. He puts off this incident from his
mind so that he can write his exam well.
Sublimation It refers to transformation of socially unacceptable A person who is getting aggressive thoughts will engage
impulses or thoughts into socially acceptable actions oneself in the sports actively.
or behavior, resulting in a long-term conversion of
the initial impulse.
Identification Unconscious modeling of one’s self toward another Girl wants to become nurse because she got impressed
person’s character and behavior. with the care rendered by a nurse in the hospital.

BIOPSYCHOSOCIAL ETIOLOGY OF MENTAL cingulum and basal ganglia are seen in patients with
ILLNESS obsessive compulsive disorder. Anatomical abnormalities
of prefrontal cortex, basal ganglia and cerebellum are seen
The causes of mental disorders vary from one another. in patients with schizophrenia. Decreased metabolism of
Mental illnesses are caused by a combination of biological, caudate nucleus is seen in eating disorders. Dysfunction
psychological, environmental and social factors. in prefrontal cortex, frontal/temporoparietal cortex,
fusiform cortex, subcortical region, basal ganglion,
Biological Factors thalamus and lingual gyri (particularly with nondominant
• Genetic factors: Individuals having family history of part of brain) is seen in organic brain disorders.
mental illness are at a higher risk of developing psychiatric • Infections: Certain infections may cause brain damage
disorders. Mental illness occurs from the interaction of and therefore, they develop mental illnesses or worsen the
multiple genes and other factors such as stress, abuse symptoms of mental illnesses. For example, a condition
or a traumatic event which can influence or trigger an known as Pediatric Autoimmune Neuropsychiatric
illness in a person who is having inherited susceptibility. Disorders associated with Streptococcal Infections
(PANDAS) leads to the development of obsessive-
Chromosome 1 and 7 defects lead to substance abuse
compulsive disorder and other mental illnesses in
disorders. Chromosome 1, 9, 11, 13q defects might
children.
lead to panic disorder. Chromosome 14q defect might
• Maternal factors: Exposure to environmental stressors,
lead to specific phobia/social phobia/panic disorder.
inflammatory conditions, toxins, alcohol or drugs during
Chromosome 3q defect might lead to agoraphobia.
prenatal period can lead to mental illness.
Chromosome 16q defect might lead to social/simple
• Prenatal damage: Evidence suggests that a disruption
phobia. Down’s syndrome, Fragile X syndrome and
of early fetal brain development or trauma at the time
Prader-Willi syndrome might contribute to mental
of birth or hypoxia at birth may be associated with the
retardation in children. Abnormality in chromosome development of mental illnesses.
12 and 15 is seen in depression. The deletion of 30–40 • Hormonal factors: Some endocrine disorders are closely
genes in middle of chromosome 22 (DiGeorge Syndrome) associated with the development of mental illnesses. For
might lead to schizophrenia. example, depression in hypothyroidism. Imbalance in the
• Biochemical factors: Abnormal functioning of nerve growth hormone, prolactin, thyroid releasing hormone
cell circuits or pathways that connect particular brain and oxytocin might lead to schizophrenia. Cortisol
regions may lead to mental illness. The increased or increases in stress-related disorders due to the stimulation
decreased levels of neurotransmitters and their associated of Hypothalamic-Pituitary-Adrenal (HPA) axis. Pineal
psychiatric disorders are listed in Table 2.14. gland secretes melatonin, which decreases in depressive
• Structural damage to brain: Defects or injuries to certain disorders. Overactivity of HPA axis is seen in anxiety
areas of the brain are linked to some mental illnesses. For disorders.
example, organic psychosis may occur in people who • Other factors: Poor nutrition and exposure to toxins
meet with an accident and sustain brain injury. Rapid such as lead may play a role in the development of mental
blood flow and metabolic activity seen in frontal lobe, illnesses.
38 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 2.14: Imbalanced levels of neurotransmitters and their association with psychiatric disorders

Psychiatric disorder Neurotransmitters

Increased Decreased
Schizophrenia Dopamine, epinephrine and norepinephrine Gamma-Amino Butyric Acid (GABA)
Mania Dopamine, epinephrine and norepinephrine –
Depression Acetylcholine Epinephrine, norepinephrine and histamine
Parkinson’s disease – Dopamine
Anxiety disorder Serotonin Gamma-Amino Butyric Acid (GABA), epinephrine
and norepinephrine
Aggression, suicide and impulsivity – Serotonin
Huntington’s disease Somatostatin –
Alzheimer’s disease – Somatostatin
Eating disorder and sleep disorder Gamma-amino butyric acid (GABA) –

Psychological Factors consisting of biopsychosocial symptoms that cluster together.

All human behaviors result from actions that originate in the
Psychological factors that may contribute to mental illnesses
brain and its interconnection of neural networks. Complex
include:
circuit of the brain interacts with the external environment,
• Severe psychological trauma suffered during childhood
memories and experiences. Through the spinal column and
period, such as emotional, physical or sexual abuse
peripheral nerves, along with the endocrine and immune
• Death of a parent
systems, the brain constantly receives or processes information.
• Neglect
Therefore, it is important for the nurse to understand basic
• Poor coping ability
nervous system and its functioning.
Environmental Factors
Central Nervous System
Certain stressors can trigger an illness in a person who is
The central nervous system (CNS) is composed of the brain,
susceptible to mental illness. These stressors include:
the spinal cord and associated nerves that control voluntary
• Divorce
acts.
• A dysfunctional family life
• Feelings of inadequacy, low self-esteem, anxiety, anger Brain
and loneliness Structurally, the brain is divided into:
• Changing jobs or schools frequently
• Social or cultural expectations Cerebrum
Cerebral hemispheres: Cerebrum is divided into right and left
Social Factors hemispheres. All lobes and structures are found in these halves
• Adverse housing conditions except pineal gland.
• The pineal body is an endocrine gland which is located
• War
between the hemispheres.
• Experience of social discrimination and stigma
• The corpus callosum is a pathway connecting the two
• Social deprivation
hemispheres and coordinating their function.
• The left hemisphere controls the right side of the body.
PSYCHOPATHOLOGY OF MENTAL DISORDERS:
REVIEW OF STRUCTURE OF BRAIN, FUNCTIONS It is the center for logical reasoning and analytical
OF BRAIN, LIMBIC SYSTEM AND ABNORMAL functions such as reading, writing and mathematical
NEUROTRANSMISSION tasks.
• The right hemisphere controls the left side of the body.
Mental disorders cannot be traced to specific physiological It is the center for creative thinking, intuition and artistic
or psychological problems. These are complex syndromes abilities.
CHAPTER 2 Principles and Concepts of Mental Health Nursing 39

Some functions of the lobes are distinct; others are integrated

(Table 2.15).
Cerebellum
• Cerebellum is located below the cerebrum and is the
center for coordination of movements and postural
adjustments.
• It receives and integrates information from all areas
of the body such as muscles, joints, organs and other
components of the CNS.

CLINICAL IMPLICATION
Figure 2.5: Lobes of brain Inhibited transmission of dopamine, a neurotransmitter, in
this area is associated with the lack of smooth, coordinated
Lobes: Each cerebral hemisphere is divided into four lobes movements in diseases such as Parkinson’s and dementia.
(Fig. 2.5):
1. Frontal lobe 2. Parietal lobe Brain Stem
3. Temporal lobe 4. Occipital lobe • Brain stem includes the midbrain, pons and medulla
oblongata and the nuclei for cranial nerves III-XII
CLINICAL IMPLICATION (Table 2.16).

Frontal Lobe Syndrome Extrapyramidal Motor System

Damage to the dorsolateral (upper and outer) areas of the frontal
lobes may cause symptoms such as lack of drive and spontaneity. It is a bundle of nerve fibers connecting the thalamus to the
Damage to the anterior aspects of frontal lobes might lead the basal ganglia and cerebral cortex. Muscle tone, common
changes in mood or affect, which in turn exhibits the impulsive reflexes and automatic voluntary motor functioning (e.g.,
and inappropriate behavior in patients. walking) are controlled by this nerve tract.

Table 2.15: Lobes of brain, their functions and impact of abnormalities

Lobes Functions Associated abnormalities

Frontal lobes Control the organization of thought, body Abnormalities in the frontal lobes are associated with schizophrenia,
movement, memories, emotions and moral attention deficit hyperactivity disorder and dementia
behavior
Parietal lobes • Parietal lobe plays an important role in • Lesions in the parietal lobe of the dominant hemisphere are
integrating sensory information from associated with dyslexia, a group of disorders that involve difficulty in
various parts of the body, knowledge of learning to read or interpret words, letters and other symbols.
numbers and the manipulation of objects • Cognitive processes regulated by parietal lobe, such as perception,
• It is also involved in processing attention, memory, planning, motor control, mental calculation,
information related to the sense of touch language, self-awareness and emotion regulation, are impaired in
• Portions of the parietal lobe are involved schizophrenia
with visuospatial processing • These cognitive functions may be impaired in schizophrenia due to
the decreased volume of parietal lobe.
Temporal lobes Center for smell, hearing, memory and Research results have shown that temporal lobe epilepsy is highly
emotional expression associated with psychiatric disorders such as anxiety disorder and
depression
Occipital lobes Assist in coordinating language generation • There is evidence in the reduction of the overall occipital lobe
and visual interpretation perception in- volume in schizophrenic patients
depth. • Functional abnormalities, such as decreased activation of occipital
lobe areas during episodic memory encoding, episodic memory
recovery and emotion processing tasks, are found to be associated
with schizophrenia
40 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 2.16: Brain stem structures, location, functions and psychiatric implications

Brain stem Location/description Functions Clinical implications

structures
Medulla Located at the top of the spinal Contains vital centers to regulate respiration and • The locus coeruleus,
oblongata cord cardiovascular functions a small group of
Pons Above the medulla and in front • Bridges the gap between medulla and cerebrum norepinephrine-
of the cerebrum both structurally and functionally • producing neurons in the
• Serves as a primary motor pathway brain stem, is associated
with stress, anxiety and
Midbrain • Connects the pons and • Reticular activating system influences motor impulsive behavior
cerebellum with cerebrum activity, sleep, consciousness and awareness
(2 cm in length) • The extrapyramidal system relays information
• Includes most of the reticular about movement and coordination from the
activating system and the brain to the spinal nerves
extrapyramidal system

Components of limbic system: Components of the limbic

CLINICAL IMPLICATION system are: (Mnemonic - BATCH)
• B – Basal Ganglia
Extrapyramidal syndrome (EPS) is a group of side effects caused
by the dopamine blockade effect of typical antipsychotic drugs.
• A – Amygdala
As the extrapyramidal tract is severely affected, it may produce • T – Thalamus and Hypothalamus
involuntary motor movements. • C – Cingulate gyrus
• H – Hippocampus
Pineal Body • B-Basal ganglia: The basal ganglia are a group of
Pineal body is located above and medial to the thalamus. nuclei lying deep in the subcortical white matter
of the frontal lobes that organize motor behavior.
It contains secretory cells that emit the neurohormone
The caudate, putamen and globus pallidus are
melatonin and other substances. These hormones are thought
major components/parts of the basal ganglia
to have a number of regulatory functions within the endocrine
(Fig. 2.6). The basal ganglia serve as a gating mechanism
system. Information received from light-dark sources controls
for physical movements, inhibiting potential movements
the release of melatonin, which has been associated with sleep
until they are fully appropriate to the context.
and emotional disorders. A modulation of immune function
The basal ganglia are also involved in:
has been postulated for melatonin from the pineal gland.
„ Rule-based habit learning (e.g., initiating, stopping,
monitoring, temporal sequencing and maintaining
Limbic System
appropriate movement).
The limbic system is essential to understand many hypotheses
related to psychiatric disorders and emotional behavior in
general. It is a complex set of structures found on the central
lower part of the cerebrum. It comprises inner sections of the
temporal lobes and the bottom of the frontal lobe. It is called
a “system” because it comprises several small structures that
work in a highly organized way.
Basic emotions, needs, drives and instincts are modulated
in the limbic system. Hate, love, anger, aggression and caring
are basic emotions that originate within the limbic system. It
combines higher mental functions and primitive emotions into
a single system. It is often referred to as the ‘emotional nervous
system’ or the ‘emotional brain’. It is not only responsible for
our emotional lives but also for our higher mental functions,
such as learning and formation of memories. Figure 2.6: Parts of basal ganglia
CHAPTER 2 Principles and Concepts of Mental Health Nursing 41

of previous emotions. This region also participates in

our emotional reaction to pain and in the regulation of
aggressive behavior.
• H – Hippocampus: The hippocampus is found
deep in the temporal lobe and is shaped like a
sea horse. It consists of two horns curving back
from the amygdala. It plays an essential role in the
formation of new memories about past experiences.
It is also responsible for general declarative memory
(memories that can be explicitly verbalized, such as
memory of facts and episodic memory).

CLINICAL IMPLICATION
Figure 2.7: Placement of amygdala, thalamus and hippocampus
Disturbances in the limbic system have been implicated in a
in limbic system
variety of mental illnesses such as:
• Memory loss that accompanies dementia.
„ Inhibiting undesired movements and permitting • Poorly controlled emotions and impulses seen with psychotic
desired ones. or manic disorder.
„ Choosing from potential actions.
„ Motor planning. Damage to the hippocampus usually results in the
„ Sequencing difficulties of forming new memories (anterograde
„ Predictive control amnesia) and access to memories formed before the brain
„ Working memory damage (retrograde amnesia).
„ Attention
• A – Amygdala: The amygdala, also known as the Autonomic Nervous System
emotional center of the brain, is a small almond-shaped Autonomic nervous system (ANS) is a subdivision of the
structure, located in each of the left and right temporal peripheral nervous system (PNS) and is closely associated with
lobes. It is involved in evaluating the emotional valence the spinal cord but not lying entirely within its column. This
of situations (e.g., happy, sad, scary). It helps the brain
system contains efferent nerves (nerves moving away from
to recognize potential threats and helps to prepare the
the Central Nervous System) or motor system neurons which
body for fight-or-flight reactions by increasing the heart
affect target tissues such as cardiac muscle, smooth muscle and
rate and respiration rate. The amygdala is also responsible
the glands. It also contains afferent nerves which are sensory
for learning on the basis of reward or punishment. Since it
and conduct information from these organs back to the central
is very close to the hippocampus (Fig. 2.7), the amygdala
nervous system.
is involved in the modulation of memory consolidation,
Autonomic nervous system is further divided into the
particularly the emotionally-laden memories.
sympathetic and parasympathetic nervous systems. These
• T – Thalamus and hypothalamus: Both the thalamus
systems are involved in the emergency “Fight-or-Flight”
and hypothalamus are associated with changes in
response as well as the peripheral actions of many medications.
emotional reactivity. The hypothalamus is a small part of
the brain located just below the thalamus on both sides of
Neurons and Nerve Impulses
the third ventricle. Lesions of the hypothalamus interfere
with several unconscious functions (such as respiration Neurons or nerve cells are the fundamental units of the brain
and metabolism) and some motivated behaviors like and nervous system (Fig. 2.8). These cells are responsible
sexuality, combativeness and hunger. The lateral parts of for receiving sensory input from the external world, and for
the hypothalamus seem to be involved with pleasure and sending motor commands to our muscles. They transform the
rage. The medial part is linked to aversion, displeasure electric signals from a neuron to other neuron.
and a tendency for uncontrollable and loud laughter. • Each neuron has a cell body or soma which holds the
• C – Cingulate gyrus: The cingulate gyrus is located in the nucleus, containing most of the cell’s genetic information.
medial side of the brain next to the corpus callosum. Its The soma also includes other organelles such as
frontal part links smell and sight with pleasant memories ribosomes and endoplasmic reticulum which carry out
42 Textbook of Psychiatric Nursing for BSc Nursing Students

Figure 2.8: Parts of a neuron

protein synthesis, the Golgi apparatus which contains Action Potential

enzymes to modify the proteins for specific functions, Nerve signals are prompted to fire by a variety of chemical
vesicles which transport and store proteins or lysosomes or physical stimuli when the stimulation of action potential
that are responsible for degradation of these proteins. starts and electrical communication of the nerves takes place.
Mitochondria containing enzymes (cell’s engine) are
Table 2.17 differentiates the events that occur during rest and
located throughout the neurons which provide the basis
with action potential of neurons.
for secreting numerous chemicals by which the neurons
communicate. Neuroplasticity
• Neurons have a structure called axon that varies in • Neuroplasticity is a continuous process of modulation in
length and conducts impulses away from the soma and neuron structure and function due to the response of changing
has numerous dendrites that receive signals from other environment.
• It contributes to understanding that how the brain function
neurons. Axons may branch as they terminate and have may be restored over time after brain damage.
multiple contacts with other neurons.
• The cell’s membrane is a double layer of phospholipid
molecules with embedded proteins. Some of these proteins Neurotransmission (Synaptic Transmission)
provide water-filled channels through which inorganic Neurotransmission is the fundamental process that transfers
ions may pass. Each of the common ions such as sodium, information between neurons. It is essential for the process of
potassium, calcium and chloride, has their own specific communication between two neurons. It occurs at specialized
molecular channel. These channels are voltage gated and regions between neurons called the synapse. The synapse
thus, opening or closing in response to the change in the is a highly specialized contact between a presynaptic and a
electrical potential across the membrane takes place. postsynaptic neuronal cell.

Table 2.17: Differences between events that occur during rest and with action potential of neurons

Neurons at rest Neurons with action potential

Membrane is polarized Membrane is depolarized
Outside of the cell is positively charged Outside the cell is negatively charged
270-mV charge is present inside the cell Inside the cell is positively charged
Passive diffusion of potassium across the membrane Voltage-gated sodium channels open
Sodium pump uses energy to move sodium from inside the cell against a Sodium moves into the cell and this action potential begins
concentration gradient
CHAPTER 2 Principles and Concepts of Mental Health Nursing 43

It is the process by which signaling molecules Step 2: Neurotransmitter Packaging

(neurotransmitters) has been released by axon terminal of This is the process by which the synthesized neurotransmitters
the neuron (presynaptic neuron) will bind and activates the are packaged into “small groups” or “vesicles” that are ready for
receptors of the dendrites in the another neuron. transmission across the synaptic cleft.
Factors Determining Neurotransmission Step 3: Neurotransmitter Release
• Availability of neurotransmitter. • Paced neurotransmitters are released in the synaptic cleft
• Release of neurotransmitter by exocytosis. when they receive an order from Ca2+ ions.
(Exocytosis is a form of active transport and bulk • When the electrical signal reaches the presynaptic
transport in which a cell transports molecules, such as terminal, it opens some voltage gated Ca2+ channels in the
neurotransmitters or proteins, out of the cell by secreting membrane.
them through an energy-dependent process). • Once these channels are open, calcium ions from the
• Binding of the postsynaptic receptor by the neurotransmitter. surrounding extracellular environment rush into the
• Functional response of the postsynaptic cell. presynaptic terminal.
• Subsequent removal or deactivation of the neurotransmitter. • As the calcium ions encounter the vesicles, the membrane
of the vesicles fuses with the membrane of the presynaptic
Steps in Neurotransmission
terminal at the synaptic cleft.
The following are the steps of neurotransmission (Fig. 2.9): • As the vesicles fuse with the membrane, the
Step 1: Neurotransmitter Synthesis neurotransmitters are “expelled” into the synaptic cleft.
There are two types of neurotransmitters: Step 4: Neurotransmitter Binding
1. Large neuropeptides. • The neurotransmitters diffuse through the synaptic cleft,
2. Smaller amines/amino acids. until they reach the postsynaptic neuron.
Large peptides are synthesized in the cell body of the neuron • The membrane of the postsynaptic neuron contains a few
and are transported to the synaptic terminal through the axon. channels (receptors) which control neurotransmitters in
The smaller amines/amino acids can be synthesized at the synapse to bind with the postsynaptic neuron.
presynaptic terminal itself.
Step 5: Stopping of Chemical Signal
• Once the chemical signal has been translated into an
electrical signal, the postsynaptic receptors need to be
cleared very quickly for two purposes.
„ To receive new neurotransmitters from new signals.
„ To prevent the traffic of neurotransmitters.
• Fate of neurotransmitters after the clearance of
postsynaptic receptors
„ Recycled back to the presynaptic terminal.
„ Degraded.
„ Absorbed by postsynaptic terminal.
Classification of neurotransmitters is given in Flowchart 2.2.
Neurotransmitters and their functions have been described in
Table 2.18.

PRINCIPLES OF PSYCHIATRIC NURSING

Principles of psychiatric nursing are formulated based on the
concept that every individual has an intrinsic worth or dignity,
potential and capabilities. Principles form the guidelines which
will help the client to meet his/her emotional needs and also
bring the desirable changes in his/her behavior. The following
are the principles of psychiatric nursing:
• Accept the client exactly as he or she is:
„ Acceptance conveys the feeling of being loved and
Figure 2.9: Steps in neurotransmission process cared for.
44 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 2.2: Classification of neurotransmitters

Abbreviation: GABA, gamma aminobutyric acid

Table 2.18: Neurotransmitters and their functions

Neurotransmitter Function Clinical implications (or) abnormal neurotransmission

Biogenic amines: Catecholamines
Dopamine Involved in pleasurable feelings and • Increased—Schizophrenia and mania
complex motor activities • Decreased—Depression and Parkinson’s disease
Norepinephrine Regulates awareness of environment, • Increased—Schizophrenia and mania
attention, learning, memory and arousal • Decreased—Anxiety, depression and sleep disorders
Epinephrine Contributes to the “fight-or-flight” response
Biogenic amines: Indolamines
Serotonin Contributes to temperature regulation • Increased—Anxiety disorders (fearfulness, avoidance)
• Decreased—Depression, aggression, suicidal
ideations and impulsivity
Histamine Involved in allergic responses, gastric acid • Weight gain associated with psychotropic meditations
secretion, arousal, suppression of eating, • Decreased level—Depression
control of pituitary hormone secretion and
cognitive function
Biogenic amines: Cholinergics
Acetylcholine Mediates cognitive functioning directly or • Increased—Depression
by modulating another neurotransmitter • Decreased—Alzheimer’s disease
indirectly; contributes to sleep-wake cycles
Neuropeptides group
Neuropeptides: Endorphins Play a secondary messenger role and Somatostatin increases in Huntington’s disease and
and enkephalins, somatostatin, contribute to modulating the pain decreases in Alzheimer’s disease. Deficit of endorphins
neurotensin, vasoactive response leads to increased pain perception by the body
intestinal peptide,
cholecystokinin and substance P
Amino acids
Excitatory: Aspartic acid, Sparse information available; high levels Disturbances in excitatory amino acids might cause
glutamic acid, cysteic acid and can be toxic schizophrenia, delirium or dementia
homocysteic acid
Inhibitory: Gamma-amino Slows down body activity • Decreased—Schizophrenia, some forms of epilepsy
butyric acid (GABA) and anxiety disorders
• Increased—Sleep and eating disorders
CHAPTER 2 Principles and Concepts of Mental Health Nursing 45

Flowchart 2.3: Punitive methods to be avoided ◆ Permitting patient to express strongly-held

feelings: Emotionally painful and suppressed
emotions are bound to the psychopathology.
The purpose of therapeutic alliance is to facilitate
the discharge of these emotions. The nurse must
encourage and accept the expression of patient’s
strong negative feelings in a more comfortable way.
◆ Bottled up emotions might damage the personality
of the individual. Therefore, sharing sadness will
reduce it to half.
• Use self-understanding as a therapeutic tool: A
psychiatric nurse should have a realistic self-concept and
should be able to recognize one’s own feelings, attitudes
„ Acceptance conveys to the client that he/she is and responses. If the nurse is able to understand one’s
respected as an individual. own strengths or limitations, then only the nurse can
„ Being accepted by nurses will lower the anxiety understand the patient’s strengths, limitations, needs and
among clients. problems.
„ Nurses should not judge clients by their appearance, • Use consistent behavior to contribute to the patient’s
behaviors or socioeconomic background. security: Consistency in nurses’ approach is necessary
Acceptance is expressed in the following ways: to develop a trusting relationship between the nurse and
◆ Being nonjudgmental and nonpunitive: The patient. Nurses’ consistency must reflect in their attitude,
client’s behavior should not be judged as right ward routines or by defining limitations in the patient’s
or wrong. Client should not be punished for behavior.
his/her undesirable behavior. All direct and • Give reassurance in an acceptable and subtle manner:
indirect methods of punishment must be avoided Nurse has to provide psychological support to the patient.
(Flowchart 2.3). The right and appropriate psychological support is
◆ Being sincerely interested in the patient: This can termed ‘reassurance’. Nurse should not give a false hope
be demonstrated by: to the patient or caregivers. The manner of providing false
¾ Observing the patient’s behavior pattern hope is termed ‘false assurance’.
¾ Involving the patient in decision-making Example: Patient who has been recently diagnosed with
process HIV/AIDS and depressive disorder has to be reassured that
¾ Identifying his/her likes and dislikes taking antiretroviral drugs will help in enhancing the life span
¾ Being honest with him/her to a great extent. He/she should not be given false assurance
¾ Sparing time to listen to the patient’s words that antiretroviral drugs will completely cure HIV/AIDS.
¾ Handling sensitive issues judiciously • Change the client’s behavior by emotional experience
◆ Recognizing and reflecting the feelings which rather than rational interpretation: Major focus in
patient may express: The nurse should not only psychiatry is on feelings and not on the intellectual
focus on the content of conversation but also aspect. Advising or rationalizing with patients is not
recognize and reflect the feelings associated with effective in changing behavior. Role play, sociodrama and
the patient’s communication. transactional analysis are few ways of creating emotional
◆ Talking with a purpose: The nurse must use experience in a patient about one’s own behavior.
the therapeutic communication techniques Example: The behavior of a patient with alcohol
when she interacts with the patient. Nurse must dependence syndrome can be modified with psychodrama
be conscientious not to use nontherapeutic because it might touch the patient emotionally and
communication techniques. exhibit the behavior change, instead providing the health
◆ Listening: Listening is an active process. The nurse teaching by saying that it is waste of time, because patient
should spend reasonable time to listen what the knows all the complications of alcoholism before the
patient is saying. Nurse has to be a sympathetic health teaching itself.
listener. He/she needs to show genuine interest in • Avoid unnecessary increase in patient’s anxiety: Anxiety
conversation. Listening conveys acceptance to the is a feeling of apprehension. It is also a threat to biological
patient. integrity or self-system (ego) of the person.
46 Textbook of Psychiatric Nursing for BSc Nursing Students

Psychiatric patients already have some amount of anxiety care should focus on the patient as a person and not on
due to their illness, disapproval and seclusion from the the symptoms.
family. Psychiatric nurses must not further increase • Explain procedures and routines according to the
anxiety of the patients by: patient’s level of understanding: Every patient has a
„ Exhibiting one’s own anxiety right to know what treatment is being done for him and
„ Showing attention to the patient’s deficits the reason for performing the treatment. Every procedure
„ Contradicting his psychotic thoughts should be explained according to the patient’s level of
„ Demanding the patients to complete difficult tasks understanding. This may depend on the limitations
„ Making the patient face repeated failures placed on him by his illness. Explanation has to be given
„ Passing sharp comments and showing indifference even if the patients do not have touch with reality or have
• Use objective observation to understand patient’s no ability to understand.
behavior: Objectivity is an ability to evaluate exactly • Many procedures are modified but basic principles
what the patient wants to say and not mix up one’s own remain unchanged: In the field of psychiatric nursing,
feelings, opinion or judgment. To be objective, the nurse many methods are adapted according to individual needs
should indulge in introspection and make sure that her own of the patients, but the underlying scientific principles
emotional needs do not take precedence over patient’s needs. remain the same. Basic nursing principles are as follows:
The nurse may lack objectivity in the following situations: „ Safety
„ Nurse is criticizing the patient „ Comfort
„ Defending or justifying himself/herself „ Privacy
„ Demanding that the patient should treat him/her in „ Therapeutic effectiveness
certain ways „ Economy in the utilization of resources to be followed
„ Judging the patient’s behavior right or wrong in all procedures
• Maintain a realistic nurse-patient relationship: Realistic
nurse-patient relationship is a planned, goal-oriented STANDARDS OF PSYCHIATRIC NURSING
relationship which is based on patient’s needs. It focuses
In 1973, the American Nurses Association (ANA) issued
upon the personal and emotional needs of the patients
standards to improve the quality of care provided by
and not on nurse’s needs. It is an interpersonal process
psychiatric and mental health nurses. These standards were
aimed at bringing adaptation, integration and emotional
revised in 1994, which are now applicable to generalists and
maturity in patient. To maintain such professional
specialists working in any setting, where the psychiatric and
relationship, the nurse should be able to empathize and
mental health nursing is being practiced. These are discussed
understand the feelings of the patient.
under the following three are as follows:
• Avoid physical and verbal forces as much as possible:
1. Standards of Care
Any kind of force applied on the patient results in
2. Standards of Professional Performance
psychological trauma. Under some circumstances, it
3. Indian Nursing Council Standards in Mental Health
may be inevitable. But it must be used judiciously. If a
Nursing
nurse is an expert in predicting patient’s behavior, she
can mostly prevent an onset of undesirable behavior.
Standards of Care
Restraining should never be used as measure of reducing
nurses’ duty. Standards of care pertain to professional nursing activities that
Example: Mr Raj, a psychiatric patient, who has been are demonstrated by the nurse through the nursing process.
scolded by the nurse is an example of verbal force. Nurse These include:
beats Mr Raj and restrains him is an example of physical • Standard I: Assessment—The mental health nurse
force. Both should not be done as per the principles of collects the patient’s health data.
psychiatric nursing. • Standard II: Diagnosis—The mental health nurse
• Focus nursing care on the patient as a person rather analyzes the assessment data for determining the
than controlling symptoms: Two patients having diagnosis.
similar symptoms may be expressing two different needs. • Standard III: Outcome identification—The mental
Analysis and study of symptoms are necessary to reveal health nurse identifies the expected outcomes which are
their meaning and significance to the patient. Nursing specific to every patient.
CHAPTER 2 Principles and Concepts of Mental Health Nursing 47

• Standard IV: Planning—The mental health nurse • Standard VI: Evaluation—The mental health nurse
develops a plan of care that prescribes interventions. evaluates the patient’s progress in attaining expected
• Standard V: Implementation—The psychiatric and outcomes.
mental health nurse implements the interventions
identified in the plan of care. Standards of Professional Performance
„ Standard Va: Counseling—The mental health nurse Standards of professional performance describe a competent
uses counseling interventions to assist patients in level of behavior in a professional role. These include:
improving or regaining their previous coping abilities, • Standard I: Quality of care—The mental health
fostering mental health, preventing mental illnesses
nurse systematically evaluates the quality of care and
and disabilities.
effectiveness of mental health practice.
„ Standard Vb: Milieu therapy—The mental health
• Standard II: Performance appraisal—The mental
nurse provides, structures, maintains a therapeutic
health nurse evaluates his/her own practice in relation to
environment in collaboration with the patient and
professional practice standards, its relevant statutes and
other health care providers.
regulations.
„ Standard Vc: Self-care activities—The mental health
• Standard III: Education—The mental health nurse
nurse structures interventions around the patient’s
acquires and maintains current knowledge in nursing
activities of daily living to foster self-care, mental and
practice.
physical well-being.
• Standard IV: Collegiality—The mental health nurse
„ Standard Vd: Psychobiological interventions—The
mental health nurse uses knowledge of psychobiological contributes to the professional development of peers,
interventions, applies clinical skills to restore the colleagues and others.
patient’s health and prevents further disability. • Standard V: Ethics—The mental health nurse’s decisions
„ Standard Ve: Health teaching—The mental health and actions on behalf of patients are determined in an
nurse, through health teaching, assists patients in ethical manner.
achieving satisfying, productive and healthy patterns • Standard VI: Collaboration—The mental health nurse
of living. collaborates with the patient, his/her significant others
„ Standard Vf: Case management—The mental health and health care providers in providing care.
nurse provides case management to coordinate • Standard VII: Research—The mental health nurse
comprehensive health services and ensure continuity contributes to nursing and mental health through the use
of care. of research.
„ Standard Vg: Health promotion and health • Standard VIII: Resource utilization—The mental health
maintenance—The mental health nurse employs nurse considers factors related to safety, effectiveness, cost
strategies and interventions to promote and maintain in planning and delivering patient care.
mental health and prevent mental illnesses.
„ Standard Vh: Psychotherapy—The mental health Indian Nursing Council Standards in Mental
nurse uses individual, group and family psychotherapy, Health Nursing
child psychotherapy and other therapeutic treatments
• The Practice Standards for Psychiatric Mental Health
to assist patients in fostering mental health, preventing
Nursing were launched in 2019.
mental illnesses or disabilities, improving or regaining
previous health status and functional abilities. • Standards were launched in order to create the scope in
„ Standard Vi: Prescription of pharmacological terms of nursing practice, nursing education, nursing
agents—The mental health nurse uses prescription administration, evidence-based practice or research and
of pharmacologic agents in accordance with the State other standards of professional performance.
Nursing Practice Act to treat symptoms of psychiatric • Standards include:
illnesses and improve functional health status. „ 14 major standards
„ Standard Vj: Consultation—The mental health nurse „ 18 substandards
provides consultation to health care providers and „ 143 measurement criteria
others to influence the plan of care for patients and to • Description of Indian Nursing Council Standards and
enhance the abilities of others to provide psychiatric Sub-standards in Mental Health Nursing with their
and mental health care and effect change in systems. measurement criteria is shown in Table 2.19.
48 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 2.19: Indian Nursing Council Standards in mental health nursing, its description, sub-standards and measurement criteria

Indian Nursing Council Description and Measurement criteria

Standards in mental health Sub-standards
nursing
Standards of Practice
Standard 1: Assessment Mental health nurse • Level of knowledge the mental health nurse possesses about the
has to perform etiology, symptoms, diagnostic criteria of mental illnesses and substance
comprehensive dependence
assessment for the • Skills to maintain rapport in order to obtain the data from patient and
health care consumers family members
to take appropriate • Systematic and accuracy in performing history collection, physical
health care decisions examination and mental status examination
Standard 2: Nursing diagnosis Mental health nurse • Skills to frame the nursing diagnosis on the basis of subjective and
has to frame the objective data
appropriate nursing • Skill to interpret the various diagnostic tests
diagnosis • Modify the diagnosis on the basis of ongoing assessment
Standard 3: Expected Mental health nurse • Skills to explore realistic goals within the stipulated time frame
outcomes of care has to identify the • Involve the health care consumers and their family members while setting
realistic goals with the the goal
existing situation • Modify the goal on the basis of ongoing assessment, if required
Standard 4: Planning Mental health nurse • Develop the individualized care plan with the health care consumers and
has to plan the nursing their family members
care as per the framed • Coordinate the plan with other health team members
goals • Ensure the plan is in congruence with the organizational policies
• Ensure the continuity of care and follow-up while planning out the
interventions
• Review and modify the plan, if required
Standard 5: Implementation Standard 5a: Nursing • Provide holistic care
(mental health nurse needs care delivery to health • Manage the emergencies effectively
to implement the planned care consumers • Implement the plan well with the use of current evidence-based practices
nursing care for the health • Coordinate with other health team members to implement effectively
care consumers) • Consider the developmental stages (children/old age) in implementation
• Utilize all the available resources well
• Document the interventions clearly and timely
Standard 5b: • Administer the psychotropic agents on the basis of therapeutic response
Assistance in the and alert the adverse effects timely to take necessary action for the same
delivery of biological • Have competent assistance in electroconvulsive therapy before, during and
therapies after delivering it
• Have competent assistance in transcranial magnetic stimulation and
stereotactic techniques for intractable psychiatric disorders
• Document the implemented biological therapies
Standard 5c: • Organizes and coordinates various psychotherapeutic interventions such as
Psychotherapeutic cognitive behavior therapy, family therapy, recreation therapy, social skills
interventions training, vocational training, etc.
• Active involvement with the family members to implement
psychotherapeutic interventions effectively
• Clearly document the delivered psychotherapeutic interventions and their
therapeutic response
Standard 5d: Safe • Orient the health care consumers about the structured schedule of the
and therapeutic hospital
environment • Orient the family members of health care consumers with regard to their
rights and responsibilities
• Skills to follow the patient safety protocols
• Document if any untoward events happens and along with the steps taken
to minimize the same
Contd…
CHAPTER 2 Principles and Concepts of Mental Health Nursing 49

Indian Nursing Council Description and Measurement criteria

Standards in mental health Sub-standards
nursing
Standard 5e: Health • Health teaching with regard to the promotion of mental health, prevention
education of mental illnesses and rehabilitation of patients with mental illnesses
• Skills to use appropriate audio-visual aids
• Provide the information, education and communication (IEC) material to
the health care consumers
• Document the health education provided
Standard 5f: • Assessment of community with the use of key informant reports,
Community mental community surveys and qualitative techniques
health nursing • Provide psychotherapeutic interventions and psychoeducation to the
services, including individuals and family
reintegration of health • Provide effective rehabilitation measures in home setting
care consumers into • Perform regular follow-up as per the organizational policy
the community • Participation in the community mental health outreach programs
• Early identification of risk factors of mental illnesses
• Utilize the locally available community resources
• Create public awareness to alleviate stigma of mental illness
• Document the services rendered in community
Standard 6: Evaluation Mental health nurse • Conduct systematic and ongoing clinical evaluation
evaluates the extent • Modify the nursing diagnosis and goal on the basis of ongoing assessment
to which the goal has • Document the results of evaluation
been achieved
Standards of Education
Standard 7: Academic Standard 7a: Personal • Actively participate in the staff development programs such as
excellence (mental health academic development conferences, workshops, seminars, etc.
nurse needs to equip oneself • Actively participate in the interprofessional educational activities
with the required knowledge • Strive for higher qualification for the progress of career development
and skills to render quality • Have commitment with lifelong learning
nursing care to the health Standard 7b: Capacity • Mentor the subordinates effectively
care consumers) Building • Encourage the subordinates for higher education
• Organize the in-service education programs
Standards of Administration
Standard 8: Administrative Standard 8a: Personal • Have clear vision on goals and implement the same
efficiency vision, commitment, • Demonstrate scientific and technical expertise on the basis of current
technical expertise trends
Standard 8b: Team • Promote a healthy work environment with mutual trust and respect
building • Be loyal and maintain integrity as team leader
• Have effective interprofessional collaboration to promote high quality care
Standard 8c: Quality • Ensure the delivery of high-quality care to the patients
assurance • Conduct and participate in the quality assurance programs
• Use the resources such as technology, education and research to provide
high-quality care
• Effectively work with interprofessional team members to ensure quality
• Document the quality care rendered timely
Standard 8d: • Actively participate in the staff development programs such as
Continuing nursing conferences, workshops, seminars, etc.
education • Support the career advancement of subordinates
Standard 8e: • Be resourceful, courageous while dealing with problematic situations
Leadership • Find innovative solutions to the problems
• Implement the right health care policy to promote mental health
• Perform key roles in administrative teams
• Revise the institutional policies or protocols to ensure quality
Contd…
50 Textbook of Psychiatric Nursing for BSc Nursing Students

Indian Nursing Council Description and Measurement criteria

Standards in mental health Sub-standards
nursing
Standard 8f: • Actively participate in the performance appraisal of subordinates
Performance appraisal • Support the subordinates to enhance their work performance
• Take decision with regard to the promotions, incentives, training,
disciplinary measures of the subordinates
Standard 8g: • Actively participate in the national and international professional
Organizational organizations
and professional • Support the superiors to promote the welfare of health care consumers
advancement
Standards of evidence-based practice and research
Standard 9: Responsible and Standard 9a: Research • Gather accurate research data to disseminate the research findings
ethical conduct of research ethics • Report unethical research practices to the appropriate authorities
and integration into practice Standard 9b: • Actively participate in research activities
Integration of research • Develop knowledge with regard to the current and best research evidence
into practice • Make the work environment full of motivation to support the
implementation of best evidences into practice
• Disseminate the research findings through publication in indexed journals
and through scientific presentation in conferences
Standard 9c: Teaching • Teach the subordinates about the importance of doing the research
scientific rigor • Guide the subordinates to perform the research activity
to young nurse
investigators
Other standards of professional performance
Standard 10: Self-care and Mental health nurse • Having strong insight about the strengths and weaknesses
Self-awareness has to know about • Use self-evaluation and peer evaluation to improve work performance
oneself and care about
self
Standard 11: Ethics Mental health nurse • Adhere to the professional code of conduct
has to follow right • Protect the rights of health care consumers
ethical practices in • Maintain the confidentiality of the patient information
nursing care • Report the unethical practices timely
Standard 12: Communication Mental health nurse • Use active listening skills
has to communicate • Build rapport with the health care consumers, their family and the health
effectively to the team members
health care consumers, • Convey right information to the health care consumers in both oral and
their family and the written form to ensure the clarity in message.
health team members
Standard 13: Culturally Mental health nurse • Understand the cultural background of health care consumers
sensitive care has to render nursing • Be empathetic to health care consumers from diverse cultures
care by considering • Provide culturally sensitive care effectively
the cultural values of
health care consumers
Standard 14: Legally safe Mental health nurse • Good knowledge with regard to mental health policies and legislation
practice has to render nursing • Utilize the knowledge well to protect the rights of health care consumers
care as per the legal • Has to perform all tasks within the scope of practice
system • Keep records complete, clear and up to date
CHAPTER 2 Principles and Concepts of Mental Health Nursing 51

A. Standards of Practice • Standard 13: Culturally sensitive care

• Standard 1: Assessment • Standard 14: Legally safe practice
• Standard 2: Nursing diagnosis
• Standard 3: Expected outcomes of care CONCEPTUAL MODELS IN PSYCHIATRIC
NURSING
• Standard 4: Planning
• Standard 5: Implementation Theories and models in the field of psychiatry are used by
„ Standard 5a: Nursing care delivery to health care mental health professionals to determine the basis of behaviors
consumers and to plan necessary initiations. Many psychosocial theories
„ Standard 5b: Assistance in the delivery of biological have been developed based on theorists’ personal experiences.
therapies Therefore, it is appropriate to refer to these as models rather
„ Standard 5c: Psychotherapeutic interventions than theories.
„ Standard 5d: Safe and therapeutic environment A model is a conceptual system that describes and explains
„ Standard 5e: Health education the relationship between the cause (factors contributing to
„ Standard 5f: Community mental health nursing illness or etiology) and effect (occurrence of illness). In this
services, including reintegration way, a conceptual model serves as a tool to guide and shape
of health care consumers into the human behavior. When models are applied to real nursing
community events, they serve to guide the understanding and behavior of
• Standard 6: Evaluation nurses.
B. Standards of Education
Existential Model/Theory
• Standard 7: Academic excellence
„ Standard 7a: Personal academic development Existential theory is a branch of philosophy that deals with
„ Standard 7b: Capacity building what it identified as existential questions. These are questions
about the meaning of life such as “why do human exists?”,
C. Standards of Administration “how do human exists?”, “what do I value?”, “who am I?” and
• Standard 8: Administrative efficiency “how can I contribute to my world?”.
„ Standard 8a: Personal vision, commitment, technical Assumptions of Existential Model
expertise
„ Standard 8b: Team building Existential psychology assumes that human beings strive to live
„ Standard 8c: Quality assurance a meaningful life. The following are the specific assumptions
„ Standard 8d: Continuing nursing education (Fig. 2.10) based on which the theory is conceptualized:
„ Standard 8e: Leadership
„ Standard 8f: Performance appraisal
„ Standard 8g: Organizational and professional
advancement

D. Standards of Evidence-Based Practice and Research

• Standard 9: Responsible and ethical conduct of research
and integration into practice
„ Standard 9a: Research ethics
„ Standard 9b: Integration of research into practice
„ Standard 9c: Teaching scientific rigor to young nurse
investigators

E. Other Standards of Professional Performance

• Standard 10: Self-care and self-awareness
• Standard 11: Ethics
• Standard 12: Communication Figure 2.10: Assumptions of existential model
52 Textbook of Psychiatric Nursing for BSc Nursing Students

• Personal power: Existential theory believes in the power • On the social dimension: Individuals relate to others
of individuals to choose their actions. as they interact with the public around them. This
• Personal identity: When an individual knows what he/ dimension includes their response to the culture as well
she is as a human, he/she can understand in a better as to the class and race they belong to. The struggle is
way what is right and wrong for him/her. Through between acceptance versus rejection and belonging versus
introspection and talking with others, he can consider isolation.
what unique things make him/her an individual. • On the psychological dimension: Individuals relate to
• Personal freedom: Existential theory believes in the themselves to create a personal world. This dimension
personal freedom of individuals to make their own includes views about their character, their past experience
choices. It also recognizes the difficulty of making and their future possibilities. Contradictions are often
important life choices. experienced regarding personal strengths and weaknesses.
• Individuals’ innate value: Existential model believes in Activity and passivity are important polarities in this
individual’s abilities to choose or make choices which are dimension.
found crucial to live a meaningful life. • On the spiritual dimension: Individuals relate to the
• Authenticity: Being authentic helps an individual to live ideal world, an ideology and a philosophical outlook.
in meaningful ways. They find meaning by putting all the pieces of the puzzle
• Relating to others: Relating to others is an essential part together for themselves. The contradictions are often
of a human life. between purpose and absurdity, hope and despair.
• Contributing to world: One way of exploring the
meaning of one’s life is by contributing to the society. Existential Therapy
Existential psychotherapy is a form of psychotherapy that
Basic Dimensions of Human Existence
contains elements of philosophies, phenomenology and
There are four basic dimensions of human existence: physical, existentialism.
social, psychological and spiritual (Fig. 2.11). These are • Within existential therapy, clinicians work with
interwoven and provide a complex four-dimensional force their clients to help them accept responsibility for their
field for people’s existence. Individuals are stretched between lives.
a positive pole of what they aspire on each dimension and a • Existential therapy deals with people with a restricted
negative pole of what they fear. existence, i.e., they have a limited awareness of themselves
• On the physical dimension: Individuals relate to their and the nature of their problems. They often see few
environment and the natural world around them. This options available to them and feel helpless or trapped.
includes their attitude toward the body, to the concrete • The goal of existential therapy is to understand the
surroundings they find themselves in, to the climate or subjective world of clients and help them come to new
weather, to objects or material possessions, to the bodies understanding and new options.
of other people, their own bodily needs, to health or • This therapy can be applied to a variety of settings such
illness and their mortality. The struggle on this dimension as individual therapy, group therapy, family or couples
is between the search for domination over the elements of therapy and community outreach areas.
nature. There is a need to accept the limitations of natural • The client is the central focus of the therapy and is given
boundaries by recognizing the limitations in order to respect, freedom of choice and responsibility for his/her
deliver a significant release of tension. actions.

Figure 2.11: Basic dimensions of human existence

CHAPTER 2 Principles and Concepts of Mental Health Nursing 53

• The limitation of this therapy is lack of a defined and 2. The personal, “I exist, who am I?”
systematic approach. 3. The transpersonal, “I know who I am. What is the
meaning of my life?”
Other Therapies based on Existential Theory The therapist helps the persons to use techniques such
• Rational-emotive therapy (Albert Ellis): It is an active as guided imagery and meditation for obtaining self-
directive, cognitive-oriented therapy. Confrontation is awareness and control over the course of his/her life.
used to assume responsibility for the patient’s behavior. • Encounter group therapy (William C Schultz, Carl
The patient is encouraged to accept himself/herself as Rogers): Encounter group therapy focuses on the
he/she is, not because of what he/she does. He/she is establishment of intimate interactions in a group setting.
taught to take risks and to try out new behavior. Action is Therapy is oriented to ‘here and now’ principle. The
emphasized for both the patient and the therapist. patient is expected to assume responsibility for his/her
• Logo therapy (Viktor E Frankl): It is a future-oriented own behavior. Feeling is stressed; intellectualization is
therapy. The patient is confronted with and oriented discouraged. Group exercises are frequently used. Group
toward the meaning of life. This search for meaning members are encouraged to share their thoughts and
(logos) is viewed as a primary life force. This includes feelings honestly.
meaning in the spiritual sense. Without a sense of
meaning, life becomes an “existential vacuum”. Psychoanalytic Model
The aim of logo therapy is to promote awareness regarding (Psychodynamic Theories or Concepts)
one’s own responsibility. In essence, the patient is guided to Psychoanalytic Model or Psychodynamic theories explain the
take control of his/her own life and to determine the meaning development of mental or emotional processes and their effects
for him/her. on behavior or relationships. Sigmund Freud (1856–1939) is
• Reality therapy (William Glasser): Central themes are known as the father of psychoanalytic theory. His theory states
the need for identity reached by sense of being loved, that deviations in human behavior result from unsuccessful
feeling worthwhile and behaving responsibly. The task accomplishment during earlier developmental stages. His
patient is helped to recognize his/her life goals and the model is useful in the development of therapeutic relationships,
way he/she keeps himself/herself motivated toward techniques and interventions.
accomplishing his/her goals. The process includes
making the individual aware of the alternatives available. Basic Tenets of Psychoanalytic Model
Another focus of therapy is development of the capacity • Structure of personality or mind
for caring, through the warm acceptance of the therapist. • Topography of mind
The patient is directed to talk about any topic but must • Psychosexual development
focus on behavior rather than feelings. • Object relations and identification
• Gestalt therapy (Frederic S. Pearls): The patient is • Behavioral motivation
encouraged to identity feelings by enhancing self-
awareness. There is focus on body sensations as they Structure of Personality or Mind
reflect feelings. The increased awareness makes the patient The personality consists of three structures: Id, ego and
more sensitive to other aspects of his/her existence. Self- superego.
awareness is expected to lead to self-acceptance. The • Id
patient is assisted in dealing with unfinished business by „ The id is present at birth and is not oriented to reality.
becoming aware of the totality of his/her responses. More „ The id is formed by unconscious desires, primitive
assertion is focused on the “how” and “what” behavior instincts and unstructured drives including sexual
rather than “why”. and aggressive tendencies that arise from the body.
• Psychosynthesis (Roberto Assagioli): Focus on the self. „ Since the id always seeks immediate reduction from
“Self ” is considered “an inner center of awareness and tension, it operates on the pleasure principle.
peace”. • Ego
Three developmental stages are described: „ The ego begins to develop at three years of age.
1. The pre-personal in which an individual asks, “Do I „ The ego develops because the id must negotiate with
exist?” external reality to meet its needs.
54 Textbook of Psychiatric Nursing for BSc Nursing Students

„ The ego consists of certain mental mechanisms such „ Information stored in the unconscious mind affects
as perception, memory and motor control as well as behavior and this information is unavailable to the
specific defense mechanisms. conscious mind.
„ The capacity to form mutually satisfying relationship
Psychosexual Development
is a fundamental function of the ego, which is not
present at birth but it is formed throughout the child’s When development occurs, a child must master the specific
development. psychosexual conflicts to become a healthy and functioning
• Superego adult. The names of the stages reflect the body, and are mostly
„ The superego begins to develop at age of three and it associated with the child’s source of gratification.
is an outgrowth of the ego. • Oral stage occurs between birth and age of 18 months
„ It projects the conscience, one’s inner sense of right „ The child’s needs are satisfied by oral gratification:
and wrong. feeding, exploring objects by placing them in the
„ It is associated with ethics, standards and self-criticism. mouth or exploring by using the lips.
„ If needs are met, the child gains a feeling of trust and
Topography of Mind
well-being.
In this model, human mind is conceptualized in terms „ If needs are not met by the desired level of satisfaction,
of conscious mental processes and unconscious mental the child becomes an adult who is afraid and becomes
processes. Conscious mental process refers to the awareness ill easily.
of events, thoughts and feelings with the ability to recall them. • Anal stage occurs between the age of 18 months and
Unconscious mental processes include thoughts and feelings 3 years
that are outside awareness and are not remembered (Fig. 2.12). „ The child develops an awareness of fullness in the
• The conscious level mind is a part of the ego rectum.
„ The conscious mind is much smaller than the „ The child takes pleasure in retaining or eliminating
unconscious mind. feces.
„ The conscious mind is reality based. „ If this stage is negotiated effectively, the child becomes
„ Any mental information readily available to an an adult who can delay gratification to attain future
individual is located in the conscious mind. goals.
• The subconscious level mind is a part of the ego „ If this stage is inadequately negotiated, the child
„ The subconscious acts as a filtering device between becomes an adult who is either excessively rigid and
the external environment and the ego.
conservative or messy and destructive.
Information stored in the subconscious can be called
• Phallic (Oedipal) stage occurs between the age of 3 and
„

into conscious awareness.

6 years
• The unconscious level mind is a part of the superego
„ The child takes pleasure in exploring and manipulating
„ Comparatively, the unconscious mind is much larger
genitalia.
than the conscious mind.
„ The child is attracted to the opposite-sex parent but
„ The unconscious mind is not reality based.
realizes that he/she cannot sexually relate with his
parent: the dilemma is resolved by identifying with
the same-sex parent.
„ During this stage, the superego develops and the
conscience is formed.
„ If needs are adequately met during this stage, the child
develops a sex-appropriate identity.
„ If needs are inadequately met during this stage, the
child becomes an adult whose sexual identity is
confused and who has problems relating to authority
figures.
• Latency stage occurs between the age of 6 and 12 years
„ The child has learned to express inner drives and
urges in socially acceptable ways: sexual tension is
Figure 2.12: Iceberg metaphor of mind sublimated into age-appropriate activities.
CHAPTER 2 Principles and Concepts of Mental Health Nursing 55

„ If this stage is successfully negotiated, the child • Anxiety arises when unresolved conflicts are stimulated.
becomes an adult who can deal with various life • Severe anxiety may produce behavioral regression to an
situations. early developmental level.
„ If this stage is not successfully negotiated, the child Behavior is always meaningful and often unconsciously
becomes an adult who has difficulty in developing motivated.
social skills and who feels inferior to others.
• Genital stage occurs between the age of 13 and 20 years Behavioral Model (Behavioral Psychology or
„ Corresponding with genital maturation is a Behaviorism)
reawakening of the sex drive. Behavioral model is a theory of learning based upon the idea
„ The child expands energy establishing psychological that all behaviors are acquired through conditioning. John B
independence from parents and family. Watson, BF Skinner and Ivan Pavlov advocated this concept
„ If this stage is completed successfully, an adult emerges and it dominated the field of psychology during the early half
whose personality structure is integrated, allowing the of the twentieth century. Behavioral techniques are still widely
development of love and work relationships. used in therapeutic settings to help clients learn new skills and
„ Unsuccessful completion of this stage results in an behaviors.
adult whose ability to establish intimacy and a strong Under Behavioral model, several types of learning exist with
personal identity is greatly compromised. the contributions of behaviorists. The most basic form is
associative learning, i.e., making a new association between the
Object Relations and Identification
events in the environment. There are two forms of associative
‘Object relations’ is a concept introduced by Sigmund Freud learning: classical conditioning and operant conditioning.
that refers to the psychological attachment to another person 1. Classical conditioning by Ivan Pavlov: It is a reflexive or
or object. He believed that the choice of a sexual partner in automatic type of learning in which a stimulus acquires
adulthood and the nature of that relationship depends on the capacity to evoke a response that was originally
the quality of the child’s object relationships during the early evoked by another stimulus.
formative years. 2. Operant conditioning by BF Skinner: It is based on the
The child’s first love object is the mother, who is the fundamental idea that behaviors which are reinforced will
source of nourishment and the provider of pleasure. Gradually, tend to continue, while behaviors which are punished will
as the child separates from the mother, the nature of this eventually end.
initial attachment influences future relationships. The child Concept of Behaviorism by John Watson: Watson studied
incorporates her mother as a love object, identifies with her how a certain stimulus provokes organisms to make responses.
and grows up to become like mother. He believed psychology was only an objective observation of
Behavioral Motivation behavior.
Behavior which is motivated by anxiety acts as the cornerstone Basic Assumptions of Behavior Theory
of psychopathology.
• All human behavior is a response to a stimulus or stimuli
from the environment.
NURSING IMPLICATION • Human beings can control or determine the behavior of
others.
Implications for Nursing Practice
• The human personality is a mere pattern of stimulus-
• Understanding the psychosexual stages of childhood provides
a framework for understanding behaviors observed in adult response chains or habits.
patients. • Both adaptive and maladaptive behavior are learned or
• Effective parenting can be promoted by teaching parents about strengthened through reinforcement.
the child’s needs during each psychosexual stage. • Maladaptive behavior can be unlearned and replaced
• Successfully identifying manifestations of anxiety provides
by adaptive behavior if the person receives exposure to
clues for planning nursing care.
• Defense mechanisms protect a patient from overwhelming specific stimuli or reinforcements for the desired adaptive
anxiety; the nurse should not deliberately interfere with behavior.
them.
• All behavior is meaningful, often representing the unconscious Basic Premises
needs and wishes of patients who do not always know why they
• There is no such thing as a defect in the personality
behave as they do.
structure.
56 Textbook of Psychiatric Nursing for BSc Nursing Students

• Behavior that is rewarded will persist, whether the

behavior is good or bad.
• Diagnostic labels are irrelevant; the focus of treatment is
the behavior that requires change.

Therapeutic Approaches
• Assertive training: It seeks to alleviate anxiety when
the patient’s anxiety is arising from interpersonal
relationships. Assertiveness implies the ability to stand
up for one’s own rights while not infringing on the rights Figure 2.13: Schema representing the process of need fulfillment
of others. It is differentiated from aggressive behavior according to interpersonal model
which violates others’ rights. In assertiveness training,
the patient identifies his/her usual mode of behavior. This Theoretical Foundations by Sullivan
increases self-esteem and sense of self-control.
Sullivan believed that all human behavior is directed toward the
• Token economy system: It is a positive reinforcement
fulfillment of two needs: Need for satisfaction and the need
program. Usage of this system is to encourage socially
for security. Need for satisfaction is derived from the person’s
acceptable behavior. The person is rewarded with a token
biological needs for air, food, sex, shelter and so on. Need for
when the desirable behavior occurs. He/she is penalized
security by a person is derived from emotional needs of feeling
by removal of tokens when undesirable behavior takes
such as interpersonal intimacy, status and self-esteem.
place. When enough tokens are accumulated, they may
An individual employs a variety of methods to meet these
be spent for snacks, to watch a movie or whatever is
needs, thereby reducing tension. The first step in the process
meaningful to the patient. This pleasurable experience
of need fulfillment is perception of needs. The second step
reinforces the future repetition for the desired behavior.
is the creation of internal tension after the needs have been
• Systematic desensitization: In this therapy, the client will
perceived. The third step in the process of need fulfillment
attain a state of complete relaxation and is then exposed
is employing the age-specific dynamisms. Final step is the
to the stimulus that elicits the anxiety response. There are
fulfillment of needs and release of tension (Fig. 2.13).
three steps in this procedure:
1. Relaxation training Response to Anxiety
2. Constructing a hierarchy of anxiety provoking stimuli
Anxiety is a central theme in the interpersonal theory. Anxiety
3. Desensitization of the stimuli
is a response to feelings of disapproval from a significant adult.
• Aversion therapy: It is a form of behavior modification
The feelings of disapproval may or may not be based on reality.
approach in which an aversive (causing a strong feeling of
When a child experiences anxiety, he defends against
dislike or disgust) stimulus is paired with an undesirable
anxiety by using any of the security operations mentioned in
behavior in order to decrease or eliminate that behavior.
Table 2.20.
• Flooding: Involves patients to a phobic object or situation
in a nongraded manner with no attempt to reduce anxiety. Table 2.20: Security operations used to defend against anxiety
Here, the person is exposed to a phobic stimulus but escape
is made impossible. Prolonged contact with the phobic Apathy Apathy is the complete absence of emotional
stimulus with therapist’s guidance and encouragement expression. So, the emotional expression will
not been associated with the anxiety producing
might decrease the level of anxiety.
situation.
Somnolent A primitive defense in which an individual falls
Interpersonal Model
detachment asleep when confronted by a highly threatening,
Interpersonal theories emphasize the importance of human anxiety producing experience
relationship; instincts and drives are less important. Harry S Selective Anxiety producing aspects of a situation are not
Sullivan is the originator of interpersonal theory. He viewed inattention allowed into awareness, enabling the individual
interpersonal relations as the basis of human development to maintain a sense of stability
and behavior. Sullivan believed that the health or sickness of Preoccupation Consuming interest in a person, thought or
one’s personality is determined by the characteristic pattern of event to the exclusion of the anxiety-producing
reality
interpersonal relations.
CHAPTER 2 Principles and Concepts of Mental Health Nursing 57

Self-concept Not me: If infants are severely deprived or when the majority of
Self-concept is an idea which is self-constructed from the the interpersonal relationships are brought with great threats
beliefs one holds about oneself and the responses of others. to their existence, infants defend themselves by dissociating
The development of self-concept begins in infancy and is the anxiety-generating experiences. Since they cannot develop
closely related to the quality of the infant’s feeding experiences. a sense of self from reflected appraisals, infants develop a “Not
Sullivan described three types of self-concept: Good me, Bad me” concept, which leads to severe emotional problems.
me and Not me. Application to Nursing
Good me: If infants frequently experience satisfaction • It helps to interact successfully with others.
and security from the mothering they receive during the • It helps to assist clients to achieve interpersonal security
feeding process, they begin to see themselves as worthwhile and a sense of well-being.
individuals; they start to develop “Good me” concept. • It is used to help the clients to achieve a higher degree of
Bad me: If the infants’ needs for satisfaction and security are independence and interpersonal functioning.
not met, it will result in anxiety and infants believe that they
are not worthwhile. This leads to the development of “Bad me”
concept.

EXTRA EDGE
ICD-10 Classification of Mental Disorders • F13 Use of sedatives and hypnotics
ICD-10 is 10th revision of the International Statistical Classification • F14 Use of cocaine
of Diseases and Related Health Problems (ICD), a medical • F15 Use of stimulants including caffeine
classification list by the World Health Organization (WHO). • F16 Use of hallucinogens
It contains codes for diseases, signs or symptoms, abnormal • F17 Use of tobacco
findings, complaints, social circumstances, and external causes of • F18 Use of volatile solvents
injuries or diseases. Work on ICD-10 began in 1983, was endorsed • F19 Multiple drug use and use of other psychoactive substances
by the Forty-third World Health Assembly in 1990, and was first • All the conditions coded from F10–19 have the following
used by member states in 1994. subtypes:
„ F 1x.0 Acute intoxication
The fifth chapter of ICD-10 contains the International
„ F 1x.1 Harmful use
Classification of Mental and Behavioral Disorders. It has two
„ F 1x.2 Dependence syndrome
separate publications. The clinical descriptions and diagnostic
„ F 1x.3 Withdrawal state
guidelines (“Blue Book”) are for clinical and general educational
„ F 1x.4 Withdrawal state with delirium
use. The diagnostic criteria for research (“Green Book”) are
„ F 1x.5 Psychotic disorder
intended for research purposes and to be used in conjunction
„ F 1x.6 Amnestic syndrome
with the guidelines within it. The following are the contents of
„ F 1x.7 Residual and late-onset psychotic disorder
fifth chapter:
„ F 1x.8 Other mental and behavioral disorder
F00–F09: Organic, including symptomatic, mental disorders „ F 1x.9 Unspecified mental and behavioral disorder
• F00 Dementia in Alzheimer’s disease
• F01 Vascular dementia F20–F29: Schizophrenia, schizotypal and delusional disorders
• F02 Dementia in other diseases classified elsewhere • F20 Schizophrenia
„ F20.0 Paranoid schizophrenia
• F03 Unspecified dementia
„ F20.1 Hebephrenic schizophrenia (Disorganized schizophrenia)
• F04 Organic amnesic syndrome, not induced by alcohol and
„ F20.2 Catatonic schizophrenia
other psychoactive substances
„ F20.3 Undifferentiated schizophrenia
• F05 Delirium, not induced by alcohol and other psychoactive
„ F20.4 Post-schizophrenic depression
substances
„ F20.5 Residual schizophrenia
• F06 Other mental disorders due to brain damage or
„ F20.6 Simple schizophrenia
dysfunction and physical disease
„ F20.8 Other schizophrenia
• F07 Personality and behavioral disorders due to brain disease,
damage or dysfunction ◆ Cenesthopathic schizophrenia
• F09 Unspecified organic or symptomatic mental disorder ◆ Schizophreniform disorder not otherwise specified (NOS)
◆ Schizophreniform psychosis NOS
F10–F19: Mental and behavioral disorders due to psychoactive „ F20.9 Schizophrenia, unspecified
substance use • F21 Schizotypal disorder
• F10 Use of alcohol • F22 Persistent delusional disorders
• F11 Use of opioids • F23 Acute and transient psychotic disorders
• F12 Use of cannabinoids • F24 Induced delusional disorder
Contd…
58 Textbook of Psychiatric Nursing for BSc Nursing Students

• F25 Schizoaffective disorders „ F51.5 Nightmares

• F28 Other nonorganic psychotic disorders • F52 Sexual dysfunction, not caused by organic disorder or
• F29 Unspecified nonorganic psychosis disease
„ F52.0 Lack or loss of sexual desire
F30–F39: Mood (affective) disorders
„ F52.1 Sexual aversion and lack of sexual enjoyment
• F30 Manic episode
„ F52.2 Failure of genital response
• F31 Bipolar affective disorder
„ F52.3 Orgasmic dysfunction
• F32 Depressive episode
„ F52.4 Premature ejaculation
• F33 Recurrent depressive disorder
„ F52.5 Nonorganic vaginismus
• F34 Persistent mood (affective) disorders
„ F52.6 Nonorganic dyspareunia
„ F34.0 Cyclothymia
„ F52.7 Excessive sexual drive
„ F34.1 Dysthymia
„ F52.8 Other sexual dysfunction, not caused by organic
„ F34.8 Other persistent mood (affective) disorders

„ F34.9 Persistent mood (affective) disorder, unspecified

disorder or disease
„ F52.9 Unspecified sexual dysfunction, not caused by
• F38 Other mood (affective) disorders
• F39 Unspecified mood (affective) disorder organic disorder or disease
• F53 Mental and behavioral disorders associated with the
F40–F48: Neurotic, stress-related and somatoform disorders puerperium, not elsewhere classified
• F40 Phobic anxiety disorders • F54 Psychological and behavioral factors associated with
„ F40.0 Agoraphobia
disorders or diseases classified elsewhere
„ F40.1 Social phobias
• F55 Abuse of non-dependence producing substances
◆ Anthropophobia • F59 Unspecified behavioral syndromes associated with
◆ Social neurosis physiological disturbances and physical factors
„ F40.2 Specific (isolated) phobias

◆ Acrophobia F60–F69: Disorders of adult personality and behavior

◆ Animal phobias • F60 Specific personality disorders
„ F60.0 Paranoid personality disorder
◆ Claustrophobia
„ F60.1 Schizoid personality disorder
◆ Simple phobia
„ F60.2 Dissocial personality disorder
„ F40.8 Other phobic anxiety disorders
„ F60.3 Emotionally unstable personality disorder
„ F40.9 Phobic anxiety disorder, unspecified
„ F60.4 Histrionic personality disorder
• F41 Other anxiety disorders
„ F60.5 Anankastic personality disorder
„ F41.0 Panic disorder (episodic paroxysmal anxiety)
„ F60.6 Anxious (avoidant) personality disorder
„ F41.1 Generalized anxiety disorder
„ F60.7 Dependent personality disorder
• F42 Obsessive-compulsive disorder
„ F60.8 Other specific personality disorders
• F43 Reaction to severe stress, and adjustment disorders
„ F43.0 Acute stress reaction
◆ Eccentric personality disorder
„ F43.1 Post-traumatic stress disorder
◆ Haltlose personality disorder
„ F43.2 Adjustment disorder
◆ Immature personality disorder
• F44 Dissociative (conversion) disorders ◆ Narcissistic personality disorder
• F45 Somatoform disorders ◆ Passive-aggressive personality disorder
• F48 Other neurotic disorders ◆ Psychoneurotic personality disorder
„ F60.9 Personality disorder not otherwise specified/
F50–F59: Behavioral syndromes associated with physiological Personality disorder unspecified
disturbances and physical factors • F61 Mixed and other personality disorders
• F50 Eating disorders • F62 Enduring personality changes, not attributable to brain
„ F50.0 Anorexia nervosa
damage and disease
„ F50.1 Atypical anorexia nervosa
• F63 Habit and impulse disorders
„ F50.2 Bulimia nervosa
„ F63.0 Pathological gambling
„ F50.3 Atypical bulimia nervosa
„ F63.1 Pathological fire-setting (pyromania)
„ F50.4 Overeating associated with other psychological
„ F63.2 Pathological stealing (kleptomania)
disturbances „ F63.3 Trichotillomania
„ F50.5 Vomiting associated with other psychological
„ F63.8 Other habit and impulse disorders
disturbances ◆ Intermittent explosive disorder
„ F50.8 Other eating disorders
• F64 Gender identity disorders
„ F50.9 Eating disorder, unspecified
„ F64.0 Transsexualism
• F51 Nonorganic sleep disorders „ F64.1 Dual-role transvestism
„ F51.0 Nonorganic insomnia
„ F64.2 Gender identity disorder of childhood
„ F51.1 Nonorganic hypersomnia
• F65 Disorders of sexual preference
„ F51.2 Nonorganic disorder of the sleep-wake schedule
„ F65.0 Sexual fetishism
„ F51.3 Sleep walking (somnambulism)
„ F65.1 Fetishistic transvestism
„ F51.4 Sleep terrors (night terrors)
„ F65.2 Exhibitionism

Contd…
CHAPTER 2 Principles and Concepts of Mental Health Nursing 59

„ F65.3 Voyeurism „ F84.1 Atypical autism

„ F65.4 Pedophilia „ F84.2 Rett’s syndrome
„ F65.5 Sadomasochism „ F84.3 Other childhood disintegrative disorder

„ F65.6 Multiple disorders of sexual preference „ F84.4 Overactive disorder associated with mental

„ F65.8 Other disorders of sexual preference retardation and stereotyped movements

◆ Frotteurism „ F84.5 Asperger’s syndrome

◆ Necrophilia • F88 Other disorders of psychological development

◆ Zoophilia • F89 Unspecified disorder of psychological development
• F66 Psychological and behavioral disorders associated with F90–F98: Behavioral and emotional disorders with onset
sexual development and orientation (Specifically states usually occurring in childhood and adolescence
that “sexual orientation by itself is not to be considered a • F90 Hyperkinetic disorders
disorder”) „ F90.0 Disturbance of activity and attention
„ F66.0 Sexual maturation disorder
◆ Attention-deficit hyperactivity disorder
„ F66.1 Ego-dystonic sexual orientation
◆ Attention deficit syndrome with hyperactivity
„ F66.2 Sexual relationship disorder
„ F90.1 Hyperkinetic conduct disorder
„ F66.8 Other psychosexual development disorders
„ F90.8 Other hyperkinetic disorders
„ F66.9 Psychosexual development disorder, unspecified
„ F90.9 Hyperkinetic disorder, unspecified
• F68 Other disorders of adult personality and behavior • F91 Conduct disorders
„ F68.0 Elaboration of physical symptoms for psychological
„ F91.0 Conduct disorder confined to the family context
reasons „ F91.1 Unsocialized conduct disorder
„ F68.1 Intentional production or feigning of symptoms or
„ F91.2 Socialized conduct disorder
disabilities, either physical or psychological (factitious „ F91.3 Oppositional defiant disorder
disorder) „ F91.8 Other conduct disorders
◆ Munchausen syndrome „ F91.9 Conduct disorder, unspecified
„ F68.8 Other specified disorders of adult personality and
• F92 Mixed disorders of conduct and emotions
behavior • F93 Emotional disorders with onset specific to childhood
• F69 Unspecified disorder of adult personality and behavior „ F93.0 Separation anxiety disorder of childhood

F70–F79: Mental retardation „ F93.1 Phobic anxiety disorder of childhood

• F70 Mild mental retardation „ F93.2 Social anxiety disorder of childhood

• F71 Moderate mental retardation „ F93.3 Sibling rivalry disorder

• F72 Severe mental retardation „ F93.8 Other childhood emotional disorders

• F73 Profound mental retardation ◆ Identity disorder

• F78 Other mental retardation ◆ Overanxious disorder
• F79 Unspecified mental retardation „ F93.9 Childhood emotional disorder, unspecified

F80–F89: Disorders of psychological development • F94 Disorders of social functioning with onset specific to
• F80 Specific developmental disorders of speech and language childhood and adolescence
„ F94.0 Elective mutism
„ F80.0 Specific speech articulation disorder
„ F94.1 Reactive attachment disorder of childhood
„ F80.1 Expressive language disorder
„ F94.2 Disinhibited attachment disorder of childhood
„ F80.2 Receptive language disorder
„ F94.8 Other childhood disorders of social functioning
„ F80.3 Acquired aphasia with epilepsy (Landau-Kleffner)
„ F94.9 Childhood disorder of social functioning, unspecified
„ F80.8 Other developmental disorders of speech and language

◆ Lisping • F95 Tic disorders

„ F80.9 Developmental disorder of speech and language,
• F98 Other behavioral and emotional disorders with onset
unspecified usually occurring in childhood and adolescence
„ F98.0 Nonorganic enuresis
• F81 Specific developmental disorders of scholastic skills
„ F98.1 Nonorganic encopresis
„ F81.0 Specific reading disorder
„ F98.2 Feeding disorder of infancy and childhood
◆ Developmental dyslexia
„ F98.3 Pica of infancy and childhood
„ F81.1 Specific spelling disorder
„ F98.4 Stereotyped movement disorders
„ F81.2 Specific disorder of arithmetical skills
„ F98.5 Stuttering (stammering)
◆ Developmental acalculia
„ F98.6 Cluttering
◆ Gerstmann syndrome
„ F98.8 Other specified behavioral and emotional disorders
„ F81.3 Mixed disorder of scholastic skills

„ F81.8 Other developmental disorders of scholastic skills

with onset usually occurring in childhood or
„ F81.9 Developmental disorder of scholastic skills, unspecified
adolescence
„ F98.9 Unspecified behavioral and emotional disorders
• F82 Specific developmental disorder of motor function
„ Developmental coordination disorder
with onset usually occurring in childhood or
• F83 Mixed specific developmental disorders adolescence
• F84 Pervasive developmental disorders F99: Unspecified mental disorder
„ F84.0 Childhood autism F99.0 Mental disorder, not otherwise specified
60 Textbook of Psychiatric Nursing for BSc Nursing Students

EXTRA EDGE
DSM IV-TR „ Substance-related disorders
The need for a classification of mental disorders has been „ Schizophrenia and other psychotic disorders
„ Mood disorders
clear throughout the history of medicine. Various systems for
„ Anxiety disorders
categorizing mental disorders have differed with respect to
„ Somatoform disorders
whether their principal objective was used in clinical areas,
„ Factitious disorders
research, or in administrative settings.
„ Dissociative disorders
Diagnostic and Statistical Manual of Mental Disorders, 4th
„ Sexual and gender identity disorders
Edition, Text Revision, also known as DSM-IV-TR, is a manual
„ Eating disorders
published by the American Psychiatric Association (APA) in 1994
„ Sleep disorders
that includes all currently recognized mental disorders.
„ Impulse-control disorders not classified elsewhere
Components of DSM-IV-TR „ Adjustment disorders
• Instructions on how to use the manual „ Other conditions that may be a focus of clinical attention.
• DSM-IV classification system • Axis II provides information about personality disorders and
• Multi axial system mental retardation. Disorders which would have fallen under
• Diagnostic criteria this axis include:
Salient Features of DSM-IV „ Paranoid personality disorder

• It provide the framework for classifying the disorders and „ Schizoid personality disorder

defining the diagnostic criteria for the list of disorders, in „ Schizotypal personality disorder

which some disorders are first diagnosed in infancy, childhood „ Antisocial personality disorder

or adolescence. „ Borderline personality disorder

• Adult diagnosis can be used for children who are considered „ Histrionic personality disorder
for a specific diagnosis. „ Narcissistic personality disorder
• Criteria for mental retardation are more compatible with „ Avoidant personality disorder
the definitions as per the American Association of Mental „ Dependent personality disorder
Retardation. „ Obsessive-compulsive personality disorder
• Categories of organic mental disorders fall under delirium, „ Personality disorder not specified otherwise
dementia and amnestic and other cognitive disorders. „ Mental retardation
• This section of schizophrenia and other psychotic disorders • Axis III provides information about any medical conditions
brings together these sections of DSM-III-R that were all that were present which might impact the patient’s mental
characterized by having psychotic symptoms as their main disorder or its management.
features. • Axis IV is used to describe psychosocial and environmental
• The mood disorder criteria have been polished (e.g., in order factors affecting a person. Factors which might have been
to qualify as mania, symptoms have to be present for at least included here are as follows:
a week). „ Problems with a primary support group
• The section of anxiety disorders starts by noting that panic „ Problems related to the social environment
attacks can be a feature of a variety of anxiety disorders. „ Educational problems
• Acute stress disorder has been added to cover acute reactions „ Occupational problems
to stress. „ Housing problems
• The diagnostic classes of dissociative disorder and sleep „ Economic problems
disorders are more compatible with the ICD-10. „ Problems with access to health care services
• The diagnostic classes of somatoform disorders and personality „ Problems related to interaction with the legal system/crime
disorders have been clarified. There is a special effort to avoid „ Other psychosocial and environmental problems.
gender bias in the section on personality disorders. • Axis V is a rating scale called the Global Assessment of
• In the multiaxial system, Axis IV codes psychosocial and Functioning (GAF); the GAF goes from 0 to 100 and provides a
environmental problems rather than a rating scale for severity way to summarize in a single number that denotes the overall
of stressors. functioning of an individual. A general outline of this scale
Multiaxial System of DSM-IV-TR would be as follows:
• Axis I provides information about clinical disorders. Any mental „ 100: No symptoms.

health conditions, other than personality disorders or mental „ 90: Minimal symptoms with good functioning.

retardation, would have been included here. Disorders which „ 80: Transient symptoms that are expected reactions to

would have fallen under this axis include: psychosocial stressors.

„ Disorders usually diagnosed in infancy, childhood or „ 70: Mild symptoms or some difficulty in social, occupational

adolescence or school functioning.

„ Delirium, dementia, amnesia and other cognitive disorders „ 60: Moderate symptoms or moderate difficulty in social,

„ Mental disorders due to a general medical condition occupational or school functioning.

Contd…
CHAPTER 2 Principles and Concepts of Mental Health Nursing 61

„ 50: Serious symptoms or any serious impairment in social, Feeding and Eating Disorders of Infancy or Early Childhood
occupational or school functioning. • 307.52 Pica
„ 40: Some impairment in reality testing or communication or • 307.53 Rumination disorder
major impairment in several areas such as work or school, • 307.59 Feeding disorder of infancy or early childhood
family relations, judgment, thinking or mood. Tic Disorders
„ 30: Behavior is considerably influenced by delusions or • 307.23 Tourette’s disorder
hallucinations or serious impairment in communication or • 307.22 Chronic motor or vocal tic disorder
judgment or inability to function in almost all areas. • 307.21 Transient tic disorder
„ 20: Some danger of hurting self or others or occasionally • 307.20 Tic disorder not otherwise specified
fails to maintain minimal personal hygiene or gross
impairment in communication. Elimination Disorders
„ 10: Persistent danger of severely hurting self or others or • 307.6 Enuresis (not due to a general medical condition)
persistent inability to maintain minimal personal hygiene or • 307.7 Encopresis, without constipation and overflow
serious suicidal act with clear expectation of death. incontinence
• 787.6 Encopresis, with constipation and overflow
DSM-IV-TR Classification System incontinence
Disorders usually first diagnosed in infancy, childhood or
Other Disorders of Infancy, Childhood or Adolescence
adolescence.
• 309.21 Separation anxiety disorder
Mental Retardation • 313.23 Selective mutism
• 317 Mild mental retardation • 313.89 Reactive attachment disorder of infancy or early
• 318.0 Moderate mental retardation childhood
• 318.1 Severe mental retardation • 307.3 Stereotypic movement disorder
• 318.2 Profound mental retardation • 313.9 Disorder of infancy, childhood or adolescence not
• 319 Mental retardation; severity unspecified otherwise specified
Learning Disorders Delirium, Dementia, and Amnestic and Other Cognitive Disorders
• 315.00 Reading disorder
Delirium
• 315.1 Mathematics disorder
• 293.0 Delirium due to... [indicate the general medical
• 315.2 Disorder of written expression
condition]
• 315.9 Learning disorder not otherwise specified
• 780.09 Delirium not otherwise specified
Motor Skills Disorders
Dementia
315.4 Developmental coordination disorder
• Dementia of the Alzheimer’s type, with early onset
Communication Disorders „ 294.10 Without behavioral disturbance
• 315.31 Expressive language disorder „ 294.11 With behavioral disturbance
• 315.32 Mixed receptive-expressive language disorder • Dementia of the Alzheimer’s type, with late onset
• 315.39 Phonological disorder • Vascular dementia
• 307.0 Stuttering • Dementia due to HIV disease
• 307.9 Communication disorder not otherwise specified • Dementia due to head trauma
Pervasive Developmental Disorders • Dementia due to Parkinson’s disease
• 299.00 Autistic disorder • Dementia due to Huntington’s disease
• 299.80 Rett’s disorder • Dementia due to Pick’s disease
• 299.10 Childhood disintegrative disorder • Dementia due to Creutzfeldt -Jacob disease
• 299.80 Asperger’s disorder • Dementia due to... [indicate other general medical condition]
• 299.80 Pervasive developmental disorder not otherwise • 294.8 Dementia not otherwise specified
specified Amnestic Disorders
Attention-deficit and Disruptive Behavior Disorders • 294.0 Amnestic disorder due to... [indicate the general
• Attention-deficit hyperactivity disorder medical condition]
„ 314.01 Combined subtype • 294.8 Amnestic disorder not otherwise specified
„ 314.01 Predominantly hyperactive-impulsive subtype Other Cognitive Disorders
„ 314.00 Predominantly inattentive subtype • 294.9 Cognitive disorder not otherwise specified
„ 314.9 Attention-deficit hyperactivity disorder not

otherwise specified Mental Disorders due to a General Medical Condition

Not Elsewhere Classified
Conduct Disorder • 293.89 Catatonic disorder due to... [indicate the general
• 312.81 Childhood onset medical condition]
• 312.82 Adolescent onset • 310.1 Personality change due to... [indicate the general
• 312.89 Unspecified onset medical condition]
• 313.81 Oppositional defiant disorder „ (Subtypes: Labile, disinhibited, aggressive, apathetic,
• 312.9 Disruptive behavior disorder not otherwise specified paranoid, other, combined, unspecified)

Contd…
62 Textbook of Psychiatric Nursing for BSc Nursing Students

• 293.9 Mental disorder not otherwise specified due to... • 292.9 Related disorder not otherwise specified
[indicate the general medical condition] • 292.0 Withdrawal
Substance-related Disorders Hallucinogen-related Disorders
Alcohol-related Disorders • 305.30 Abuse
• 305.00 Abuse • 304.50 Dependence
• 303.90 Dependence • 292.89 Induced anxiety disorder
• 291.89 Induced anxiety disorder • 292.84 Induced mood disorder
• 291.89 Induced mood disorder • 292.11 Induced psychotic disorder, with delusions
• 291.1 Induced persisting amnestic disorder • 292.12 Induced psychotic disorder, with hallucinations
• 291.2 Induced persisting dementia • 292.89 Intoxication
• 291.5 Induced psychotic disorder, with delusions • 292.81 Intoxication delirium
• 291.3 Induced psychotic disorder, with hallucinations • 292.89 Persisting perception disorder
• 291.89 Induced sexual dysfunction • 292.9 Related disorder not otherwise specified
• 291.89 Induced sleep disorder Inhalant-related Disorders
• 303.00 Intoxication • 305.90 Abuse
• 291.0 Intoxication delirium • 304.60 Dependence
• 291.9 Related disorder not otherwise specified • 292.89 Induced anxiety disorder
• 291.81 Withdrawal • 292.84 Induced mood disorder
• 291.0 Withdrawal delirium • 292.82 Induced persisting dementia
Amphetamine (or amphetamine-like) Related Disorders • 292.11 Induced psychotic disorder, with delusions
• 305.70 Abuse • 292.12 Induced psychotic disorder, with hallucinations
• 304.40 Dependence • 292.89 Intoxication
• 292.89 Induced anxiety disorder • 292.81 Intoxication delirium
• 292.84 Induced mood disorder • 292.9 Related disorder not otherwise specified
• 292.11 Induced psychotic disorder, with delusions Nicotine-related Disorders
• 292.12 Induced psychotic disorder, with hallucinations • 305.1 Dependence
• 292.89 Induced sexual dysfunction • 292.9 Related disorder Not Otherwise Specified
• 292.89 Induced sleep disorder • 292.0 Withdrawal
• 292.89 Intoxication Opioid-related Disorders
• 292.81 Intoxication delirium • 305.50 Abuse
• 292.9 Related disorder not otherwise specified • 304.00 Dependence
• 292.0 Withdrawal • 292.84 Induced mood disorder
Caffeine-related Disorders • 292.11 Induced psychotic disorder, with delusions
• 292.89 Induced anxiety disorder • 292.12 Induced psychotic disorder, with hallucinations
• 292.89 Induced sleep disorder • 292.89 Induced sexual dysfunction
• 305.90 Intoxication • 292.89 Induced sleep disorder
• 292.9 Related disorder not otherwise specified • 292.89 Intoxication
Cannabis-related Disorders • 292.81 Intoxication delirium
• 305.20 Abuse • 292.9 Related disorder Not Otherwise Specified
• 304.30 Dependence • 292.0 Withdrawal
• 292.89 Induced anxiety disorder Phencyclidine (or Phencyclidine-like) Related Disorders
• 292.11 Induced psychotic disorder, with delusions • 305.90 Abuse
• 292.12 Induced psychotic disorder, with hallucinations • 304.60 Dependence
• 292.89 Intoxication • 292.89 Induced anxiety disorder
• 292.81 Intoxication delirium • 292.84 Induced mood disorder
• 292.9 Related disorder not otherwise specified • 292.11 Induced psychotic disorder, with delusions
Cocaine-related Disorders • 292.12 Induced psychotic disorder, with hallucinations
• 305.60 Abuse • 292.89 Intoxication
• 304.20 Dependence • 292.81 Intoxication delirium
• 292.89 Induced anxiety disorder • 292.9 Related disorder not otherwise specified
• 292.84 Induced mood disorder Sedative, Hypnotic or Anxiolytic Related Disorders
• 292.11 Induced psychotic disorder, with delusions • 305.40 Abuse
• 292.12 Induced psychotic disorder, with hallucinations • 304.10 Dependence
• 292.89 Induced sexual dysfunction • 292.89 Induced anxiety disorder
• 292.89 Induced sleep disorder • 292.84 Induced mood disorder
• 292.89 Intoxication • 292.83 Induced persisting amnestic disorder
• 292.81 Intoxication delirium • 292.82 Induced persisting dementia

Contd…
CHAPTER 2 Principles and Concepts of Mental Health Nursing 63

• 292.11 Induced psychotic disorder, with delusions „ Major depressive disorder, recurrent
• 292.12 Induced psychotic disorder, with hallucinations ◆ 296.36 In full remission
• 292.89 Induced sexual dysfunction ◆ 296.35 In partial remission
• 292.89 Induced sleep disorder ◆ 296.31 Mild
• 292.89 Intoxication ◆ 296.32 Moderate
• 292.81 Intoxication delirium ◆ 296.33 Severe without psychotic features
• 292.9 Related disorder not otherwise specified ◆ 296.34 Severe with psychotic features
• 292.0 Withdrawal ◆ 296.30 Unspecified
• 292.81 Withdrawal delirium „ Major depressive disorder, single episode

Polysubstance-related Disorder ◆ 296.26 In full remission

• 304.80 Polysubstance dependence ◆ 296.25 In partial remission
◆ 296.21 Mild
Other (or unknown) Substance-related Disorder
◆ 296.22 Moderate
• 305.90 Abuse
◆ 296.23 Severe without psychotic features
• 304.90 Dependence
◆ 296.24 Severe with psychotic features
• 292.89 Induced anxiety disorder
◆ 296.20 Unspecified
• 292.81 Induced delirium
• 311 Depressive disorders not otherwise specified
• 292.84 Induced mood disorder
• 292.83 Induced persisting amnestic disorder Bipolar Disorders
• 292.82 Induced persisting dementia • 296.80 Bipolar disorder not otherwise specified
• 292.11 Induced psychotic disorder, with delusions • Bipolar I disorder, most recent episode depressed
• 292.12 Induced psychotic disorder, with hallucinations „ 296.56 In full remission
• 292.89 Induced sexual dysfunction „ 296.55 In partial remission
• 292.89 Induced sleep disorder „ 296.51 Mild
• 292.89 Intoxication „ 296.52 Moderate
• 292.9 Related disorder not otherwise specified „ 296.53 Severe without psychotic features
• 292.0 Withdrawal „ 296.54 Severe with psychotic features
• 293.0 Delirium due to general medical condition „ 296.50 Unspecified

Schizophrenia and Other Psychotic Disorders • 296.40 Bipolar I disorder, most recent episode hypomanic
• Schizophrenia • Bipolar I disorder, most recent episode manic
„ 296.46 In full remission
„ 295.20 Catatonic type
„ 296.45 In partial remission
„ 295.10 Disorganized type
„ 296.41 Mild
„ 295.30 Paranoid type
„ 296.42 Moderate
„ 295.60 Residual type
„ 296.43 Severe without psychotic features
„ 295.90 Undifferentiated type
„ 296.44 Severe with psychotic features
• 295.40 Schizophreniform disorder
„ 296.40 Unspecified
• 295.70 Schizoaffective disorder
• 297.1 Delusional disorder • Bipolar I disorder, most recent episode mixed
„ Erotomanic subtype „ 296.66 In full remission

„ Grandiose subtype „ 296.65 In partial remission

„ Jealous subtype „ 296.61 Mild

„ Persecutory subtype „ 296.62 Moderate

„ Somatic subtype „ 296.63 Severe without psychotic features

„ Mixed type „ 296.64 Severe with psychotic features

• 298.8 Brief psychotic disorder „ 296.60 Unspecified

• 297.3 Shared psychotic disorder • 296.7 Bipolar I disorder, most recent episode unspecified
• Psychotic disorder due to... [indicate the general medical • Bipolar I disorder, single manic episode
condition] „ 296.06 In full remission

„ 293.81 With delusions „ 296.05 In partial remission

„ 293.82 With hallucinations „ 296.01 Mild

• 298.9 Psychotic disorder not otherwise specified „ 296.02 Moderate

„ 296.03 Severe without psychotic features

Mood Disorders
„ 296.04 Severe with psychotic features
• 293.83 Mood disorder due to...[indicate the general medical
„ 296.00 Unspecified
condition]
• 296.89 Bipolar II disorder
• 296.90 mood disorder not otherwise specified
• 301.13 Cyclothymic disorder
Depressive Disorders • 293.83 Mood disorder due to... [indicate the general medical
• 300.4 Dysthymic disorder condition]
• Major depressive disorder • 296.90 Mood disorder not otherwise specified
Contd…
64 Textbook of Psychiatric Nursing for BSc Nursing Students

Anxiety Disorders • 608.89 Other male sexual dysfunction due to... [indicate the
• 300.02 Generalized anxiety disorder general medical condition]
• Panic disorder • 302.70 Sexual dysfunction not otherwise specified
„ 300.21 With agoraphobia
Paraphilias
„ 300.01 Without agoraphobia
• 302.4 Exhibitionism
• 300.22 Agoraphobia without history of panic disorder • 302.81 Fetishism
• 300.29 Specific phobia • 302.89 Frotteurism
• 300.23 Social phobia • 302.2 Pedophilia
• 300.3 Obsessive-compulsive disorder • 302.83 Sexual masochism
• 309.81 Post-traumatic stress disorder • 302.84 Sexual sadism
• 308.3 Acute stress disorder • 302.3 Transvestic fetishism
Somatoform Disorders • 302.82 Voyeurism
• 300.81 Somatization disorder • 302.9 Paraphilia not otherwise specified
• 300.82 Undifferentiated somatoform disorder Gender Identity Disorders
• 300.11 Conversion disorder • Gender identity disorder
• Pain disorder „ 302.85 In adolescents or adults

„ 307.89 Associated with both psychological factors and a „ 302.6 In children

general medical condition „ 302.6 Gender identity disorder not otherwise specified

„ 307.80 Associated with psychological factors • 302.9 Sexual disorder not otherwise specified
• 300.7 Hypochondriasis
Eating Disorders
• 300.7 Body dysmorphic disorder
• 307.1 Anorexia nervosa
• 300.82 Somatoform disorder not otherwise specified
• 307.51 Bulimia nervosa
Factitious Disorders • 307.50 Eating disorder not otherwise specified (EDNOS)
• 300.19 With combined psychological and physical signs and
Sleep Disorders
symptoms
• 300.19 With predominantly physical signs and symptoms Primary Sleep Disorders
• 300.16 With predominantly psychological signs and • 307.44 Primary hypersomnia
symptoms • 307.42 Primary insomnia
• 300.19 Factitious disorder not otherwise specified • 347 Narcolepsy
• 780.59 Breathing-related sleep disorder
Dissociative Disorders • 307.45 Circadian rhythm sleep disorder
• 300.6 Depersonalization disorder • 307.47 Dyssomnia not otherwise specified
• 300.12 Dissociative amnesia • 327.03 Insomnia related to mood disorder (ICD 9)
• 300.14 Dissociative identity disorder
Parasomnias
• 300.15 Dissociative disorder not otherwise specified
• 307.47 Nightmare disorder
Sexual and Gender Identity Disorders • 307.46 Sleep terror disorder
Sexual Dysfunctions • 307.46 Sleepwalking disorder
• 625.8 Female hypoactive sexual desire disorder due to... • 307.47 Parasomnia not otherwise specified
[indicate the general medical condition] Other Sleep Disorders
• 608.89 Male hypoactive sexual desire disorder due to... • Sleep disorder
[indicate the general medical condition] „ Sleep disorder due to... [indicate the general medical
• 302.71 Hypoactive sexual desire disorder condition]
• 302.79 Sexual aversion disorder „ 780.54 Hypersomnia type
• 302.72 Female sexual arousal disorder „ 780.52 Insomnia type
• 302.72 Male erectile disorder „ 780.59 Mixed type
• 607.84 Male erectile disorder due to... [indicate the general „ 780.59 Parasomnia type
medical condition] • 307.42 Insomnia related to... [indicate the Axis I or Axis II
• 302.73 Female orgasmic disorder disorder]
• 302.74 Male orgasmic disorder • 307.44 Hypersomnia related to... [indicate the Axis I or Axis II
• 302.75 Premature ejaculation disorder]
• 302.76 Dyspareunia (not due to a general medical condition)
• 625.0 Female dyspareunia due to... [indicate the general Impulse-Control Disorders Not Elsewhere Classified
medical condition] • 312.34 Intermittent explosive disorder
• 608.89 Male dyspareunia due to... [indicate the general • 312.32 Kleptomania
medical condition] • 312.31 Pathological gambling
• 306.51 Vaginismus (not due to a general medical condition) • 312.33 Pyromania
• 625.8 Other female sexual dysfunction due to... [indicate the • 312.39 Trichotillomania
general medical condition] • 312.30 Impulse-control disorder not otherwise specified

Contd…
CHAPTER 2 Principles and Concepts of Mental Health Nursing 65

Adjustment Disorders „ 333.1 Postural tremor

• 309.9 Unspecified • Neglect of child

• 309.24 With anxiety „ V61.21 Neglect of child

• 309.0 With depressed mood „ 995.5 Neglect of child (if focus of attention is on victim)

• 309.3 With disturbance of conduct • Neuroleptic-induced

• 309.28 With mixed anxiety and depressed mood „ 333.99 Acute akathisia

• 309.4 With mixed disturbance of emotions and conduct „ 333.7 Acute dystonia

„ 332.1 Parkinsonism
Personality Disorders (AXIS II)
„ 333.82 Tardive dyskinesia
Cluster A (odd or eccentric) „ 333.92 Neuroleptic malignant syndrome
• 301.0 Paranoid personality disorder • V71.09 No diagnosis on Axis II
• 301.20 Schizoid personality disorder • V71.09 No diagnosis or condition on Axis I
• 301.22 Schizotypal personality disorder • V15.81 Noncompliance with treatment
Cluster B (dramatic, emotional or erratic) • V62.2 Occupational problem
• 301.7 Antisocial personality disorder • V61.20 Parent-child relational problem
• 301.83 Borderline personality disorder • V61.10 Partner relational problem
• 301.50 Histrionic personality disorder • V62.89 Phase of life problem
• 301.81 Narcissistic personality disorder • Physical abuse
„ V61.1 Physical abuse of adult
Cluster C (anxious or fearful)
„ 995.81 Physical abuse of adult (if focus of attention is on
• 301.82 Avoidant personality disorder
• 301.6 Dependent personality disorder victim)
„ V61.21 Physical abuse of child
• 301.4 Obsessive-compulsive personality disorder
„ 995.5 Physical abuse of child (if focus of attention is on
NOS
victim)
301.9 Personality disorder not otherwise specified
• 316 Psychological factors affecting medical condition
Additional Codes • Relational problem
• V62.3 Academic problem „ V62.81 Relational problem not otherwise specified

• V62.4 Acculturation problem „ V61.9 Relational problem related to a mental disorder or

• 995.2 Adverse effects of medication not otherwise specified general medical condition
• 780.9 Age-related cognitive decline • V62.89 Religious or spiritual problem
• Antisocial behavior • V61.1 Sexual abuse of adult
„ V71.01 Adult antisocial behavior • 995.83 Sexual abuse of adult (if focus of attention is on victim)
„ V71.02 Child or adolescent antisocial behavior • V61.21 Sexual abuse of child
• V62.82 Bereavement • 995.53 Sexual abuse of child (if focus of attention is on victim)
• V62.89 Borderline intellectual functioning • V61.8 Sibling relational problem
• 313.82 Identity problem • 300.9 Unspecified mental disorder (non-psychotic)
• Medication-induced • 799.9 Diagnosis deferred on Axis II
• Movement disorder • 799.9 Diagnosis or condition deferred on Axis I
„ 333.90 Movement disorder not otherwise specified • V65.2 Malingering

SUMMARY
• Mental health nursing is defined as a branch of nursing which deals with the study of measures in order to prevent mental illnesses,
promote mental health and restore the patient with mental illnesses.
• International Classification of Diseases (ICD) has been given by World Health Organization (WHO). The codes of ICD-11 are
alphanumeric and cover the range from 1A00.00 to ZZ9Z.ZZ. Codes starting with ‘X’ indicate an extension code (see Extension codes).
The inclusion of a forced number at the 3rd character position prevents spelling ‘undesirable’ words. The letters ‘O’ and ‘I’ are omitted
to prevent confusion with the numbers ‘0’ and ‘1’. Chapters are indicated by the first character. For example, 1A00 is a code in Chapter 1,
and BA00 is a code in Chapter 11.
• Diagnostic Statistical Manual (DSM) Classification of Mental Disorders has been given by American Psychiatric Association (APA).
DSM-5 diagnostic chapters are as follows:
„ Schizophrenia spectrum and other psychotic disorders

„ Bipolar and related disorders

„ Depressive disorders

„ Anxiety disorders

„ Obsessive-compulsive and related disorders

„ Trauma and stressor-related disorders

Contd…
66 Textbook of Psychiatric Nursing for BSc Nursing Students

„ Dissociative disorders
„ Somatic symptom and related disorders
„ Feeding and eating disorders

„ Elimination disorders

„ Sleep-wake disorders

„ Sexual dysfunctions

„ Gender dysphoria

„ Disruptive, impulsive and conduct disorders

„ Substance-related and addictive disorders

„ Neurocognitive disorders

„ Personality disorders

„ Paraphilic disorders

„ Other mental disorders

• Personality is defined as a set of behaviors, cognitions and emotional patterns that evolve from biological and environmental factors.
• Perspectives in personality theory are psychoanalytic perspective, behaviorist perspective, humanistic perspective and trait perspective.
• Theories of personality development include psychoanalytic theory, Neo-Freudian approaches, Jung theory, Erikson’s theory of
psychosocial development, Bandura’s social learning theory, Rogers theory of personality and trait approach.
• Defense mechanism is defined as ‘unconscious processes which defend the individual and protect from the anxiety’.
• George Eman Vaillant, a psychiatrist, described four-level classification of defense mechanisms as pathological, immature, neurotic
and mature type.
• Pathological defense mechanisms are conversion, denial, superiority complex and inferiority complex.
• Immature defense mechanisms are acting out, fantasy, wishful thinking, idealization, passive aggression, projection and somatization.
• Neurotic defense mechanisms are displacement, dissociation, hypochondriasis, intellectualization, rationalization, reaction formation,
regression, repression, undoing, withdrawal, upward and downward social comparison.
• Mature defense mechanisms are patience, acceptance, mindfulness, humility, courage, gratitude, altruism, forgiveness, anticipation,
emotional self-regulation, humor, emotional self-sufficiency, thought suppression, sublimation and identification.
• Biopsychosocial etiology of mental illness includes biological factors (genetic factors, biochemical factors, structural damage to brain,
infections, maternal factors, prenatal damage, hormonal factors and other factors), psychological factors, environmental factors and
social factors.
• Structurally, the brain is divided into cerebrum, cerebellum, brain stem and limbic system.
• Neuron is the structural and functional unit of brain. Neurotransmission is the fundamental process that transfers information between
neurons. Neurotransmitters are classified based on the chemical structure (amino acid group, cholinergic group, catecholamines,
neuropeptides group, indolamines group) and they depend on the functions (excitatory and inhibitory).
• Principles of psychiatric nursing include:
„ Accept the client exactly as he/she is

„ Use self-understanding as a therapeutic tool

„ Use of consistent behavior might contribute to the client’s security

„ Give reassurance in an acceptable and subtle manner

„ Change the client’s behavior by emotional experience rather than rational interpretation

„ Avoid unnecessary increase in client’s anxiety

„ Use objective observation to understand client’s behavior

„ Maintain a realistic nurse-client relationship

„ Avoid physical and verbal forces as much as possible

„ Focus nursing care on the patient as a person rather than controlling symptoms

„ Give all explanations of procedures and routines according to the client’s level of understanding

„ Many procedures are modified but basic principles remain unchanged.

• Standards of care include:

„ Standard I: Assessment

„ Standard II: Diagnosis

„ Standard III: Outcome identification

„ Standard IV: Planning

„ Standard V: Implementation

◆ Standard Va: Counseling

◆ Standard Vb: Milieu therapy
◆ Standard Vc: Self-care activities
◆ Standard Vd: Psychobiological interventions
◆ Standard Ve: Health teaching
◆ Standard Vf: Case management
◆ Standard Vg: Health promotion and health maintenance

Contd…
CHAPTER 2 Principles and Concepts of Mental Health Nursing 67

◆ Standard Vh: Psychotherapy

◆ Standard Vi: Prescription of pharmacological agents
◆ Standard Vj: Consultation
„ Standard VI: Evaluation

• Standards of professional performance include:

„ Standard I: Quality of care

„ Standard II: Performance appraisal

„ Standard III: Education

„ Standard IV: Collegiality

„ Standard V: Ethics

„ Standard VI: Collaboration

„ Standard VII: Research

„ Standard VIII: Resource utilization

• Conceptual models in psychiatric nursing include existential model, psychoanalytical model, behavioral model and interpersonal
model.
• Indian Nursing Council Standards in Mental Health Nursing
A. Standards of Practice
◆ Standard 1: Assessment
◆ Standard 2: Nursing diagnosis
◆ Standard 3: Expected outcomes of care
◆ Standard 4: Planning
◆ Standard 5: Implementation
¾ Standard 5a: Nursing care delivery to health care consumers
¾ Standard 5b: Assistance in the delivery of biological therapies
¾ Standard 5c: Psychotherapeutic interventions
¾ Standard 5d: Safe and therapeutic environment
¾ Standard 5e: Health education
¾ Standard 5f: Community mental health nursing services, including reintegration of health care consumers into the
community
◆ Standard 6: Evaluation
B. Standards of Education
◆ Standard 7: Academic excellence
◆ Standard 7a: Personal academic development
◆ Standard 7b: Capacity building
C. Standards of Administration
◆ Standard 8: Administrative efficiency
¾ Standard 8a: Personal vision, commitment, technical expertise
¾ Standard 8b: Team building
¾ Standard 8c: Quality assurance
¾ Standard 8d: Continuing nursing education
¾ Standard 8e: Leadership
¾ Standard 8f: Performance appraisal
¾ Standard 8g: Organizational and professional advancement
D. Standards of Evidence-Based Practice and Research
◆ Standard 9: Responsible and ethical conduct of research and integration into practice
¾ Standard 9a: Research ethics
¾ Standard 9b: Integration of research into practice
¾ Standard 9c: Teaching scientific rigor to young nurse investigators
E. Other Standards of Professional Performance
◆ Standard 10: Self-care and self-awareness
◆ Standard 11: Ethics
◆ Standard 12: Communication
◆ Standard 13: Culturally sensitive care
◆ Standard 14: Legally safe practice
68 Textbook of Psychiatric Nursing for BSc Nursing Students

ASSESS YOURSELF
Long Answer Questions 4. Carl Rogers views the personality in terms of ______.
1. Define mental health nursing/psychiatric nursing. a. Self-esteem b. Self-concept
Explain the principles of psychiatric nursing with c. Self-confidence d. Self-control
appropriate examples. 5. The outward bodily expression of emotions that range
2. Elaborate various defense mechanisms with examples. from joy to sorrow or anger is termed:
3. Elaborate the classification of mental disorders. a. Mood b. Affect
4. Describe the theories of personality development. c. Anhedonia d. Depression
5. Explain the psychopathology of mental disorders. 6. In Erikson’s theory of psychosocial development,
stage of old age is:
Short Answer Questions a. Initiative versus guilt
1. What is collective unconscious? b. Industry versus inferiority
2. Define Freud’s psychoanalytical theory of personality. c. Generativity versus stagnation
3. Which standards are included in standards of professional d. Ego Integrity versus despair
performance? 7. ________ denotes pleasure principle in psychoanalytic
4. Define self-concept. theory.
a. Id b. Ego
Short Notes c. Superego d. Superior ego
Write short notes on: 8. The conscious way of pushing out the negative
1. Standards of psychiatric nursing thoughts or feelings is:
2. Conceptual models in psychiatric nursing a. Repression b. Suppression
3. Neurotransmitters c. Regression d. Rationalization
4. Etiology of mental disorders
9. __________ is considered the emotional brain.
a. Cerebrum b. Cerebellum
Multiple Choice Questions
c. Brain stem d. Limbic system
1. ICD-11 Code for Autism Spectrum disorder is:
10. ___________ is the originator of interpersonal
a. 6A02 b. 6A70
relational theory.
c. 6A30 d. 6A52
a. Harry S Sullivan
2. Level of dopamine in Schizophrenia is: b. Albert Ellis
a. Increased b. Decreased c. Sigmund Freud
c. Normal range d. Not specific d. Hippocrates
3. __________ is the structural and functional part of
Answer Key
the brain.
1. a 2. a 3. a 4. b 5. b
a. Neuron b. Cell
c. Tissue d. Myocytes 6. d 7. a 8. b 9. d 10. a
 CHAPTER
Assessment of
Mental Health Status 3
LEARNING OBJECTIVE

After studying this chapter, the student will be able to gain knowledge regarding assessment in psychiatric nursing to render the quality
nursing care for mentally ill patients.

CHAPTER OUTLINE
• Psychiatric History Collection • Mini Mental Status Examination or Folstein Test
• Mental Status Examination • Investigations in Psychiatry
• Neurological Assessment • Psychological Tests

KEY TERMS
History collection, Mental status examination, Mini-mental status examination, Psychological test, Insight, Form of thought,
perseveration, Flight of ideas, Clang association, Mood, Affect, Premorbid personality, Pedigree, Omega sign, Otto veraguth folds,
Nasolabial folds, Delusion, Hallucination, Illusion, Circumstantiality, Tangentiality, Neologism, Fear, Anxiety, Mutism, Panic attack,
Thought block, Thought retardation, Thought broadcasting, Amnesia, Paramnesia, Retrograde amnesia, Anterograde amnesia,
Confabulation, Déjà Vu, Jamais Vu, Abstract thinking, Glasgow coma scale, Cranial nerve assessment, Reflexes, Romberg test, Tandem
walking test, Stereognosis, Baragnosis, Calorie test, Graphesthesia, Toxicology screening, Drug levels, Electrophysiological test, Brain
imaging test, Neuro-endocrine test, Neuropsychological test, Personality test, Occupational test, Intelligence test, Aptitude test,
Interest test, Individual/Group tests, Paper-pencil/Performance test, Speed/Power tests, Computer-assisted tests.

PSYCHIATRIC HISTORY COLLECTION Table 3.1 shows differences between general history collection
and psychiatric history collection.
Introduction
History means inquiry or the knowledge acquired by Purposes
investigations. Its roots lie in the past and are supported by • To know about the patient.
available written documents. In nursing, history means the • To use it as a pathway to perform right health
story of a patient which might be collected from patient, assessment.
caregivers/family members/informant (who meet the criteria • To provide the baseline data about patient.
of reliability). Collateral history collection means collecting • To understand the past treatment and outcomes.
history from friends, police and strangers who might know • To identify the causative factors for each issue.
the information about the patient. Collecting history is a • To compare the patient’s condition/symptoms before the
vital part for a nurse to have strong knowledge about patient. onset of illness.
70 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 3.1: Differences between general history collection and psychiatric history collection

Aspects General history collection Psychiatric history collection

Information Maximum from patient For psychosis: Maximum history collected from informant in case
collected of psychosis (so, reliability of informant has to be checked before
collecting history).
For neurosis: Maximum history collected from patient.
Present and past Included only if, there is psychiatric A vital component of history collection.
psychiatric history problem to patient or to family members
Family history Two-generation chart can be drawn Three-generation chart to identify the root cause/genetic influences.
Behavior problems Addressed only if, it is present Act as vital source for problem identification.
in personal history
Premorbid Not necessary It is essential to identify the differences in patient before and after the
personality onset of illness.
For example, patient himself an anxious person from childhood might
be diagnosed as anxious personality disorder; not to be diagnosed as
generalized anxiety disorder.

History Collection Format II. Chief complaints/presenting complaints (list with

duration):
I. Demographic data
„ Use verbatim technique (write the patient’s complaint
„ Name
exactly in the same words as verbalized by the
„ Age
patient or informant). Organize and write the chief
„ Gender
„ Education complaints in such a way that, ‘complaints with longer
„ Occupation duration should be written first and shorter duration
„ Monthly income at the last’.
„ Universal Hospital Identity Number (UHID No.)/ Example: Unable to sleep properly for past 10 days,
In Patient Number (I.P.No.)/Out Patient Number Hearing male voices for past 8 days, Loss of appetite
(O.P.No.) for past 3 days
„ Ward/OPD III. Present psychiatric history/nature of the current
„ Unit episode
„ Marital status „ Onset
„ Nationality ◆ Abrupt (symptoms occur within 48 hours)
„ Religion ◆ Acute (symptoms occur within 2 weeks)
„ Date and time of admission ◆ Insidious (symptoms occur from several weeks to
„ Diagnosis months)
„ Doctors in-charge „ Intensity: Same/increasing/decreasing
„ Address „ Duration: Days, weeks or months
„ Informant (Name/Relationship) „ Course: Continuous/episodic
„ Reliability of Informant „ Precipitating factors: Yes/no (if yes, describe the
Criteria to collect history from reliable informant are as follows: factors such as stressful events of life, nonadherence
• Informant should have a close relationship with patient and to medications, etc.)
he/she should be living together with the patient from last „ History of current episode (write in detail about the
2 years. presenting complaints)
• Informant should not have any communication deficit
(hearing/vision problems).
„ Associated disturbances: Includes present medical
• Informant should be a sound minded person (i.e., not suffering problems (e.g., disturbances in sleep pattern,
from any mental illness). problems with appetite, interpersonal relations with
• Information provided by the informant should be reliable and others, social functioning with others, problems faced
adequate.
in occupation, etc.)
CHAPTER 3 Assessment of Mental Health Status 71

IV. Past psychiatric history Table 3.2: Genogram symbols

„ Number of episodes with onset, duration of each
episode, intensity and course
„ Complete or incomplete remission of symptoms
„ Treatment details and its side effects, extrapyramidal
effects, if any
„ Prognosis of the previous treatment/hospitalizations
„ Previous suicidal attempts, if any
„ Description of any precipitating factor, if present.
V. Medical history, surgical history, obstetrical history
(if the patient is female)
VI. Family history
„ Family genogram: Draw three-generation chart
which should include grandparents. Include the
particular generation which has specific psychiatric
family history. Table 3.2 shows some symbols of
genogram.
„ Types of family: Joint/Nuclear/Extended
„ Consanguinity: Present/Absent
VII. Personal history
„ Birth history
◆ Prenatal history: Fetus having exposure to
radiation, maternal infections and other maternal
complications.
◆ Natal history: Type of delivery (normal/cesarean/
vacuum/forceps), newborn cried at birth, neonatal
infections and other complications.
◆ Milestones: Normal or delayed
„ Behavior during childhood
◆ Excessive temper tantrum
◆ Feeding habits or pica
◆ Habit disorders
„ Illness during childhood
◆ Seizures
◆ Neurotic disorders
◆ Central nervous system infections
◆ Malnutrition
„ Schooling/educational history
◆ Age of joining school
◆ Academic performance in the school „ Occupational history
◆ Relationship with peer group ◆ Age of joining the job
◆ Relationship with teachers ◆ Relationship with colleagues, subordinates and
◆ Learning disability and attention deficit in supervision
childhood ◆ Frequent change of job, if so, give details with
◆ Reason for discontinuation from education rationale
„ Play history ◆ Frequent absenteeism in job
◆ Involvement in play activities „ Menstrual and puberty history
◆ Preferred type of play ◆ Age of attaining puberty
◆ Preferred play materials ◆ Menstrual cycles are regular/irregular
72 Textbook of Psychiatric Nursing for BSc Nursing Students

„ Sexual history Format of Mental Status Examination

◆ Source and extent of knowledge about sex
I. General appearance and behavior
◆ Any extramarital relationship (Ask if the
„ Facial expression (Depressed/anxious/smiling/
information is found to be essential)
blunted/anger/irritable): Anger expression denotes
„ Marital history the patient might be having chance of getting violent.
◆ Name, age, education and occupation of spouse Smiling is considered normal and also seen in patients
◆ Duration of married life with mania. Blunt facial expression is considered
◆ Love or arranged marriage neutral and needs further examination. Irritable facial
◆ Number of marriages expression denotes the abnormality and sometimes it
◆ Bonding in marital relationship might be due to the effect of extrapyramidal symptoms
• Premorbid personality: Personality might change after the in initial stage. Facial expression which denotes
onset of an illness. Description of the personality before the extreme sadness, omega sign (furrowed brow due to
onset of the illness aims to rule out the change occurred in sustained contraction of corrugator muscle), Otto
behavior of individual after illness. Veraguth folds (upward inward folds of upper eyelids)
„ Attitude toward others in social, family and sexual
and nasolabial folds (lines on the either side of mouth
relationship: Ability to develop trust on others and ability
to sustain the relationship with others. extend from the edge of nose to outer corner of mouth)
„ Attitudes toward self: Selfish, feel proud, over concerned, might suggest depression (Fig. 3.1).
egocentric, dramatizing, self-conscious, satisfied about „ Posture (normal/stooped/stiff/guarded): Stooped
self, unhappy or dissatisfied about self. posture is seen in patients with Parkinson’s disease.
„ Moral and religious attitudes and standards: Identify any
Stiff posture may suggest neurological defects and also
specific religious beliefs or having excessive religiosity.
Check out the importance given for moral values. the extrapyramidal symptoms due to antipsychotics.
„ Mood: Ask regarding the stability of mood, anxious mood, Guarded posture denotes that the patient is feeling
irritable mood, worrying always, mood swings. Ability to insecure and it may be the sign of phobia or anxiety.
express and control anger, depression and anxiety. „ Mannerisms (stereotype, negativism/tics/normal):
„ Leisure activities and hobbies: Enquire the patient about
Negativism is defined as apparently motiveless
the hobbies performed in leisure time.
„ Fantasy life: Enquire regarding day dreams and amount of
resistance to all instructions which are seen in
time spent in day dreaming. catatonic stupor. Repetitive movements which are
„ Reaction pattern to stress: Ability to tolerate frustrations irregular, purposeless and jerky are considered tics/
or sudden disappointments, and situations causing anger, stereotypical movements.
anxiety or depression. Whether individual might use coping
„ Eye to eye contact (maintained/intermittently
mechanism or defense mechanism to reduce stress.
„ Habits: Sleeping, eating and ill-health habits
maintained/not): Patients with depression will not

MENTAL STATUS EXAMINATION

Definition
Assessment performed for the patients/individuals to assess
the present mental status which involves mood, thought,
speech, perception, cognitive functions and insight.

Purposes
• To assess the mental status of an individual.
• To provide a guideline/pathway to decide the treatment
modalities.
• To diagnose the patient’s condition.
• To assess the improvement in patient’s condition with the
treatment regimen. Figure 3.1: Facial expressions
CHAPTER 3 Assessment of Mental Health Status 73

maintain eye contact and native Americans/Alaskan II. Speech: Write the sample of speech (record as verbatim
culture might feel that maintaining eye contact is a technique—what patient says exactly)
rude act. „ Coherence: Coherent/incoherent
„ Rapport (built easily/not built/built with difficulty): „ Relevance: (answer the questions appropriately)
Difficulty in building up rapport will be there in Relevant/irrelevant
patients with depression as well the patients who „ Volume: Normal/soft/loud/ low
exhibit negative symptoms of schizophrenia and „ Tone: Normal/high pitch/low pitch/ monotonous
psychosis. „ Manner: Excessive formal/relaxed/inappropriately
„ Consciousness (conscious/drowsy/unconscious): familiar
Drowsiness might denote the inadequate sleep, sleep „ Reaction time (time taken to answer the question):
disorders or due to the sedative effect of antipsychotics Normal/increased/decreased.
or immediate effect of any substance abuse. Decreased
III. Mood (subjective) and affect (objective)
need for sleep is present in patient with mania.
„ Appropriate/inappropriate to the situation
„ Social behavior (overfriendly/disinterested/
„ Congruent/incongruent to the thought.
preoccupied/aggressive/normal): Patients with
„ Pleasurable affect: Euphoria (mild elated mood
mania build rapport and exhibit overfriendliness
exhibits hypomania)/Elation (moderate elated mood
with everyone. Patients with psychotic disorders/
exhibits psychomotor agitation)/Exaltation (severe
patients with substance use disorder are at high risk
elated mood exhibits delusion of grandeur/ecstasy
of aggression.
(very severe elated mood or extreme blissfulness; it
„ Dressing and grooming (well-dressed/ appropriate/
exhibits delirious or stupor mania).
inappropriate to season and situation/neat/dirty):
„ Unpleasurable affect: Grief (response to loss of
Dressing inappropriately especially wearing so
beloved ones)/mourning (act of exhibiting great
colorful dress/ornaments is seen in patients with
sadness)/depression.
mania. Depression patients keep themselves dirty and
„ Other effects: Anxiety (apprehension of danger)/
are not well-dressed or groomed well. Wearing dress
fear/panic (anxiety with high level of physiological
according to the season can be a triggering factor to
response such as raised blood pressure, heart
identify the seasonal affective disorder.
rate, etc.)/free floating anxiety (another name of
„ Physical features (look older/younger than age/
general anxiety disorder)/apathy (lack of emotional
underweight/overweight/physical deformity): Over-
expression)/aggression (behavior intended to cause
weight denotes obesity might be due to genetic/faulty
harm due to anger)/mood swing (change of mood
lifestyle/due to side effects of certain antipsychotics.
from mania to depression or depression to mania)/
Underweight condition is seen in patient with
emotional lability (also known as emotional
anorexia nervosa/bulimia nervosa. Patient with
incontinence or pseudobulbar affect which means
depression might look older than age due to folds seen
uncontrolled expression of emotions such as laughing
in the patient’s face.
or crying out suddenly).
„ Psychomotor activity (normal/increased/decreased/
compulsive/echopraxia/stereotyped movements/ IV. Thought
negativism/automatic obedience): Increased „ Form of thought/formal thought disorder: Normal/
psychomotor activity is seen in patients with mania. not understandable/circumstantiality/tangentiality/
Compulsive acts are due to obsession (repetitive neologism/ambivalence/word salad/perseveration.
thoughts) seen in obsessive compulsive disorder The concepts of formal thought disorders are
and also in the patients who exhibit command explained in the Table 3.3.
hallucination. Echopraxia is defined as mimic of „ Stream of thought/flow of thought (pressure of
activities performed by other individual, seen in speech/flight of ideas/thought retardation/thought
schizophrenia. Automatic obedience is performing an block/mutism/aphonia/clang association): Pressure
action said by others irrespective of thinking about the of speech is a rapid urge to speak. Speech with
consequences due to the specified action, this is seen pressure is a hallmark symptom of mania. Pressure
in schizophrenia. Decreased psychomotor activity of speech is also seen in patients with schizophrenia,
is seen in patients with depression and negative anxiety disorder and Attention Deficit Hyperactivity
symptoms of schizophrenia. Disorder (ADHD).
74 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 3.3: Formal thought disorders

Formal thought Description Example

disorders
Circumstantiality Speech of the individual Nurse: Did you have your breakfast?
reaches the goal or center Patient: I like to go home now, I feel sleepy, I would like to see my mother, I had my
point toward the question breakfast (At last, patient verbalized the answer that he has had breakfast after an
raised only after the unwanted speech)
unwanted speech
Tangentiality Speech of the individual Nurse: Did you have your breakfast?
does not reach the goal or Patient: I like to go home now, I feel sleepy, I would like to see my mother (Patient
center point talks something but never answered to question whether he had breakfast or not)
Neologism Coining of new words Patient: He says, “Jammba, Kummba, Thangu” (New words which doesn’t have any
meaning)
Ambivalence Coexistence of two opposing Patient says, I want to invite my uncle for function and also feels not to invite his
forces or impulses, desires uncle because he will come to function along with his wife.
or emotions
Word Salad Mixture of words Patient verbalizes lion, water, pen, mother…
Perseveration Persistent repetition of Patient verbalizes father, father, father, father….
words beyond the point of
relevance

„ Flight of ideas is a rapid shifting of one idea to ◆ Preoccupation: Keep on thinking of something.
other ideas seen in mania, schizophrenia and in ◆ Fantasy: Creative/day dreaming.
some patients with ADHD. Thought retardation is
V. Disorders of perception
a decreased idea identified by decreased content of
„ Illusions
speech which is seen in patients with depression,
„ Hallucinations: Auditory/visual/olfactory/gustatory/
dementia, nervousness, memory impairment and
tactile or haptic
schizophrenia. Thought block is a condition of
„ Others: Hypnogogic/hypnopompic/command or tele-
sudden interruption of thoughts exhibited by silence
ological/Lilliputian/kinesthetic/macropsia/micropsia
for few seconds to minutes which is commonly seen
Types of delusion, illusion and hallucination are summarized
in patients with schizophrenia. Mutism is complete
in the Tables 3.4, 3.5 and 3.6, respectively.
absence of speech seen in patients with depression,
negative symptoms of schizophrenia and in catatonic VI. Cognitive functions
stupor. Aphonia is defined as the inability to produce „ Consciousness
voiced sound due to laryngeal nerve damage or ◆ Conscious/semiconscious/unconscious (or)
secondary thyroidectomy and also due to underlying ◆ Alert/confused/somnolent(sleepy)/lethargy/
psychological problems. Clang association is rhyming obtunded (difficult to arouse)/stupor (very
of words seen in patients with schizophrenia. difficult to arouse)/unresponsive or coma.
„ Content of thought „ Attention and concentration
◆ Delusion: Delusion is a strong fixed unshakable ◆ Digit span test: For example, repeat the numbers
belief irrespective of their sociocultural background. 1, 3, 7, 9
However, it is different from overvalued ideas, it ◆ Digit forward test: For example, say the numbers
means more significance has been given to single 1 to 10
ideation. The types are delusion of persecution/ ◆ Digit backward test: For example, say the numbers
delusion of reference/delusion of influence from 10 to 1
or passivity/hypochondrial delusions/delusions ¾ Method of testing (asking to list the months of
of grandeur/nihilistic delusion/derealization/ the year forward and backward)
depersonalization/delusion of infidelity. ¾ Serial subtraction test (100 – 7 = 93, Patient is
◆ Obsession (repetitive thoughts) asked to recall the events happened immediately
◆ Phobia (fear of something) 93 – 7 = 86, 86 – 7 = 79)
CHAPTER 3 Assessment of Mental Health Status 75

Table 3.4: Types of delusion

Types of delusion Description Example

Delusion of persecution Having a strong suspicious belief that others are trying to harm Patient verbalizes that, “My friend is
him/her making a plan to kill me”
Delusion of grandeur Strong unshakable belief that he/she is an important famous Patient verbalizes that, ‘I am the God’
personality or superior knowledge or ideation or power
Delusion of reference Strong unshakable belief that the other person is referring Patient verbalizes that, ‘They are talking
oneself with a neutral event in the environment about me’
Delusion of influence or Strong unshakable belief that one’s thoughts or actions are Patient verbalizes that, ‘My hand is moved
passivity imposed by someone from outside by an external source’
Nihilistic delusion Strong unshakable belief that the world is not existing Patient verbalizes that, ‘World is not
existing’
Delusion of infidelity (or) Strong unshakable belief that his/her spouse has extramarital Patient verbalizes that, ‘My wife is having
Delusion of jealousy (or) relationship with other person a love affair with other guy’
Othello syndrome
Erotomanic delusion (or) Strong unshakable belief that some famous personality is Patient verbalizes that, ‘Actor is having
Delusion of love having love desire on oneself. love desire toward me’
Somatic delusion Strong unshakable belief in regard to physical appearance, body Patient verbalizes that, ‘I feel sound of
functioning and sensation which is unreal but considered real running water in my stomach’
Delusion of guilt (or) Strong unshakable belief that the individual feels more guilt to Patient felt that, he is highly responsible
Delusion of sin an extent which is unreal for the disaster happened
Delusion of poverty Strong unshakable belief that he/she will be deprived of Patient verbalizes that, ‘My assets are
material possessions. going to be stolen by my friend’
Delusion of control Strong unshakable belief that one’s own thoughts or actions are Patient verbalizes that, ‘My actions are
controlled from outside controlled by ghost’
Delusion of thought Strong unshakable belief that one’s own thoughts have Patient verbalizes that, ‘My ideas are
broadcasting been projected/displayed in mass media such as television, shown in TV’
newspaper, internet, etc.

Table 3.5: Types of illusion

Types of illusion Description Example

Affect Illusion Misperception with the heightened emotions Tree moving in a dark place is perceived as a ghost
Completion Illusion Illusion is mainly due to lack of attention Misreading the bus route wrongly in the name board of the bus
Pareidolic Illusion Illusion which is seen over the other illusion Seeing face like figure in the clouds

Table 3.6: Types of hallucination

Types of hallucination Description Example

Auditory Misperception of hearing. It is of two types: Simple (or) Patient verbalizes that ‘Someone talking to me’
Elementary and Complex. is example of complex auditory hallucination.
Simple Auditory Hallucination means misperception When patient verbalizes that, ‘I am hearing the
of Sounds and Complex auditory hallucination means water pouring sound every time’ is an example
misperception of words of simple auditory hallucination.
Visual Misperception of visualization Patient verbalizes that, ‘I am able to see my
uncle often who is dead.’
Olfactory Misperception of smell Patient verbalizes that, ‘I feel always a bad smell’
Gustatory Misperception of taste Patient verbalizes that, ‘I feel a metallic taste
often’
Tactile or Haptic Misperception of touch Patient verbalizes that, ‘I feel an insect is
crawling on my skin’.
Contd…
76 Textbook of Psychiatric Nursing for BSc Nursing Students

Types of hallucination Description Example

Somatic Misperception of internal body organs Patient verbalizes that, ‘I am able to feel the
blood was circulating in my stomach’.
Functional Misperception within the same sensory stimuli (For Patient verbalizes that, ‘I am hearing voices
example, hallucination belonging to auditory sensory when I hear the bird’s sound’.
stimuli)
Extracampine Misperception outside the limits of sensory field Hearing voices from India when you are in USA
Reflex Stimulus in one sensory field produces hallucination Patient verbalizes that ‘I feel painful when I hear
of another sensory field or modality (For example, one a sneezing sound’.
sensory field was touch, i.e., feel of pain and other
sensory field was auditory, i.e., hearing sneezing sound)
Command/teleological Auditory hallucination which is said to be command in Patient verbalizes that, ‘Someone is asking me to
nature commit suicide’.
Hypnogogic Misperception when going into sleep Patient verbalizes that, ‘I feel that a ghost is
speaking to me daily while I am getting into
sleep’.
Hypnopompic Misperception while awakening from sleep Patient verbalizes that ‘I feel that a ghost is
speaking to me daily when I am awakening from
sleep.
Autoscopy (or) Phantom Misperception as seeing oneself Patient verbalizes that ‘I am seeing my internal
mirror image organs often’.
Kinesthetic Hallucination involves the sense of body movements Patient verbalizes that ‘I feel like my hands are
moving often without my control’.
Alice in Wonderland • A rare condition that causes temporary episodes of distorted perception and disorientation.
syndrome(or) Todd’s • Micropsia (or) Lilliputian: Objects appear smaller than the original size
Syndrome (or) Lilliputian • Macropsia: Objects appear larger than the original size
hallucination (or) • Pelopsia: People/objects/things appear closer than the original place
Dysmetropsia • Teleopsia: People/objects/things appear far away than the original place

„ Memory answer the approximate time without looking at

◆ Immediate: Patient is asked to recall the events clock or watch).
happened immediately. ◆ Place: Where he/she is now?
◆ Recent memory: Patient is asked to recall the ◆ Person: Who has accompanied him or her?
events happened 24 hours ago. „ Abstraction: Patient’s ability to answer the exact
◆ Remote: Patient is asked to recall the events meaning of the given proverb will identify the
happened long back (For example, can you tell presence of abstract thinking (e.g., All that glitters is
your date of birth?). not gold).
¾ Amnesia/Paramnesia/Retrograde amnesia/ „ Intelligence of general information
Anterograde amnesia: Amnesia means ◆ Similarities and differences: For example,
memory loss. Paramnesia means a distorted patient will be asked to say the similarities and
memory or confusion of facts or fantasy. dissimilarities of apple and orange.
Retrograde amnesia means loss of memory of ◆ General information: For example, who is the
the events that happened before the injury or Prime Minister of India?
onset of illness. Anterograde amnesia means „ Judgment
loss of memory of the events that happened ◆ Personal: Ask the patient about his/her future
after the injury or onset of illness. plans. For example, what you are planning to do
¾ Confabulation: False filling of memory gaps after your discharge from the hospital?
¾ Déjà vu: Familiar of unfamiliar things/Jamais ◆ Social: Observation made by the examiner that
vu: Unfamiliar of familiar things. how patient is being socialized with others.
¾ Hyperamnesia: Excessive loss of memory ◆ Test: Test the present situation response and
„ Orientation ask for his/her responses to different kinds of
◆ Time: What is the time now? (Ask the patient to situations.
CHAPTER 3 Assessment of Mental Health Status 77

¾ Rain test: Ask the client what he/she will do ¾ Grade IV: Awareness of being sick, due to
when rain comes. something not known to oneself.
¾ Envelope test: Ask the client what he/she will ¾ Grade V: Intellectual insight (aware about one’s
do when an envelope is kept on road with own mental illness in detail).
stamp and address. ¾ Grade VI: True emotional insight—Awareness
¾ Fire test: Ask the client what he/she will do of one’s own mental illness and how the family
when there is a fire in his/her home. members suffer out of it due to patient’s illness.
¾ Child cry test: Ask the client what he/she will
do when a child is crying on a road. Mental Status Examination of Uncooperative
Insight: (Present/Absent/Partially present)
„
Patients
◆ Grading of Insight
¾ Grade I: Complete refusal of illness Psychiatric patients might be uncooperative sometimes and
¾ Grade II: Slight awareness of being ill make it difficult to perform the mental status examination by
¾ Grade III: Awareness of being sick attribute a nurse/doctor. Such challenging situations can be performed
toward external or physical factor. using Kirby’s method of examination (Table 3.7).

Table 3.7: Kirby’s method of performing mental status examination for uncooperative patients

Aspects Description
General reaction Spontaneous action performed
and posture • Any show of activities such as playfulness, assaultiveness or mischievousness occasionally
• Whether the patient looks neat or untidy
• Whether the patient eats voluntarily or needs assistance
• Whether the patient dresses himself or requires assistance
• Whether the patient voids or defecates voluntarily or needs assistance
• Whether the actions show slowness initially or consistently throughout the day
Behavior toward the examiners
• Resistant, irritable, apathy, complaining others, evasive, etc.
Voluntary postures:
• Comfortable, natural or awkward or constrained.
• What does the patient do when placed in an awkward position?
Whether the behavior remains constant or keep on changing with time?
Facial movement It is the facial expression of being alert or smiling or mask like face or placid or anxious or perplexed or anger or distressed.
and expression Whether the facial expression remains constant or keep changing.
Eyes and pupils • Eyes are open or closed: Whether it is resistant to open the client’s eyes by examiner
• Does patient give attention to examiner and move the eyes with that object
• Does patient have fixed or evasive gaze
• Is there blinking of eyes or flickering of eyelids
• Patient responds to examiner if sudden movement of hand has been performed by examiner near to patient’s eyes
• Presence/absence of corneal reflex
Reaction toward • Patient’s response to simple commands of the examiner
the examiner’s • Presence of negativism—whether active or passive, uncooperativeness exists.
questions and • Monitor for automatic obedience, echolalia and echopraxia
tests • Movements of limbs are slow or fast or being interrupted often
Muscular • Assess for muscle tonicity—waxy flexibility/cog wheel rigidity/Gegenhalten/Mitmachen/Mitgehen.
reactions Waxy flexibility is a psychomotor symptom seen in catatonic schizophrenia, bipolar disorder and other psychiatric
disorder in which the patient has less response to the stimuli and remains in immobile posture. Cog wheel
rigidity is a ratchet-like start-and stop passive movements while performing the physical assessment mainly
seen in patients with Parkinson’s disease. Gegenhalten is an involuntary resistance to the passive movement
seen in cerebral cortical disorders. Mitmachen is a sign in which the patient’s body can be put into any posture
even though it has been instructed to resist. Mitgehen is a severe form of Mitmachen in which even the slight
pressure will move the particular body part. So, it is also called angle-poise effect (or) angle poise lamp sign.
• Check out urinary or fecal incontinence
• Whether patient speaks spontaneously
• Whether patient is mute—Is it consistent or keep changing
• Whether patient takes effort to create sounds or whisper
78 Textbook of Psychiatric Nursing for BSc Nursing Students

NEUROLOGICAL ASSESSMENT „ Stuporous: Arise with more difficulty

„ Semi-comatose: No response to verbal stimuli, little
The various aspects of neurological assessment are as follows: response to pain and little motor function is seen.
• Level of consciousness „ Comatose: No response to verbal stimuli, pain and no
• Mental status assessment motor function is present
• Special cerebral function • Special cerebral function: Assess for agnosia, apraxia
• Cranial nerve function and aphasia
• Sensory function „ Agnosia: Inability to recognize the objects with senses
• Motor function „ Apraxia: Inability to perform learned motor activities
• Cerebellar function „ Aphasia: Inability to speak
• Reflexes The Glasgow Coma Scale facilitates nurses to assess the
• Level of Consciousness patient’s level of consciousness that has been described in
„ Alertness: Awake and respond well to verbal stimuli Table 3.8.
„ Lethargic: Drowsy, inattentive and frequently sleepy Neurological effects on cranial nerve have been summarized
but can be wakened up in Table 3.9.

Table 3.8: Glasgow Coma Scale (GCS)

Glasgow Coma Scale Categories Scores Nurses’ responsibility in documentation of GCS

Eye response • Spontaneous eye opening 4 Document ‘C’—Swollen eyes due to injury/infection
• To verbal stimuli 3
• To pain stimuli 2
• No response 1
Verbal response • Oriented to time, place and person 5 VT—Patient in tracheostomy
• Confused 4
• Inappropriate speech 3 VE —Patient is in endotracheal tube
• Incomprehensive sounds 2
• No response 1
Motor response • Obeys command 6 Record the response in upper extremities (Right/Left) or
• Localizes pain 5 lower extremities or both
• Flexion withdrawal 4
• Abnormal flexion 3
• Abnormal extension 2
• No response 1
Total GCS Score 15
Minimal GCS Score 3
Comatose patient <7

Table 3.9: Neurological effects on cranial nerves

Cranial nerves Sensory/ Assessment Findings

motor/both
I – Olfactory Sensory Ask the patient to identify the odor of some Anosmia—Absence of smell
substance from each nostril separately
II – Optic Sensory • Testing visual acuity—Ask the patient to • Impaired visual acuity (right eye/left eye/
identify numbers/alphabets/signs using both)
Snellen’s chart • Impaired visual field (right eye/left eye/both)
• Assessment of visual fields: Assess the sight • Examination of fundus in eye using
of vision on various directions by showing ophthalmoscope reveals traumatic eyeball,
the fingers on various directions and ask the diabetic retinopathy and increased
client to see the finger without turning the intracranial pressure
head • Examine the eye for cataract, foreign bodies,
• Examine the fundus of eye using infections, inflammation or any other
ophthalmoscope significant abnormalities
Contd…
CHAPTER 3 Assessment of Mental Health Status 79

Cranial nerves Sensory/ Assessment Findings

motor/both
III – Occulomotor Motor Check for pupillary constriction by showing the Tumor or trauma in base of the brain
IV – Trochlear torch light from outer canthus of eye to pupil. Increased Intracranial pressure
VI – Abducent Assess the accommodation and visual field by
checking out whether eyes are focusing the
near and far objects or not.
V – Trigeminal Both sensory Ask the patient to move the mouth against Asymmetry of temporal muscles and trigeminal
and motor resistance, move the jaw side to side and neuralgia
perform chewing movements. Check the
sensation of entire face by:
• Pain: Using sharp objects
• Touch: Using wisp of cotton
• Temperature: Using hot or cold water in a
test tube
VI – Facial Both sensory Motor • Bell’s palsy
and motor • Observe the patient’s symmetry of face • Contusion in parotid region
• Ask the client to smile, frown, raise the eye • Temporal bone fracture
brows, whistle, puff the cheeks and show • Peripheral laceration
teeth
VII – Sensory • It has two divisions—Cochlear for hearing Meniere’s syndrome
Vestibulocochlear and Vestibular for equilibrium Acoustic neuroma
(or) Acoustic nerve Cochlear Hearing loss (sensory-neural, conductive, mixed)
• Assess ear acuity with whispering voice Vertigo
• Bone conduction and air conduction test
should be performed using tuning fork
(Weber’s test and Rinne’s test)
• Weber’s test: Tuning fork is kept in middle
of head. Normal individuals will hear
the sound equally from both ears. If
lateralization is felt on one side it denotes
hearing loss (Fig. 3.2)
• Rinne’s test: Keep the tuning fork in mastoid
bone and then near to patient’s ear after
striking it. When air conduction is more than
bone conduction, it is normal. If the bone
conduction is more than air conduction it
denotes conductive hearing loss
(Figs 3.3A and B)
Vestibular
• Romberg test: This test is performed to
assess the balance or equilibrium of body.
Ask the patient to stand straight with the
eyes closed. Nurse has to be cautious while
performing this test, since patient has a risk
of fall
• Caloric test (oculovestibular reflex): This test
is performed to assess the coordination of
eye and ear muscles. Pouring of cold water
in the ear will move the opposite eyeballs
and the warm water in ear will move the
same side of eyeballs. Mnemonics to
remember this is:
C—Cold water
O—Opposite eye ball movement
W—Warm water
S—Same side eye ball movement

Contd…
80 Textbook of Psychiatric Nursing for BSc Nursing Students

Cranial nerves Sensory/ Assessment Findings

motor/both
IX – Both sensory Ask the patient to: • Brain tumors
Glossopharyngeal and motor • Open the mouth widely and say ‘ah’ to • Brain stem trauma
and X – Vagus observe the movement of uvula and palate. • Neck trauma
The palate has to raise symmetrical with • Stroke
uvula
• Assess gag reflex by touching the side of
pharynx with tongue depressor
XI – Accessory Motor Ask the patient to: • Neck trauma
• Raise the shoulder with or without • Torticollis
resistance • Drooping of shoulders
• Turn the head to one side • Muscle atrophy
• Move the chin away from midline with • Weak shoulders
resistance
• Push the head forward with resistance force
XII – Hypoglossal Motor Ask the patient to move the tongue in, out and • Deviation of tongue from midline
side to side • Neck injury associated with damage to blood
vessels

Figures 3.4 and 3.5 show neuroexamination tray arrangement

and vital sign examination tray arrangement, respectively.

Figure 3.2: Weber’s test

Figure 3.4: Neuroexamination tray arrangement

A B

Figures 3.3A and B: Rinne’s test: A. Air conduction; Figure 3.5: Vital signs examination tray arrangement
B. Bone conduction
CHAPTER 3 Assessment of Mental Health Status 81

• Assessment of motor functions: It includes assessment But it lacks in patient with peripheral neuropathy
of muscle size, muscle tone, muscle strength, muscle (due to the complications of alcohol, complications
coordination, movement and gait. (Table 3.10). of diabetes, and disorders of dorsal columns).
Table 3.10: Muscle strength—Strength’s score ◆ Choreiform gait (or) hyperkinetic gait: Jerky
irregular and involuntary movements in both
Strength’s Description the extremities. It is seen in Huntington’s disease,
score chorea, athetosis and dystonia.
5/5 Normal complete strength. Active range of motion ◆ Hypokinetic gait (or) magnetic gait: Inability
against gravity and applied resistance
to lift the feet from the floor results in decreased
4/5 Active range of motion is possible against gravity mobility. It is a cardinal sign of normal pressure
but weak with applied resistance
hydrocephalus.
3/5 Muscle moves active against gravity only ◆ Cautious gait (or) senile gait: Excess degree of
2/5 Muscle moves across surface but unable to age-related changes in walking (slow and wide
overcome gravity based abducted arm) and having a fear of fall.
1/5 Muscle contraction is possible; flickering ◆ Waddling gait (or) myopathic gait: Individual
movement is present
walks like a duck due to the weakness present in
0/5 Undetectable muscle contraction or movement the proximal muscles of pelvic girdle. This gait is
„ Muscle size: Check for all muscles in a comparative seen in congenital hip dysplasia, pregnancy, spinal
manner bilaterally either symmetrical or not, assess muscular atrophy and muscular dystrophies.
for atrophy or hypertrophy of muscle. ◆ Scissor gait: It happens due to the contractures
„ Muscle tone: Assess for hypotonicity (muscle tone is of all spastic muscles (hypertonia of leg muscles),
decreased), hypertonicity (muscle tone is increased), increased adduction of leg. It is seen in spastic
rigid/spastic muscle. cerebral palsy and upper motor neuron lesion.
„ Muscle coordination: Deficits in this might be due to „ Muscle movements: Assess the gross motor
cerebellum or posterior column lesion. movements such as walking, running, jumping, etc.
„ Gait: It means the manner of walking. Ask the patient and fine motor movements (using fingers) such as
to stand still, walk slowly and walk in tandem to assess writing, drawing, etc.
the muscle power and coordination. If the patient is • Assessment of Sensory Function
weak, support the patient’s arm to prevent fall. Gait „ Assessment of pain: It is assessed using the large–
abnormalities are commonly seen in depression, headed safety pin with a sharp end and blunt end
sleep disorders, substance abuse, fear of falling, (Sharp end should not to be sharp enough to puncture
organic brain disorder and use of psychotropics the skin). Instruct the patient to close the eyes. Prick
and antidepressants. Common abnormal gaits are the patient’s hand with this safety pin and ask the
mentioned here: patient where the pain is felt. This helps to rule out
◆ Ataxic gait: Unsteady, uncoordinated staggering hypoalgesia or hyperalgesia or analgesia as shown in
gait happens due to damage of cerebellum (part of Flowchart 3.1.
brain controls the muscle coordination). „ Assessment of vibration: Vibration sense is assessed
◆ Shuffling gait: Individual drag his/her feet to by keeping the tuning fork in the patient’s toes or
walk (seen in disorders associated with dementia, fingers and ask the patient to verbalize when the
Parkinsonism, etc.). vibration stops.
◆ Propulsive gait (or) Parkinsonian gait: A stiff and „ Assessment of touch: Ask the patient to close the eyes.
stooped posture with head/neck forward. It is seen Touch the patient with the wisp of cotton or tissue
in Parkinson’s disease, carbon monoxide poisoning paper or camel-hair brush. Ask the patient to identify
and manganese toxicity. the sense of touch. It may be decreased (hypoesthesia)
◆ Steppage gait (or) neuropathic gait (or) equine or increased (hyperesthesia) or absent (anesthesia) as
Gait: Abnormal gait characterized by foot drop shown in Flowchart 3.1.
due to absence of dorsiflexion of foot. „ Assessment of temperature: Ask the patient to close
◆ Sensory gait (or) stomping gait: It happens when the eyes. Keep the hot or cold-water test tube in the
the patient lacks proprioceptive information patient’s arm. Ask the patient to identify whether it is
to the brain when the foot touches the ground. hot water or cold water.
82 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 3.1: Sense of touch and pain

„ Assessment of pressure: Ask the patient to close the Flowchart 3.2: Classification of reflexes
eyes. Apply firm pressure on the patient’s skin and ask
the patient to identify the place where the pressure is felt.
„ Two-point discrimination: Ask the patient to close
the eyes. Apply firm pressure on the patient’s skin at
two different points in the same arm simultaneously
and ask the patient to explore the distance between
two points.
„ Proprioceptive awareness: Ask the patient to close
the eyes. Joint is moved through a range of motion and
kept in a static position. Ask the patient to identify the
position of the moved arm.
• Assessment of cerebellar function:
„ Finger to finger test: Patient has to touch nurse’s
index finger with his/her index finger.
„ Finger to nose test: Patient has to touch his/her nose
with his/her index finger. This has to be done with • Graphesthesia: Graphesthesia is the ability to recognize
opened and closed eyes, respectively. This test will writing on the skin purely by the sensation of touch.
assess the coordination.
„ Romberg test: Patient has to stand erect for 10 MINI MENTAL STATUS EXAMINATION OR
FOLSTEIN TEST
seconds with the eyes closed. This is done to assess
the patient’s balance. Introduction
„ Tandem walking test: Patient is asked to walk over
the heel in straight line. This is done to assess for Mini mental status examination (MMSE) was introduced by
unsteadiness or staggering or imbalance gait. Folstein in 1975 to differentiate the organic and functional
• Assessment of reflexes: psychosis.
„ The types of reflexes can be superficial or cutaneous
and deep tendon or muscle-stretch reflexes as shown Definition
in Flowchart 3.2. The responses during assessment of Mini mental status examination is a method that uses 30-point
reflexes have been presented in Table 3.11. questionnaire to assess the cognitive impairment in clinical
and research settings (Table 3.12).
Special Tests in Neurological Assessment
• Stereognosis (or) haptic perception (or) tactile gnosis: Purposes
Ability to perceive and recognize the object using tactile • To assess the progression and severity of cognitive
sense. impairment of an individual.
• Barognosis (or) baresthesia: It is the ability to evaluate • To diagnose the patient’s condition, administer the
the weight of objects, or to differentiate objects of different treatment.
weights, by holding or lifting them. It is done to assess loss • To assess the improvement in cognitive status after the
of the ability to sense weight. treatment regimen.
CHAPTER 3 Assessment of Mental Health Status 83

Table 3.11: Assessment of reflexes and responses

Assessment of Description Response

reflexes
Corneal reflex Touching the cornea Blinking of eyes
with wisp of cotton
Pharyngeal (or) Stimulation with Gagging
gag reflex tongue blade in back
of throat and pharynx
Abdominal reflex Stroking of the skin Abdominal
in the abdominal muscle contracts
quadrant and umbilicus
move toward the Figure 3.6: Assessment of biceps reflex
stimulated side
Cremasteric reflex Stroking the inner Elevation of
thigh of patient Ipsilateral testicle
Anal reflex (or) Stroking the skin Contraction of rectal
anal wink (or) around the anus sphincter
perineal reflex
(or) anocutaneous
reflex
Plantar reflex Touching the foot’s Contraction of toes
outer plantar surface
from heel toward toes
Biceps reflex Arm gently flexed at Flexion of forearm
elbow, tap the biceps (Fig. 3.6) Figure 3.7: Assessment of triceps reflex
brachii tendon
Triceps reflex Tapping of triceps Extension of
brachii tendon in forearm (Fig. 3.7)
elbow
Brachioradialis Tapping of styloid Flexion of elbow/
process of radius hand/fingers and
about 1–2 inches supination of
above the wrist forearm (Fig. 3.8)
Patellar reflex Tapping of quadriceps Extension of leg
femoris tendon
(present below
patella)
Achilles tendon Tapping of Achilles Plantar flexion of
reflex tendon foot Figure 3.8: Assessment of brachioradialis

Advantages • It lacks its sensitivity to assess the patients with mild

cognitive impairment; it’s difficult to differentiate
• No special equipment or instrument is required to
between patient with mild Alzheimer’s disease and a
administer this test.
normal person.
• No special training is required to administer this test.
• Items in mini mental status examination are highly verbal
• It has both reliability and validity.
and little with visuospatial (ability to visualize or imagine
• It is helpful in longitudinal assessment of cognitive status.
the objects) and constructional praxis (ability to build the
objects).
Disadvantages
• Remembering the physical health problems or other
• This test is affected with the demographic factors such as mental disorder or motor deficits that might affect the
age, education, etc. results of Mini-Mental Status Examination (MMSE).
84 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 3.12: Mini-mental status examination (MMSE) format

Sl. no. Components Description Max. score Total score

1. Orientation Year, month, day, date, season 5
Country, state, town, place, floor 5
2. Registration Examiner names the three objects (example, pen, apple and table). Patient is 3
asked to repeat the objects, one score for each
3. Attention Subtract 7 from 100 then repeat from the result for five subtractions 5
4. Recall Ask the name of objects learned earlier 3
5. Language Name a pencil and watch 2
Repeat ‘No ifs and or buts’ 1
Give a three-stage command. Score one for each stage. (For example, ‘Take this 3
piece of paper in your right hand, fold it in half and place it on the table’
Ask patient to read and obey a written command on the piece of paper stating: 1
‘Close your eyes’
Ask patient to write a sentence. Score correct if it has a subject and verb 1
6. Copying Ask the individual to copy the intersecting pentagons. Score if it overlaps and has 1
five sides
Results indicate:
Total score Cognitive impairment
24–30 No cognitive impairment
18–23 Mild cognitive impairment
0–17 Severe cognitive impairment

Grand Total = _________/30

INVESTIGATIONS IN PSYCHIATRY

Blood Tests
Various blood investigations are carried out on a psychiatry patient which have been presented in Table 3.13.
Table 3.13: Various blood investigations conducted on psychiatric patients

Blood investigations Description

Hemoglobin Routine screening is helpful to rule out anemia.
Blood glucose level and Increased or decreased blood glucose levels are associated with delirium. Atypical antipsychotics
glycosylated hemoglobin might cause impaired glucose tolerance. Clozapine and olanzapine pose risk of increasing blood glucose.
Quetiapine, Risperidone and phenothiazines pose moderate risk of increasing blood glucose. Haloperidol
is considered low risk to increase blood glucose. Amisulpride, asenapine, ziprasidone, aripiprazole has only
minimal risk to increase the blood glucose.
Total leukocyte count (TLC) Monitored when the patient is on treatment with following drugs—clozapine, carbamazepine and lithium

Mean corpuscular volume Increased in patients with alcohol dependence syndrome

(MCV)
Renal function test (RFT) Monitored in treatment with Lithium

Contd…
CHAPTER 3 Assessment of Mental Health Status 85

Blood investigations Description

Liver function test (LFT) Monitored in patients with alcohol dependence syndrome. Increased ammonia level may suggest hepatic
encephalopathy which includes delirium and lethargic behavior. Treatment with drugs—Benzodiazepines,
carbamazepine and sodium valproate.

Total electrolytes panel Phosphate level is low in eating disorder due to purging. Magnesium is low in agitated, confused,
(TEP) delirious patient and also in patients with alcohol dependence. Calcium level might be low in delirium
and eating disorder with laxative use, it might be high in psychosis and may be high or low in depression.
Sodium level is monitored in dehydration and Syndrome of inappropriate secretion of antidiuretic
hormone (SIADH) because serotonin plays a vital role in regulation of antidiuretic hormone (ADH) and
hence, antidepressants are associated with hyponatremia (usually seen in 30 days of commencement
of treatment) Treatment with drugs such as antipsychotics, carbamazepine and lithium is suggestive to
monitor electrolyte level.
Thyroid function test (TFT) • Hyperthyroidism is associated with mania, anxiety and psychosis.
• Hypothyroidism is associated with depression and psychosis. Treatment with drugs–Carbamazepine
will suppress the thyroid stimulating hormone.
• (TSH) and lithium will inhibit the triiodothyronine (T3) and thyroxine (T4).

Triglycerides Some antipsychotics might cause hyperlipidemia and so, it has to be monitored in patient with psychosis.
Beta blockers, corticosteriods and retinoids also increase the level of triglycerides.
Venereal disease research It is used to identify syphilis infection because long standing syphilis infection may lead to dementia.
laboratory (VDRL)
Serum creatine Increased in neuroleptic malignant syndrome.
phosphokinase (CPK)
C-reactive protein (CRP) Clozapine might cause Myocarditis so it needs to be monitored on 7th, 14th and 21st days after the
and troponin commencement of clozapine. If CRP >100 mg/L and troponin (normal range is <0.04 ng/mL) is more than
the twice of upper limit, then quit clozapine due to suggestive myocarditis and it is needed to be confirmed
with echocardiogram.

Toxicology Screening on psychiatric patients, which have been summarized in

Table 3.15.
Toxicology screening is done in substance abuse disorders
such as alcohol, barbiturates, benzodiazepines, cannabis, Table 3.15: Electrophysiological tests
cocaine, etc. to determine the approximate amount and type of
Electrophysiological Description
legal or illegal drug in blood of a user (Table 3.14). tests
Table 3.14: Drug levels in blood EEG Used in patients with dementia
and abnormal behavior. It is also
Name of the drug Blood therapeutic value used to differentiate seizure with
Lithium 0.6–1.8 mEq/L pseudoseizure
Carbamazepine 6–12 mg/mL Polysomnography/sleep Components include:
studies • Electroencephalogram (EEG)
Sodium valproate 50–100 mg/mL
• Electrocardiogram (ECG)
Haloperidol 8–18 ng/mL • Electrooculogram (EOG)
Imipramine 200–250 ng/mL • Electromyogram (EMG), oxygen
saturation, airflow measurement,
Nortriptyline 50–150 ng/mL body temperature, galvanic
skin response (GSR) and body
Electrophysiological Tests movements
Holter monitor Used in panic anxiety disorder
A number of electrophysiological tests are performed
86 Textbook of Psychiatric Nursing for BSc Nursing Students

Brain Imaging Tests Further investigations are carried out to identify the sexual
disorders in psychiatric patients (Table 3.17).
Computed tomography (CT scan) is used in patients with
psychosis, organic brain disorder and seizure disorder. Table 3.17: Investigations to identify the sexual disorder
Magnetic resonance imaging (MRI scan) has high resolution
Investigations in Description
than CT scan. Positron emission tomography (to check brain patients with sexual
physiology), Magnetic resonance (MR) angiography and disorders
magnetic resonance (MR) spectroscopy may be used for the Papaverine test Intracavernosal injection
assessment of disorders in psychiatric patients. (drug given at the base of
penis) of papaverine is used
Neuroendocrine Tests to differentiate organic and
nonorganic male erectile
Neuroendocrine tests are given in Table 3.16. dysfunction
Table 3.16: Neuroendocrine tests Serum testosterone Decreased in hypoactive sexual
desire disorder, impotence and
Neuroendocrine tests Description anabolic steroid abuse
Dexamethasone If the plasma cortisol level is Penile Doppler and Done in patients with male
suppression test more than 5mg/100 mL after nocturnal penile erectile dysfunction
administering dexamethasone tumescence
(plasma cortisol level is checked
at 8AM, 4PM and 11PM next day).
Dexamethasone will suppress Miscellaneous Tests
the plasma cortisol but it won’t
suppress the plasma cortisol, if • Genetic test: Tests based on cytogenetics are used in
there is a presence of depression. children with mental retardation.
It is a test used to identify the • Lactate provocation test: 70% of patients with panic
response to antidepressants, ECT disorders will get panic attack with the infusion of sodium
and also helpful to differentiate
manic depressive disorder with mild lactate.
dysphoria. • Amytal interviews: Administration of drug amytal will
Thyroid releasing If the serum Thyroid Stimulating help the patient to talk from his/her subconscious mind.
hormone (TRH) Hormone is more than 35 mlU/mL It is also helpful in patients with catatonia, dissociative
stimulation test (following TRH 500 mg administered stupor and unexplained mutism.
intravenously), it suggests the test
is positive. Test is helpful to monitor
lithium-induced hypothyroidism and PSYCHOLOGICAL TESTS
refractory depression.
Psychological testing is the administration of psychological
Serum prolactin test Used to differentiate the patients
with seizures and pseudoseizures tests, which are designed to be “an objective and
(hysterical fits), Increased standardized measure of a sample of behavior.” Psychological
prolactin is due to drugs such as tests are designed to assess the behavior of psychiatric
antipsychotics, domperidone and patients.
methyldopa. Prolactin is also seen
to increase in stress, pregnancy,
lactation, during exercise, during Characteristics of Psychological Tests
sleep and coitus. Pathological causes • Standardization: All health team members have to follow
of raised prolactin are primary
hypothyroidism, renal failure and the uniform way of administering the test.
prolactinoma • Objectivity: Assessment needs to be performed
Serum Monitored in organic mood disorder with accurate observation and not with a subjective
17-hydroxycorticosteroid judgment.
Serum melatonin Monitored in seasonal affective • Reliability: Repetition of the test has to be performed to
disorder reveal the same results which should be consistent when
Estrogen Decreased in menopausal tested with the same or different evaluator.
depression and premenstrual • Validity: It denotes the accuracy of measurement what it
syndrome is intended to measure.
CHAPTER 3 Assessment of Mental Health Status 87

Principles of Psychological Tests Flowchart 3.3: Classification of psychological tests

• Items for psychological test are prepared by the expertise

in a high technical quality.
• It has three basic components: Standardization of the
test, content of the test and the protocol or procedure to
conduct the test.
• It has norms to compare an individual test with another
known group.
• It has to be standardized so that it can be used by all health
team members.

Purposes/Uses of Psychological Tests

• It helps to assess the psychopathology, level of functioning,
disability and to formulate diagnosis.
• It is a helpful tool to observe the patient’s behavior in
order to provide the treatment. performing this test. Few psychological tests lack reliability.
• It is helpful to assess the mental status of the individual. Either the patient or the psychologist needs to complete the
• It is also helpful to identify any academic backwardness full test for the best assessment.
and developmental delay in children.
Classification
Limitations of Psychological Tests Classification of psychological tests has been given in
Need of psychologists or professionals who have knowledge Flowchart 3.3 and the summarized description has been
and skills to perform the test. Patient might feel anxiety while explained in Table 3.18.

Table 3.18: Types of psychological tests with their descriptions and examples

Psychological tests Description Example

Individual and Test conducted individually is called Rorschach inkblot test used to assess the personality is an example
group test individual test and as a group is of individual test and the assessment test to evaluate the academic
termed group test performance of students as a group is an example of group test
Paper-pencil test Individual will use paper and pencil Letter cancellation test in which a single alphabet was told to the
to perform this test. Answers will be participant to cancel the same in a given paragraph within the scheduled
recorded in the standard sheet time.
Interpretation of the test:
No. of letters correctly identified:
No. of letters omitted (or) missed out:
No. of letters wrongly identified:
Speed and power Speed test is performed within the Sentence completion test administered with time limit is considered
test time limit whereas power test has no speed test and the same test administered without time limit is termed
time limit to complete it power test
Computer assisted Use of computer to assess the group Multiple Choice Questions have been administered to all the
test of people in this test participants with the equal level of difficulty in the group, as such it has
been programmed in the computer to conduct test.
Achievement test To assess the level of knowledge in Conducting a university semester examination for a college student
education and in employment sectors
Aptitude test Helps to assess the attention, General Aptitude Test Battery (GATB) and Differential Aptitude Test
accuracy and perceptual speed (DAT)
Intelligence Test To assess the intelligence level of For Children
individual Wechsler Intelligence Scale for Children (WISC), Stanford-Binet Test Scale
For Adults
Wechsler Adult Intelligence Scale (WAIS), Binet-Kamat test of
Intelligence, Bhatia battery test of intelligence
Contd…
88 Textbook of Psychiatric Nursing for BSc Nursing Students

Psychological tests Description Example

Interest test To assess the interest and personal Interest inventory is used to assess the interest of Higher Secondary
preferences Board Exam passed students to pursue their higher education
Neuropsychological To assess the cognitive functioning • Neuropsychological test automated battery (CANTAB)
tests (ability to think, speak and respond) • Wisconsin card sorting test
• PGI memory scale
• PGI battery of brain dysfunction
• Bender gestalt test
• Benton Visual Retention Test (BVRT)
• Luria-Nebraska Neuropsychological Test Battery
• Halstead-Reitan Neuropsychological Test Battery
• Wechsler Adult Memory Scale (WAMS)
• NIMHANS Neuropsychological Battery of Lobe Dysfunction
Personality test To assess the personality of the Rating Scales
individual • Eysenck’s Personality Inventory (EPI)
• Minnesota Multiphasic Personality Inventory (MMPI)
• Big five personality inventory (neuroticism, extraversion, openness,
agreeableness, conscientiousness)
• Myer’s Briggs Type Indicator (MTBI) Scale (Extroversion-Introversion
scale, Sensing-intuition scale, Thinking-feeling scale, Perception-
judging scale)
• Cattell’s 16-personality inventory
Projective Tests
• Rorschach Inkblot test
• Thematic Apperception Test (TAT)
• Rotter Incomplete Sentence Blank (RISB)
• Draw A Person Test (DAP)
Occupational test To assess the interest of an individual McQuaig Occupational Test
with present employment
Specific clinical test To assess the specific clinical situation Psychosis
• Brief Psychiatric Rating Scale
• Psychiatric Symptoms Checklist
Anxiety
• Hamilton Anxiety Rating Scale
• Anxiety Self-Rating Scale
• Beck’s Anxiety Scale
• Trait and State Anxiety Scale
Depression
• Hamilton depression scale
• Geriatric depression scale
• Beck’s depression scale
Schizophrenia
• Positive and Negative Symptoms Scale (PANSS)
• Extrapyramidal Symptom Rating Scale
Alcohol Dependence syndrome
• CAGE Questionnaire (Cut down, Annoyance, Guilt, Eye opening)
Mania
• Young Mania Rating Scale
• Manic State Rating Scale
OCD
• Yale Brown Obsessive Compulsive Scale (YBOCS)
Suicide
• Suicide Intent Scale
Contd…
CHAPTER 3 Assessment of Mental Health Status 89

Psychological tests Description Example

Others
• Depression Anxiety Stress Scale (DASS-21)
• Global Assessment of Functioning (GAF) Scale
• Insight and Treatment Attitude Questionnaire (ITAQ)
• Child Behavior Checklist (CBCL)
• Nurses’ Observation Scale for In-patient Evaluation (NOSIE)
• Situational Self-awareness Scale

SUMMARY
• Psychiatric history collection includes patient profile, chief complaints, past and present psychiatric history, past and present medical/
surgical history, family history, personal history and premorbid personality.
• Mental status examination includes assessment of general appearance, behavior, psychomotor activity, perception, speech, thought,
mood, affect, judgment, attention/concentration, memory, intelligence, abstract thinking and insight.
• Kirby’s method of examination was used to perform Mental status examination for uncooperative patients. It includes general
reaction, posture, facial movement/expression, eyes/pupils, and reaction to examiner’s questions, muscular reactions, emotional
responsiveness, writing and vital signs.
• Neurological assessment includes level of consciousness, mental status assessment, special cerebral function, cranial nerve function,
sensory function, motor function, cerebellar function and reflexes.
• Mini mental status examination (or) Folstein test is a 30-point questionnaire test which is used to assess the cognitive status of
the patient. The components of test are orientation, registration, attention, recall, language and copying. Score <17 denotes severe
cognitive impairment, score 18–23 denotes mild cognitive impairment, and score 24–30 denotes normal.
• Investigations in psychiatry include the blood investigations such as hemoglobin, blood glucose level and glycosylated hemoglobin,
Total Leukocyte Count, Mean Corpuscular Volume (MCV), Renal Function Test (RFT), Liver Function Test (LFT), Total Electrolytes Panel
(TEP), Thyroid Function Test (TFT), Triglycerides, Venereal Disease Research Laboratory (VDRL), serum Creatine Phosphokinase (CPK),
C-Reactive Protein (CRP) and troponin. The electrophysiological tests such as EEG, polysomnography/sleep studies and Holter monitor
are used for the assessment of psychiatric disorders. The brain imaging tests such as Computed Tomography (CT scan), Magnetic
Resonance Imaging (MRI Scan), Positron Emission Tomography, Magnetic Resonance (MR) Angiography and Magnetic Resonance
(MR) spectroscopy may be used. Neuroendocrine tests such as dexamethasone suppression test, Thyroid Releasing Hormone (TRH)
stimulation test, serum prolactin test, serum 17-hydroxycorticosteroid, serum melatonin and estrogen can be done. Investigations to
identify the sexual disorders are papaverine test, serum testosterone, penile Doppler and nocturnal penile tumescence. Other tests such
as genetic test, lactate provocation test, amytal interview can be done if required.
• Classification of psychological tests based on construction and administration are individual and group tests, paper-pencil test, speed
and power tests, computer-assisted tests.
• Classification of psychological tests based on knowledge, skill and abilities are achievement test, intelligence test, aptitude test,
interest test, neuropsychological test, personality test, occupational test and specific clinical test.

ASSESS YOURSELF
Long Answer Questions Short Notes
1. Define mental status examination and explain the Write short notes on:
various components of mental status assessment with 1. Mini-mental status examination
appropriate examples. 2. Psychological tests
2. Define neurological examination and explain the 3. Psychiatric history collection
various components of neurological examination with 4. Investigations in psychiatry
appropriate examples. 5. Mental status examination for uncooperative patient

Short Answer Questions Multiple Choice Questions

1. What are the purposes of psychiatric history 1. Description of the personality before the onset of the
collection? illness:
2. What are the purposes of mental status examination? a. Premorbid personality b. Personality
c. Personality disorder d. None of these
90 Textbook of Psychiatric Nursing for BSc Nursing Students

2. _________ Method of examination was used to 6. Misperception with the heightened emotions is
perform Mental Status examination for uncooperative known as ________.
patients. a. Affect illusion b. Completion illusion
a. Kirby’s b. Folstein c. Pareidolic illusion d. All of these
c. Freud d. Hippocrates 7. Misperception of taste is _______ hallucination.
3. Furrowed brow due to sustained contraction of a. Auditory b. Visual
corrugator muscle is ______________. c. Functional d. Gustatory
a. Otto Veraguth folds b. Omega sign 8. Ability to recognize the writing on skin is termed ___.
c. Nasolabial folds d. None of these a. Stereognosis b. Graphesthesia
4. Speech of the individual reaches the goal or center c. Baragnosis d. Haptic Perception
point toward the question raised only after the 9. Therapeutic drug Lithium level is _________.
unwanted speech is _______________. a. 6–12 mg/mL b. 50–100 mg/mL
a. Circumstantiality b. Tangentiality c. 8–18 ng/mL d. 0.6–1.8 mEq/L
c. Neologism d. Ambivalence 10. Steppage Gait is also known as __________.
5. Strong unshakable beliefs that the world does not a. Neuropathic gait b. Propulsive gait
exist is ________. c. Ataxic gait d. Stomping gait
a. Delusions of grandeur
Answer Key
b. Nihilistic delusion
c. Delusion of guilt 1. a 2. a 3. b 4. a 5. b
d. Delusion of control 6. a 7. d 8. b 9. d 10. a
 CHAPTER
Therapeutic
Communication and
Nurse-Patient Relationship 4
LEARNING OBJECTIVE

After studying this chapter, the student will be able to gain knowledge regarding the therapeutic communication in order to communicate
with the patient effectively using appropriate techniques and to avoid the therapeutic impasses.

CHAPTER OUTLINE
• Communication • Ethics and Responsibilities
• Types of Relationship • Dynamics of Therapeutic Nurse-Patient Relationship or
• Nurse-patient Relationship or Therapeutic Relationship Therapeutic use of Self for Gaining Self-awareness
• Communication Process and its Barriers • Johari Window of Interpersonal Relationship
• Therapeutic Impasses • Process Recording
• Therapeutic Communication

KEY TERMS
Communication, Ruesch’s theory, Transactional analysis, Neurolinguistic programming, Proximity, Posture, Gesture, Restating,
Empathy, Focusing, Active listening, False reassurance, Being judgmental, Resistance, Transference, Countertransference, Boundary
violations, Johari window of IPR, Nurse-patient relationship, Ethics, Self-awareness, Process recording and verbatim.

COMMUNICATION Theories of Communication

• Ruesch’s theory (1961): Ruesch suggested that
Meaning of Communication
communication is a circular process, i.e., sender sends
The term ‘Communication’ came from the Latin word message to receiver and again the message from receiver
‘Communis’ which means common understanding. turn toward the sender as feedback. Ruesch coined
the term, “Disturbed communication” as unsuccessful
Definition of Communication interaction. He also verbalized the unique difference
Communication is defined as ‘interaction process between between therapeutic and social relationship, i.e.,
the sender and receiver in which the receiver receives the therapeutic relationship is to bring positive change where
message exactly what the sender intended to say as such, i.e., as social relationship might not focus in such aspect.
both the sender and receiver have a common understanding • Transactional analysis: The term ‘Transactional
of a message’. Analysis’ was first used by Dr Eric Berne (1964).
92 Textbook of Psychiatric Nursing for BSc Nursing Students

Dr Eric Berne suggests that there are three ego states existing in an individual listed here.
1. Parent: Focus on rules/regulations/values
2. Adult: Approach based on previous observations
3. Child: Focus on emotions and desires
• Neurolinguistic programming: Neurolinguistic programming is the item from the concept of Milton H Erickson. Effective
communication exists at the state of hypnosis or by alteration of individual person’s state of consciousness.

Types of Communication
Types of communication are categorized on the basis of forms, formality, levels, directions and other types. These all are well
explained in Flowchart 4.1 and Table 4.1.

Flowchart 4.1: Types of communication

Table 4.1: Types of communication with brief description and example

Types of communication Description Example

Verbal communication Oral: Communication by speaking/talking to Nurse collects history from the patient
others
Written: Communication to others in writing Nurse documents a post electroconvulsive therapy
(ECT) procedure in nurses notes
Visual: Communication to others with the use of Nurse kept a ‘No Smoking Board’ in ward
symbols
Contd…
CHAPTER 4 Therapeutic Communication and Nurse-Patient Relationship 93

Types of communication Description Example

Nonverbal communication Facial expression: Showing sadness/happiness in Extreme sad facial expression seen in depression
face
Posture: Position that one holds the body while Stooped posture seen in Parkinson’s disease
sitting or standing
Gesture: Movement of body part especially head Patient points out the location of abdominal pain
or hand to convey the ideas with finger
Gait: Manner of walk Patient might have irregular involuntary gait if he/she
has basal ganglia disorders.
Eye contact: Receiver giving attention by seeing Poor eye to eye contact seen in depression
the sender
Body language: Mixture of gesture, posture and Student might express the unwillingness to
expressions participate in a program with body language
Proximity: Nearness in time, space and Special care and permission is required if touching
relationship the vulnerable zone (face, neck and front of body)
Personal appearance Patients with mania wear attractive dress to enhance
the personal appearance.
Touch Therapeutic touch by nurse heals the patient well
Silence Being silence helps the nurse to listen the patient
actively
Formal communication Communication among professionals Official meetings
Informal communication Communication among friends Gossips among friends
Intrapersonal Communication within oneself Thinking
communication
Interpersonal Communication between two members Nurse-patient interaction
communication
Transpersonal Communication with God Prayer
communication
Horizontal communication Upward: Communication from lower hierarchy Student communicating to the teacher
level to higher level in an institution
Downward: Communication from higher Teacher communicating to the student
hierarchy level to lower level in an institution
Vertical communication Communication takes place between same Students communicating among themselves
hierarchy level in an organization
Chain communication Discussion takes place among a group Group discussion and panel discussion
Metacommunication Communication within a communication Raja says to Sita that I am glad to see you with a staring
look, denotes Raja is not actually glad to see Sita
Animal communication Communication takes place between the animals One dog barks to gather all the dogs
Physiological Communication takes place within the human Sneezing happens when a microorganism enters the
communication body nose
Communication through Communication takes place through television, Sending a message through WhatsApp
mass media radio, newspaper, social networking (Facebook,
WhatsApp, mail, etc.)

TYPES OF RELATIONSHIP

Relationship means how one is related with other, i.e., the relation is based on purpose. It can be classified as social, intimate and
therapeutic as explained in Table 4.2. The zones of space are intimate, personal, social and public zone as explained in Table 4.3.
The zones of touch are intimate, vulnerable, consent and social as explained in Table 4.4.
94 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 4.2: Types of relationship

Aspects Social relationship Intimate relationship Therapeutic relationship

Meaning Relationship among friends/ Relationship maintained between Relationship maintained between nurse
social companionship husband and wife and patient for therapeutic purpose
Zones of space Social and public zone Intimate and personal zone Social and public zone
Zones of touch Social and consent zone Intimate and vulnerable zone Social and consent zone

Table 4.3: Zones of space

Zones Distance Example Relationship maintained

Intimate zone 0–18 inches Mother-child relationship Intimate relationship
Personal zone 18 inches–4 feet Persons who are more familiar
Social zone 4–12 feet Business meeting Social relationship and therapeutic
Public zone 12 feet Public speaking relationship

Table 4.4: Zones of touch

Zones Permission to touch Body parts can be touched Relationship maintained

Intimate zone Yes (great sensitivity needed) Genitalia and rectum Intimate relationship
Vulnerable zone Yes (special care needed) Face, neck and front side of body
Consent zone Yes Feet, mouth and wrist Therapeutic and social relationship
Social zone No Extremities, shoulders and back

NURSE-PATIENT RELATIONSHIP OR Purposes

THERAPEUTIC RELATIONSHIP
• To bring insight and promote behavioral change in
Definition patients.
• To promote self-realization/self-acceptance.
Relationship maintained between nurse and patient in order • To develop mutual respect.
to gain mutual respect and trust collaboratively is known as • To solve the problems.
nurse-patient relationship (Fig. 4.1). • To have genuineness and trustworthiness in relationship.
• To meet the daily routines.
• To develop the coping skills.

Characteristics of Therapeutic Nurse-Patient

Relationship
• Able to set and achieve realistic goals.
• It can maintain safe therapeutic environment.
• It maximizes ego strength.
• Relationship is said to be goal oriented.
• Nurse-patient relationship has to follow the phases.
• It has to clarify problems of the patients.
• It has to modify maladaptive behavior into normal
behavior.

Principles of Nurse-Patient Relationship

• Nurse has to treat the client as an individual.
Figure 4.1: Nurse-patient relationship • Nurse has to accept the client as he/she is.
CHAPTER 4 Therapeutic Communication and Nurse-Patient Relationship 95

• Nurse should be aware of client’s complete needs and Phases of Nurse-Patient Relationship
problems.
Phases of nurse-patient relationship are preorientation phase,
• Nurses should have an ability to prioritize the needs.
orientation, identification, intervention, maintenance and
• Nurse has to maintain limits.
termination phase as shown in Figure 4.3. Each phase has been
• Nurse has to set goals.
described in Table 4.6 along with nurses role in each phase of
• Nurse has to follow the institutional norms.
nurse-patient relationship.
• Nurse can establish good rapport.
• Nurse needs to maintain confidentiality.
• Nurse can behave in such a way that it bring confidence
in client.

Essential Elements of Therapeutic Relationship

Essential elements of therapeutic relationship are trust-
worthiness, professionalism, mutual respect, care, empathy,
genuineness and unconditional positive regard. These
elements have been described in Table 4.5.
Figure 4.3: Phases of nurse-patient relationship
Table 4.5: Essential elements of therapeutic relationship
Table 4.6: Phases of nurse-patient relationship with nurses’ role
Essential elements of Description in each phase
therapeutic relationship
Trustworthy Nurse can develop the trust with Phases of Description of Nurses’ role in each
patient. It can be gained with nurse-patient the tasks phase
proper interpersonal relationship relationship
and step by step explanation of Preorientation Nurse has to Nurse is reading the
every procedure to the client with phase prepare oneself patient’s previous file and
high level of clarity before interacting collecting history from the
Professionalism Nurse behaves in a professional way with the patient client’s family members

Mutual respect Nurse respects the client and client Orientation Nurse orienting Nurse explains to the
in turn respects the nurse phase the patient in client that visitors are
regard with permitted to ward in the
Caring Nurse shows caring attitude toward orientation of evening from 4 pm to
the patient self, other health 6 pm
Empathy Nurse has to see the situation by team workers
thinking from the client’s point of and routines of
view hospital
Genuineness Nurse has to be truthful in every Identification Nurse is identifying Nurse identified that
aspect phase the client’s needs the client was unable to
Unconditional positive Overall acceptance of the patient and problems consume food due to pain
regard irrespective of the nurse’s personal in throat while swallowing
opinion. This concept was food and there is need
developed by Carl Rogers (Fig. 4.2), of Ryle’s tube feeding to
humanistic psychologist. maintain the nutritional
needs of the patient
Intervention Nurse is rendering Nurse is rendering
phase care/intervention therapeutic back massage
to solve the to prevent bed sore for a
client’s problems bedridden client
Maintenance Nurse has to Nurse gives routine
phase follow-up the nursing care based on
delivered nursing client’s needs
care in this phase
Termination Examines the level Nurse provides discharge
phase of goal achieved summary, explains
and establishes the regarding the next
plan of continuous outpatient department
Figure 4.2 Carl Rogers (1902–1987) assistance (OPD) visit
96 Textbook of Psychiatric Nursing for BSc Nursing Students

Patient’s Response in Termination Phase of i.e., nurse is visualizing the situations by standing in his/
Nurse-Patient Relationship her position.
The patient might exhibit the three responses in termination Autonomy
phase such as continuation, regression and withdrawal as
In the nurse-patient relationship, patient can independently
listed here.
verbalize his/her own point of view at any time.
1. Continuation: Patient tries to continue the nurse-patient
relationship by bringing out the new problem or else Caring Attitude
seeking help from nurse.
Nurse has to show a caring attitude toward the patient. This will
2. Regression: Patient returns back to the previous
help to maintain a good interpersonal relationship between
maladaptive behavior.
nurse and patient. This will also help the patient to trust the
3. Withdrawal: Patient refuses the help from the nurse and
nurse in all aspects.
tries to quit nurse-patient relationship.
Hopefulness
Components of Nurse-Patient Therapeutic
Relationship Nurse and patient have to be confident enough in the
treatment process so that a good interpersonal relationship
T – Trust (having faith) can be maintained.
E – Empathy (seeing out things by standing in his/her position)
A – Autonomy (independent) COMMUNICATION PROCESS AND
C – Caring attitude (nurse rendering care to patient) ITS BARRIERS
H – Hopefulness (feeling confident)
Barriers of communication process have been explained with
Trust each element in a communication process. The barriers in case
Nurse has to maintain good interpersonal relationship (IPR) of a sender are unwillingness or disinterest to communicate,
with the patient in order to develop trust. Nurse can explain lack of knowledge and problems related to speech or speech
each and every procedure and hospital routines to the client in deficits. The barriers in case of receiver are unwillingness or
a way so the patient’s anxiety might get reduced and it develops disinterest to listen, low level of understanding and hearing
the sense of trust in patient. problems. Barriers with channeling process as mobile phone
is not functioning, no internet connection, etc. Barriers of
Empathy environment are high noise and extreme hot or cold weather.
Nurse has to understand the problems of patient and the Concepts of communication barrier related to communication
nurse has to think if it happens to me, how will I react?— process are shown in Flowchart 4.2.

Flowchart 4.2: Barriers of communication related with communication process

CHAPTER 4 Therapeutic Communication and Nurse-Patient Relationship 97

Flowchart 4.3: Barriers of communication

Barriers of communication are further classified into 3. Reactions of intense anxiety, especially in response to
physical, psychological, environmental and barriers related resistance by the patient.
to organization. The examples of physical barriers are hearing • Boundary violations: The categories of boundary
deficit, speech deficit and eye problems. The examples of violations are role, time, space, place, money, gifts,
psychological barriers are nonwillingness to communicate, clothing, language, self-disclosure, post discharge social
fear/anxiety and psychological upset or mental illness. The boundaries and physical contact boundaries. Categories
examples of environmental barriers are extreme heat/cold, of boundary violations have been given in Table 4.7.
noise and poor ventilation. Barriers related to organization Table 4.7: Boundary violations
are like organization’s norms/protocols/rules and regulations/
policies that have not been communicated within the Categories of Description
organization. Barriers of communication have been shown in boundary violations
Flowchart 4.3. Role Nurse or patient performs other than
their own specified and accepted role
THERAPEUTIC IMPASSES Time Patient meets the nurse in
inappropriate timings or at night
• Resistance: Patient is not willing to communicate the Space Nurse and patient have to follow the
troubling aspect of oneself and patient is not willing to specified zone of space, if not, it is
change when the change is expected. considered violation of boundaries
„ Primary (For example, patient takes an inappropriate Place Patient meets the nurse in places other
role model and so the patient is unwilling to change). than hospital
„ Secondary (For example, resistance is due to financial Money Nurse accepts money from the patient
problem, unpleasant situation, attention seeking, social Gifts Nurse accepts gifts from the patient
pressure, etc.). Clothing Nurse accepts dress/clothes from the
• Transference: Transfer of client’s feeling toward the nurse. patient
„ Negative or hostile transference (Feel of anger or Language Talking in an unprofessional language
enmity that the client expresses toward the nurse).
Self-disclosure Nurse/patient shares their personal
„ Positive or dependent transference (client is information between them
emotionally dependent on nurse).
Post discharge social Nurse tries to develop social
• Countertransference: Nurse is emotionally dependent boundaries relationship with the patient after
on patient. discharge or the patient tries to
There are three types of countertransferences as develop social relationship with nurse
mentioned here. after discharge
1. Reactions of intense love or caring. Physical contact Patient tries to have a physical contact
2. Reactions of intense disgust or hostility. boundaries with the nurse
98 Textbook of Psychiatric Nursing for BSc Nursing Students

Management of Therapeutic Impasses Principles or Characteristics of Therapeutic

• Maintain limits with the patient. Communication
• Do not use nontherapeutic techniques on the patient The principles or characteristics of therapeutic communication
while communicating. are listed here.
• Identify and follow proper zones and spaces. • Patient is a primary focus in the interaction process.
• Have a proper professional relationship. • Maintain the client’s confidentiality.
• Early identification is important, when the client tends to • Avoid unnecessary advice and social relationship with the
cross boundaries. patient.
• Accurate documentation is essential. • Use self-disclosure only if it is found to be therapeutic.
• Have a nonjudgmental attitude.
THERAPEUTIC COMMUNICATION • Ask the patient to reinterpret one’s own experiences
rationally.
Definition • Assess the client’s intelligence level to determine the level
Interaction process between nurse and patient with a of understanding.
therapeutic purpose is known as therapeutic communication. • Always have a professional attitude.
This type of communication provides support and information
to the patient. Therapeutic Communication Techniques
Techniques of therapeutic communication are categorized as
Goals of Therapeutic Communication techniques helpful in development of description, development
The goals of therapeutic communication are listed here. of analysis, development of conclusion, development of
• Helps to identify the patient needs. conclusion to get a meaningful explanation and highlighting
• Assesses the perception of patient’s problem. the importance of techniques which are helpful in development
• Promotes the patient’s ventilation of emotions. of solving a problem and making a right. These techniques are
• Provides interventions based on patient’s needs. helpful in completion of plans. The techniques of therapeutic
• Establishes a proper therapeutic nurse-patient relationship. communication have been presented in Table 4.8.

Table 4.8: Therapeutic communication techniques

Therapeutic communication Description Example

techniques
Techniques helpful in development of description
Offering self Nurse making oneself available to listen the Nurse verbalizes to get a meaningful explanation to
client’s problems client as, ‘I will stay here to listen you.’
Using silence Not giving any verbal remarks and allowing the Nurse sits silently without any interruption in
client to talk conversation
Active listening Paying attention to client’s communication Nurse while maintaining eye contact with patient
(Mnemonic – SOLER): conveys the interest through facial expression
S – Sit facing the client
O – Open posture
L – Lean forward toward client
E – Establish eye contact
R – Relax
Empathy Talk out by standing or thinking from other’s Nurse verbalizes to client that, ‘I am able to
point of view understand how much it hurts you, really…’
Offering general leads Use neutral expressions and encourage the Nurse verbalizes to client that, ‘I am listening…you
client to talk continuously can continue…’
Questioning Asking questions in order to promote Nurse asks question to the client, ‘when? How?
discussion What? Why? Where? Who?’
Restating Repetition of main thoughts expressed by Nurse verbalizes to the client, ‘You said that you are
client happy only with your mother nowadays.’
Giving broad openings Encourage the client to select the topic for Nurse asking open ended questions such as ‘Can
discussion you say about your life?’
Contd…
CHAPTER 4 Therapeutic Communication and Nurse-Patient Relationship 99

Therapeutic communication Description Example

techniques
Verbalizing the implied Rephrasing the client’s words to enlighten the Patient: I am not interested in studies.
underlying message Nurse: Are you bored of your subjects?
Techniques helpful in development of analysis
Seeking clarification and Asking the client to elaborate or state examples Nurse asking doubts to the client, ‘Whether you
validation or voicing doubt of vague ideas or thoughts actually mean this in your conversation?’
Making observations Verbalizing the observations made Nurse verbalizes to client, ‘You got irritable when I
talk about your husband.’
Encouraging description of Encourage the patient to verbalize what has Nurse verbalizes to client, ‘Can you share what is
perceptions been perceived happening to you right now?’
Presenting reality Clarification of misconceptions, that the client Nurse verbalizes to client, ‘In reality, what bothers
is expressing you is wrong thoughts that you have about your
family?’
Sharing perceptions Nurse can share his/her perception to the Nurse verbalizes to client, ‘You are looking dull now.’
client during the conversation
Placing the event in time or Clarifying the relationship of events in time Nurse verbalizes to client, ‘Which event happens
sequence first and which one happened next?’
Encouraging comparison Encourage the patient to compare the Nurse verbalizes to client, ‘Which seems to be better
similarities and differences in regard with ideas when compared with previous one?’
or experiences
Techniques helpful in development of conclusion
Summarizing Highlighting the important points and review Nurse verbalizes to client, ‘I just summarized the
back the entire conversation main concepts of our discussions as…’
Theme identification Encourage the client to identify the recurrent Nurse verbalizes to client, ‘Vital concept of your
pattern of ideas, behavior and feelings problems in your life is your anger which makes you
deteriorated.’
Techniques helpful in development of conclusion to a meaning and highlight the importance
Focusing Focus toward the single idea or word Nurse verbalizes to client, ‘Can you describe that
event little more?’
Exploring Further identification of ideas or experiences Nurse verbalizes to client, ‘Can you elaborate little
more?’
Interpreting Nurse provides the view of meaning or Nurse verbalizes to client, ‘Actual problem which
significance of something troubles you is your inferiority complex?’
Techniques helpful in development of solving a problem and making a right decision
Encourage goal setting Encourage the client to decide the change Nurse asks to client, ‘When did you think the task
needed need to be done?’
Offering help Nurse offers help to client to solve the problem Nurse verbalizes to client, ‘I am there to help you.’
Encourage decision Advise the client to make a choice from various Nurse asks a client that, ‘Can you take decision out
options of these options?’
Formulating plan of action Plans are made to perform the next level of Nurse asks a client, ‘How are you going to do this
action task?
Techniques helpful in completion of plans
Giving recognition or Acknowledging the client for the correct Nurse verbalizes to client, ‘you have done a good
Reinforcement response job.’
Limit setting Discourage the unproductive feelings or Nurse verbalizes to client that, ‘you are becoming
behavior angry now. It has to be controlled.’
Supportive confrontation Convey the difficulties to change and encourage Nurse verbalizes to client, ‘I understand it is difficult
the client to change for a correct action to do, but you can perform still.’
Encouraging evaluation Encouraging the client to provide the view of Nurse verbalizes to client, ‘How do you done this in
meaning or significance of something an excellent way?’
100 Textbook of Psychiatric Nursing for BSc Nursing Students

Nontherapeutic Communication Techniques

Nontherapeutic techniques of communication are giving false reassurance, rejection, giving advice, unnecessary probing,
defending, requesting an explanation, indicating the existence of external source of power, belittling feelings expressed, making
stereotyped comments, cliches and trite expressions, using denial, parroting, being judgmental and other techniques which are
explained in Table 4.9.
Table 4.9: Nontherapeutic techniques of communication

Nontherapeutic Description Example

communication techniques
Giving false assurance Reassurance is different from that of false Nurse verbalizes to HIV patient that taking
reassurance. antiretroviral medications will prolong your life
span and enhance the capacity of daily living, is
an example of reassurance. If nurse verbalizes to
the patient that, HIV will get cured soon, it is an
example of false reassurance
Rejection/Rejecting Refuse the client’s ideas/concept/behavior Nurse verbalizes to client, ‘I won’t accept your
view about your mother.’
Giving advice Nurse gives advice to the client that whatever is Nurse verbalizes to client, ‘You can do better than
said is the best for him/her this instead of that.’
Unnecessary probing Asking out ‘why’ often which is not needed Nurse verbalizes to client, ‘Why so happened…
actually why so only to you….why you responded as
such…..’
Defending Trying out to defend in such a way that client has Nurse verbalizes to client, ‘You don’t have rights
no rights to express his/her own thoughts to talk anything about your negative thoughts
here.’
Requesting an explanation Asking ‘why’ might implies the client to defend Nurse verbalizes to client, ‘Why did you do this?’
one’s idea or behavior
Indicating the existence of an Encourage the client to blame on others for Nurse verbalizes to client, ‘It is not your mistake
external source of power one’s own mistake and it is happened because of your wife.’
Belittling feelings expressed Make the client feels that the feelings expressed Nurse verbalizes to client, ‘It seems to be very
are insignificant. silly.’
Making stereotyped comments, Meaningless comments with unusual Nurse verbalizes to client, ‘You are powerless
cliches and trite expressions expressions when you talk….no life in your speech……inactive
talk……powerless speech…’
Using denial Refusing the discussion with patient Nurse verbalizes to client, ‘I don’t like to discuss
this.’
Parroting Continuous repetition of patient’s words Nurse verbalizes to client, ‘You said that I feel sad
since I am jobless.’
Being judgmental
Approving or disapproving Passing judgment as ‘good’ or ‘bad’ in regard Nurse verbalizes to client, ‘What you have done
with client behavior is so bad.’
Agreeing or disagreeing Judgment as ‘right’ or ‘wrong’ in regard with Nurse verbalizes to client, ‘What you have done is
client ideas too wrong?’
Miscellaneous
Introducing an unrelated topic
Failure to listen
Failure to explore the patient’s point of view
Giving inadequate answers
Vague description
CHAPTER 4 Therapeutic Communication and Nurse-Patient Relationship 101

ETHICS AND RESPONSIBILITIES about oneself. SWOT analysis is an integral part for self-
awareness.
Definition
S – Strength
Ethics is a branch of philosophy which deals with the study of W– Weakness
values and moral standards related to nursing profession. O – Opportunities
T – Threats
Primary Principles in Ethical Decision Making
Campbell (1980) identified holistic nursing model of self-
The American Nurses Association (ANA) has explained the awareness. It has four aspects which are mentioned here.
four ethical principles involved in the decision-making process 1. Psychological: Knowledge of motives, emotions, self-
which are discussed as follows: concept and personality.
1. Autonomy: Patient taking an independent decision. 2. Physiological: Knowledge of general physiology.
2. Beneficence: Nurse doing good to patient. 3. Environmental: Knowledge of relationship of human
3. Justice: Nurse doing which is fair to patient. with nature or environment.
4. Veracity: Nurse and patient are being truthful. 4. Philosophical: Knowledge of sense of life.

Responsibilities of the Nurse for Being Ethical in Power

All Aspects
Appropriate use of power will help the nurse to work out
Nurse always has to respect the patient’s dignity and cultural toward the achievement of goal. Nurse should not consider the
belief. Nurse has to provide privacy whenever and wherever power as advantage since the patient is vulnerable.
necessary. Nurse has to perform the role of an advocate to
protect the patient’s rights. Nurse has to respect the autonomy Intimacy
or freedom of patient in decision-making process. Nurses
working in psychiatric health setup have to take necessary Kinds of activities that nurses perform to develop the personal
steps to follow the guidelines provided by ANA code of nurses. and private closeness with patient at various elements such as
physical, social, spiritual and psychological aspects.
DYNAMICS OF THERAPEUTIC NURSE-PATIENT
RELATIONSHIP OR THERAPEUTIC USE OF SELF Trust
FOR GAINING SELF-AWARENESS Nurse has to develop the sense of trust with the patient. Nurse
has to explain the ward routines, and orient the patient. It is
Dynamics is the force which is helpful to produce change in a
always approachable to gain trust.
psychological or social system. It is the vital responsibility of a
nurse to understand about these forces which are listed here.
Respect
• Therapeutic use of self-awareness
• Improving self-awareness Nurse have to respect the patient irrespective of their race,
• Power culture, gender, socioeconomic status, occupation, etc. The
• Intimacy basic sense of respect given by the nurse will help the nurse to
• Trust maintain the good nurse-patient therapeutic relationship.
• Respect
JOHARI WINDOW OF INTERPERSONAL
Therapeutic Use of Self-Awareness RELATIONSHIP
Using the self-awareness in order to provide the nursing Joseph Luft and Harry Ingham (1950) described the concept
interventions. Hildegard Peplau (1952), mother of Psychiatric of interpersonal relationship. The prefix of both the names,
nursing, concluded that nurses have to understand oneself ‘Joseph’ and ‘Harry’, was adjoined together and termed Johari
thereby he/she might improve the patient’s health condition. window (Fig. 4.4). Other names are as follows:
• Disclosure or feedback model of self-awareness
Improving Self-Awareness
• Information processing tool
If an individual is aware of oneself, he or she might develop The Johari window has four quadrants that represent four
an ability to fight against any issue in his/her day to day life. combinations as follows:
Self-awareness includes self-concept, values, belief and life 1. Quadrant 1 (arena or open): Information was known to
experiences. Self-awareness is a vital part for a nurse to aware the self and also known to others. When Quadrant 1 is
102 Textbook of Psychiatric Nursing for BSc Nursing Students

Time of Recording
It should be done either during the nurse-patient interaction
or immediately after the nurse as patient interaction.

Purposes
Overall aim of process recording is to improve the quality of
interaction process and it also acts as learning experience for
the nurse regarding the improvement in interaction process.
The specific purposes are as follows:
• Helps to identify the problems and promotes skills to
solve those problems.
• Enhances the observational skills during thinking,
and categorizing the interaction process into different
heading.
• Compares the verbal and nonverbal communication
Figure 4.4: Johari Window of interpersonal relationship pattern.
• Helps to develop the awareness about the interaction
large, it denotes nurse is open to others and self. When process.
Quadrant 1 is small, it denotes nurse is partially open to • To plan, structure and evaluate the interaction of nurse
others and self. and patient.
2. Quadrant 2 (blind spot): Information was not known to the • Acts as a prerequisite to nursing process.
self but known to others. Blind spot denotes the lack of self-
Thus, process recording is considered teaching or educative
awareness. People in the group might learn from the verbal
tool, diagnostic or assessment tool, therapeutic or intervention
cues, mannerisms or style of speech.
tool, evaluative tool and tool for self-awareness.
3. Quadrant 3 (facade or hidden): Information was known
to the self and not known to others. When Quadrant 2
Prerequisites for Process Recording
is large, it denotes nurse has higher self-awareness and
not opened to others. It is comparable with introvert • Physical organizational setup
personality in which the individual does not share • Good and noise-free environment
anything out due to fear about the group or unwillingness • Consent from the patient should be taken if voice
to share to others. recording is needed.
4. Quadrant 4 (unknown): Information was not known • Willingness of patient should be assessed whether he/she
to self and also to others. When the individual or he/she wants to proceed with the interaction process or not.
felt that the information is not known to him/her is the
time to remove the ignorance and enlighten the patient Format of Process Recording
with knowledge. When the individual got awareness Patient Profile:
about oneself, the chances of sharing knowledge will also Name:
increase. Age:
Gender:
PROCESS RECORDING Education:
Occupation:
Definition
Hospital identity number:
It is a method of recording nurse-patient interaction, which Ward/OPD:
has been done by the nurses in psychiatric setup. Date of admission:
Name of treating doctor:
Recording Technique Chief complaints:
Verbatim recording technique is used for recording the nurse- Objectives or Purposes:
patient interaction. (The term ‘verbatim’ denotes record the Prerequisites or Preparation of Patient and Environment:
exact words verbalized by the patient.) Date, time and place of Process recording:
CHAPTER 4 Therapeutic Communication and Nurse-Patient Relationship 103

Context of Interaction:
Participants in Verbal Nonverbal communication Inference
interaction communication
Nurse: Record in verbatim (Document Include facial expression, posture, gesture, Write the interpretation that what
Patient: the exact words verbalized by mannerism, eye contact, tone of voice, pacing you have interpreted on comparing
the patient) and gait of patient during conversation. It is the verbal and nonverbal
important to include any peculiar behavior communication of nurse and
such as biting the nail, periods of silence, patient interaction
shouting or exhibiting aggression, etc.

Outline of Process Recording Analysis of Interaction

Introductory Concept It includes the inference or interpretation of process recording
It includes the patient profile, medical/surgical/psychiatric of both the verbal and nonverbal communication of the
history, date/time/place of interaction, reason for choosing the patient. Identification in terms of thoughts and feelings is more
client and duration of interaction. concerned.

Objectives Ideal Duration of Interaction

‘SMART’ is a Mnemonic to remember the nature of goal The total time required for process recording is 30 minutes, in
setting in process recording. which 20 minutes are considered active time and remaining
It has to be: 10 minutes are for conclusion of recording.

S – Specific Summary of Process Recording

M – Measurable
A – Achievable Summarize the entire interaction process and identify the
R – Realistic and short-term goals whether these have been met or not. If the
T – Timely in nature goals are not met, modify the conversation process and replan/
reschedule for the next time.
Setting the short-term goal is found appropriate in the initial
phase of nurse-patient interaction, i.e., on preorientation,
orientation and identification phase. Long-term goal
has to be set during the intervention, maintenance and
termination phase of nurse-patient interaction which includes
rehabilitation and follow-up of nursing care as shown in
Figure 4.5.

Context of Nurse-Patient Interaction

It includes verbal and nonverbal communication of nurse-
patient interaction. It also includes any abnormal behavior Figure 4.5: Goals of process recording during the phases of
elicited during interaction. nurse-patient relationship

SUMMARY
• Communication is defined as ‘interaction process between the sender and receiver in which the receiver receives the message exactly
what the sender intended to say as such.
• Theories of communication include Ruesch’s theory, transactional analysis and neurolinguistic programming.
• Types of communication are verbal, nonverbal, formal, informal, interpersonal, intrapersonal, transpersonal, horizontal, vertical,
animal, physiological, chain, metacommunication and communication through mass media.
• Barriers of communication process have been categorized into barriers related to sender, channel, receiver and environment. Barriers
of communication are also categorized as physical, physiological, environment and organization.
• Therapeutic impasses are resistance, transference, countertransference and boundary violations such as role, time, space, place,
money, gifts, clothing, language, self-disclosure, post discharge social boundaries and physical contact boundaries.

Contd…
104 Textbook of Psychiatric Nursing for BSc Nursing Students

• Therapeutic techniques of communication are offering self, using silence, active listening, offering general leads, empathy, questioning,
restating, giving broad openings, verbalizing the implied, seeking clarification and validation or voicing doubt, making observations,
encouraging description of perceptions, presenting reality, sharing perceptions, placing the event in time or sequence, encouraging
comparison, summarizing, theme identification, focusing, exploring, interpreting, encourage goal setting, offering help, encourage
decision, formulating plan of action, giving recognition or reinforcement, limit setting, supportive confrontation, encouraging evaluation.
• Nontherapeutic communications are giving false assurance, rejection/rejecting, giving advice, unnecessary probing, defending,
requesting an explanation, indicating the existence of an external source of power, belittling feelings expressed, making stereotyped
comments, cliches and trite expressions, using denial, parroting, approving or disapproving, agreeing or disagreeing, introducing an
unrelated topic, failure to listen, failure to explore the patient’s point of view, giving inadequate answers and vague description.
• Dynamics of nurse-patient relationship includes therapeutic use of self-awareness, improving self-awareness, power, trust, intimacy
and respect.
• Joseph Luft and Harry Ingham (1950) described the concept of interpersonal relationship termed Johari window of IPR which has four
quadrants as: known to self, known to others, not known to self and not known to others.
• Process recording is a process of recording nurse-patient interaction in psychiatric setup.

ASSESS YOURSELF
Long Answer Questions 4. Transfer of client’s feeling toward the nurse means
1. Define therapeutic communication. Explain the _____________.
techniques of therapeutic communication with example. a. Transference b. Countertransference
2. Define nurse-patient relationship. Explain the principles, c. Resistance d. None of these
phases and components with appropriate examples. 5. Johari window of IPR is also known as __________.
a. Disclosure or Feedback model of self-awareness
Short Answer Questions b. Information processing tool
1. List out the therapeutic techniques of communication? c. Both a and b
2. Define Process Recording? d. None of the above
6. The therapeutic technique of communication is
Short Notes __________.
Write short notes on: a. Active listening b. Being judgmental
1. Types of communication c. Both a and b d. None of these
2. Nurse-patient relationship
7. The nontherapeutic technique of communication is
3. Barriers of communication __________.
4. Therapeutic impasses and their management a. Focusing b. Defending
5. Communication process c. Both a and b d. None of these
6. Techniques of therapeutic communication
8. The communication within a communication means
7. Therapeutic use of self
__________ communication.
8. Johari window of IPR
a. Verbal b. Meta
Multiple Choice Questions c. Informal d. Animal
1. Communication takes place among professionals is 9. Communication takes place within oneself means
________ communication. __________ communication.
a. Formal b. Informal a. Intrapersonal b. Interpersonal
c. Both a and b d. None of these c. Transpersonal d. Formal
2. Johari window of IPR has _____ quadrants. 10. The term ‘Blind Spot’ in Johari window of IPR denotes
a. 1 b. 2 ________.
c. 3 d. 4 a. Not known to self and others
3. The below phrase which is best to describe the b. Known to self and not known to others
meaning of communication is _____________. c. Not known to self but known to others
a. Common understanding between the sender and d. None of the above
receiver Answer Key
b. Interaction between sender and receiver
1. a 2. d 3. a 4. a 5. c
c. Two members talking each other
d. None of the above 6. a 7. b 8. b 9. a 10. c
 CHAPTER
Treatment Modalities
and Therapies used in
Mental Disorders 5
LEARNING OBJECTIVE

After studying this chapter, the student will be able to understand the basic concepts of psychological therapies and administer the
appropriate psychological therapies to the patient based on the needs and issues.

CHAPTER OUTLINE
Psychopharmacology • Meditation
• Antipsychotics • Biofeedback
• Antidepressants Alternative and Complementary Medicine
• Antianxiety Agents (or) Anxiolytics • History
• Antiparkinson Agents • Definition
• Mood Stabilizers • Principles of Alternative and Complementary Medicine
• Stimulants (or) Psychostimulants • Major Domains of Alternative and Complementary
Psychological Therapies Medicine
• Psychotherapy Occupational Therapy
• Cognitive Therapy • Definition
• Behavioral Therapy • Aims of Occupational Therapy
• Cognitive Behavioral Therapy • Principles of Occupational Therapy
• Therapeutic Community • Basic Elements of Psychiatric Occupational Therapy
• Milieu Therapy • Indications
• Supportive Psychotherapy • Settings of Occupational Therapy
• Family Therapy • Occupational Therapy Activities
• Group Therapy • Classification of Occupational Therapy
• Play Therapy • Services Given in Occupational Therapy
• Psychodrama • Occupational Therapy Process
• Music Therapy • Advantages of Occupational Therapy
• Dance Therapy (or) Dance Movement Psychotherapy
Electroconvulsive Therapy
• Recreational Therapy (or) Therapeutic Recreation
• Historical Background
• Light Therapy (or) Phototherapy (or) Heliotherapy
• Definition
• Relaxation Therapy
• Classification of Electroconvulsive Therapy
• Guided Imagery or Guided Affective Imagery (or)
Katathym—Imaginative Psychotherapy Psychosurgery or Functional Neurological Surgeries
• Deep Brain Stimulation
Miscellaneous
• Psychological Therapies
• Yoga
106 Textbook of Psychiatric Nursing for BSc Nursing Students

KEY TERMS
Antipsychotics or neuroleptics or major tranquilizers or dopamine receptor blockers, Neuroleptic malignant syndrome, Pseudo-
Parkinson’s disease, Akathisia, Acute dystonia, Rabbit syndrome, Tardive dyskinesia, Antidepressants or thymoleptics or mood
elevators, Tricyclic antidepressants, Selective Serotonin Reuptake Inhibitors (SSRI), Serotonin Norepinephrine Reuptake Inhibitors
(SNRI), Monoamine Oxidase Inhibitors (MAOIs), Atypical antidepressants, Serotonin syndrome, Hypertensive crisis, Gamma-Amino
Butyric Acid (GABA), Antianxiety agents or anxiolytics or minor tranquilizers, Barbiturates, Benzodiazepines, Anti-Parkinson’s drugs,
Substantia nigra, Mood stabilizers, Stimulants, Amphetamines, Individual psychotherapy, Hypnosis, Abreaction, Reality therapy,
Insight psychotherapy, Free association, Psychoanalytical therapy, Cognitive therapy, Behavioral therapy, Classical conditioning,
Operant conditioning, Systemic desensitization, Flooding or implosive therapy, Assertiveness training, Aversion therapy, Modeling,
covert sensitization, Overt sensitization, Contingency contracting, Token economy, Rational emotive therapy, Meta-cognitive therapy,
Dialectical behavior therapy, Mindfulness based cognitive therapy, Acceptance-commitment therapy, Cognitive behavioral therapy,
Supportive psychotherapy, Family therapy, Therapeutic community, Milieu therapy, Group therapy, Play therapy, Psycho–drama,
Music therapy, Dance therapy, Recreational therapy, Light therapy or phototherapy or heliotherapy, Relaxation therapy, Autogenic
training, Jacobson Progressive Muscle Relaxation (JPMR), Guided imagery, Ashtanga yoga, Surya namaskar, Pranayama, Kriyas, Asanas,
Acupuncture, Homeopathy, Naturopathy, Ayurveda, Aromatherapy, Herbal therapy, Exercise, Massage therapy, Tai chi technique,
Bioelectromagnetic therapy, Reflexology, reiki, Therapeutic touch, Spiritual healing, Art therapy, Sound therapy, Meditation,
Biofeedback, Electroconvulsive therapy, Psychosurgery, Deep brain stimulation.

PSYCHOPHARMACOLOGY History of Antipsychotics

Sen and Bose (1931) were the first to introduce Reserpine. Jean
ANTIPSYCHOTICS Delay and Pierre Deniker (1952) were the first to introduce
Chlorpromazine. Janssen (1958) was the first to introduce
Antipsychotics are medications used to treat psychotic Haloperidol. Comparison of typical antipsychotics and
disorders or psychosis related to other psychiatric and medical atypical antipsychotics is explained in Table 5.1.
disorders.

Synonymous terms NOTE

• D2 receptor blockers High potency antipsychotics should be avoided in Parkinson and
• Major tranquilizers in patients with history of extrapyramidal symptoms. Low potency
• Neuroleptic agents antipsychotics should be avoided in patients with heart diseases,
• Ataractics delirium, benign prostrate hypertrophy in elders and closed angle
• Anti-schizophrenic drugs glaucoma.

Table 5.1: Comparison of conventional (or) traditional (or) typical antipsychotics and atypical antipsychotics (or) second generation
antipsychotics

Aspects Conventional (or) traditional (or) typical Atypical antipsychotics (or) second generation
antipsychotics antipsychotics

Treatment of symptoms Treat positive symptoms more than negative symptoms Treat negative symptoms well
Side effects Cause extrapyramidal side effects Cause anticholinergic and metabolic side effects
Antagonize the Antagonize Dopamine (D2) receptors Antagonize Dopamine (D2), serotonin, alpha and
receptors histamine receptors
Types/classification/ High potency medication (High affinity to dopamine • Risperidone (Risperdal)
examples receptors is present and hence low dose is required) • Clozapine (Clozaril)
• Fluphenazine (Prolixin) • Olanzapine (Zyprexa)
• Haloperidol (Haldol) • Ziprasidone (Geodon)
Moderate potency medication • Quetiapine (Seroquel)
• Perphenazine (Trilafon) • Aripiprazole (Abilify): Considered Novel (or)
Low-potency medication (Low affinity to dopamine Third generation antipsychotics
receptors, therefore, high dosage is required)
• Chlorpromazine (Thorazine)
• Thioridazine (Mellaril)
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 107

Types of Antipsychotics Mood Disorders

Typical Antipsychotics • Mania
• Phenothiazines • Depression with psychotic symptoms
„ Aliphatics: E.g., Chlorpromazine (300–1500 mg/day
Childhood Disorders
oral or 50–100 mg/day IM)
„ Piperidines: E.g., Thioridazine (300–800 mg/day oral) • Autism
„ Piperazines: E.g., Fluphenazine (2–20 mg/day oral) • Enuresis
• Thioxanthenes • Attention-deficit hyperactivity disorder (when stimulants
„ Aliphatics: E.g., Chlorprothixene (75–600 mg/day oral are contraindicated)
or 25–75 mg/day IM) • Conduct disorder
„ Piperazines: E.g., Flupenthixol (3–40 mg/day oral)
Neurotic Disorders
• Butyrophenones: E.g., Haloperidol (5–100 mg/day oral
• Intractable obsessive compulsive disorder (Thioridazine
or 5–20 mg/day IM)
is drug of choice)
• Diphenylbutylpiperidines: E.g., Pimozide (4–20 mg oral) • Intractable anxiety (Olanzapine is drug of choice)
• Indolic Derivatives (or) Dihydroindolones: For example,
Molindone (50–225 mg/day oral) Medical Disorders
• Dibenzoxazepines: E.g., Loxapine (25–100 mg/day oral) • Tics/tourette syndrome
• Tetanus
Atypical Antipsychotics • Nausea/vomiting
• Dibenzodiazepines: E.g., Clozapine (50–450 mg/day • Eclampsia
oral) • Heat stroke
• Intractable hiccups
• Benzisoxazole: E.g., Risperidone (2–10 mg/day oral)
• Intractable pruritus
• Benzisothiazole: E.g., Ziprasidone (40–160 mg/day • Huntington’s chorea
oral) • Severe pain during malignancies
• Substituted Benzamides: For example, Amisulpride
(400–1200 mg/day oral) Contraindications
• Dibenzothiazepine: E.g., Quetiapine (300–500 mg/day Contraindications of antipsychotics are illustrated in
oral) Flowchart 5.1.
• Thienobenzodiazepine: E.g., Olanzapine (5–20 mg/day
oral) Drug Interactions of Antipsychotics
Drug interactions of antipsychotics are given in Flowchart 5.2.
Indications
Organic Mental Disorders Classification of Side Effects of Antipsychotics
• Delirium Antidopaminergic Side Effects
• Dementia with psychotic features/violent behavior • Extrapyramidal symptoms (Fig. 5.1 and Table 5.2)
• Organic hallucinosis • Hyperprolactinemia
• Organic delusional disorder
• Psychosis due to withdrawal of substance/drug Antihistaminic Side Effects
Sedation
Functional Disorders
• Acute Psychosis Anti-Alpha Adrenergic Side Effects
• Schizophrenia • Orthostatic hypotension
• Schizoaffective disorder • Sexual dysfunction
• Delusional disorder • Cardiac arrhythmias
108 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 5.1: Contraindications of antipsychotics Flowchart 5.2: Drug interactions of antipsychotics

Figure 5.1: Extrapyramidal side effects

Table 5.2: Management of side effects due to antipsychotics

Side effects Occurring due to Medical management Nursing management

Autonomic side effects
Dry mouth (due to • No need of treatment • Maintain oral hygiene
blockage of facial and • Pilocarpine 2% (occasionally) • Use sugarless chewing gum
glossopharyngeal nerve)
Chlorpromazine (thorazine)
Constipation (due to • No need of treatment • High fiber diet
blockage of vagus nerve) • Laxatives (occasionally) • More intake of water
• Increase physical activity
Orthostatic hypotension • Chlorpromazine (thorazine) • Use plasma expanders (when • Monitor blood pressure
(due to blockage of alpha-1 • Clozapine (clozaril) severe) regularly
receptor) • Thioridazine (mellaril) • Raise the leg • Advise the client to get up from
• Change safer drugs lying or sitting in a slow manner
Central anticholinergic • Physostigmine • Prevent falls
syndrome (delirium) • Diazepam (occasionally) • Provide safety measures
• Orient the patient
Urinary retention • Assess benign prostrate • Maintain intake output chart
hypertrophy • Assess for bladder distension
• If persists, urinary • Advise the client to report the
Chlorpromazine (thorazine) catheterization can be done difficulty in voiding
• Pour water on patient’s back to
stimulate urination
Cycloplegia • No need of treatment • Report the side effects
• Pilocarpine 2% (occasionally) immediately to the doctor so
• Change the safer antipsychotics that safe antipsychotics might
be prescribed
Contd…
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 109

Side effects Occurring due to Medical management Nursing management

Impotence (due to blockage • Document the side effects and
of α-2 receptor) measures taken
Mydriasis (due to blockage
of Oculomotor nerve)
Impaired ejaculation Thioridazine (mellaril)
(due to blockage of
α-2 receptor)
Extrapyramidal side effects (EPS)
Neuroleptic malignant • Bromocriptine • Report the Extrapyramidal side
syndrome • Baclofen effects immediately to doctor
• Dantrolene • Quit the next dose of
• Electroconvulsive therapy prescribed antipsychotics and
(rarely) inform the same to doctor
Pseudo-Parkinson’s disease • Anti-Parkinson’s agents (stop the drug because it is
Traditional (or) typical
• Benzodiazepines causing the Extrapyramidal side
antipsychotics
• Anticholinergics effects)

Akathisia • Beta blockers

Acute dystonia • Anti-Parkinson’s agents
• Benzodiazepines
Rabbit syndrome • Anticholinergics
Tardive dyskinesia Unknown (equal chance with • Focus on prevention
all antipsychotics)
Central nervous system side effects
CNS depression Unknown • Antidepressants (occasionally)
• Electroconvulsive therapy
Seizure Chlorpromazine (thorazine) • Decrease the dosage • Safety measures
• Change to safer antipsychotics • Put side rails
• Prevent falling back of tongue
• Don’t restrict the movements
• Turn head to one side during
the seizure to prevent
aspiration
• Monitor and document
the duration and nature of
seizure
Sedation • Olanzapine (zyprexa) • Maintain sleep chart
• Clozapine (clozaril) • Prevent fall/injury in all
• Thioridazine (mellaril) activities
Allergic side effects
Cholestatic jaundice Chlorpromazine (thorazine) Change to safer antipsychotics
Agranulocytosis Clozapine Filgrastim • Weekly checking of White
Blood Cells (WBC) count
• Isolation
• Infection control measures
Metabolic and endocrine side effects
Weight gain (due to • Chlorpromazine (thorazine) • Monitor the weight regularly
blockage of H1 receptor) • Clozapine (clozaril) • Diet control
• Thioridazine (mellaril) • Exercise
• Olanzapine (zyprexa) • Change to other safer medication as prescribed
Galactorrhea Haloperidol Change to other safer medication as prescribed

Contd…
110 Textbook of Psychiatric Nursing for BSc Nursing Students

Side effects Occurring due to Medical management Nursing management

Cardiac side effects
ECG Changes: Prolonged Chlorpromazine (thorazine) Change to the safer antipsychotics • Check pulse and blood pressure
QTC interval (fatal • Report immediately if chest
arrhythmia: Torsades de pain is felt by patient
pointes)
Ocular side effects
Granular deposit in cornea Chlorpromazine (thorazine) Change to the safer antipsychotics Ophthalmic examination
and lens
Pigmentary retinopathy Thioridazine (mellaril)
Dermatological side effects
Contact dermatitis Chlorpromazine (thorazine) • Skin assessment
• Symptomatic management
Photosensitivity reaction Use of sunscreen and avoid
exposure to sunlight

Antimuscarinic Side Effects „ Bradykinesia

• Blurred vision „ Stooping posture
• Tachycardia „ Drooling of saliva
• Dry mouth „ Akinesia
• Urinary retention „ Ataxia
• Constipation „ Pill rolling tremors
• Seizure • Akathisia
• Weight gain „ Agitation
• Increased liver enzymes „ Restless (For example, patient tapping the palm on the
• Eye problems lap in a fast manner)
• Skin problems • Acute dystonia
„ Opisthotonus
Extrapyramidal Symptoms
„ Oculogyric crisis (upward lateral movement of eye)
• Neuroleptic malignant syndrome • Rabbit syndrome: Presence of orofacial tremors
„ Life threatening disorder that occurs in small number • Tardive dyskinesia
of patients receiving antipsychotics. „ Abnormal choreoathetoid movements are seen in
„ Onset is rapid, within 24–72 hours muscles of head, trunk and limbs
„ Mental symptoms „ Most common in older women
◆ Stupor/altered consciousness „ Severe form of Extrapyramidal symptoms might lead
„ Autonomic disturbances to disfigurement of face
◆ Tachycardia
◆ Increased sweating Pharmacokinetics of Antipsychotics
◆ Urinary incontinence
• Absorption: Oral medications are absorbed in GI tract
◆ Unstable blood pressure
and reach blood stream
◆ Increased salivation
„ Secondary features • Distribution: Lipophilic and bind to proteins
◆ Renal failure • Metabolism: Takes place in liver (hepatic microsomal
◆ Cardiovascular collapse enzyme)
◆ Pneumonia • Excretion: Enterohepatic circulation (liver and kidney)
◆ Thromboembolism
• Pseudo-Parkinson’s disease
Pharmacodynamics of Antipsychotics
„ Masked face • Site of action: Antipsychotics act on dopamine
„ Cog-wheel rigidity type 2 (D2) receptors.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 111

NURSING IMPLICATION
Nurses’ Responsibility for Patients Receiving Antipsychotics
• Follow the rights of medications.
• Advise the client to take sips of water to prevent xerosis
(dryness of mouth).
• Advise the client to take high fiber diet and more intake of
water to prevent constipation.
• Advise the client to get up from bed slowly to prevent
orthostatic hypotension.
• Observe the client for extrapyramidal symptoms.
• Take seizure precautions.
• Advise the client to take antipsychotic drug at bed time since
the drugs might cause sedation.
• Advise the client to use sunscreen, wear full sleeves and use
dark glasses for photosensitive reactions.
Figure 5.2: Dose-response curve • Patient receiving clozapine is having risk of developing
agranulocytosis. So, WBC count has to be monitored weekly
• Dose-response curve: It denotes the drug effect versus once. If WBC count <3000/mm3 then stop the drug. Advise the
plasma concentration (Fig. 5.2). client to report if he/she develops sore throat or fever, since it
denotes sign of infection.
Example: Risperidone found more potent than
• Advise the patient that antipsychotics should not be
Olanzapine (4 mg of risperidone = 20 mg of olanzapine discontinued suddenly because it leads to antipsychotic
with same beneficial effects). withdrawal syndrome characterized by nausea, vomiting,
• Therapeutic window: Blood level of drug below the diarrhea, rhinorrhea, and diaphoresis, lack of sleep, agitation
therapeutic window is not effective and higher than and malaise. This withdrawal symptoms occur within 2 weeks
when patient quits the drug. So, slow tapering of the drug is
therapeutic window is toxic.
advisable.
• Advise the client to have drug compliance in order to prevent
Mechanism of Action the relapse.
Dopamine (D2 receptor) blockage on the dopamine pathways
will lead to the following effects (Fig. 5.3): ANTIDEPRESSANTS
• Nigrostriatal tract: Causes extrapyramidal symptoms.
• Tuberoinfundibular tract: Modulates pituitary thereby Synonymous terms
increase prolactin. • Thymoleptics
• Mesolimbic tract: Reduces positive symptoms • Mood elevators
(hallucinations and delusions).
• Mesocortical tract: treats negative and cognitive History of Antidepressants
symptoms.
• Imipramine was the first discovered antidepressant.
• Iproniazid and antituberculosis medications were found
to have antidepressant effects.
• In 1957, tricyclic antidepressants were evolved and so
these are referred to as first generation drugs.

Indications for Antidepressants

Neurotic and Stress-Related Disorders
• Endogenous depression
• Panic disorders
• Obsessive compulsive disorder (SSRI)
• Generalized anxiety (SSRI)
• Social phobia
Figure 5.3: Dopaminergic pathways in the brain • Panic disorder
112 Textbook of Psychiatric Nursing for BSc Nursing Students

• Post-traumatic stress disorder (SSRI) Selective Serotonin Reuptake Inhibitors (SSRI)

• Premenstrual dysphoric disorder • Fluoxetine 20–80 mg
Medical Disorders • Sertraline 50–200 mg
• Paroxetine 20–50 mg
• Migraine (amitriptyline and nortriptyline)—neuropathic
• Fluvoxamine 50–300 mg
pain
• Citalopram 20–60 mg
• Chronic pain
• Escitalopram 10–30 mg
• Irritable bowel syndrome
• Premature ejaculation Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
• Pain related to fibromyalgia (SNRI)
Venlafaxine 75–225 mg
• Pain related to neuropathy (SNRI)
Atypical Antidepressants
Eating Disorders
• Bupoprion (wellbutrin) 150–450 mg
• Anorexia nervosa
• Nefazodone (serzone) 200–600 mg
• Bulimia nervosa
• Obesity
Mechanism of Action for Antidepressants
Miscellaneous • Monoamine hypothesis: Deficiency of monoamines
• Insomnia (doxepin) such as serotonin, norepinephrine and dopamine leads to
• Schizoaffective disorder depression.
• Nocturnal enuresis in children • Postsynaptic receptors to upregulate.
• Borderline personality disorder • Monoamine hypothesis of gene expression states abnormal
• Smoking functioning of genes that might lead to depression.
• Alcoholism
Mechanism of Action—Selective Serotonin
Types of Antidepressants Reuptake Inhibitors (SSRI)
• First generation antidepressants (or) tricyclic anti- • SSRI will block serotonin transporter (SERT) and so it
depressants (TCA)—drug of choice for severe depression. will inhibit the reuptake of serotonin in presynapse.
• Second generation antidepressants (or) selective serotonin • Serotonin is synthesized in serotonergic neuron by amino
reuptake inhibitors (SSRI)—drug of choice for mild to acid ‘Tryptophan’.
moderate depression. • Tryptophan from vesicles starts to release into synapse
• Serotonin norepinephrine reuptake inhibitors (SNRI). and binds with the receptors of postsynapse. At the same
• Monoamine oxidase inhibitors (MAOI). time, there will be reuptake process too.
• Atypical antidepressants. • Serotonin in the synapse is reabsorbed into presynapse by
Tricyclic Antidepressants serotonin transporter (SERT).
• When serotonin reuptake takes place, it partially
• Tertiary amine tricyclic antidepressants reuptakes into vesicles and partially gets broken down
„ Amitriptyline 100–200 mg
into metabolites by monoamine oxidase (MAO) enzymes.
„ Doxepin 100–200 mg
• Antidepressants will tend to produce maximum benefits
„ Imipramine 100–200 mg
by forming the G-protein as cluster in brain cell membrane
„ Clomipramine 100–200 mg
namely lipid graft. G-Protein lacks access to molecule
• Secondary amine tricyclic antidepressants called Cyclic-AMP which is important to work with the
„ Nortriptyline 75–150 mg signals of serotonin.
„ Protriptyline 15–40 mg • SSRI will help to release G-protein from lipid raft and
„ Desipramine 100–200 mg reach the membrane to function better. So, in order to
„ Amoxapine 200–300 mg carry out all the above processes, antidepressants are
„ Maprotiline 100–150 mg taken for 6–8 weeks to get maximum benefits (Fig. 5.4).
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 113

Mechanism of Action—Tricyclic Antidepressants (TCA)

(Fig 5.5)
• Tricyclic antidepressants (TCA) will block serotonin
transporter and norepinephrine transporter primarily.
• Desipramine is more selective in inhibiting nore-
pinephrine transporter than serotonin transporter.
• However, TCA also blocks alpha, histaminic and
muscarinic receptors. Thus, serotonin, norepinephrine
and dopamine get increased in synapse.

Mechanism of Action—Monoamine Oxidase Inhibitors

(MAOI) (Fig. 5.6)
• Monoamine oxidase is present in brain, gut and liver.
• It has MOA-A and MOA-B:
„ MOA–A: Preferably metabolizes serotonin but it also
metabolizes norepinephrine and dopamine.
Figure 5.4: Mechanism of action of SSRI „ MOA–B: Preferably metabolizes dopamine.
• Monoamine oxidase inhibitors will inhibit the mono-
Mechanism of Action—Serotonin Norepinephrine amine oxidase enzyme, which then automatically
Reuptake Inhibitors (SNRI)
decreases the availability of monoamines such as
• Serotonin norepinephrine reuptake inhibitors (SNRI) serotonin, norepinephrine and dopamine.
will inhibit the serotonin transporter (SERT) and • Selegiline selectively blocks MAO-B (dopamine
norepinephrine transporter (NET) and thereby reuptake metabolism) and so it is helpful in Parkinson’s disease.
process will get inhibited. • MAOI has drug food interactions and is present in
• Now adequate norepinephrine and serotonin will be the gut/intestines. The inhibited monoamines due to
present to bind with postsynapse. administration of MAOI might metabolize tyramine.

Figure 5.5: Mechanism of action of tricyclic antidepressants

114 Textbook of Psychiatric Nursing for BSc Nursing Students

Figure 5.6: Mechanism of action of MAOI

• Increased tyramine acts as catecholamines releasing Table 5.3: Side effects of antidepressants
agent, that leads to hypertensive crisis and further leads
Blockage of receptors by Side effects
to stroke.
tricyclic antidepressants
(TCA)
Mechanism of Action—Atypical Antidepressants
Alpha • Orthostatic hypotension
• Bupropion is a weak norepinephrine and dopamine • Giddiness
reuptake inhibitor. It reduces nicotine craving. Histaminic • Sedation
• Mirtazapine is an alpha receptor antagonist. It also • Cognitive impairment
blocks histamine receptor and serotonin receptor in the Muscarinic Anticholinergic effects
postsynapse. • Common: Dry mouth, blurred
• Trazadone and nefazodone will block serotonin vision, constipation, sinus
transporter (SERT), 5-HT 2A receptor, histamine and tachycardia
• Occasional: Urinary retention,
alpha receptor.
mental clouding, delirium
• Vilazodone is serotonin (5-HT) partial agonist, i.e., it
Blocks cardiac sodium channels: Cardiac conduction
blocks serotonin transporter (SERT) and also prevents
abnormalities (Produce antiarrhythmic effects like clonidine)
postsynaptic serotonin stimulation.
• Allergic rashes are common with drug maprotiline
• 5-hydroxytryptamine (5-HT) or serotonin receptors blockage
Side Effects of Antidepressants may cause weight gain
The side effects of antidepressants have been given in • 5HT reuptake inhibition might cause nausea, diarrhea and
decreased appetite
Table 5.3.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 115

Side Effects Drug and Food Interactions

Selective Serotonin Reuptake Inhibitors (SSRI): Drug and Food Interactions of Monoamine Oxidase
• Excess stimulation of serotonin in brain will cause Inhibitors
insomnia, anxiety and irritability. Monoamine oxidase inhibitors (MAOIs) consumed by the
• Excess stimulation of serotonin in spinal serotonin receptor patient along with certain medications, tyramine rich food
will cause sexual side effects (Erectile dysfunction). items and other food items (as shown in Figure 5.7) will leads
• Excess stimulation of serotonin in gastrointestinal system to hypertensive crisis. Monoamine oxidase inhibitors (MAOIs)
will cause nausea, vomiting and diarrhea. consumed by the patient along with narcotic analgesics might
• Abrupt withdrawal of SSRI will cause headache, nausea, cause hypertension or hypotension, coma, seizure and death
vomiting, agitation and sleep disturbances. (as shown in Figure 5.7).
Serotonin Norepinephrine Reuptake Inhibitors (SNRI):
Drug Interactions of SSRI
• Hypertension
• Tachycardia • Cimetidine: Raises the concentration of SSRI
Mnemonics to remember are given in Table 5.4. • Diazepam: Enhances sedation
Table 5.4: Mnemonics to remember
• Warfarin: Increases bleeding time
• When Selective serotonin reuptake inhibitors (SSRI)
Mnemonic to remember side effects of SSRI group of drugs is taken along with Lithium, Dopamine
• S : Serotonin syndrome agonist (e.g., bromocriptine) and psychostimulants, they
• S : Stimulation of CNS may lead to serotonin syndrome due to increased level of
• R : Reproduction dysfunctions in male serotonin.
• I : Insomnia
Serotonin syndrome Drug Interactions of TCA
• H : Hyperthermia • Guanethidine and clonidine: Enhance the effects of
• A : Autonomic instability (delirium)
• R : Rigidity
guanethidine and clonidine
• M : Myoclonus • Warfarin: Increases bleeding time
• Other symptoms are altered sensorium, fluctuating blood • Sympathomimetic: Hypertension, cardiac arrhythmias
pressure, restlessness, tremors and shivering
• Antipsychotics: Extrapyramidal side effects
Mnemonic to remember side effects of Tricyclic • Levodopa: Agitation, rigidity and tremors
Antidepressants (TCA’s)
• Alcohol and anxiolytics: Excessive daytime sleepiness
• T : Tremors • Phenytoin, barbiturates and carbamazepine: Decrease
• C : Cardiovascular (cardiac arrhythmias, ischemic heart
disease, postural hypotension) the effect of TCA
• A : Anticholinergic effects • Guanidine and procainamide: Prolonged cardiac
• S : Sedation, seizure conduction
• Anticholinergic agents: Raised anticholinergic effects
Contraindications of antidepressants have been shown in
• MAOI: Hypertensive crisis, seizure, muscle rigidness,
Flowchart 5.3.
hyperthermia and mania
Flowchart 5.3: Contraindications of antidepressants
NURSING IMPLICATION
Nursing Management for Patient with Overdose of
Tricyclic Antidepressants
• Check vital signs
• Keep the patient’s airway patent
• Gastric lavage/cathartics to prevent further absorption
• Give antidote: Physostigmine (antilirium) is an acetyl
cholinesterase inhibitor (prevents the breakdown of
acetylcholine)

Role of nurse in managing the side effects of antidepressants

are enlisted in Table 5.5.
116 Textbook of Psychiatric Nursing for BSc Nursing Students

Figure 5.7 Drug and food interactions of MAOI

Table 5.5: Role of nurse in managing the side effects of antidepressants

Common side effects of Nursing management

antidepressants
Dry mouth Sugarless chewing gum and intake of more fluids
Constipation More water intake and high fiber diet
Urinary retention More water intake and pouring water on client’s back to stimulate micturition.
Blurred vision Eye examination, caution while driving, and follow the safety measures. Remove the sharp objects which
can cause injury and report any significant visual impairment immediately.
Eye pain Screen for glaucoma
Reduced lacrimation Advise to use artificial tears
Mydriasis Advise to wear sunglasses outside
Weight gain/weight loss Monitor weight regularly and advise the patient to take balanced diet.
Headache Advise the patient to drink adequate water and if the headache persists, then report the treating physician.
Insomnia Maintain sleep chart and provide relaxation therapy
Anhydrosis/decreased It may increase body temperature. So, adequate fluids and suitable clothing might be helpful
sweating
Increased sweating More water intake to prevent dehydration
Serotonin syndrome Prevention
• Aware of drug interactions with serotonin.
• Monoamine oxidase inhibitors (MAOI) should not be used with tricyclic antidepressants (TCA) and
selective serotonin reuptake inhibitors (SSRI).
• If monoamine oxidase inhibitors (MAOI) have been stopped then we need to wait for at least 2 weeks
before starting tricyclic antidepressants (TCA)
Contd…
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 117

Common side effects of Nursing management

antidepressants
Management
• Discontinue the medication
• Monitor vital signs
• Inform the doctor immediately
• Follow the measures to control fever and seizures
Hyperpyrexia Check temperature, cold sponging and reassess temperature
Seizure Seizure precautions: Safety measures (put side rails), turn head to side during seizure will prevent the
aspiration of oral secretions, avoid falling back of tongue, use bite block to prevent the tongue bite during
seizure, don’t restrict movements, monitor the nature and duration of seizure, and remove the tight clothing.
Extrapyramidal symptoms Management has been discussed in the topic of antipsychotics. (Amoxapine is a tricyclic antidepressant
which causes extrapyramidal symptoms)
Orthostatic hypotension Check vital signs, advise the client to take caffeine if he/she prefers, promote supportive stockings,
adequate fluid intake, advise the client to get up slowly from lying position.

ANTIANXIETY AGENTS (OR) ANXIOLYTICS „ Pentobarbital

„ Amobarbital
Synonymous terms • Long acting barbiturates (>8 hours—duration of action)
• Minor tranquilizers „ Phenobarbital
• Anxiolytics
Nonbarbiturate and Nonbenzodiazepine
Benzodiazepines Anxiolytic Agents
• Short acting benzodiazepines • Carbamates: Tybamate, meprobamate and carisoprodol
„ Triazolam • Piperidinediones: Glutethimide
• Intermediate acting benzodiazepines • Quinazolines: Methaqualone
„ Alprazolam • Alcohols: Ethanol, ethchlorvynol and chloral hydrate
„ Oxazepam • Cyclic Ethers: Paraldehyde
„ Lorazepam • Beta Blockers: Propranolol
„ Halazepam • Antipsychotics: Thioridazine
„ Temazepam
• Long acting benzodiazepines Miscellaneous Antianxiety Agents
„ Diazepam
• Buspirone
„ Clonazepam
• Hydroxyzine
„ Chlordiazepoxide
• Meprobamate
„ Clorazepate
Flurazepam
Antidepressants Causing Antianxiety Effects
„

„ Prazepam
„ Quazepam • Selective serotonin reuptake inhibitors (SSRI):
Fluvoxamine, fluoxetine, paroxetine, sertaline,
Barbiturates clomipramine.
• Selective norepinephrine reuptake inhibitors (SNRI):
• Ultra short acting barbiturates (<1 hour—duration of
Venlafaxine.
action)
Thiopentone sodium
Indications of Antianxiety Drugs
„

„ Methohexital
• Short acting barbiturates (1–5 hours—duration of Anxiety Disorders
action) • Generalized anxiety disorder
„ Secobarbital • Post-traumatic stress disorder
• Intermediate acting barbiturates (5–8 hours—duration • Obsessive compulsive disorder
of action) • Panic disorder
118 Textbook of Psychiatric Nursing for BSc Nursing Students

• Social phobia Flowchart 5.4: Mechanism of action of antianxiety drugs

• Agoraphobia
• School phobia

Mood Disorders
• Bipolar I disorder
• Acute mania
• Depression

Sleep Disorders
• Insomnia
• Nightmares
• Enuresis and somnambulism—Stage 4 [Nonrapid Eye
Movement (NREM) sleep disorder].

Psychotic Disorders NOTE

• Acute psychoses • Benzodiazepine receptor I is linked with GABA receptor
• Antipsychotic-induced akathisia • Benzodiazepine receptor II is linked with cognition and motor
• Violent behavior due to psychosis control.
• Treatment resistant schizophrenia
Drug Interactions
Miscellaneous
Drug interactions with benzodiazepines are given in Table 5.6.
• Psychosomatic disorders
• Premedication as anesthetic agent Table 5.6: Drug interactions of benzodiazepines
• Endoscopic/obstetric/surgical procedure Drugs Effect of drug interactions of
• Aggression due to influence of substance abuse benzodiazepines
• Adjustment disorder with anxiety Tricyclic Confusion, excessive day time sleepiness
• Status epilepticus/myoclonic seizure antidepressants and altered motor activity
• Alcohol withdrawal syndrome Monoamine Central nervous system depression
• Narcoanalysis/abreaction oxidase inhibitor
Succinylcholine Reduced neuromuscular blockage
Mechanism of Action Phenytoin Raised anticonvulsant serum value
GABA-A is an ionotropic receptor (or) ligand-gated ion Disulfiram Raised benzodiazepines plasma level
channel. GABA-A is the major inhibitory neurotransmitter Cimetidine
present in central nervous system which is linked with Antacids Alteration in absorption of benzodiazepine
chloride channels. GABA-A receptor has two alpha subunits, Alcohol Central nervous system depression and
two beta subunits and two gamma subunits. GABA-B excessive day time sleepiness
receptor is metabotropic receptor (or) G protein-coupled
receptor, which is linked with potassium channels. In anxious Side Effects and their Nursing Management
situation, there will be rapid excitatory action of neurons in
the amygdala (limbic system) of the brain. Administration Side effects of benzodiazepines and their nursing management
of the antianxiety drugs stimulates the GABA-A to bind have been given in Table 5.7.
in postsynaptic receptor and thereby releases negatively
charged chloride ion in postsynaptic neuron. This chloride Signs of Benzodiazepine Toxicity
ion in postsynaptic neuron will prevent excitatory action of • Increased sleepiness
the neurochemicals and so it prevents the action potential. • Confusion
Hence, it calms the central nervous system and reduces • Coma
anxiety. Benzodiazepine receptors are type I and type II as • Reduced reflexes
shown in the Flowchart 5.4. • Hypotension
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 119

Table 5.7: Side effects of benzodiazepines and their nursing ANTIPARKINSON AGENTS
management
• Parkinson’s disease is a neurodegenerative disorder caused
Side effects of Nursing management
due to degeneration of substantia nigra of midbrain.
benzodiazepines
So, dopamine containing neuron in substantia nigra
Dry mouth • Chew the sugarless gum
• Drink more water
pathway also gets degenerated and due to the imbalance
• Rinse the mouth frequently of dopamine, it leads to Parkinsonism.
Giddiness and • Safety measures to be carried out • Antiparkinson’s agents are the drugs which are used
Drowsy • Be cautious in driving to treat Parkinson’s disease and drug-induced extra-
• Take medications preferably at bed time pyramidal symptoms.
• Help the client in ambulation
Ataxia Assist the client in walking Common Drugs
Nausea Medicine has to be taken with food • Anticholinergics
„ Trihexiphenidyl
Benzodiazepine in Pregnancy „ Procyclidine
Benztropine
First Trimester: Cleft lip and cleft palate
„
•
Biperiden
Labor: Floppy infant syndrome (or) benign congenital
„
•
• Antihistamine
hypotonic disorder.
„ Diphenhydramine
Benzodiazepines Among Elders • Dopaminergic agonists
• Lorazepam and oxazepam are safe drugs. „ Bromocriptine
• Diazepam and chlordiazepoxide are not to be used in „ Amantadine
elders due to extended half-life and active metabolites.
Contraindications
Contraindications of Antianxiety Drugs
• Benign prostrate hypertrophy
• Hypersensitivity reaction • Angle closure glaucoma
• Pregnancy and Lactation • Intestinal obstruction
• Chronic renal failure • Myasthenia gravis
• Liver failure
• Narrow angle glaucoma Mechanism of Action
• Shock
• Imbalance of dopamine will lead to increased cholinergic
• Depression/Pre-existing psychosis may worsen
activity.
• Antiparkinson’s agent will help to balance dopamine and
NURSING IMPLICATION acetylcholine in central nervous system.
Nurses’ Responsibility in Administration of Antianxiety Drugs
Side Effects
• Oral drug: Administer with food to prevent nausea/gastric
irritation. • Anticholinergic effects • Nausea
• Intramuscular injection: Administer deep IM injection for • Orthostatic hypotension • Diarrhea
better absorption of drug.
• Intravenous injection: Do not mix with other drugs due to • Sedation • Worsening of psychosis
harmful effects of drug interaction and slow IV should be • Giddiness
given to prevent respiratory arrest/cardiac arrest. Vital signs
with oxygen saturation to be monitored. Extravasation of drug
might cause phlebitis/thrombosis. NURSING IMPLICATION
• Overdose of benzodiazepines: Administer Flumazenil 0.2 to
• Management of side effects of these drugs has been discussed
1.0 mg IV for 1–2 minutes.
earlier.
• Advise the client that abrupt withdrawal of drug might cause
• Maintain intake output chart to watch out the urinary
irritability, insomnia and seizures.
retention.
• Remember barbiturates, ethyl alcohol and methaqualone
might develop cross-tolerance. • Advise the client not to drive because the drug may cause
• Client should not use CNS depressants and other self- giddiness.
medications because they will cause life threatening effects • Advise the client not to take self-medication as it will cause
due to drug interactions. severe drug interaction.
120 Textbook of Psychiatric Nursing for BSc Nursing Students

MOOD STABILIZERS reuptake or by reducing the metabolism of GABA. This

suppresses the influx of calcium through specified calcium
Lithium channels.
This drug has been explained in Chapter 7.
Drug Interactions
Sodium Valproate Drugs that increase the serum level of valproate
• Erythromycin
In 1963, Meunier identified the antiepileptic properties of this • Aspirin
drug and in 1966, Lambert identified that this drug can be used • Ibuprofen
to treat mania. The various preparations or available forms are: • Fluoxetine
• Divalproex (enteric coated form or sodium valproate and • Cimetidine
valproic acid in 1:1 ratio) • Phenothiazines
• Valproate sodium • Fluvoxamine
• Chrono preparations (enteric coated form or sodium Drugs that decrease the serum level of valproate
valproate and valproic acid in 3:2 ratio) • Phenytoin
Pharmacokinetics • Rifampicin
• Ethosuximide
Peak plasma levels will reach at 1–4 hours with a single dose. • Carbamazepine
Half-life period is 8–17 hours. Therapeutic blood level is 50– • Phenobarbital
150 μg/mL. • Mefloquine
Dosage Valproate increases the serum level of below mentioned
drugs
1000–3000 mg/dL oral in divided doses. • Tolbutamide
Indications • Zidovudine
• Lamotrigine
Bipolar Disorder
• Tricyclic antidepressants
• Acute mania
• Poor response to lithium Side Effects
• Mania associated with seizure disorder • Common side effects of sodium valproate: Tremors,
• Mixed affective episodes or rapid cycling bipolar disorder nausea, weight gain, sedation, menstrual disturbances in
or mixed dysphoric mania women, alopecia, thrombocytopenia, hyperandrogenism
• Neurological disorder and polycystic ovaries.
• Seizure disorder: Absence seizure, myoclonic seizure, • Uncommon side effects of sodium valproate: Acute
complex partial seizure, generalized tonic clonic seizure. hemorrhagic pancreatitis, hepatic toxicity and Stevens-
• Migraine Johnson syndrome.
• Pain syndrome: Neuropathic pain and trigeminal
neuralgia Carbamazepine
• Miscellaneous disorders In 1953, Schindler identified carbamazepine as a tricyclic
• Conduct disorder compound.
• Mental retardation
• Attention deficit hyperactive disorder Onset of Action
• Schizoaffective disorder Faster than lithium but slower than sodium valproate.
• Tardive dyskinesia
• Alcohol withdrawal syndrome Dosage
• Impulse control disorder 600–1600 mg/day
• Borderline personality disorder
• Panic disorder Therapeutic Blood Level
6–12 μg/mL. Toxic level is >15 μg/mL.
Mechanism of Action
Sodium valproate dissociates the valproate ion in GI tract Drug Action
and it also increases GABA levels in brain either by reducing Analgesics, antiepileptic and mood stabilizing agent.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 121

Indications • Glaucoma
Mental Disorder • Usage of monoamine oxidase inhibitors
• Marked anxiety
• Bipolar mood disorder (Acute mania or rapid cyclic or
• Motor tics or family history of Tourette’s disorder
lithium intolerant patients)
• Acute psychosis
• Psychosis with mania
• Heart diseases
• Schizoaffective disorder
• Cocaine withdrawal syndrome Amphetamines
• Borderline personality disorder
• Impulse control disorder Amphetamines is the group of phenylethylamine stimulants,
which increase the level of dopamine and norepinephrine
Seizure Disorder by preventing the reuptake and also the direct release of
• Complex partial seizure dopamine and norepinephrine from the storage vesicles in the
• Alcohol withdrawal seizure cells. They elevate the mood and hence, are used to treat major
• Generalized tonic clonic seizure depression.
Paroxysmal Pain Disorders
Modafinil
• Trigeminal neuralgia
• Phantom limb pain Modafinil is an approved drug to treat narcolepsy, excessive
• Neuralgia day time sleepiness associated with the obstructive sleep
apnea, attention deficit hyperactive disorder, schizophrenia,
Side Effects depression, Parkinson’s disease, cocaine addiction and illness
• Major side effects of carbamazepine: Drowsiness, related fatigue. Modafinil increases the release of monoamines
fatigue, diplopia, nausea, vomiting, skin rashes, ataxia, and also increases hypothalamic histamine levels and thus
photosensitivity, Stevens-Johnson syndrome, oliguria, promotes the wakefulness.
hypertension, cholestatic jaundice, leukopenia,
Ampakines
hyponatremia, toxic epidermal necrosis (TEN) and
thrombocytopenic purpura. Ampakines are also called Eugeroics or Good Arousal
• Dangerous side effects of carbamazepine: stimulant. It means, increase in alertness without the
Cardiovascular collapse and bone marrow depression. peripheral body effects. So, they do not have addiction or abuse
potential unlike other stimulants. They do not cause rebound
STIMULANTS (OR) PSYCHOSTIMULANTS hypersomnolence. These drugs are in the clinical trials and
need further research before the usage.
Stimulants are those which enhance the mental and
physical function by increasing the alertness, wakefulness, Norepinephrine Reuptake Inhibitor and
etc. Example for the central nervous system stimulants are Norepinephrine-dopamine Reuptake Inhibitor
caffeine, nicotine, methylenedioxy-methamphetamine
Norepinephrine Reuptake Inhibitor and Norepinephrine-
(MDMA-Ecstasy), modafinil, ampakines, etc.
dopamine Reuptake Inhibitor inhibit the reuptake of
dopamine and norepinephrine that leads to increase in the
Indications
neurotransmission and thereby causes the stimulating effect.
• To reduce the sleep in narcolepsy Examples for norepinephrine-dopamine reuptake inhibitor
• To improve the attention and concentration in attention (NDRI) are bupropion and methylphenidate. Examples for
deficit hyperactive disorder norepinephrine reuptake inhibitor (NRI) are reboxetine and
• To decrease the appetite in obesity atomoxetine. These drugs have lower addictive potential as
• To reduce lethargy and fatigue compared to amphetamines.
• Sometimes, it is used to treat depression
Effect of Stimulants on the Body
Contraindications Stimulants constrict the blood vessels and thereby increase the
• Hypersensitivity blood pressure. They raise the blood glucose and heart rate.
• Hypertension They provide the sense of euphoria. They open the pathways of
• Hyperthyroidism respiratory system.
122 Textbook of Psychiatric Nursing for BSc Nursing Students

Withdrawal Effects of Stimulants Goals of Psychotherapy

The withdrawal effects of stimulants include sleep disturbances, Psychotherapy helps the individuals with the Psychiatric
depression, paranoia, fatigue and feeling of hostility. disorders by:
• Enhancing the coping skills and problem solving ability
Side Effects of Stimulants • Promoting the sense of control, self-esteem, positive
attitude and psychological well-being.
Headache, irregular heartbeat, impotence, dizziness, insomnia, • Identifying the problems which act as contributing factors
dry mouth, constipation or diarrhea, restlessness, confusion, to the illness.
hypertension, anxiety and tremors. • Strengthening the ego
• Creating the deeper insight (or) sense of self-identity
NURSES RESPONSIBILITY • Developing a therapeutic relationship with patient
• Mediating the disturbed pattern of behavior and
Nurses should monitor the heart rate and blood pressure in modifying the deviated personality
order to monitor the side effects of stimulants at early stage.
• Understanding the ideas, emotions, and behavior which
Nurse should observe unexpected symptoms. She should teach
the patient and his/her family members in regard with the usage contribute to mental illness and develop the ability to
of stimulants and their side effects. She has to teach the patient solve the same.
to avoid the over the counter drugs because the stimulants have
high addictive potential. Contraindications of Psychotherapy
• Acute phase of organic psychosis
• Violent psychotic patient
PSYCHOLOGICAL THERAPIES • Unmotivated and unwilling patients
• Antisocial personality disorders (Patient will not respond back)
PSYCHOTHERAPY • Conversion disorder, hypochondriasis—Group psycho-
therapy is contraindicated.
Definition
• Psychotherapy is defined as, ‘treating the patient by Stages of Psychotherapeutic process
psychological means, problems of emotional nature, in First stage is assessment with regard to the necessity of
which the therapist deliberately establishes the professional psychotherapy, in which the nurse or the psychotherapist needs
relationship with patient to modify or remove or reduce to assess the actual need of psychotherapy and its benefits to
the present symptoms, mediate the disturbed patterns of the patient. The contraindications of the psychotherapy need
behavior, promote the positive growth and development to be considered before the commencement of therapy. The
of the personality.’ second stage is therapeutic work, in which the psychotherapy
 —Wolberg is administered actually. Conclusion of psychotherapy can be
• Psychotherapy is defined as, ‘way to help the people with done by the therapist if the desired effect has been achieved or
variety of mental illnesses or emotional difficulties. It also else when the therapist feels the psychotherapy won’t work out
helps to control or remove the symptoms which trouble on the particular patient (Fig. 5.8).
the person, function in a better way, increase the sense of
well-being and promote healing.’
 —American Psychiatric Association

Common Factors
• Restoration of morale: Most clients who are being treated
might experience repeated failures and get demoralized.
Therefore, continuous motivation by the therapist is
necessary for the restoration of morale.
• Release of emotion: Therapist encourages the client to
ventilate the feelings or emotions, because bottled-up
emotions harm a person. The release of negative emotions
might reduce the sadness. Figure 5.8: Psychotherapeutic process
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 123

Classification of Psychotherapy
Classification of psychotherapy is given in Flowchart 5.5.
Flowchart 5.5: Classification of psychotherapy

Individual Psychotherapy in 1800. Jean-Martin Charcot used a hypnosis for the women
Individual psychotherapy is the interaction process suffering with hysteria. Sigmund Freud began to work with
(psychotherapy) between the patient and the mental health Jean-Martin Charcot and continued his work and research
activity with Josef Breuer, his colleague. Freud and Josef Breuer
professional or therapist on one to one basis. The issues
published a book namely ‘Studies on Hysteria’ and the former
addressed in the individual psychotherapy are life adjustment
developed the concept of talk therapy.
issues, relationship issues, issues related to personal growth
or self-esteem or self-confidence, issues related to mental Basic Assumptions of Psychoanalytical Psychotherapy
health problems, issues related to stress or coping skills, (Fig. 5.9)
issues related to sexual problems, issues related to work life • Being aware of one’s motivation helps to be more adaptive
balance, issues related to spirituality, issues related to physical to acquire the change.
disorders, etc. • The causes/reasons behind the maladjustment are
unresolved conflicts.
Psychoanalysis (or) Psychoanalytical Psychotherapy
(or) Psychodynamic Psychotherapy Goal of Psychoanalysis
The prefix, ‘psycho’ denotes mind and the suffix ‘analytical’ Psychoanalysis helps to understand the unconscious motives
denotes analysis, which means analysis of mind. Hence, it is which direct the behavior. Patients are expected to express
a psychological therapy which analyses the mind. The suffix, the healthy impulse during the time of analysis which helps
‘dynamic’ denotes change. So, change of mind also takes place to strengthen the daily activities and develop a positive
here. perception toward the life.

Definition Psychoanalytic Techniques

Psychoanalytical Psychotherapy is defined as, ‘form of insight • Free association: Patients are asked to talk freely
therapy which aims to overcome the unconscious conflicts whatever strikes in their mind in regard with one’s own
and it also aims to identify the relationship between the thoughts and feelings. Psychotherapist plays a passive
unconscious motivation and the abnormal behavior.’ role and performs only observations but at the same time
psychotherapist can raise the questions in order to clarify
Historical Development the doubts.
Sigmund Freud, a psychoanalyst/Austrian neurologist, framed • Dream analysis: Analysis of the dreams helps to give
the therapeutic techniques related to psychoanalytic theory insight to the unconscious motivation.
124 Textbook of Psychiatric Nursing for BSc Nursing Students

Figure 5.9: Basic concepts of psychoanalytical psychotherapy

• Treatment alliance: Therapeutic relationship exists • A therapist instead of recovering the repressed memories,
between the therapist and patient which helps in the inoculates the false memories.
treatment process. • Psychoanalysis is only about the sex and libido.
• Acting out: Patient presents the feelings and ideas not in Differences between Psychoanalytic Psychotherapy
words but in action, i.e., in the form of behavior. and Cognitive Behavioral Therapy (Table 5.8)
• Interpretations: Interpreting the context, cause, idea,
Table 5.8: Major differences between psychoanalytic and cognitive
feeling, set of behavior and other issues in the session.
behavioral therapy
Indications
Psychoanalytic Cognitive behavioral
• Neurotic and stress-related disorders such as Panic psychotherapy therapy (CBT)
disorders, obsessive-compulsive disorder, phobias, Focus on full range of emotions, Focus on cognition and
generalized anxiety disorder and post-traumatic stress how they have been expressed behavior
disorder Exploring the reason for Reason for avoiding certain
• Persistent feelings of sadness, isolation and loneliness avoiding certain topics or topics is not explored
• Sexual problems thoughts will take place
• Borderline personality disorders Talk about the past experiences Focus on the present (here and
• Psychosomatic disorders now concept)
• Relationship issues Explore the interpersonal Interpersonal relationship of
relationship of present and past past will not be explored
• Self-destructive behavior
• Emotional trauma Focus on the relationship Relationship building between
existing between the therapist the therapist and patient is not
• Depression and patient a matter of concern
• Identity problems
Exploring the fantasy life of CBT is highly structured and
Disadvantages patient goal oriented, therefore, it does
not deal with the fantasy life of
• Patient needs to be highly motivated and cooperative. patient
• Patient could afford his/her time and money for this
treatment. when compared to other treatment modalities,
psychoanalytic psychotherapy takes longer time for NURSES RESPONSIBILITY
treatment. Nurse should provide and maintain the conflict free and safe
Myths about Psychoanalytic Psychotherapy environment to render psychoanalytic psychotherapy. She has to
ensure whether the psychological needs have been met. She has
• Psychoanalysis is non-scientific, subjective and not to take a leadership role and plan the weekly sessions or have a
precise. regular follow-up to see the prognosis in the patients. She needs
• Concept of id, ego and superego is not linked with the to provide counseling to the patient and his/her family members
if required.
reality.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 125

Hypnosis Definition
Patient is put into deep trance state with the suggestions of Cognitive therapy is a form of psychotherapy in which the
relaxation and is asked to concentrate on a single object. distorted cognitions are modified into positive cognitions.
He/she will recall the forgotten memories and it helps to relieve
the tension or anxiety. This therapy is used in psychosomatic Indications
disorder, dissociative disorder, anxiety disorder, sexual
• Depression
dysfunction, phobias, habit disorder, overeating, pain
• Bipolar disorder
management and other addictive disorders. The risk of
• Panic disorder
hypnotherapy is that the patient might develop confabulation
• Schizophrenia
(false memories). The side effects of hypnosis is headache,
• Post-traumatic stress disorder
dizziness and anxiety.
• Social phobias
Abreaction Therapy • Generalized anxiety disorder
The repressed painful experiences are brought back to the • Obsessive compulsive disorder
conscious mind in abreaction therapy. This can be done • Eating disorder
with or without the medications. This is extremely helpful in • Substance abuse
neurotic disorders. • Personality disorders
• Problems with married couples
Reality Therapy • Hypochondriasis
Reality therapy is a psychotherapeutic technique focused • Somatoform disorder
on the present behavior and the present coping ability of the
patient against the stressors. The active relationship between Goals of Cognitive Therapy
the therapist and patient might focus to promote the realistic After the successful cognitive therapy sessions, the patient will:
behavior at present. • Observe one’s own negative automatic thoughts.
Insight Psychotherapy (or) Uncovering • Identify that a connection exists between cognition, affect
and behavior.
This therapy or technique is helpful to bring the patient’s • Substitute the realistic interpretation in the biased
repressed conflict and traumatic experience into the surface situations.
level in order to gain the insight.
• Identify and alter the dysfunctional belief.
Supportive Psychotherapy • Explore the reason for distorted automatic thoughts.

This therapy is helpful to provide the basic psychological Principles of Cognitive Therapy
support to the patient so that, the patient’s level of self esteem
will improve. • Cognitive therapy needs a good therapeutic alliance
(trusting relationship between therapist and patient)
COGNITIVE THERAPY • It requires active participation and collaboration
• It is problem-focused.
Historical Background • It is goal-oriented.
Cognitive therapy originated in early 1960s when the research • It focuses on the present rather than the past.
on depression was done by Aaron Beck. In his research, • It is completed in limited time (12–16 sessions).
he focused on negative cognitive processing in depression • It has structured sessions.
patients. Common theme was rejection of passive listening • It is educative, aimed to teach the patient with a special
in psychoanalytic methods, behavioral techniques such as emphasis on relapse prevention.
modeling and expectancy of reinforcement that have been • It uses various techniques to modify thinking, behavior
used within the cognitive domain. The ‘Personal appraisal and mood.
and coping’ book written by Lazarus and Folkman (1984) has • It teaches the patient to identify, evaluate and respond to
explored the importance of cognitive approach. their dysfunctional thoughts.
126 Textbook of Psychiatric Nursing for BSc Nursing Students

Basic Concepts Didactic Aspects

Automatic thoughts (or) Cognitive Errors Prepare the patient eventually by providing the adequate
Automatic thoughts are rapidly occurring thoughts in response information about the cognitive therapy either orally or
to the situation without any rational analysis. The thoughts are using videos/audio in order to identify the distorted thinking
usually negative. The different types of cognitive errors are patterns.
listed below. Cognitive Techniques
• Absolutistic thinking (or) over generalization: Getting
Recognizing the Automatic Thoughts and Schemas
into conclusion based on one incident.
• Arbitrary inference: Getting into conclusion without • Socratic thinking (or) guided discovery: Therapist
any fact to support it or even when there is presence of raises the question about any particular situation. Client
contradictory evidence. with the socratic thinking is able to explain the feelings
• Dichotomous thinking: Individual views the situations associated with the situation.
in terms of good or bad, black or white, all or nothing. • Role play and imagery: When socratic thinking fails,
• Selective abstraction (or) Mental Filter: Getting into therapist asks the client to perform imagery exercises or
conclusion based on selected portion of evidence. role play to explore the automatic thoughts. With the help
• Catastrophic thinking: Always thinking the worst will of guided imagery, client is asked to relieve the stress by
occur without considering the positive outcome. imaging the stress situations and settings in which it has
• Magnification: Exaggeration of the negative significance occurred. Client is also asked to participate in role play to
of an event. recognize the automatic thoughts.
• Minimization: Undervaluing the positive aspect of an • Thought recording: Client is asked to write in a notebook
event. when patient gets the automatic thoughts. This is given as
• Personalization: Person takes the complete responsibility a homework outside the therapy sessions.
of the situation without realizing that the other Modifying Automatic Thoughts and Schemas
circumstances also contribute to the outcome.
• Examining the evidences: Therapist and the client might
keep the automatic thoughts as hypothesis and they study
Schemas (or) Core Beliefs
the evidence for and against the hypothesis.
Concepts might be general or specific, adaptive or maladaptive, • Generating the alternatives: Therapist helps the client
become evident when trigger happens by a specific stressful to generate the alternatives or possibilities toward the
stimulus. automatic thoughts.
• Decatastrophizing: Therapist helps the patient to
Techniques of Cognitive therapy examine the validity of negative automatic thoughts.
The techniques of cognitive therapy have been divided into • Reattribution: This technique helps to reverse the
components such as didactic aspects, cognitive techniques and negative attribution into positive one.
behavioral interventions (Fig. 5.10). • Daily record of dysfunctional thoughts (DRDT): Patient
is asked to rate the intensity of thoughts and emotions in a
0 to 100 point scale daily.
• Cognitive rehearsal: Discussion as a rehearsal or use
of mental imagery in order to identify and modify the
dysfunctional thoughts.

Behavioral Interventions
• Activity scheduling: Client is asked to keep the record
of the daily activities and also asked to rate the activity in
terms of mastery and pleasure in a 0 to 10 scale.
• Graded task assignments: Whole task has been sub-
divided into small tasks and patient is asked to perform
the small task. This completion of small task will enhance
the self-esteem of patient and develop the motivation to
Figure 5.10: Cognitive therapy complete the further tasks.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 127

• Behavior rehearsal: This technique is used to perform • Unconditioned stimulus (eating food) → unconditioned
role-play to rehearse the maladaptive behaviors which response (salivation)
contribute to the dysfunctional cognition. • Unconditioned stimulus (seeing food) → conditioned
• Distraction: Activities are planned to distract and response (salivation)
divert the patient from intrusive disturbed thoughts and • Conditioned stimulus (bell) → no response
ruminations. • Unconditioned stimulus (food) + conditioned stimulus
• Miscellaneous techniques: Assertiveness training, (bell) → conditioned response (salivation)
relaxation therapy, role modeling and social skills training • Conditioned stimulus (bell) → conditioned response
are also useful. Thought stopping technique (explained (salivation)
in Chapter 8) is used to alter the dysfunctional thinking
patterns. Operant Conditioning
B F Skinner (1953), American Psychologist, developed the
operant conditioning. In classical conditioning, the focus is on
NURSES RESPONSIBILITY
behavioral responses but in operant conditioning, the focus is
Nurse has to help the patient to identify the distorted thoughts on the consequences of the behavioral responses. A stimulus
with the use of various techniques as discussed above. She has to which gives out a response is called reinforcing stimulus
plan the cognitive therapy sessions scheduled after coordination
(or) reinforcer and the function is termed reinforcement.
with the psychotherapist. She should ensure the patient is
attending the sessions as per the scheduled plan (weekly or The probability of increasing the desirable behavior with
biweekly). Monitor the improvement in patient when 16 weeks a reinforcing stimulus is called positive reinforcement
of cognitive therapy session is completed and also ensure that (In Skinner box experiment, giving a food pellet to rat when
the sessions should not prolong for more than 26 weeks. If the
it presses the lever is the example of positive reinforcement).
improvement is not satisfactory, then the other therapies have to
be considered. She has to follow-up with the patient to ensure the The probability of increasing the desirable behavior with
successful completion of therapy sessions. the help of aversive stimulus is called negative reinforcement
(In Skinner box experiment, giving a loud noise until the rat
presses the lever is the example of negative reinforcement).
BEHAVIORAL THERAPY The behavior which has been reinforced previously is no
longer effective when the reinforcing stimulus is stopped,
Definition called Extinction (In Skinner box experiment, when the
Behavioral therapy is defined as ‘form of psychotherapy in rat pushed the lever, it was offered with food pellet. After
which the maladaptive behavior is aimed to change as adaptive some time, when food pellet was stopped being offered, it
behavior.’ led to the rat not pushing the lever. This is an example of
Extinction.)
History
Behavior therapy techniques is based on classical conditioning
Indications
by Ivan P. Pavlov and operant conditioning by B F Skinner. • Autism
• Bipolar disorder
Classical Conditioning • Obsessive compulsive disorder (OCD)
Ivan P Pavlov, a russian physiologist, developed the classical • Post-traumatic stress disorder
conditioning. In his trials, dog began to salivate was an • Schizophrenia
unconditioned response and dog began to eat the food was • Social anxiety
an unconditioned stimulus. Next time, when the food was • Phobia
shown, the dog started salivating, which was the learned • Substance abuse
behavior of the dog. Pavlov called this response as conditioned • Personality disorder
response. When bell alone rings, there is no response from • Eating disorder—anorexia nervosa, obesity
the dog. The combination of unconditioned stimulus (food) • Tics
and conditioned stimulus (bell) leads to conditioned response • Nocturnal enuresis
(salivation). After this, only with conditioned stimulus (bell), • Sexual dysfunction
conditioned response (dog salivation) occurs due to learned • Tension headache
behavior. • Psychosomatic disorders
128 Textbook of Psychiatric Nursing for BSc Nursing Students

Contraindications out in hierarchy of anxiety provoking stimuli, the person

will be ‘flooded’ with the continuous presentation of phobic
Mentally ill patients who are acute and symptomatic might
stimulus until the anxiety comes down. Flooding does not exist
not be given behavior therapy because it won’t work out and
in practice because this intense anxiety might be dangerous to
it is ideal waste of time for therapist and sometimes, it might
the individuals and it may lead to heart attack or death. For
increase the symptoms due to delay in treatment process.
Therefore, routine mental status assessment and psychotropic example, if the individual is having the fear of insects, then the
drugs are the first line of treatment to the acute psychiatric individual is flooded with more phobic stimuli by putting him/
patients. her into the room with more number of insects.

Premack Principle
Techniques
This technique has been named after its originator. The
Systemic Desensitization
frequently occurring response (R1) might act as a positive
Systemic desensitization is developed by Joseph Wolpe. It has reinforcement for the response (R2) which is occurring less
three steps (Fig. 5.11): frequently. For example, Raja is playing with his friends more
1. Relaxation training: Relaxation gives the physiological (frequently occurring response - R1) and not completing his
effects which are opposite to the anxiety. homework (less frequently occurring response - R2). Mother
2. Hierarchy construction: Arrange the conditions in order asked Raja that, if you complete the homework, you will be
of increasing anxiety. allowed to play with your friends; if not; you are not allowed.
3. Desensitization of stimulus: Gradual exposure of the Hence, Raja is motivated to perform the less frequently
individual from least to most anxiety provoking state. occurring response with the help of more frequently occurring
Systemic desensitization is suitable for anxiety disorders response.
(phobia and obsessive compulsive disorder) and certain sexual
Therapeutic Graded Exposure
disorders.
Examples to explain the systemic desensitization concept Therapist helps the patient to construct the fear hierarchy from
for a person who is having fear of dogs. mild to severe which is ranked according to the difficulties.
• Discuss about the dog Therapy begins with mild level and proceeds to the harder
• Show the picture of dog ones.
• Show the dog doll
• Play the barking sounds of dog Social Skills Training
• Show the dog with a distance of 10 feet Social skills training is a form of behavior therapy which
• Take the person near to the dog focuses on enhancing the social skills among patients.
• Ask the person to touch the dog The techniques are mentioned below:
• Ask the person to walk along with the dog • Instruction: Modeling of the appropriate social behaviors.
For example, teaching the patient how to perform hand
Flooding (or) Implosive Therapy
shake to others.
Flooding is used to desensitize the person to phobic stimuli. • Behavioral rehearsal (or) role play: Motivate the patients
It differs from systemic desensitization as instead of working to practice the new skills in the simulated situations. For
example, motivate the patient to start the conversation
in front of the mirror by assuming the other person is
standing before the patient.
• Corrective feedback: Give feedback during practice in
order to improve social skills. For example, when the
patient is not maintaining eye contact, then the therapist
asks to do it as a part of corrective feedback.
• Positive reinforcement: Give positive rewards when
the patient shows an improvement in social skills. For
example, take the patient to an outdoor game as a positive
reinforcement when the patient shows an improvement
Figure 5.11: Systemic desensitization in social skills.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 129

• Homework assignments: It helps the patient to practice Modeling

the new social skills out of the therapy sessions. For Modeling is learning out the new behavior by imitating the
example, ask the patient to write 20 open ended questions behavior of the others. We usually take a person as a role
in a notebook.
model, whom we admire and wish to imitate.
Assertiveness Training Example
Assertiveness training was developed by Andrew Salder in Child with mild mental retardation, learns to button and
1961. Training is provided to stand up for one’s own rights unbutton his shirt by seeing the therapist how he is performing,
by expressing one’s feelings, thoughts, ideas in an honest and this is an example for modeling.
direct manner. By being assertive, one should also respect
the feelings, thoughts and ideas of others. The techniques of Aversion Therapy
assertiveness training are as follows: Treatment to arouse the aversion or hatred toward undesirable
• Broken record (or) repeated assertion: It is the state behavior. For example, aversion therapy for patient with
of continuously repeating the refusal toward the request alcohol dependence syndrome can be classified into below
raised. For example, friends of an alcoholic calling him types such as:
to consume alcohol, he might respond as, I have taken
Electrical Aversion
treatment to quit alcohol, I won’t drink, please don’t call
me.’ (Patient says the same answer again and again toward Ask the client to smell the desired brand of alcohol and low volt
the question raised) electrical stimuli will be administered immediately. Alcohol
• Fogging: Agreeing the truth in the statement even it is intake (desired response) will be changed by undesirable
limited without being anxious or defensive. For example, electrical stimuli.
I agree, I will take rest for some time during my work due Chemical Aversion
to high stress in my job.
Disulfiram therapy (Disulfiram is antabuse drug administered
• Negative assertion: Agree the negatives or criticism
to the alcoholic patients who want to remain in sobriety).
without letting out the demand. For example, I agree I am
The detailed explanation about this drug is discussed in
not willing to listen to the comments of my peer groups.
substance abuse chapter.
• Negative inquiry: Listen the criticism carefully and
clarify the negative feelings so that one can ignore if the Aversion Through Emesis
information is manipulative. For example, Do you feel Administer alcohol along with emetics which will induce
that I am not interested in this project? vomiting after alcohol intake, thereby client develops aversion.
• Free information: Learn to listen the other person’s
information completely. Extinction
• Self-disclosure: Assertively disclose about oneself that, A gradual reduction in the frequency or the disappearance
how do you feel and think about the information. For of the responses occurs when the positive reinforcement has
example, I feel you can ventilate the hard feelings to your been withheld.
close friends and get solution from them.
Example
• Workable compromise: Bargain for the material goals
unless the compromise satisfies the personal feel of self- Temper tantrums are so common among children. When the
respect. For example, I know you are busy with your work attention from the parents (positive reinforcement) is withheld
and I too have the same but what about the board meeting then automatically the temper tantrums will get reduced.
scheduled now?
Covert Sensitization
Shaping Patient will be advised to imagine the unpleasant symptoms
Shaping the behavior with the positive reinforcement for the whenever required to stop the stimulus of undesirable behavior
performance of the approximate desired response. by self.
Example Example
Child with autism was trained for the speech therapy. Positive Patient with obesity has strong craving to eat more foods,
reinforcement can be given for watching the teacher’s lips and he will be asked to imagine the scene of nausea or vomiting
imitating the sounds of the teachers (approximate desired (unpleasant symptoms) when the patient would require to
response). stop the signals of eating more food (undesirable behavior).
130 Textbook of Psychiatric Nursing for BSc Nursing Students

Overt Sensitization will be issued to the patient for performing the desirable
Overt sensitization is a kind of aversion therapy in which behavior. Patient might be allowed to exchange the token for
unpleasant consequences for the undesirable behavior are designated privileges.
introduced. Example
Example Patient with negative symptoms of schizophrenia is not taking
Patient with alcohol dependence syndrome will be taking bath daily. Nurse uses token economy stating that, if the patient
disulfiram (antabuse therapy) to stop the alcohol. Provide takes bath daily, then he will get single token. For three tokens,
psychoeducation to the patient that if he consumes alcohol he is permitted for movie or coffee shop. For six tokens, he is
while taking disulfiram, it might lead to Disulfiram-Ethanol permitted for games or offered with biryani.
Reaction (DER) such as dyspnea, palpitations, nausea,
vomiting, headache, etc. (unpleasant consequences). Patient NURSES RESPONSIBILITY
consuming alcohol feels undesirable behavior here. So,
unpleasant consequences of DER takes place due to the Nurse has to identify the behavior which is needed to be modified
undesirable behavior of consuming alcohol. in the patient and break it out into small manageable segments to
proceed. She has to plan the behavior therapy sessions and use
the appropriate techniques with the help of the psychotherapist.
Time Out
She needs to observe, record and outline the behavioral changes
Time out is an aversive stimulus, in which the patient will continuously. Nurse has to plan additional psychotherapies to
be taken out from the particular environment where the the patient based on the requirement and need. She has to take
measures to enhance the social skills and assertive behavior of
unacceptable behavior has been exhibited. Patient will be
the patient. She needs to evaluate the prognosis of patient and
isolated usually so that the reinforcement from the particular re-frame the behavior therapy sessions accordingly.
stimulus will be absent.
Example
COGNITIVE BEHAVIORAL THERAPY
Patient with obsessive compulsive disorder repeatedly pours
hot water on his body for a number of times without having Historical Background
control. Using time out technique, patient will be removed
and put in another room where the hot water facility is not • Epictetus, a Greek philosopher, found people were
available. disturbed not because of what was happening around but
how an individual perceived the event.
Contingency Contracting • Aaron beck is pioneer of cognitive behavior therapy.
Contract has been drawn up between the patient and the health He is Professor in Psychiatry at University of Pennsylvania.
team personnel. The desired behavior change is mentioned He initially developed cognitive therapy and behavior
in the contract and its reinforcers which will be given after components have been added in it.
the behavior changes are also mentioned in the contract.
Punishment will be provided if the desired behavior change is Introduction
not met. However, flexibility is vital and renegotiations can be • Identification of negative cognitions and maladaptive
considered if necessary. behavior is helpful to improve the client’s mood
Example (Flowchart 5.6).
• Cognitive behavior therapy requires active participation
Patient with Alcohol Dependence Syndrome signed the
of patient.
contract stating that he won’t consume alcohol after the
• Cognitive triad denotes negative view of self, others and
discharge. The treatment cost of ` 20,000/- will be paid to the
future
patient after 2 years if he is in abstinence (positive reinforcers).
Failing which the patient has to pay ` 20,000/- to the hospital • Cognitive errors denote thinking in the negative schemas
as a fine.
Characteristics of Cognitive Behavioral Therapy
Token Economy • Thought governs behavior and feelings
Token economy is a kind of contingency contracting in which • Short term and time limited therapy
the contract can be either made orally or signed. Here, tokens • Focus on the current behavior
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 131

Flowchart 5.6: Identification of cognition, behavior and mood • Psychoeducation: Therapist teaches the patient by role
play, modeling, instructions, etc.
• Solution focused: Therapy focuses on generating the
solution and not just gaining the insight.
• Dynamics: Schema is a basic template of understanding
the individual’s world. Dynamic level of this therapy
focuses on modifying the schema.

Techniques of Cognitive Behavioral Therapy

• Plays collaborative role of therapist and patient • Cognitive rehearsal: Client is asked to recall the
• Therapy is based on “Rationale thoughts or facts” and not problematic thoughts of the past. Therapist and client
based on assumptions work together to find the solution to the problem.
• Structured and goal oriented therapy (Table 5.9) • Validity testing: Therapist tests the validity of the
Table 5.9: Sessions in cognitive behavior therapy thoughts or beliefs of the patient and the therapist asks
the patient to defend his/her thoughts.
Total sessions 12–16 • Writing in a journal: Ask the patient to maintain a
Sequence of session Once in a week diary of thoughts associated with the situations and the
Duration of each session 1 hour behavior associated with the situations.
• Guided discovery: Help the patient to come out of the
Indications cognitive distortions. Hence, the change of perception in
• Mild/moderate depression patient will automatically show a significant change in
• Anger management behavior.
• Mood swings • Modeling, aversive conditioning and positive
• Sleep disorders reinforcement: Discussed in the behavior therapy
• Conduct disorders techniques.
• Attention deficit hyperactivity disorder • Self-instructional coping methods: Therapist aims to
• Anxiety disorders—obsessive compulsive disorder, teach the coping methods to deal with the stressor.
post-traumatic stress disorder • Homework: Therapist assigns some sort of homework
• Substance abuse to be performed out of the therapy session in order to
• Sexual/relationship problems overcome the cognitive distortions.
• Eating disorders • Problem solving method: Therapist suggests the
• Childhood and adolescent problems alternative solutions to the problems and picks out the
• Chronic pain best one to solve the problem.
• Facial tics • Computer-assisted therapy: Use of computer-based
• Sexual and relationship problems programs in the cognitive behavior therapy.
• Chronic fatigue syndrome
Forms of Cognitive Behavioral therapy
Elements of Cognitive Behavioral Therapy • Cognitive therapy and behavioral therapy: Discussed in
• Motivational: Therapist should motivate the client for the previous topics.
behavioral change. • Rational emotive therapy: Albert Ellis was the proponent
• Active: Patient is active key participant in therapy process. for this therapy. It is a short term psychotherapy in which
• Directive: Therapist develops the treatment plan and the self-defeating thoughts and feelings are identified,
directs the client toward therapeutic process. rationalized and replaced with the productive thoughts
• Structured: Therapy follows the structured treatment and ideas.
plan. • Schema focused therapy: Jeffrey E Young was
• Collaborative: Therapist and patient work collaboratively the proponent for this therapy. It is an integrative
to achieve the goal. psychotherapy in which the concept of psychoanalytic
• Problem oriented: Therapy focuses on the discrete theory, object relations theory, gestalt therapy, attachment
problems. theory and cognitive behavior therapy have been used.
132 Textbook of Psychiatric Nursing for BSc Nursing Students

• Meta-cognitive therapy: Adrian Wells was the proponent Aim

for this therapy. It focuses on modifying the meta-
Therapeutic community should be democratic and not
cognitive (higher order thinking) belief which causes
authoritative, which focuses on the welfare of the client.
worry. It is most commonly used to treat anxiety disorders
and depression.
Philosophy
• Acceptance-commitment therapy: Steven C Hayes was
the proponent for this therapy. It is a concept of clinical The main philosophy of therapeutic community is that the
behavior analysis which focuses on the acceptance clients are active participants. The community responsibilities
(agreement or positive welcome) and behavioral strategies are shared among the health team staff and client.
in order to move toward the valued behavior. Patient is
asked to open up unpleasant feelings and move toward Objectives
the right behavior. • To utilize the client’s social environment for the
• Dialectical behavior therapy: Marsha M Linehan was therapeutic purpose.
the proponent for this therapy. It is focused on improving • To make the client an active participant and involve in the
the cognitive and emotional regulation by learning community-based activities.
about the triggers that cause stress. This therapy is used • To increase the self-esteem, self-worth, sense of
to treat borderline personality disorder, mood disorder, independence and to gain control over the personal
depression, substance abuse, post-traumatic stress activities
disorder, binge eating disorder, traumatic brain injury, • To change the maladaptive behavior into the adaptive
suicidal ideation and individuals with risk of self-harm. one.
• Mindfulness based cognitive therapy: Jon Kabat-Zinn • To help the client realize that, one’s own negative behavior
was the proponent for this therapy. This therapy is affects the others.
rendered with the combination of mindfulness meditation • To help the client to solve the problems, plan the
practices along with the cognitive therapy. necessary activities and frame the rules/regulations for
the community.
THERAPEUTIC COMMUNITY
Elements
Introduction
• Active participation of the client
Therapeutic community is done for individuals with substance
• Ensure the free communication in the community
abuse/addictive behavior for about 40 years. Therapeutic
• Responsibilities have to be shared among them
community is a group-based participative approach usually
• Involvement in the decision-making process
performed by the therapist and patient in a residential unit.
• Understand the roles, responsibilities and limitations of
It is based on the principles of milieu therapy and group
each member.
psychotherapy.
The components of therapeutic community have been given
History in Table 5.10.
In 1960, Maxwell Jones and Wilmer developed the concept of
Length of Treatment
therapeutic community retrieved from the therapeutic milieu.
Good outcomes can be expected if the individual
Definitions completes at least 90 days of stay. Previously the length of
Psychiatric nurse structures, gives and maintains the treatment was 18–24 months, but presently, duration of
therapeutic environment in collaboration with the patient and the treatment has been reduced to 12 months due to the
other health team workers. restrictions of the fund.
 —American Nursing Association, 2000
Structure
Therapeutic community is a drug free environment in which
the individuals with addictive behavior join together in a It is a typical set up in the community-based settings with the
structured manner in order to promote drug free society. capacity to accommodate 40 to 80 members. It is designed
It forms a miniature of society, staff act as facilitators and based on the need, funding and the willingness of the
residents join together to promote the transitional process. community members. For example, Ground of former camps
 —Ottenberg, 1993 or sub-urban houses.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 133

Table 5.10: Components of therapeutic community

Components Description
Daily community Conduct regular meetings composed of 60 to 90 clients for 1 hour. Frank discussions are encouraged with
meetings outburst of emotions. All levels of staff and administrative personnel are involved. Acute patients aren’t
involved in the meetings.
Patient government As per the decisions made in the community meetings, a group of 6 patients will be allotted with the specific
(or) ward council responsibilities such as meal distribution, physical exercise, housekeeping, personal hygiene, monitoring the
patients who have suicidal risk, etc.
Staff meetings (or) Staff meetings will be conducted following the community meetings in which only the staff is involved and not
reviews the patients, in which staff will examine one’s own expectations, responsibilities and responses.
Living and learning Learning opportunities are given along with social milieu in order to create the realistic learning experience.
opportunities

Treatment Process individual is allowed to enter into therapeutic community, in

which the house constitutes multiple rooms and each room
Treatment process involves the components of therapy,
has 6–8 members grouped together. Insisting the individuals
education and training. It involves the below written events:
with the regular maintenance work, disciplined schedule, and
• Treatment of substance abuse
privileges based on the behavior patterns, giving the work
• Education
which has more physical activity will make the individual feel
• Primary medical and dental care
• Vocational skills training tired and thereby individual will not have any thoughts to get
• Job placement back to the previous lifestyle.
• On-site help to involve in business Primary Treatment
• Help in legal activities
• Life skill counseling In this, residents are expected to take care of the welfare of
others. Vocational training areas are introduced in this stage.
Stages of Therapeutic Community Residents will undergo training to develop literacy, computer
skills and to obtain general equivalency diploma course, etc.
The stages of therapeutic community are shown in Fig. 5.12.
At the end of this phase, residents might complete the diploma
Induction and Treatment program, choose the vocational training area in which they
need to specialize, participate in the group activity, deal the
This phase takes place in the first month (30 days) to assimilate
daily life and follow the rules or regulations of the facility.
the individual into therapeutic community. When the
interview or assessment part has been completed, then the Vocational Skills Training
Vocational training programs are conducted. Money will be
saved for the vocational work done by the residents and it will
be given when he/she starts his/her new life or when he/she
exits the program. Residents are encouraged for the social
activities.

Re-entry
Residents need to acquire skills and develop the coping abilities
in order to re-enter into the society.

Staffing Pattern
The ratio of staff and resident is 1:15. Staff is the mix up of
self-help professionals who have recovered already and other
traditional professionals such as staff nurses, doctors, case
Figure 5.12: Stages of therapeutic community workers, counselors, etc.
134 Textbook of Psychiatric Nursing for BSc Nursing Students

Daily Regimen Definition

An ideal therapeutic community starts at 7 am and concludes Milieu is the scientific structuring of the environment in order
at 11 pm. It includes morning and evening house meetings, to elicit the behavioral changes, enhance the psychological
seminars, job assignments, scheduled personal time, group health and functioning of the individual. —Skinner, 1979
tasks, individual counseling and recreation. Activities
of therapeutic community are organized to enhance the Historical Background
interpersonal and social interactions as the primary purpose, The historical background has been given in Table 5.11.
which can be achieved through:
Table 5.11: Historical background of milieu therapy
• Community meetings: To review goals and functioning
of therapeutic community. Year Description
• Clinical groups: It use various therapeutic approaches to Late 1770s Pipel in France formulated the term ‘moral
address the problems. treatment’ to explain the new approach
of mental health care on the basis of
• Vocational and educational activities: It will develop the
humanitarianism (For example, by removing
individual through training/education and work. the chains/restraints in psychiatric patients).
• Community and clinical management activities: To Early 1800 Tuke in England created York retreat based
make sure that the life of resident is productive and on the atmosphere of kindness, family
orderly. environment and treating the patients as
guests.
Advantages of Therapeutic Community Late 1800 Service pattern in psychiatric organization
was domestic service pattern in which the
• It helps to build self-confidence. patient care is custodial.
• It helps to develop the harmonious relationship with the Early 1900 Hospital atmosphere has been declined,
community members. results in the development of environment
• It builds the leadership ability. which is custodial.
• It improves the problem solving capacity. 1930 Sullivan began to experiment with the
• It promotes the ability to live and think collectively along various milieu by selecting the staff who
have good interactions with patient.
with the members of community.
• It makes the individual as a sociocentric person. 1939 Menninger developed the attitude on the
basis of psychoanalytical principles which
determine the staff patterns.
Disadvantages of Therapeutic Community
1940 Medical Intervention pattern was framed,
• Resident may feel the transition to the community is a which helped the nurses to provide care.
difficult one. 1946 Thomas main coined term, ‘therapeutic
• Individual concerns/needs have not been met. community’ to describe the resocialization
• Group responsibility might be no one’s responsibility. of neurotic patients through social
interactions.
• Blurring of role between the staff and resident.
1948 Bettelheim coined term ‘Milieu therapy’
and use of environment for disturbed
NURSES RESPONSIBILITY children.
1953 Maxwell Jones utilized therapeutic
Nurse has to coordinate with the members to select group leader. community approach in the treatment of
She has to maintain the environment without conflicts. She has to antisocial personality disorders.
motivate the patient in decision making process. She has to carry
out the supervisory functions. She has to share the responsibilities 1990 Milieu therapy has been developed based
with the residents. on the research to explore the milieu
structure, which was found effective for the
specific treatment groups.
MILIEU THERAPY
Goals of Milieu Therapy
Meaning • Patient is expected to develop the adaptive coping skills,
The word, ‘Milieu’ is a French word for ‘middle’ which denotes relationship ability and interaction skills to generalize all
the meaning, ‘environment or surroundings’. the aspects of one’s life.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 135

• To achieve the patient’s level of independence. Progressive Levels of Responsibility as per the
• To manipulate the environment in all aspects of patient’s Self-care Capacity of the Client
hospital experience as therapeutic.
Level 1: Exhibiting destructive behavior to self/other/
Principles of Milieu Therapy environment
In level 1, the client exhibits poor personal hygiene without
• It gives opportunities for patient to be a part of unit
management. taking care of oneself. Client is disoriented with time, place
• It helps to promote socialization, improve the self-esteem and person. Client will not get involved in the group therapy.
and also the fundamental respect to both client as well as Level 2: Not Exhibiting Destructive behavior
staff members. In level 2, the client attempts to maintain personal hygiene.
• This will help to utilize the communication between Client is oriented with time, place and persons. Client will
patient and staff to attain the maximum therapeutic
participate in at least one group therapy session.
benefit.
• Team approach is helpful but the individual is responsible Level 3: Involve in all the therapeutic activities
for one’s own actions. In level 3, the client participates in the community meetings
• Peer pressure has been used to reinforce the rules and and family sessions. Client will develop self-directed behavior
regulations. to solve the problem. Client will know about the time of
• Clients are motivated to perform the task based on the medicine that needs to be taken.
ability to promote the self-esteem.
• Temporary seclusion is encouraged for acting out Level 4: Take an active role in promoting the changes in
other clients
behavior.
• Nurse will function consistently to promote the goals of In level 4, the client will develop an active leadership role and
milieu. act as a good role model to other clients. Client will actively
participate in all the scheduled events and group meetings.
Characteristics of Milieu Therapy Client will initiate the discussions with mental health team
Strategies have been formulated to counteract the negative members regarding the discharge planning.
effects of institutionalization and these have been presented Progressive levels of responsibility are shown in
below in Table 5.12. Figure 5.13.

Table 5.12: Strategies formulated to counteract negative effects of institutionalization

Strategies Description
Distribution of power The approach used here is ‘flattening,’ i.e., all participants might involve in the decision making process.
Governing council will take the final decision on the basis of the input from all the small groups. This gives
autonomy to every individuals.
Open communication Open communication is helpful to make the effective treatment decisions. It also helps to create awareness
that everyone is working toward the common goal.
Structured interactions Menninger KA was the first person to introduce the concept of structured interaction approach to all the
staff. It helps all the staff members to approach the client in the consistent way toward the treatment goals.
Work related activities An effective work therapy program is based on three factors:
1. Client has to choose the type of work based on his/her wish.
2. Work activity that improves the skill found necessary in actual job situations.
3. Activities give an opportunity to test out the individual’s ability in different areas based on the job
interests that are going to be attained in future.
Involvement of Community mental health centers emerge because they help to involve the family members and
community and family community people at larger extent. This will help the client to reduce the isolation and enhance the family
members in therapeutic interaction process.
process
Adaptation of Adaptation to the environment in order to meet the various needs is a great challenge. This can be done
environment to meet the with the inclusion of family members of different age groups in the therapeutic milieu.
developmental needs
136 Textbook of Psychiatric Nursing for BSc Nursing Students

• Visualize the contribution as a whole and not only the tasks

• Accept the responsibilities
• Strong decision making capacity
Programs within the milieu therapy unit have been given
below in Table 5.13.
Table 5.13: Programs within the milieu therapy unit

Client government Work activities

• Conducting the structured • Create and offer variety of
meetings at least once in a activities
week • Provide opportunity to
Figure 5.13: Progressive levels of responsibility • Making decisions for the the client for selecting the
benefits to the client work required to do
• Involve the client in planning • Ensure the monetary
Key Concepts of Milieu Therapy the activity schedule benefits for the successful
The key concepts include containment, validation, structured • Discuss the problems which completion of the work
arise daily
interaction and open communication.
• Containment: It focuses on safety and security needs of
client, attain the basic needs and protect the client against NURSES RESPONSIBILITY
social stigma.
• Validation: Interactions between the staff and client Nurses Responsibility in Milieu Therapy
should ensure the client’s humanity and should protect the • Physical dimension: Nurse has to participate in designing the
human rights. Client has to feel that the communication physical infrastructure or in renovation required to enhance
the therapeutic physical environment.
of the staff is respectful. Example: Bulletin boards are required to display the
• Structured interaction and open communication: It is occupational therapy activities, separate therapy room is
explained in the characteristics of milieu therapy. required to conduct group therapy and bed side lockers are
required to keep the personal items of client, etc.
Milieu Therapy Team Members • Intellectual dimension: Nurse has to communicate with the
physical design experts regarding the color, lighting and texture
• Psychiatrist of the building, because these factors help to improve the
• Psychiatric nurse perceptual clarity. Nurse has to coordinate with all the health
• Clinical psychologist team members in order to make referrals and promote the
participation of client.
• Psychiatric social worker
• Occupational therapist • Social dimension: Nurse should take the leadership role and
promote the interaction process among the clients.
• Recreational therapist
• Emotional dimension: Nurse has to create the warm, fruitful,
• Music therapist cooperative, relaxed, work with a purpose and rewarding
• Art therapist emotional atmosphere to promote the mental health.
• Dietician • Spiritual dimension: Allotment of specific quiet area for
• Chaplain worship is vital to promote the spiritual needs.
• Mental health assistant

Characteristic Features of Milieu Therapist Advantages of Milieu Therapy

A good milieu therapist should have: • Client improves the self-confidence and involves in the
• Self-respect/self-esteem/self-worth decision making process.
• Warm and supportive nature • Client becomes sociocentric person.
• Empathetic thinking capacity • Client develops the leadership roles.
• Contribute effectively toward the organization goals • Client is able to adopt the behavior which is acceptable to
• Share problems within the context and work out to solve the therapeutic environment.
effectively • A therapeutic milieu is a safe place to develop the strengths
• Able to function in various roles and responsibilities and abilities.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 137

• Client develops a fruitful relationship with the other Differences between expressive and supportive psychotherapy
members in community. have been given in Table 5.14.
• Client learns to live and think collectively for the members The supportive psychotherapy includes advising,
in the community. comforting, reassuring, encouraging and active listening.
Table 5.14: Differences between expressive psychotherapy and
Disadvantages of Milieu Therapy supportive psychotherapy
• Client finds that transition to the community is a difficult
Components Expressive Supportive
one. psychotherapy psychotherapy
• Individual concerns/needs do not meet.
Goal of the Patient has to Patient’s symptoms have to
• Group responsibility might be no one’s responsibility. therapy gain insight be reduced.
• Blurring of role between the staff and client. Style of the Not transparent Therapist converses well
• Milieu therapy is limited to the hospitalized clients. therapist with the patient
• Client and Staff ratio is minimal. Regression Need to be Need to be reduced
• Open communication is required between the staff and enhanced
client. Transference Examine it Nurture the positive
properly transference
SUPPORTIVE PSYCHOTHERAPY Level of Focus at Focus at conscious
consciousness subconscious level
Definition and unconscious
level
Supportive psychotherapy is defined as psychotherapeutic
approach which integrates various components such as Use of Interpret the Reinforce the mature
defenses defenses defenses
cognitive-behavioral, psychodynamic and interpersonal
techniques.
Techniques of Supportive Psychotherapy
Supportive psychotherapy is defined as a kind of
psychotherapy which helps to decrease the psychological Directive Techniques
conflict and strengthen the patient’s defenses with the help of • Advice
techniques such as suggestion, reassurance, counseling, re- • Teaching
education, etc. • Change of environment
• Solving the problems or issues
Goals of Supportive Psychotherapy • Cognitive restructuring
• To reduce the intensity of the presenting symptoms or • Modeling (therapist reveals oneself to enhance the
distress. patient’s identity)
• To decrease the behavioral problems caused by psychic
Explanatory Techniques
conflicts.
• To reinforce the adaptive patterns of behavior. • Motivation
• To provide the healthy supportive relationship with the • Instilling home
patient. • Empathy
• Reassurance
Do’s and don’ts in supportive psychotherapy have been • Promoting self-esteem
presented below: • Build therapeutic alliance
Do’s Don’ts • Containment
• Managing transference
Have an emotional Solve the problems for the
connection patient
• Reality testing

Promote catharsis Interrupt the feelings of the Components of Supportive Psychotherapy

patient
Bloch (1979) explained the key components of supportive
Develop the therapeutic Interpret the transference
psychotherapy as given below:
alliance
• Reassurance is vital to clarify the doubts and
Focus on patient’s Assign the homework misconceptions. It has to be realistic and helpful to
strength
promote the climate of hope and positive expectation.
138 Textbook of Psychiatric Nursing for BSc Nursing Students

• Detailed explanation about the disease has to be focused Goals

here and now concept, however, the overall aim is to
• To improve the communication skills among the family
enhance the coping ability rather than the improvement
members.
of self-awareness.
• To reduce the existing conflicts within the family.
• Individual has to know when to seek help.
• To strengthen the ability of the family members to cope
• Suggestion by the therapist can result in change of patient’s
with the stressors.
behavior.
• To integrate the family system along with the social
• Motivation helps to promote self-esteem and decrease the
system.
inferiority complex.
• To decrease the dysfunctional behavior among the family
• Environmental change might cause the vital changes in
members.
patient.
• To raise the awareness about the needs of individuals in
• Active listening, unconditional acceptance and promoting
the family.
catharsis is helpful.
• To establish the empathetic and supportive connection
among the family members.
FAMILY THERAPY

Historical Development Indications

Family is fundamental unit of the human life. Nathan • Existing family conflicts.
Ackerman, an American Psychiatrist, coined the term ‘family • Interdependence of issues and symptoms (Example: wife
therapy’ in 1950. Nathan Ackerman (1958) and Murray Bowen is getting depressed because the husband is consuming
(1978) were the pioneers of family therapy. Sigmund freud alcohol; husband is taking alcohol because he/she
explained that, the unconscious process like identification, perceives the wife is having extramarital relationship:
projection, and introjection are considered individual Othello syndrome).
experiences and might be transmitted across the generations • Failure of individual therapy.
in family. Virginia Satir is an American author/social worker • Continuous stressors among family members and lack of
and she is the mother of family therapy (Fig. 5.14). coping ability.
• Relationship issues in the family (Existing communication
Definition gap or generation gap).
Family therapy is defined as, ‘a form of psychotherapy in
Contraindications
which, the issues or problems or conflicts existing among
the family members are addressed and the solution is • Unwillingness of the family members to accept the
identified.’ therapy.
• Unavailability of any family member who is involved in
the conflicts.
• Family members staying separately.
• Family members who exhibit high level of negative
emotions or unwillingness to listen to the conversation.
The functions of family have been presented in Table 5.15.

Types of Family Therapy

• Individual family therapy: Each family member in the
family will have a separate family therapist and the whole
family will meet occasionally with one or two therapist to
work out the specific issues.
• Conjoint family therapy: It is a psychotherapy in which
two or more members in a single nuclear family are
involved in the therapy, for example, problems between
Figure 5.14: Virginia Satir: American author and social worker; the parents and children, marriage counseling, etc. are
mother of family therapy addressed here.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 139

Table 5.15: Functions of a family

Functions of family Description

Communication Communication gap is a major issue for the conflicts existing in the family. So, communication with the family
function members will give a chance to express the feeling and emotions of the family members.
Boundary function Boundary will maintain the limits between the individual members in the family. Rigid boundary prevents the
innovative ideas and communication within the family and might cause family dysfunction.
Supportive function It helps to grow and obtain the new roles in the family.
Biological function Family is the medium for procreation.
Socialization function Family interaction will improve the social skills and coping skills of the family members.
Psychological function Love, affection, emotional attachment, belongingness, sympathy, security, intimacy, etc. are the psychological
functions existing in the family.
Protective function Family provides the feeling of safety and security among each other.
Educational function Parents are the first teachers and care givers. Child’s personality will get molded up according to the activities
and the teaching from them.
Recreational function Family creates the atmosphere to recreate, play, entertain and share happiness among them.
Social function Family provides the identity to maintain the social status.
Religious function Family gives religious thoughts and ideation toward the God.
Cultural function Family will mold its members based on their cultural values, belief, tradition and customs.

• Couple therapy: This is also called marital therapy in • Cognitive behavioral family therapy: It is the use of
which the problems exist between the married couples, cognitive therapy techniques and behavior therapy
i.e., husband and wife and are discussed here. techniques within the family context.
• Multiple family group therapy: It is a psychotherapy • Family psychoeducational therapies: It is a health
working out with the collection of more families in a teaching to the family members with the concern of
group setting. psychological well-being. Nurse should not provide any
• Network therapy: The network constitutes 40–60 wrong assurance stating about the cure of mental illness.
individuals who are experiencing crisis, issues and Instead, the discussion should focus on psychotropic
problems within the family and can attend network drugs, awareness about the disease, care required, follow-
therapy. This gathering includes family, neighbors, up, rehabilitation, etc.
friends, professional groups and any individual in the
community. People who gather will interact regularly Family Therapy Assessment
regarding their family issues and obtain the solution to Boyer and Jeffrey (1984) listed six elements which are helpful
the problem. to assess whether family is functional or dysfunctional.
• Psychodynamic family therapy: It is a family therapy 1. Family interactions: Healthy family communication and
which integrates the Sigmund Freud’s Psychoanalytical expressing the family expectations during the interactions
concept (unconscious aspects of individual personality will resolve the conflicts.
traits integrates with the family context). 2. Family climate: Positive family climate is based on the
• Structural family therapy: It is a psychotherapy method trust and openness among the family members.
developed by Salvador Minuchin. It focuses on the 3. Communication: Family members are encouraged
pattern of interactions that create the problems among to express the honest feelings or opinions, while other
family members. members in the family will be active listeners. There
• Strategic family therapy: Jay Haley is the pioneer of are few factors which influence the communication gap
strategic family therapy. In this family therapy, the within the family such as:
therapist solves the present problems specific to the „ Failing to listen: Members in the family don’t
interactions between the family members. It is a brief, listen the conversation of others or listen very
solution-oriented and process-focused therapy. The key selectively and it would be the reason for wrong
concepts are mentioned in Table 5.16. interpretation.
140 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 5.16: Key concepts of strategic family therapy

Key concepts of Description

strategic family
therapy
Avoid paradoxical Contradiction between what is said and what is expressed
injunctions
Avoid paradoxical Direct the patient to continue the behavior
directives
Have a control over Therapist helps the patient with his/her need and determines the level of control over the behavior
one’s own behavior
Avoid double bind Conflicting messages are verbalized
communication
Relabeling (positive Therapist will change label attached to the person from negative side to positive one, from which the new
connotation) responses are expected because of the positive perception
Family homeostasis Families tend to preserve the organization of the family
First order changes Superficial changes of the behavior in the system is done but the structure of system doesn’t change
Second order changes Changes in the systemic interaction and so the structural and functional changes take place
Avoid faulty family Ignoring the problem when action is needed and taking action when it is not needed gives faulty solutions
solutions
Pretend technique Therapist motivates the family members to pretend as playful, fantasy, etc.
Neutrality Therapist has to be neutral with all the family members and avoid coalitions.
Circular questioning Focus on the connections among family members rather than identifying the differences among them
Reflexive questioning Help the family members to reflect on the perception, values and beliefs
Hypothesizing Determining that how the family members have to organize to solve problems

„ Belittling feeling: Members in the family should be

encouraged to hold the honest feelings and ignore NURSES RESPONSIBILITY
the hurts or negative feelings caused by others.
Nurse has to assess the strengths, problems and goals of the
Example: Sister developed anger toward the brother
family. She has to explore the expectations of the family members.
because he is scolding continuously. Father asked his She should pay attention to the needs of the family members. She
daughter to ignore the negative feeling. has to coordinate the treatment process. She has to promote
„ Indirect communication: Members in the family active listening and to have a clear communication among family
should pass the message directly, i.e., sender has to members. Sessions have to focus toward the resolution of family
conflicts. She has to motivate the family members to expand their
send the message to the receiver directly instead of
social support networks and adjust with their expectations. Nurse
passing the message to the third person as it might has to follow-up regularly for the further sessions and render
cause improper delivery of messages. continuous support.
4. Positive reinforcement is used among the family
members: Family members have to provide the positive
reinforcement by using the encouraging words in order to GROUP THERAPY
motivate each other for their daily achievements.
5. Expectations of the family members: Each family Human beings are social animals. Social interaction plays the
member has different strengths and weaknesses. Every vital role for the human beings. Psychotherapy in the group
individual might have different expectations from the helps the individual to share the issues or problems to the peer
family and so each member in the family has to be valued groups and obtain the right solution. It helps the individuals to
independently. understand their own deficits in a better way.
6. Handling differences: It is difficult for the two individuals
living together to agree with each other all the time. Those
Historical Development
differences have to be put into neutral situation for the In 1905, Joseph Pratt used group therapy for the patient with
smooth functioning of the family. tuberculosis. Strict hygienic measures have been encouraged
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 141

in the nursing homes and so the group health teaching for Therapeutic Principles (or) Functions of Group
the patients has been initiated regularly. Cody Marsh, a Therapy (or) Factors Contributing the Group
psychiatrist, was the first person to initiate the dance classes in Therapy Process
the group. Later, Sigmund Freud understood the significance
According to Yalom (1985), the therapeutic principles of group
of group dynamics. In World War II, many therapists were
psychotherapy are listed below:
involved in the group works. Kurt Lewin’s work stimulated
• Instillation of hope: In the mixed group, a member who
the interest in group process. The emergence of Gestalt theory,
solved the problem can be an inspirational person or a
transactional analysis, existential models and bioenergetics motivator to another member who is still struggling with
developed the group therapy field. Slavson, educationalist of the problem.
psychoanalytic persuasion developed the group psychodrama/ • Imparting the information: Structured health teaching
group psychotherapy and he also made efforts to form or psychoeducation is vital to the group members.
American Group Psychotherapy Association. In late 1930s, • Universality: Patient will feel that others in the group
Emmanual Schwartz and Alexander Wolf applied the have thoughts, problems and feelings similar to his/her
psychoanalytic concepts in the group therapy. own.
• Corrective recapitulation of the primary family group:
Definitions Unconsciously patient perceives the therapist as parents
• Group therapy is defined as, ‘mentally ill patients are and other members as siblings in the form of transference.
placed into groups, guided by the therapist for the purpose The therapist’s interpretations can help group members to
of changing maladaptive behavior.’ understand the impact of childhood experiences on their
• Group therapy is defined as, ‘psychosocial treatment personality, and they may learn to avoid unconsciously
where the patients meet regularly to talk, interact and repeating unhelpful past interactive patterns in present-
discuss the problems with each other along with the day relationships.
therapist.’ • Altruism: It is the process of helping each other.
• Group therapy is defined as, ‘a type of psychotherapy in • Imitative behavior: Patient attains the growth by the
which the group sessions are guided by the therapist and imitation of healthier aspect of behavior from others.
the patients will confront their personal problems. Here, • Development of socialization: Role play in the group
the interaction is the integral part of therapy’ therapy will enhance the social skills.

Purposes Types of Group Therapy

• To examine and relieve the distortions. Types of group therapy are given in Table 5.17.
• To treat the psychopathology.
• To improve the coping skills. Common Topics Addressed in the Group
Therapy
Components of Group Therapy • Addiction
• Members: 8–10 members in a group. Not more than • Behavioral issues
15 members are advised. • Anger management
• Duration: 1–2 hours is the duration of group therapy. • Communication related issues
• Number of sessions: One group therapy session is held • Grief and loss
within two weeks. • Parenting
• Norms: Each group may have one’s own rules, regulations • Emotional problems like depression, anxiety, etc.
and standards. • Relationship issues like trust, intimacy, self-esteem, etc.
• Cohesion: Group members work together to achieve a • Domestic abuse or violence
common goal. • Divorce
• Role: Each patient involved in the group therapy might • Food and eating related issues
have separate role to perform.
• Power: Individual power may influence over the group. Stages of Group Therapy
• Communication: Free communication within the group In Initial stage, the member’s involvement is superficial.
is allowed. Structuring the group rules, norms and responsibilities
142 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 5.17: Types of group therapy

Types of group Description

therapy
Open group Members of this group can join at any time.
Closed group • Members of this group can join only in the initial time of commencement.
• Only those participants will attend the meeting for the further sessions.
Small group Group constitutes 3–4 members.
Large group Group constitutes more than 4 members.
Primary group Group where only the family members are involved.
Secondary group Group where the patients of different families are involved.
Homogenous group Group where the members with similar problems and issues have been involved, e.g., only the patients with
alcohol dependence syndrome were involved.
Heterogeneous group Group where the members with various problems and issues are involved, e.g., patients with alcohol
dependence syndrome, neurotic patients and their family members were involved.
Psychoanalytic group Application of the psychoanalytical principles in the group therapy. Group communication at conscious,
psychotherapy semiconscious and unconscious levels has been focused. Free association, dream interpretation and
latent content has been focused in the group therapy. Psychotherapist turns out all these experiences into
conscious healthy learning experience to the patient.
Rational emotive It is aimed to enhance the rational thinking of the group.
therapy
Transactional analysis Three ego states of individuals such as adult, parent and child role is examined in this group.
Interpersonal group Interactions between the group members help to decrease the anxiety and stress caused due to
therapy interpersonal relations.
Psychodrama group Therapist directs the subject with role play and implement the therapeutic ideas into action.
Encounter group It is aimed to bring the personal change due to the deep felt experiences.
Community support It develops the feeling of togetherness, group cohesion, understanding, social support and thereby it
group improves the good patterns of behavior.

begin here. Members in the group search out their similarity be confidential, until and unless the permission is given, it
among them. At Working Stage, members in the group work should not be discussed outside. Therapist needs to inform
together with co-operation in order to solve the problems. the authorities if the patient verbalizes ‘harm toward self
In Termination stage, the group members evaluate and or others’. Therapist should ensure the entire session is non-
summarize their experiences and also explore the positive/ judgmental and should provide a positive growth to all the
negative feelings. The follow-up and next meeting of group members in the group. The sessions have to be free from
session will be planned (Fig. 5.15). discrimination, threats, harassment, etc.

Ethics of Group Therapy Therapeutic Techniques (or) Interventions used

All the group members must protect the identity of fellow in Group Therapy
members and the information shared in the group should • Acceptance: Accept the participants without implying
any approval of particular behavior.
• Approval: Encourage the right attitude or action or
performance.
• Clarification: Restate the statement to clarify the doubts.
• Identify allies: Identify tbfhe helpful and co-operative
members for the benefit of the group.
• Information giving: Saying the facts in regard to the
problem.
• Reinforcement: Motivate the group members for the
Figure 5.15: Stages of group therapy positive outlook and to regain the confidence.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 143

• Encouraging expression of feelings: Motivate the • It is a cost-effective therapy.

participants to ventilate the feelings. • It gives an opportunity for the group members to learn
• Support: Psychological support gives a comfort to the different styles of communication.
group. • It helps the group members to understand the reason for
• Teaching: Teach the group in regard to the unknown problems in a better way.
concepts or phenomenon. • It helps the group members to learn multiple problem-
• Listening: Concentrate the communication of the group solving skills from others.
without interpretation.
• Limit setting: Set the limit when the group members Disadvantages of Group Therapy
speak out of boundary limits. Therapist has to guide the • Lack of privacy for the group members.
conversation in group therapy, which has to be related to • Sometimes ethics of the group therapy can be out of
the context. control.
• Use of silence: Being without speaking. • Resistance or showing reluctance to change by the group
• Structuring: Shaping out the contents to have a group members may be present.
meeting. • Domination by the therapist might take place sometimes,
• Themes: Explore the main concepts in the group particularly at the time of limit setting.
discussion. • Members lack the freedom to join in between the closed
Group psychotherapy for the special population has been group therapy.
given in Table 5.18. • It may consume more time, when the discussion about
the different issues in the heterogeneous group take place.
Advantages of Group Therapy
• It develops the socialization skills. Role of therapist in Group Psychotherapy
• It encourages the group members to share their ideas and According to Lieberman (1973), four basic dimensions of
feelings. therapist behavior are as follows:

Table 5.18: Group psychotherapy of special population

Disease condition Description

Alcohol and other Psychological conflicts, family problems, financial issues, health problems, occupational and legal issues
substance abuse are addressed in the group therapy. Example: Alcoholic Anonymous (AA) group, Narcotic Anonymous (NA)
group, Al-anon, etc.
Schizophrenia and other Realistic testing, dealing with interpersonal interactions, coping skills, social skills and drug adherence has
psychotic patients been discussed. However, group psychotherapy is contraindicated with acute psychotic patients.
Mood disorders Based on the psychological strengths of the patients, supportive approach or expressive approach of
treatment will be provided.
Personality disorders These patients are usually unaware of maladaptive behavior and at certain extent, patient might irritate or
show anger on others. So, this sustained negative behavior pattern is unfolded and confronted with one’s
own psychopathology. Personality disorder patients perform well in the heterogeneous groups.
Anxiety disorders, Patients with high level of anxiety require trusting relationship with the therapist. Patient with post-
eating disorders and traumatic stress disorders require homogenous group therapy to address the social phobia. In eating
somatoform disorders disorders, educational approach, intrapsychic exploration and motivation of interpersonal learning is
essential. In somatoform disorders, homogenous group therapy gives adequate psychological support to the
patients.

Cancer patients These patients might face huge psychosocial problems because of cancer. So, the pre-existing coping skills
have to be strengthened to handle out the crisis situations and adequate psychological support is essential.
Physically disabled In the rehabilitation centers, issues related to feeling of isolation, loneliness, reduced self-esteem have to be
patients addressed. Group programs have to be conducted to gain the new coping skills.
Mentally retarded- Need of love, sharing, acceptance and closeness is vital for the mentally retarded group. However, therapist
patients has to set limits in patients with hyperactive and impulsive behavior to enhance the realistic socialization.
144 Textbook of Psychiatric Nursing for BSc Nursing Students

1. Emotional stimulation: Therapist acts as a self-revealing Definition of Play Therapy

member of the group. Therapist stimulates the group
Play therapy is a form of psychotherapy in which the therapist
emotionally for the behavior change and not merely by
utilizes the child’s fantasy and symbolic meaning as a medium
teaching.
of play to have a communication or understanding about
2. Caring: Therapist shows the cluster of behavior such as
the children. It also gives a chance to the child to express the
love, affection, friendship, support, protection and praise.
feelings and experiences.
3. Meaning attribution: The ideas or concepts expressed
by the group members might gain the group experience.
Theories of Play
Therapist might guide the group members to follow the
group experience, if found fruitful. • Natural theory: Play seems to be natural and instinctive
4. Executive functions: Therapist directs the group one. Children will play on their basis of age and
members toward the functioning in the social system. development. Interests in the particular age is said to be
universal. Play can be correlated with the chronological
PLAY THERAPY age and the physical development.
• Energy theory: This theory explains that the concept of
Historical development of play therapy is shown in Table 5.19. play is based on the levels of energy. Children might get
Table 5.19: Historical development of play therapy involved in active and aggressive play because of high
energy level present in them. Children who are inactive
Year/ Description exhibit the lack of energy level.
Period
• Practice theory: This theory explains the concept of play
429–347 BC Plato said, ‘Person can be discovered within one as a practice or the way of preparing and functioning
hour of play, more than one year of conversation.’
oneself toward the adult life.
18th Rousseau wrote a book, ‘Emile’ in which it is • Recreation theory: Play is considered an escape from
Century mentioned that play is a way to understand the
children. the fatigue of everyday life. It enhances the physiological
needs of relaxation and thereby promotes the recreational
1903 In Friedrich Frobel’s book, ‘The Education of Man’
mentioned the significance of symbolism in play value.
(i.e., Play gives higher development by the way of • Catharsis theory: Play helps to ventilate the bottled up
free expression) emotions. It decreases the negative emotions such as
1909 Melanie Klein implemented the play technique aggression, anger, hatred, hostile behavior, etc.
to analyze the under 6 children. She strongly • Discovery theory: Play gives a chance to the child to
believed that children’s play is associated with free discover the environment through the interpersonal
association used in adults.
relationship with others.
1930 David Levy developed the technique or structured
• Pleasure principle theory: Sigmund Freud, a
approach called ‘Release therapy’. He proposed
that introducing the play items in stressful situation psychoanalyst, said that play is a pleasure principle
helped to release the associated emotions. because play gratifies oneself, feel relaxed and happy.
1946 Anna Freud used play to enhance the positive
attachment with therapist and to assess the Qualities of Play Therapist
children’s inner life.
Play therapist should be friendly, appealing and must have
1953 Clark Moustakas published first book entitled, good rapport with children. Play therapist has to understand
‘Children in Play Therapy.’
the feelings of the children through the facial expressions. Play
1955 Gove Hambidge expanded David Levy’s technique, therapist should accept their faults. He/she has to make the
‘Release therapy’ (Usage of play items to relieve
the stress). children comfortable so that they can express their feelings.
He/she should have a capacity to reciprocate or reflect the
1964–1970 Alexander, Landreth, Muro, Myrick, Holdin, Nelson
and Waterland were the counselor-educators who feelings of the child in order to gain insight in the child’s
used the play as educative and preventive tool to behavior. He/she should be free from conflicts to conduct play
detect and solve the problems in children. therapy sessions. He/she must have a zeal that the therapy
1973 Moustakas published the novel, ‘The child’s should help the children to maximum extent. Play therapist
discovery of himself,’ which focused on the growth should have strong knowledge on child psychology to
experience with play therapy. understand the behavior of the children.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 145

Indications of Play Therapy

• Children with aggression (or) temper tantrums
• Children with sleep disturbances (or) nightmares
• Children with poor bowel and bladder control
• Children who experience physical or sexual abuse
• Children who are neglected
• Children with no care from family members
• Children with excess worries
• Children with low self-esteem
• Children with learning disorder
• Mentally retarded children
• Children with anxiety disorder or having emotional
disturbances Figure 5.16: Phases of play therapy

Types of Play therapy • Rebellious phase: This phase is helpful for the child
to explore the strong anger or repressed feelings or
• Controlled (or) situational play: Therapist creates a
depression which helps to improve the positive mental
variety of toys/dolls and asks the children to speak with
health.
the doll assuming the various characters such as parents,
• Working through phase: After the awareness about the
teachers, siblings, friends, etc. The various scenes arranged
feeling of the child, therapist uses the productive methods
in the play interview will help the child to gain insight
to develop the healthy behavior in children.
into mental mechanisms. Newell said that situational
• Termination phase: After working out with the child’s
play gives us clues to identify the wishes of parents (when
emotions, when the therapeutic gain occurs, the therapy
child hides the doll behind), Oedipus wishes regarding
can be terminated and the next follow-up session can be
masturbatory activities, castration anxiety and other
planned by the therapist.
primitive sex theories.
• Free (or) spontaneous play: Therapist leaves all the
Duration and Design of Play Therapy
initiation of play toward the child. This type of play will
help the child to explore the fear, guilt, anxiety, fantasies The ideal duration of the play therapy is 30–45 minutes.
regarding birth, death, hostility and sex. Play therapy is exclusively designed for the children below
• Individual play (or) solitary play: In individual play, 12 years of age.
child will play with himself/herself.
• Group play: Child plays with the group of children. Principles of Play Therapy
• Structured play: Play is organized based on the situation Principles of play therapy are enlisted in Table 5.20.
and the plans.
Table 5.20: Principles of play therapy
• Unstructured play: Play is not organized on the basis of
situation and the plans. Principles Description
• Directive play: Therapist has an active role by directing Friendly This behavior helps to promote the trust
the children through the play. rapport with between the therapist and the child’s
• Non-directive play: Therapist has a passive role and the children relationship.
therapist will not direct the children during the play. Accept the Accepting the child irrespective of his/her
child as intelligence, capacity, socioeconomic
Phases of Play Therapy he/she is background, interests, skills etc. is the ethical
norm needed to be followed by the therapist.
Phases of play therapy are shown in Figure 5.16. Ability toward It helps to facilitate the creativity in children
• Introductory phase: It is the preliminary task of the the problem
therapist to establish the trust of the children. It usually solving skills
takes 5 minutes but might extend depending on the Direct the child Guidance by the therapist will provoke the child
personality of the children. toward play to involve in the play activities at full extent.
• Honeymoon phase: This phase is helpful to explore Therapist uses Build the appropriate required relationship
the anxiety in the various settings such as school, home the limits between therapist and children. It also
setups, entertainment areas, etc. sparingly prevents the boundary violations.
146 Textbook of Psychiatric Nursing for BSc Nursing Students

Play Items used for the Therapy PSYCHODRAMA

• Preschooler: Crayons, color pencils, color books,
Historical Development
magnetic boards, puppets, story books, recorded videos,
safe hospital equipment, etc. Jacob L Moreno (1889–1974) was the first person to identify
• Children in school age: Board games, toys/dolls, crafts, the concepts of psychodrama and sociometry. In 1913, Jacob L
story books, recorded videos, use of computer, etc. Moreno grouped the prostitutes to discuss regarding the social
stigma and problems encountered in the form of support
Functions of the Play Therapy group. In 1925, Jacob L Moreno introduced his work done on
Psychodrama to the American psychologists. Following this,
• Creative function: It improves the creativity of the child.
Wilhelm Reich, Sigmund Freud and Jacob L Moreno developed
It gives an opportunity to get rid of one’s own conflicts the concepts of psychodrama. Jacob L Moreno began to work
and learn positive qualities as well as emotional growth on children and later conducted the psychodrama sessions in a
from other children. large group in Carnegie Hall.
• Diagnostic function: It helps to identify the difficulties
contributing toward the issues in children. It also helps Definition of Psychodrama
to understand the child’s personality and explore the
Psychodrama is a form of group psychotherapy, in which the
relationship existing between the siblings. It also helps to
dramatization or dramatic presentation of the group is done to
explore the intellectual capacity according to the age.
gain self-insight.
Neuroscience and Play Therapy
Hollander Psychodrama Curve and its Phases
Play therapy helps to improve the development of the
Another pioneer in the psychodrama field is Carl Hollander.
interconnections between the neurons. Effect of trauma might
He got certification from Jacob L Moreno in psychodrama.
reside in the nonverbal brain areas such as hippocampus,
He created Hollander Psychodrama Curve, which is used to
thalamus, brain stem and amygdala. Play therapy in the form
understand the structure of psychodrama.
of role playing helps to move out the traumatic experiences
Warm-up is the phase of spontaneity and creativity to
from nonverbal brain areas.
open the act of psychodrama. Activity is the phase where
the enactment of psychodrama takes place. Integration is the
Advantages of Play Therapy
phase where discussion and closure of the session are brought
Play therapy reduces the level of stress, frustration, fear, together.
tension, aggression, confusion, anxiety, depression and thereby The classic psychodrama includes three phases such as
promotes the psychological well-being in children. It helps the (Fig. 5.17):
therapist to identify and analyze the problems in children. It 1. Warm-up: Activities done initially to ensure the trust of
helps the child to ventilate the negative feelings or thoughts group members and to promote group cohesion.
or bottled up emotions. It provokes the thinking and decision 2. Shaping and presentation: Engaging in the psychodrama
making capacity in children. It acts as an add-on therapy to scenario. Protagonist and the members of psychodrama
treat the children with mental disorders. actively participate in this phase.

NURSES RESPONSIBILITY
Nurse should select the type of play item and the type of play
as per the need and age of the children. She should assess the
underlying issue of the children in the honeymoon phase and
rebellious phase of play therapy. She has to work out these
issues with the help of play therapist. She should remember that
children with mental retardation should not be assigned the play
task beyond the intellectual level and it should not be conducted
in a competitive sense because it can provoke anxiety among
them. She should involve the parents in the play therapy which
will help in strengthening the mother-child bonding. Figure 5.17: Phases of psychodrama
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 147

3. Sharing and discussion: Group members have to discuss Psychological applications of Psychodrama
how this enactment is useful to them. Sharing will help Clinical Arena
to clear the doubts and also analyze the perception of the
group regarding the enactment. It will also enhance the • Conditions to decrease psychological trauma
social bonding. • Neurotic and stress related disorders particularly post-
traumatic stress disorders
Elements of Psychodrama • Patients with substance abuse/alcohol dependence
syndrome
Elements of psychodrama are given in Table 5.21. • Autism
Table 5.21: Elements of psychodrama • Eating disorders
• Adoption and attachment issues
Elements Description
Stage To enact or play drama. Nonclinical Arenas
Protagonist Person holding the main character in the • Education sector
drama.
• Business
Director Therapist who directs the actors. • Professional training areas
Producer person who narrates the story and uses the
appropriate psychodrama techniques such as Principles of Psychodrama
mirroring, doubling, role playing, soliloquy,
role reversal, future projection, magic shop • Action principle: It helps to understand oneself and is an
and empty chair. integrative part in social learning.
Auxiliary egos Participants in the psychodrama who simulate • Social atom principle: Each individual in the
the particular situations for protagonist. psychodrama is the central person for the social
Use of double Auxiliary Egos express the thoughts/feelings interaction network.
feedback which are difficult to express by the • Potentiality to grow: It helps the individual not to get
Protagonist stagnated with the past and to promote the chances of
growth potential toward the future.
Core Psychodrama Techniques • Spontaneity: It helps to respond the old situation by
Core psychodrama techniques have been summarized in ‘degree of novelty (new thing)’ and the new situation by,
Table 5.22. ‘degree of adequacy.’

Table 5.22: Core psychodrama techniques and description

Techniques Description
Mirroring Protagonist is asked to act out the experience. Patient will act in the scene and also watch another actor step into
his/her role and portray in the scene.
Doubling It is to bring the thoughts or feelings into conscious mind, which the patient is unable to express due to
guilt, shyness, fear, politeness, anger, inhibition, etc. (Doubling denotes, ‘one is making attempts to bring
the unexpressed or under expressed thoughts or feelings into conscious mind and other is to give a form to
unconscious mind).
Role playing Patient portrays and acts like a person who is problematic to oneself.
Soliloquy Client speaks his/her thoughts aloud to understand oneself.
Role reversal (or) Patient is asked to portray another person while the second actor portrays patient in a particular scene.
role training
Future projection Enactment was done by the members to work out regarding the future concerns.
Magic shop It is a warm-up technique in which the individual imagines to put oneself in the shop which has different
personality traits. Participants will express the qualities of different persons.
Empty chair It is actually taken from Gestalt therapy technique, in which an individual has to think about a person with
whom he would like to converse sitting on an empty chair and starts conversing. (Example: Mr Raj is the patient
who is conversing with his mother imagining that she is sitting on the empty chair. When Raj wants to perform his
mother’s role, then Raj has to sit on the empty chair and communicates/takes up the role of his mother). It helps to
promote mental ventilation or catharsis.
148 Textbook of Psychiatric Nursing for BSc Nursing Students

• Catharsis: Bursting out of the negative emotions during • Music therapy has been in use to build therapeutic
psychodrama will help toward the positive growth in life relationship to empower the physical, emotional,
pattern. cognitive, and social needs of an individual after the
• Surplus reality: Roles enacted in the psychodrama create assessment done by a professional music therapist. It also
the surplus chance of reality. promotes the avenues for communication to express the
• Tele principle: Have a constant interaction to strengthen thoughts or feelings into words and thereby it provides
the existing relationship between people and environment. the emotional support to the client and families.
 —American Music Therapy Association
Advantages or Benefits of Psychodrama • Music therapy is a variety of expressive art therapy which
helps to improve physical, psychological and social well-
• It improves the life skills and learning.
being with the help of listening music, playing musical
• It helps to express the feelings in a safe and supportive
instrument or by singing songs.
environment.
• It identifies the problem clearly; and also identifies the History of Music Therapy
misperceptions, distortions in the realistic perceptions
and unrealistic goals. During the time of World War, music groups played music
• It explores the client’s adaptive and maladaptive coping for hospitalized veterans. Doctors began to realize the healing
effects of music. Hence, professional musicians have been
response to the problem.
recruited by the hospitals.
• It helps to promote self-confidence and well-being.
In 1944, Michigan State University included the music
• It promotes healing by overcoming the loss and grief.
therapy in the curriculum. In 1950, first organization for
• It increases the communication and thereby improves the
music therapists was formed namely National Association for
relationships.
Music Therapy (NAMT). In 1998, American Music Therapy
• It promotes the new way of thinking and promotes the
Association (AMTA) was formed and merging of NAMT and
acceptable behavior.
AMTA took place. AMTA focuses on access to music therapy,
raising the awareness of services to promote the music therapy
NURSES RESPONSIBILITY in various sectors such as education, training, and research.

Nurse needs to supervise the psychodrama sessions and Famous Quotes on Music Therapy
coordinate with the patients. She has to clarify the doubts of
patient and motivate the client to perform the psychodrama using • Music expresses, which we can’t express in words.
the appropriate techniques. She has to organize or conduct the  —Victor Hugo
psychodrama sessions as per the hospital protocol. She has to keep • Where word fails, music speaks. —H C Anderson
in mind that psychodrama doesn’t work out for acute psychotic
patients. She should instruct the spectators not to communicate • Music washes away from the soul, dust of everyday life.
in between the psychodrama, whereas the doubts can be clarified  —Berthold Auerbach
in the discussion phase. She should have clarity about the various • Music expresses that which we can’t be said and on which
roles of the members involved in the psychodrama sessions. it is impossible to be silent. —Victor Hugo
Have a regular follow-up with the further sessions to elicit the
improvement in patients.
Mechanism of Music Therapy
• Stimulation of endorphins, peptides and natural opiates
MUSIC THERAPY secreted by hypothalamus produce pleasure.
• Synchronization of body rhythms with the musical
Definitions
rhythm takes place in music therapy. This rhythm guides
• Music therapy is defined as, ‘utilization of music in the body to have a slow and deep breathing and thereby it
treatment, training, education, rehabilitation of children gives calming effect as shown in Figure 5.18.
and adults who are suffering from physical or mental • Synchronization reduces the activity of sympathetic
disorder’. —Alvin, 1975 nervous system.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 149

Indications of Music Therapy

Psychiatric Disorders
• Depression
• Neurotic and stress related disorders (Anxiety)
• Dementia
• Autism
• Developmental disorders
• Insomnia
• Substance dependency
• Personality disorders
• Schizophrenia patients—to decrease aggression, delusions
and hallucinations
• Pregnant mothers in labor—to reduce stress level
• Grief and loss

Physical Disorders
Figure 5.18: Mechanism of music therapy
• Heart disease
• Stroke
Types of Music Therapy • Aphasia
Types of music therapy with their benefits have been given in • Pain management
Table 5.23. • Terminally ill patients
• Affective, cognitive and sensory disorders
Aims of Music Therapy • Patient with carcinoma
• It acts as a diversional technique in a stressful situation. • Hypertension
• It helps to relax the mind. • Neurological disorders/brain injuries
• It encourages patient in promoting the self-expression
through music. Effects of Music Therapy
• It obtains a specific behavioral change in an individual. • Physical effects: It relieves muscle tension and improves
• It reduces pain, stress and isolation. the motor skills.

Table 5.23: Types of music therapy and their benefits

Types Description Benefits

Receptive music therapy Listening the live or recorded music. Decreases/reduces
(or) passive music therapy (Example: It decreases stress among patients • Decreases anxiety
with post-traumatic stress disorder) • Reduces behavioral problems
• Decreases the pain
• Reduces the stress
Expressive (or) active Making the music by playing the instrument
Increases/promotes/improves
music therapy or by singing songs. (Example: It increases the
• Promotes relaxation
speech fluency in the children with attention
• Enhances mood
deficit hyperactive disorder)
• Enhances attention span
• Enhances coping skills
• Improves motor skills
• Increases social skills
• Expresses the emotions
• Improves communication
• Improves memory
• Enhances the physical and psychological well-being
• Enhances the self-esteem and self-concept
• Improves group cohesion
150 Textbook of Psychiatric Nursing for BSc Nursing Students

• Mental effects: It decreases the level of stress and So, to get success, music therapist has to ensure the musical
improves the psychological well-being by keeping the preferences and accordingly, the treatment has to be taken into
mind in relaxed state. consideration.
• Emotional effects: Music gives a chance to express the
emotions and feelings which cannot be expressed in DANCE THERAPY (OR) DANCE MOVEMENT
words. PSYCHOTHERAPY

Guidelines for the Effective Music Therapy Dance Movement therapy is an expressive art therapy in which
psychotherapeutic movements or dance are performed to
• Choose the slow rhythm of music in general. Fast music enhance the emotional, psychological, intellectual and motor
is advised for the purpose of stimulation and to enhance functions of the body.
the energy level.
• Have a good concentration in music. Definitions
• Listen to the sounds in the nature.
• Breathe along with the music. • Dance therapy is defined as, ‘psychotherapeutic use
• Hear the familiar songs. of movement as a process which promotes physical,
emotional and cognitive integration of the individual.
Aspects of Music Therapy  —American Dance Therapy Association (ADTA)
• Dance therapy is defined as, ‘therapeutic modality in
Merent (1997) explored the healing aspects of music therapy as which, the participants are motivated to express emotions,
a restoring agent as follows: reduce tensions, improve body image, enhance the body
• Anxiolytic music therapy: It reduces anxiety. awareness and improve the social interaction with the
• Algolytic music therapy: It reduces pain. help of rhythmic exercises and music.’ —Goldenson, 1984
• Tensiolytic music therapy: It decreases tension.
• Psycholytic music therapy: It secures the person from Historical Development
evil spirits.
• Patholytic music therapy: It aims to relieve grief or loss. In 1840–1930, new philosophy of dance has been formulated
in USA and Europe, i.e., dance is not merely an expressive art
Indian Music Therapy therapy, it also has an effect on movements. In 1916, Jung said
that dance or movement is an active imagination. In 1966,
Indian music is generally very unique due to thousands of raga Marian Chace formed American Dance Therapy Association
and tunes. These tunes are the combination of seven notes to support the emerging professionals in the field of dance
or Sapta Swaras that might derive the base on nine human therapy. Marian Chace is the Pioneer of Modern Dance
emotions (or) Navarasas. Stirring of human emotions might Therapy (Fig. 5.19).
increase the human self to experience the joy and bliss.
Areas where the music therapy sessions were conducted: Principles of Dance Therapy
• Counseling room
• Rehabilitation centers • Dance therapy is based on the body-mind interaction.
• De-addiction treatment centers • The conscious and unconscious movements of a person
• Physical therapy units reflects one’s personality.
• Massage therapy rooms
• Labor rooms
• Operation theater
• Patient waiting halls

Limitations of Music Therapy

Music therapy might give positive result by reducing the
symptoms and by producing the psychological well-being, but
it is not considered only treatment for the serious medical and
mental illness. Selection of the music is based on the individual
preference and everyone does not find all types of music to
be therapeutic. Some forms of music may lead to agitation. Figure 5.19: Marian Chace: Pioneer of modern dance therapy
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 151

• Dance or movement is a symbolic function of cues, facial expressions, body movements and emotional
understanding oneself. expressions during the dance in order to frame the
• The interaction of body, mind and spirit in the dance interventions.
therapy gives a sense of wholeness:
„ Body refers to the discharge of energy through the Techniques of Dance Therapy
musculoskeletal system as per the stimuli received • Body movements: It is the basic technique in which
from the brain. movements are in rhythmic pattern produced by the
„ Mind refers to attention, perception, reasoning, manipulation of body parts. This technique helps to
decision making, imagery and evaluation. increase body awareness and flexibility.
„ Spirit refers to the feeling or engaging or be empathetic • Props: Use of some inanimate objects or materials in
in nature. order to motivate the spectators. This technique is used as
• Dance therapy improves the social skills, relationship an aid to express the emotions of patients.
dynamics and the quality of life. • Imagery and movement: Patient imagines a certain
• Dance therapy creates the deeper sense of awareness situation and performs the dance accordingly. For
about oneself. example, while dancing, patient imagines oneself as a
• Dance therapy allows the creative expression of thoughts. lion in the forest and performs the dance movements
accordingly.
Stages of Dance Therapy • Space awareness: Patient is aware of the space around
Bonnie Meekums, a dance therapist, explained the four stages him/her and uses it appropriately during the dance
of dance therapy as follows (Fig. 5.20): performance.
1. Preparation: It is a warm-up stage, where the distractions • Memory movements: Sequence of movements stored
have to be omitted and the client is prepared for in the memory is executed. This will improve cognition/
movements with the eyes closed. memory/intelligence level.
2. Incubation: Therapist asks the participant to get into • Group coordination: Two or more participants learn to
subconscious mind and to produce the symbolic perform the movements in a synchronized manner. This
movements with the relaxed internal atmosphere. will improve the social skills and group cooperation.
3. Illumination: This process focuses on the integration with
the conscious awareness. Self-awareness was increased Settings for Dance Therapy
and the unconscious motives are resolved. • Hospitals/nursing homes
4. Evaluation: Discussion is based on the insight in therapy • Rehabilitation center
and process can be ended if the goal is achieved. • Psychiatric set ups
• Education sector
Dance Therapy vs Dance • Day care centers
Dance is considered movement or exercise performed
according to the music played. In dance therapy, the Benefits of Dance Therapy
participant will communicate the conscious and unconscious The benefits of dance therapy in different disease conditions
feelings through dance. Therapist will observe the nonverbal are given in Table 5.24.

Advantages of Dance Therapy

Dance therapy promotes the self-confidence and self-
esteem. It helps the patients to express their unconscious
motives through the movements. Dance therapy reduces the
stress, anxiety and depression. It is helpful for the patients
with negative symptoms of schizophrenia to improve the
social skills. It is indicated for the patient with Parkinson’s
disease to improve the gait and balance. It improves the
cognition. It helps to maintain the physical fitness. Overall, it
promotes the physical, mental, cognitive, emotional and social
Figure 5.20: Stages of dance therapy well-being.
152 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 5.24: Benefits of dance therapy in different disease conditions

Disease conditions Benefits of dance therapy

Visually impaired Enhances personal awareness, improves body image and motor skills.
Hearing impaired Decreases the feel of isolation and enhances relationship.
Learning disability Improves self-confidence and develop learning skills.
Mental retardation Improves social skills, body image, and motor skills/coordination.
Autism Enhances cognitive abilities and development of sensory-motor skills.
Physically handicapped Improves body appearance and motor skills.
Eating disorder Improves the distorted body image.
Parkinson’s disease Improves motor ability and balance.
Post-traumatic stress disorder Confronts the painful memories and reduces the level of stress.
Elders with dementia/depression Decreases the loneliness, isolation and improves social interaction.

RECREATIONAL THERAPY (OR) Benefits of Recreational Therapy

THERAPEUTIC RECREATION
• Helps to improve physical, mental and social health.
Definitions • Reduces the effects of disabilities
• Provides cost-effective treatment
• Recreational therapy is a systematic process which utilizes
• Enhances the independent functioning of physical, social,
the recreation and other activity-based interventions
cognitive and emotional domains
based on the needs of individuals with illness or disabling
• Helps to identify and use the community resources which
conditions which mean to improve the psychological/
promote the independent functioning
physical health, recovery and well-being.
—American Therapeutic Recreation Association (ATRA) • Improves the quality of life
• Recreational therapy uses education, treatment and • Promotes motor development, intellectual development
recreational services to help the people with disabilities and sensory development
recover or use their leisure in the ways which enhance • Aids to promote the psychological expression of thoughts/
their health, independence, functional abilities and ideas
quality of life. • Reduces the level of stress, anxiety and depression.
 —National Therapeutic Recreation Society (NTRS)
• Recreational therapy is defined as, ‘purposeful or Indications
deliberate use of intervention process aimed to help • Psychiatric and medical disorders
persons with disabilities or illness to improve the health, • Developmental disabilities
enhance their capacity to utilize recreation, use of leisure • Rehabilitation
time to improve the ongoing health and quality of life.’
• Childhood disorders
 —Shank and Coyle, 2002
• Substance abuse
History of Recreational Therapy • Geriatrics with cognitive deficits

In 2000 BC, Egyptians used songs, dances and games for Qualities of Recreational Therapist
recreation for Melancholic patients (patients with depression).
• Leadership skills
Florence Nightingale used the recreation therapy in the
hospital for soldiers. At the time of World War I, American • Listening skills
Red Cross used recreation therapy in hospitals. From 1920s, • Compassion
recreation therapy was started in the mental hospitals and • Patience
schools for mentally retarded children. Recreation is a form of • Resourcefulness
amusement, play and relaxation. • Speaking skills
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 153

Goals of Recreational Therapy Areas of Practice

General Goals • Psychiatric hospitals
• Administer the structured normal activities of daily living. • Day care centers
• Promote the measures to bridge gap between the hospital • Rehabilitation centers
and community. • Deaddiction centers
• Assist the patients to use the leisure time suitable to the • Community mental health centers
patient’s lifestyle. • Special schools

Goals Related to Psychological Health Classification of Recreational Therapy

• To help to augment other psychotherapies. Recreational therapy is classified based on the place of
• To improve the memory, attention and concentration. recreational activity performed and based on the benefits of
• To enhance the sense of responsibility by organizing and recreational activity (Flowchart 5.7).
leading the game well. • Based on the place of recreational activity performed, it
• To give a chance to express oneself. is further classified into indoor activities and outdoor
• To improve the self-esteem and self-confidence. activities.
• To develop the psychological well-being. „ Examples for indoor activities are crossword puzzle,
reading, debating, carom game, chess, role play,
Goals Related to Physical Health painting, clay modeling, drawing, badminton, board
• It improves muscle power and muscle strength. games, ludo, cooking, dancing, stamp collection, etc.
• It improves the circulation. „ Examples for outdoor activities are volleyball,
• It stabilizes respiration. hockey, football, badminton, cricket, gardening,
• It increases appetite. basketball, baseball, hide and seek, etc.
• It develops good posture. • Based on the benefits of recreational activity, it is
• It improves the overall physical endurance. classified into motor development, sensory development,

Flowchart 5.7: Classification of recreational therapy

154 Textbook of Psychiatric Nursing for BSc Nursing Students

intellectual development and promotion of psychological Table 5.25: Recreational activities for various psychiatric disorders
expression. Promoting gross motor development
Psychiatric disorders Recreational activities
are volleyball, hockey, football, shuttlecock, cricket,
gardening, basketball, baseball, dancing, etc. Schizophrenia Social activities that contact with reality.
For example, carom, chess, etc.
• Activities promoting fine motor development are carom
game, painting, clay modeling, drawing, embroidery Depression Noncompetitive outdoor activities to
outlet the anger For example, walking,
works, etc. jogging, etc.
• Activities promoting sensory development are looking
Mania Individual games on one to one basis are
at motion pictures, listening music, painting, art works, planned to drain out the excess energy,
drawing, etc. for example, volleyball, football, etc.
• Activities promoting intellectual development are Dementia Concrete activities have familiarization
chess, crossword puzzles, etc. and comfort. For example, craft works,
• Activities promoting psychological expression are embroidery works, etc.
painting, clay modeling, drawing, writing, dancing, etc. Anxiety disorders Activities help to divert the patient from
the anxiety provoking situations. For
Recreational therapy is also classified as: example, listening music, singing songs,
• Team games: For example, football etc.
• Creative play: For example, role play Childhood and Children: Playing, painting, story telling
• Curiosity play: For example, chess adolescent disorders Adolescent: Gross motor activities like
• Vicarious play: For example, visualizing the motion volleyball, football, cricket, etc.
pictures
• Social play: For example, games in party
• Aesthetic play: For example, drawing NURSES RESPONSIBILITY
• Acquisition play: For example, stamp collection
Nurse has to motivate the patients to participate in the recreational
• Imitative play: For example, performing a group dance activities which will help the patient to enhance self-esteem and
with similar steps self-confidence. She should be aware that recreational therapy
• Goal games: For example, hide and seek. empowers the patient to develop the existent skills, interests
and also to develop the new roles. She has to coordinate with
Recreational Therapy Process the recreational therapist to assess the patient’s expression of
interest and plan the activities accordingly. She has to create
Recreational therapy is a systematic process of assessment, an opportunity to the patient to enhance their social skills by
planning, implementation and evaluation (Flowchart 5.8). increasing the social interactions.
Assess the patient’s interests, skills and abilities. Plan the
activities according to the domain in which the improvement
LIGHT THERAPY (OR) PHOTOTHERAPY (OR)
is required (motor, sensory, intellectual, psychological
HELIOTHERAPY
expression). Implement the recreation activities into practice.
Evaluate to what extent the goal of recreational therapy has Light therapy is the use of light with the specified intensity for
been achieved (Table 5.25). therapeutic purpose.

Flowchart 5.8: Process of recreational therapy Historical Development

Ancient Egypt, Ancient Greece and Ancient Rome used the
various forms of light therapy. Early Germans, Assyrian and
Inca worshiped sun for the healthy living. In 1500 BC, sunlight
along with the natural herbs was used to treat nonpigmented
skin diseases.
Niels Finsen, a Faroese physician, is the father of modern
phototherapy. He is the one to discover the first artificial light
therapy. He first used the light with short wavelength to treat
lupus vulgaris, 400 nanometers generated reactive oxygen that
would kill the bacteria (Fig. 5.21).
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 155

NOTE
Light therapy used for skin conditions might emit ultraviolet rays
that should not be used for other conditions because it might
harm the eyesight.

Contraindications
• Tendency to develop mania (History of hypomania or
mania)
• Photosensitive skin conditions
• Marked agitation
• Insomnia
• Eyes vulnerable to get phototoxicity
Figure 5.21: Niels Ryberg Finsen: Father of modern light therapy • Use of photosensitizing herb (E.g., St. John’s wort)
• Patients with porphyria
Niels Finsen used the red light to treat the small pox • Patients taking methotrexate or chloroquine (because this
lesions. In late 19th century, light therapy was used in medical drug and light interaction might cause porphyria)
treatments for varicose ulcers and sick children in the UK.
Side Effects
Indications Common Side Effects
• Skin disorders • Headache
„ Atopic dermatitis • Nausea
„ Psoriasis • Jitteriness
„ Vitiligo • Eye irritation
„ Acne vulgaris • Poor vision
„ Skin cancer • Skin rashes
„ Cutaneous t-cell lymphoma • Skin irritation
„ Eczema • Agitation
„ Polymorphous light eruption • Irritability
„ Atopic dermatitis
„ Lichen planus Rare Side Effects
• Wound healing • Manic episode
• Neonatal jaundice • Increased suicidal thoughts
• Bulimia nervosa
• Premenstrual syndrome Mechanism of Action of Light Therapy
• Migraine headache The mechanism of action of light therapy can be easily
• Retinal conditions understood from Figure 5.22.
„ Diabetic macular edema The light waves pass through the retina of the eye and
„ Diabetic retinopathy activate the hypothalamus in the brain. Hypothalamus sends
• Mood- and sleep-related disorders the signals to pineal gland. This gland suppresses the Melatonin
„ Seasonal affective disorder immediately and stimulate the production of serotonin.
„ Nonseasonal depression Serotonin makes the individual to be active and energetic
„ Jetlag (Fig. 5.22).
„ Chronic circadian rhythm sleep disorders
„ Situational circadian rhythm sleep disorders
Key Elements of Light Therapy
„ Sleep disorder in Parkinson’s disease • Intensity: Light box intensity is recorded in lux. For
„ Sleep disorder in Alzheimer’s disease seasonal affective disorder, 10,000 lux light box at a
156 Textbook of Psychiatric Nursing for BSc Nursing Students

Figure 5.22: Mechanism of action of light therapy

distance of 16–24 inches (or) 41–61 centimeters from the RELAXATION THERAPY
face is recommended.
• Duration: Light box with 10,000 lux has to be administered Historical Development
for 20–30 minutes for daily sessions. Administration of Dr Edmund Jacobson published the book ‘Progressive
lower intensity light box with 2,500 lux requires 2 hours Relaxation’ for doctors/scientists and thereby the concept
duration in order to obtain treatment efficiency. of relaxation in psychology has been popularized. In 1934,
• Timing: Early in the morning after getting up from bed is Jacobson published the book called ‘You Must Relax’ for general
the best time to administer light therapy. public. In 1908, Jacobson started the research at Harvard
University and later proceeded to Cornell and University of
Process of Light Therapy Chicago. The research work was aimed to improve the human
Light box has a set of fluorescent bulbs in a box with diffusion well-being. In 1932, Wolfgang Luthe and Johannes Schultz
screen. Light box has to be kept on a table at a distance of developed the method of relaxation called autogenic training.
16–24 inches. Light should not be seen directly through the In 1975, Miriam Z Klipper and Herbert Benson published
eye. Patient is advised to perform regular activities inside the the book called ‘The Relaxation Response’, which explains the
room such as reading, writing, eating, talking over phone, etc. concept of integrating the meditation techniques into daily
The time and consistency have to be maintained regularly. activities.

Advantages of Light Therapy Definition

Light therapy is a cost-effective, noninvasive procedure with Relaxation therapy is a component of body-mind intervention
minimal side effects. Routine light therapy might have a quick in which the therapist helps the participants at the higher
response in some patients. extent of mind relaxation.

Disadvantages of Light Therapy Indications

Patient needs to visit the health care provider regularly and Psychiatric Disorders
commit to the time for light therapy specifically. • Generalized anxiety disorder
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 157

• Post-traumatic stress disorder Types of Relaxation Therapy

• Substance abuse/smoking cessation Autogenic Training
• Depression
• Sleep disorder In 1932, Wolfgang Luthe and Johannes Schultz (German
• Acute stress reaction due to (HIV)/(AIDS). Psychiatrist) developed the method of relaxation called
autogenic training. This is a relaxation therapy in which the
Medical Disorders series of self-statements about heaviness and warmth in
• Hypertension different parts of the body helps in relaxation.
• Asthma Preliminary Measures
• Migraine headache Patient has to be seated in a calm room. Patient has to remove
• Chronic pain the watch, belt or anything that could cause constriction.
• Side effects of chemotherapy Patient is advised to empty the bowel and bladder before the
• Fibromyalgia therapy. Patient is asked to put the cell phone in the silent
• Neurocardiogenic syndrome mode.
• Myocardial infarction
• Angina Steps
• Huntington’s disease 1. Ask the patient to take a few slow and even breaths.
• Osteoarthritis pain and rheumatoid arthritis 2. Ask the patient to feel that “I am completely calm”.
• Facial paralysis 3. Ask the patient to have attention on his/her arms and feel
• Menopausal symptoms that his/her arms are heavy. Ask the patient to do the same
• Premenstrual syndrome for six times.
• Irritable bowel syndrome 4. Ask the patient to have re-attention on his/her arms and
feel that his/her arms are warm. Ask the patient to do the
Benefits of Relaxation Therapy same for six times.
5. Ask the patient to have attention on his/her legs and feel
The benefits of relaxation therapy are given in Figure 5.23.
that his/her legs are heavy. Ask the patient to do the same
for six times.
6. Ask the patient to have re-attention on his/her legs and
feel that his/her legs are warm. Ask the patient to do the
same for six times.
7. Ask the patient to focus on his/her breathing and feel that
his/her breathing is calm and regular. Ask the patient to
do the same for six times.
8. Ask the patient to focus on his/her heartbeat and feel that
his/her heartbeat is calm and regular. Ask the patient to
do the same for six times.
9. Ask the patient to have attention on his/her abdomen and
feel that his/her abdomen are calm. Ask the patient to do
the same for six times.
10. Ask the patient to have attention on his/her forehead and
feel that his/her forehead is cool. Ask the patient to do the
same for six times.
11. Ask the patient to enjoy the feel of relaxation, heaviness
and warmth. Ask the patient to quietly say to oneself
that the arms are firm, breathe deeply and keep the eyes
Figure 5.23: Benefits of relaxation therapy open.
158 Textbook of Psychiatric Nursing for BSc Nursing Students

Jacobson Progressive Muscle Relaxation (JPMR) 13. Arch the back away and feel the tension for 5 seconds.
Definition Relax it and feel relaxation for 10 seconds.
14. Tense both thigh muscles and buttocks by contracting
This is a relaxation therapy in which the series of guided steps
together and feel the tension for 5 seconds. Release it,
about tension and relaxation of the different body parts helps
relax and feel relaxation for 10 seconds.
in relaxation.
15. Point the toes toward the head, create the tension in calf
Preliminary Measures muscles, feel tension for 5 seconds. Relax and feel the
Follow all the measures similar to that of autogenic training. relaxation for 10 seconds.
Advise the patient not to worry about the thoughts which 16. Point the toes away from the head, feel the tension for
might arise during the therapy sessions and don’t fight over 5 seconds. Relax and feel the relaxation for 10 seconds.
the thoughts because it keeps the individual stressed instead 17. Relax the complete body for 2 minutes.
of relaxation. 18. Keep the eyes closed and remain in the relaxed position.
19. Open the eyes and feel relaxed.
Steps
1. Clench right and left fist separately and feel the tension in GUIDED IMAGERY OR GUIDED AFFECTIVE IMAGERY
fist and forearm for 5 seconds. Release the fist and feel the (OR) KATATHYM—IMAGINATIVE PSYCHOTHERAPY
relaxation for 10 seconds.
2. Bend right and left arm separately at the elbow and tense Definition
the biceps for 5 seconds. Release the arms and feel the Guided therapy is defined as, ‘a form of relaxation therapy
relaxation for 10 seconds. in which the therapist helps the participants in relaxation by
3. Straighten the right and left arm separately and tense the evoking the mental images which stimulate or recreate the
triceps and feel tensing for 5 seconds. Relax and feel the sensory perception of sound, sights, taste, movement, smell
relaxation for 10 seconds. and touch.’
4. Wrinkle the forehead and try to make the eyebrows touch
the hairline which creates tension, feel the tension for Types
5 seconds. Release the eyebrows and feel relaxation for
10 seconds. Guided therapy is classified based on the ways of generating
5. Close your eyes and tense the muscles around the eyes mental imagery, based on the implementation of guided
for 5 seconds. Release it, relax and feel the relaxation for imagery and based on the numbers of persons involved in the
10 seconds. intervention (Flowchart 5.9).
6. Tense the jaw by biting the teeth, feel the tension of • Voluntary: It resembles the previous sensory perception
jaw muscles for 5 seconds. Release it, relax and feel the which has been recalled from the memory, for example,
relaxation for 10 seconds. patient went to the beach and enjoyed in the past and now
7. Press the tongue against roof of mouth with the lips closed has been put into the imagination presently.
and feel the tension for 5 seconds. Release it, relax and feel • Involuntary: Image which is generated from the present
the relaxation for 10 seconds. sensory stimulation and not from the past memory. For
8. Push the head back as far as possible, feel the tension for example, therapist shows the object and helps the patient
5 seconds. Bring head back to its position, relax and feel to create the mental image out of it.
relaxation for 10 seconds.
9. Bring the head down and press the chin down on to the Flowchart 5.9: Guided imagery types
chest for 5 seconds. Bring the head to its position, relax
and feel the relaxation for 10 seconds.
10. Tense shoulder by shrugging the shoulders up to your
ears, feel the tension for 5 seconds. Release it, relax and
feel relaxation for 10 seconds.
11. Take a deep breath completely, hold the breath for
few seconds and exhale. Relax and feel relaxation for
10 seconds.
12. Pull in the abdomen and tense the abdominal muscle
for 5 seconds. Release it, relax and feel relaxation for
10 seconds.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 159

YOGA

‘Yoga lets the people discover the sense of oneness with

yourself, the world and the nature.’ —Mr Narendra Modi

Meaning
The word Yoga came from the Sanskrit word ‘Yuj’ which means
union or connect or balance or join, i.e., joining of Jivatma
with Paramatma, joining of the individual consciousness with
Figure 5.24: Stages of guided imagery the consciousness of the universe.

• Direct method by the therapist: Steps are guided directly Historical Development
by the therapist. Yoga began from the ancient practice of 3000 BC Stone-
• Use of audio or video tapes or recordings: Steps have carved postures of yoga are seen in Indus Valley. Yoga sutras of
been guided with the help of audio or video recordings. Patanjali were created in 4th century Common Era. Yoga has
• Individual: Only the therapist and single participant are become popular in abroad across various cultures and avenues
involved in the guided imagery intervention. these days. Patanjali Maharishi is the founder of Modern Yoga
• Group: Therapist and the group of participants are (Fig. 5.25).
involved in the guided imagery intervention. This
group may be homogenous (with the similar psychiatric Logo of International Yoga Day
disorders) or heterogeneous group (with the different
Every year, June 21st is the International Yoga Day celebration.
psychiatric conditions).
In the logo (Fig. 5.26), the union of hands denotes the joining
of the individual consciousness with the consciousness in the
Stages of Guided Imagery
universe. Leaves symbolize earth element and nature. Base of
Stages of guided imagery are shown in Figure 5.24. the logo symbolizes water element and brightness symbolizes
• Image generation: Generating the mental imagery by the fire element. On a whole, this symbol denotes the harmony
sensory stimulation or from past memories or from the and peace.
fantasy.
• Image maintenance: Participant has to maintain the
image clearly in mind. Few participants feel difficult to
maintain the same and so it is difficult to proceed to the
transformation stage. Practice to sustain the attention
control that will help to maintain the image.
• Image inspection: The maintained image has
been inspected on the basis of interpretation and
transformation. Here, the participant directs the attention
across the image in the perception aspects, i.e., whether
the image is generated spontaneously or because of the
description given by the therapist during the session.
• Image transformation: Finally, with the help of the
guided steps from the therapist, the participant transforms
the mental image to provoke positive emotion and coping
ability.

MISCELLANEOUS
The other therapies which help in the relaxation are Pet therapy
(animal assisted therapy), Meditation, Yoga, Bio-feedback,
Physical exercises, Aquarium therapy, Occupational therapy,
Massage therapy, Tai chi technique, Prayer, etc. Figure 5.25: Patanjali Maharishi—Founder of Modern Yoga
160 Textbook of Psychiatric Nursing for BSc Nursing Students

4. Pranayama
Pranayama is the control of vital energy of the body through
the breath.

5. Pratyahara
Pratyahara denotes the willful control of senses such as
sound, sight, smell, touch and taste.

6. Dharana
Dharana is connecting the mind with particular object.

7. Dhyana
Dhyana is the meditation with the constant flow of thoughts
or ideas.
Figure 5.26: Logo of International Yoga Day
8. Samadhi
Astanga Yoga (or) Eight Limbs or Yoga (or) Samadhi is super-conscious state as the highest stage of yoga in
Eight Folds of Yoga which one will enjoy the external bliss.
Patanjali Maharishi has mentioned the 8 limbs of yoga in his
yoga sutras which are explained below:
Obstacles to Practice Yoga
1. Yama • Vyadhi: Illness
2. Niyama • Styana: Unpreparedness
3. Asanas • Samshaya: Doubt
4. Pranayama • Pramada: Indifference
5. Pratyahara • Alasya: Laziness
6. Dharana • Avirati: Entanglement of sense object
7. Dhyana • Bhranti Darshana: Illusion
8. Samadhi • Alabdha Bhumikatva: Lack of stability
• Anavasthitatva: Slackness in practice
1. Yama
It has five commandments of Social Discipline: Six Branches of Yoga
1. Ahimsa: Nonviolence
1. Hatha yoga: The word, ‘Hatha’ came from Sanskrit word,
2. Satya: Truth
in which the prefix ‘Ha’ denotes sun and ‘Tha’ suffix
3. Asteya: Nonstealing
denotes moon. Hatha yoga is the total mastery of the
4. Aparigraha: Non accumulation of wealth
mind and physical bodily functions.
5. Brahmacharya: Celibacy or Continence
2. Raja yoga: It denotes the eight limbs of yoga.
2. Niyama 3. Karma yoga: It denotes the path of unselfish activities.
Karma Yoga says, ‘Do your duty and don’t expect any
It has five commandments of Personal Discipline such as:
benefits out of it.’
1. Saucha: Cleanliness
4. Bhakti yoga: It denotes the path of devotion.
2. Santhosha: Contentment
5. Jnana yoga: It denotes the path of wisdom.
3. Tapas: Endurance to face joy or sorrow, regard or
6. Tantra yoga: It came from the Sanskrit word, which
disregard
4. Swadhyaya: Self-study means woven together or leading principle. Tantra’s
5. Ishwarapranidhana: Dedication to the god and work rituals encourage their followers to build up the Kundalini
without self-motives or not working for the praise. energy to the top of the chakras.

3. Asanas Kriyas
Body postures and poses by which all the impurities from the Kriya is defined as cleansing techniques used in yoga.
body are eliminated that keeps the body in good health. • Kapalabhati: Stimulating the brain cells.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 161

• Neti: Cleaning the nasal passages. exhaling activity and the backward bending is done with the
„ Jala Neti: Cleaning the nasal passages by pouring the inhaling activity (Fig. 5.27).
lukewarm water in one nostril and then the water 1. Take the hands above the head and bend backward
comes out through opposite nostril. (Inhale).
„ Sutra Neti: Cleaning the nasal passages with rubber 2. Bend the body toward front and forehead has to touch the
catheter. knees (Exhale).
„ Dugdha Neti: Milk and ghee is used to clean instead 3. Take left knee forward and right leg back, keep the left
of lukewarm water. foot and the palm in same line with the heads up (Inhale).
„ Vyutkrama Kapala Neti: Similar to Jala Neti, in this 4. Take left leg back and rest only in palm and toes (Exhale).
the water comes out of mouth instead of opposite 5. Bend at knee, abdomen at rest on the knee with the arms
nostril. extended in front (Inhale and Exhale).
„ Sitkarma Kapala Neti: Take water in the mouth and 6. Come forward. In this position, palms, chest, forehead,
the water has to come through nostril. knees and feet will be touching the ground and buttocks
• Dhouti: Cleaning the intestinal tract up to the stomach. raised up (Exhale).
• Nauli: Control of the abdominal rectus. 7. Raise the head and trunk and make spine in a concave
• Trataka: Fixing the mind by gazing the flame in the upward position with hands/feet in the ground (Inhale).
candle without blinking of eyes. 8. Push the head down and have a complete arch with heel
• Shankhaprakshalana kriya: Complete bowel wash. touching the ground and palms on floor (Exhale).
9. Same as the 5th step (Inhale and Exhale).
Surya Namaskar 10. Same as the 3rd step but here bring the right leg forward
Yoga consists of 12 steps which are performed at the time instead of left leg (Inhale).
of sunrise by facing the sun with the regulation of breath. 11. Same as the 2nd step (Exhale).
At every step of yoga, the forward bending is done with 12. Come to stand erect posture.

Figure 5.27: Surya namaskar

162 Textbook of Psychiatric Nursing for BSc Nursing Students

Asanas Yoga in Mental Health

Asanas are the various forms of postures performed and Yoga promotes both the physical and psychological endurance.
maintained for few seconds to minutes along with the There is an association between the physical health and
breathing pattern. Examples of asanas are below: mental health, termed psychosomatic concept. Yoga helps in
• Padmasana: Lotus posture enhancing the attention, concentration, memory and overall
• Dhanurasana: Bow posture psychological well-being. Asana gives physical flexibility
• Sarvangasana: Standing on shoulders so it promotes the mental flexibility. Yoga gives holistic
• Ardhakatichakrasana: Lateral arc posture development to an individual. Yoga cures, treats and prevents
• Padahastasana: Forward bend posture both the physical and psychological diseases. Thus, the branch
• Ardha chakrasana: Half wheel posture of yoga is termed Therapeutic yoga that is evolving nowadays.
• Trikonasana: Triangle posture Yoga can be practiced by any individual from children to old
• Parsvakonasana: Lateral angle posture age in order to promote the psychological well-being.
• Vajrasana: Ankle pose
• Sasankasana: Rabbit posture
• Chakrasana: Wheel posture NURSES RESPONSIBILITY
• Savasana: Corpse pose Nurse has to motivate the patient to practice the yoga regularly.
She has to coordinate with the yoga therapist to conduct the
Pranayama regular yoga therapy sessions. She has to teach the benefits of
yoga to the patient as well as to his/her family members. She has
Breathing practices in the yoga are termed pranayama. The to assess the patient’s needs of asana/kriya/pranayama and plan
types are explained below: the individual session if required. Nurse has to encourage the
• Sectional breathing (only particular section was involved patient to practice the yoga in home setup after the discharge.
in the inhale and exhale processes)
„ Abdominal or diaphragmatic breathing
„ Thoracic breathing or intercostal breathing
MEDITATION
„ Upper lobar breathing or clavicular breathing The word meditation came from the Latin word “meditatio”,
• Anuloma-viloma: Simple inhalation and exhalation
which indicates the type of physical or intellectual exercise that
pranayama
promotes healing.
• Chandranuloma-viloma: Both the inhalation and
exhalation through the left nostril (Chandra Nadi) Definition
• Suryanuloma–viloma: Both the inhalation and
exhalation through the right nostril (Surya Nadi) Meditation is defined as ‘an experience of relaxing the body,
• Surya bhedana: Inhalation through right nostril by mind and spirit.’ Meditation is defined as the process of
closing the left nostril and exhalation through the left encouraging and deepening of consciousness or awareness,
nostril by closing the right nostril. and also helps in the deeper understanding of self and
• Chandra bhedana: Inhalation through left nostril by others.
closing the right nostril and exhalation through the right
nostril by closing the left nostril. Benefits of Meditation
• Reduces the level of stress, anxiety and depression.
Bandhas and Mudras • Increases the levels of energy, creativity and spontaneity.
Bandhas and mudras are advanced techniques of hatha yoga. • Decreases blood pressure
The Yoga Mudras are simple rituals used in Hinduism and • Decreases the psychological pain
Buddhist traditions which explain some symbolic gesture. • Helpful in anger management
Bandhas are safety locks used in the process of holding • Helps to relax the mind
the breath. Mula Bandha is contraction of the perineum. • Improves the levels of awareness and concentration
Uddiyana bandha is contraction of the abdomen into the rib • Improves the cognition and thinking ability
cage. Jalandhara Bandha means tucking the chin close to the • Develops the sense of self and spirituality
chest. Maha Bandha is the combination all three of the above • Helps to promote better relationship with others
bandhas. • Promotes the satisfaction with the life and work done.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 163

Tools Helpful to Practice Meditation • Mantra meditation: Meditation is performed with the
help of mantras such as om, ham, yam, rama, etc.
• Quiet place or sound proof room.
• Transcendental meditation: It is the technique developed
• Images or symbols
by Maharishi Mahesh Yogi. It is a silent mantra meditation
• Music or audio recordings
• Diary to record about the event of meditation performed for 20 minutes.
• Candle with light • Nada yoga (or) sound meditation: Meditation is
• Straight backed chair or mat. performed with the concentration of sound.
• Third eye meditation: Meditation is performed with the
Preliminary Measures before Meditation concentration of third eye, i.e., forehead, a place between
the eyebrows.
The individual has to be seated in the calm room. The
• Taoist emptiness meditation: Meditation evolved from
constrictive things such as rings, watch, belt, etc. has to be
the Chinese traditional concept in which the negative
removed. Avoid any distractions such as cellphone sounds, etc.
thoughts, feelings and sensations are to let go out of the
Ask the individual to empty the bowel and bladder. Individual
body.
is instructed not to fight with the arising thoughts during the
• Meditation with self-inquiry: Meditation evolved from
meditation and also instruct to ignore the thoughts.
the Sanskrit concept ‘atma viricha,’ i.e., investigation is
Types of Meditation done by exploring the self and answering the questions,
‘Who am I?’ ‘Why am I getting this thought?’ ‘Why am
• Mindfulness meditation (or) breathing meditation: I feeling like this?’
Meditation is performed by focusing on the breathing • Kundalini meditation: A concept of meditation in which
(Inhale and Exhale). The breathing has to be slow and deep. the energy that has been bundled up in the base of spine
• Metta meditation (or) loving-kindness meditation: will get into the crown by practicing deeper concentration
The concept of Meditation from Theravada Buddhism.
of breathing.
Meditation is performed by directing the love and
kindness toward the self or other friend or universe.
• Chakra meditation: Meditation is performed by focusing NURSES RESPONSIBILITY
on the various chakras in the body. Chakras are the
Nurse has to instruct the preliminary measures before the
wheels of energy which bundle the nerve roots and organs commencement of meditation. She has to select the type of
(Fig. 5.28). meditation according to the ability and need of the patient.
• Object meditation (or) gazing meditation: Meditation She has to instruct the patient to do the meditation regularly
is done by concentrating on an object or symbol. in order to get the fruitful outcome and also instruct that, only
regular practice will ensure the psychological well-being. She has
to teach the benefits of meditation to the patient as well as to
his/her family members. Involve the family members to perform
the meditation along with the patient which will be helpful for the
entire family to practice in their home after the discharge.

BIOFEEDBACK

Historical Development
Biofeedback is the concept known thousands of years ago.
In 1865, scientific evidences for these concepts arose with the
research conducted by Claude Bernard, who was the first to
introduce the concept of homeostasis. In 1885, J R Tarchanoff
demonstrated that voluntary control of heart rate is possible.
In 1969, Biofeedback Research Society was formed by Barbara
Brown and now it is known today as the Association for
Applied Psychophysiology and Biofeedback. Presently, many
Figure 5.28: Chakra meditation research activities on Biofeedback is on process.
164 Textbook of Psychiatric Nursing for BSc Nursing Students

Definition • Breathing: Bands attached in the chest and abdomen

help to monitor the respiratory rate. This type is used in
Biofeedback is defined as, ‘psychophysiological therapy in
patients with asthma and Chronic Obstructive Pulmonary
which the individual is able to monitor the physiological
Disease (COPD).
changes in the body which happened due to the psychological
• Heart rate: Sensors attached in the chest with
stressors.’
electrocardiogram (ECG) help to monitor the
heart rate. This helps to assess irregular heartbeats
Purposes
(Fig. 5.29).
• To improve the self-regulation and self-monitoring skills • Sweat gland activity (or) galvanic skin response:
to enhance the well-being. Sensors attached in the fingers of the palm with the
• To be aware about one’s own physiological responses due electrodermogram (EDG) help to monitor the sweat
to stress. gland activity. It is used to assess the level of anxiety and
• To control the bodily functions or control over the health. increased sweat due to any physiological changes.
• To improve the benefits of medications and to avoid the • Temperature: Sensors attached in the fingers of the hand
medications. help to monitor the blood flow to the skin and thereby
surface body temperature can be assessed. This type is
Indications used in patients with headache and Raynaud’s disease.
Psychiatric Disorders • Muscle contraction: Sensors attached in the skeletal
muscles with the electromyograph (EMG) help to monitor
• Generalized anxiety disorder
the muscle contraction. This type is used in patients with
• Post-traumatic stress disorder
anxiety disorders, headache, back pain, incontinence and
• Substance abuse
muscle retraining after the injury.
• Depression
• Sleep disorder Flowchart 5.10: Types of biofeedback
• Eating disorder
• Attention deficit hyperactive disorder
• Bruxism

Medical Disorders
• Hypertension
• Asthma
• Migraine headache
• Chronic pain
• Side effects of chemotherapy
• Fecal incontinence
• Urinary incontinence
• Fibromyalgia
• Stroke
• Raynaud’s disease
• Irritable bowel syndrome
• Constipation
• Temporomandibular joint disorder

Types of Biofeedback Based on the Monitoring

of Physiological Functions
Types of biofeedback are given in Flowchart 5.10.
• Brain waves: Sensors attached in the scalp with
electroencephalogram (EEG) help to monitor the brain
waves. This type is used in patients with seizure and
attention deficit hyperactive disorder. Figure 5.29: Monitoring heart rate
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 165

Types of Biofeedback Based on the Devices

Used
Interactive computer programs or mobile devices or wearable
devices—Band is worn on the wrist, if the individual is tensed,
then the application in the mobile phone will send the alert
message stating the prolonged tension by tracking out the
heart rate, breathing pattern, etc.
Figure 5.30: Phases of biofeedback therapy
Phases of Biofeedback Therapy
Phases of biofeedback therapy is illustrated in Figure 5.30. ALTERNATIVE AND
• Initial evaluation: The patient’s psychophysiological COMPLEMENTARY MEDICINE
profile in response to the moderate stressor is
evaluated. HISTORY
• Skills training: Training is provided to learn the readings National Center for Complementary and Alternative Medicine
of biofeedback machine which will ensure the greater (NCCAM) at National Institute of Health was formed in
control. 1992 to value the alternative and complementary treatment
• Therapy: Biofeedback assisted psychotherapy is the methods.
focus in which the emotional change in respect to the
sympathetic nervous system is taught. Here, the individual DEFINITION
puts oneself into the relaxed state and asks oneself to
watch the readings in the biofeedback machine. So, the Alternative and complementary medicine is defined as, ‘a
individual will realize and keep oneself relaxed with the group of diverse medical/health care systems, practices and
help of biofeedback machine. products that are not presently considered to be a part of
conventional medicine.’
Course of Treatment —National Center for Complementary and
Alternative Medicine (NCCAM), 2002
There are 8–15 sessions and might extend up to 40 or
The terms complementary medicine, alternative medicine and
50 sessions biweekly or monthly or on weekly intervals. integrative medicine are used interchangeably but the exact
difference and meaning are as follows:
Limitations of the Biofeedback • Complementary medicine: It is a nonmainstream
Using the Biofeedback is difficult for the individuals who practice used along with conventional medicine.
have cognitive impairment. Some might feel apprehensive • Alternative medicine: It is a nonmainstream practice
regarding the usage of electrodes and may be unfamiliar used instead of conventional medicine.
with the use of mechanical devices. Poor contact between • Integrative medicine: Uses both the nonmainstream and
the sensor/electrodes and skin might show the false readings. conventional medicine appropriately and depends on the
Patients who would need to claim insurance for the treatment patient’s need and also focuses on holistic health of an
process might not get coverage of expenses. individual.

PRINCIPLES OF ALTERNATIVE AND

NURSES RESPONSIBILITY COMPLEMENTARY MEDICINE
Nurse has to assess the need of biofeedback therapy. She has Eliopoulos (1999) explored the five basic principles of
to coordinate with the psychotherapist if the patient requires alternative and complementary medicine:
biofeedback. She has to teach the patient in regard with the usage
1. Body has ability to clean itself.
of biofeedback machine and the way to monitor the readings. She
has to follow-up the patient and plan the further therapy sessions 2. Healing practices are individual centric.
that depend on the patient’s needs. She has to monitor the level 3. Health and healing are related to harmony of body and
of patient’s progress after few sessions. She has to encourage the spirit.
patient to follow this in the home setup, after the discharge from 4. Good health practices develop the good healing process.
the hospital.
5. People are responsible for their own healing.
166 Textbook of Psychiatric Nursing for BSc Nursing Students

MAJOR DOMAINS OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Major domains of alternative and complementary medicine have been illustrated in Flowchart 5.11.
Flowchart 5.11: Domains of alternative and complementary medicine

Alternative Medicine System Ayurveda

Acupuncture The word, ‘Ayurveda’ is a Sanskrit word which means, ‘science
Acupuncture is an ancient traditional Chinese medicine that of life and longevity.’ Ayurvedic medicine has a belief that life
works on the principle of stimulating the points in the body force is called prana which moves through chakras. Chakras
in order to correct the imbalance in energy flow (Qi) through are considered centers of energy in the body. Seven major
the channels known as meridians. Interaction of five elements chakras are present from the head to torso.
such as wood, fire, earth, metal and water have profound
Ayurveda recommends the three types of treatment for the
effects on internal organs either yin or yang.
mental disorders such as:
Five elements represent five emotions such as: 1. Daiva Vyapashraya Chikitsa: Divine or spiritual therapy
1. Fire: Happiness (measures like mantras, wearing gems, oblations, vows,
2. Water: Fear prostrations, pilgrimage, etc.)
3. Wood: Anger
2. Yuktivyapashraya Chikitsa: (Logical Therapy): It
4. Earth: Worry
5. Metal: Grief denotes usage of ahara (diet) and oushadha (drugs).
„ Ayurvedic diet recommended for psychiatric
In the treatment process, acupuncture needles are inserted
disorders are milk, ghee, grapes, jack fruit, buffalo
in acupoints in the skin and left for 20 minutes on average.
meat, cuckoo meat, wood apple, etc.
The benefits of acupuncture include the following:
„ Ayurvedic medicines for psychiatric disorders are
• It improves the microcirculation
• It relaxes the muscle brahmi ghrita, panchagavya ghrita, kalyanaka ghrita,
• It activates B and T lymphocytes ashwagandharishta, brahmyadiyoga, brahmi, tagara,
• It releases encephalin, endorphin, serotonin and bala, etc.
adrenocorticotropic hormone „ Treatment process includes nasal instillation, enema,
• It improves the complete blood count purgation, streaming of medicated oil or milk in
forehead, application of medicated wet cake in
Acupuncture helps to reduce the mild level of anxiety by
relaxing the muscle. Acupuncture helps to reduce mild level of head, etc.
depression by increasing the serotonin. Modern acupuncture 3. Satvavajaya Chikitsa: Psychotherapy—this is best
treatment is also useful in treating alcoholism/smoking achieved by gaining knowledge, memory, courage,
addiction and eating disorders. analytical thinking and concentration.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 167

Naturopathy problems such as bed-wetting, insomnia, over-eating and

In 1985, the term, ‘Naturopathy’ was coined by Dr John Scheel smoking.
and in 20th century, it was formalized by Benedict Lust.
Art Therapy
Naturopathy is the way of life in which body innately knows
to maintain the health and heal oneself. Promotion of health is • Art therapy is defined as ‘a form of psychotherapy which
done by high fiber and low red meat diet pattern. Hope, faith uses the art media as a primary mode of expression and
and beliefs are vital in treatment. Hospitalization and usage of communication.’—British Association of Art Therapists
drugs are rarely done. • Art therapy promotes the healing process and mental
well-being through the expression and psychotherapeutic
Homeopathy relationship between the therapist and patient. Art therapy
In 18th century, homeopathy treatment was founded by is useful for chronic depression, bipolar disorders, anxiety
Dr Samuel Hahnemann. The term homeopathy came from disorders, dementia, autism, schizophrenia, eating
Greek word ‘homios’ means ‘like’ and pathos means ‘suffering.’ disorders, etc.
Hence, Homeopathy means to ‘treat like with like.’ It means
Sound Therapy or Vibrational Medicine
substance which causes symptoms of disease in healthy
individual may, in minute doses, also used to cure the Ancient technique in which the sounds of objects such as bell
similar symptoms resulting from the disease. It augments the rings, tuning forks, gongs, chants and drum beats have been
individual’s own immune system. used to promote vibration in the body and thereby promote
The commonly used homeopathic remedies for anxiety the healing process. Vibrations of the human voices are also
disorder are Aconitum napellus, Cantharis vesicatoria, done.
Gelsemium sempervirens, Ignatia amara, Lycopodium and Psychotherapy, Music therapy, Dance therapy, Yoga,
Spongia tosta. Meditation, Biofeedback and Relaxation: Discussed earlier
The commonly used homeopathic remedies for depression in this chapter.
are Ignatia amara, China officinalis and Bryonia alba.
Biological Based Therapies
Mind-Body Interactions Aromatherapy
This domain focuses on the capacity of mind which affects the In 1937, the term ‘Aromatherapy’ was first coined by Rene-
bodily functions (psychosomatic functions). Maurice Gattefosse (french chemist). It is the use of plant oil
for the therapeutic purposes such as antimicrobial, analgesics
Spiritual Healing and Prayer and psychological effects.
In 19th century, religion and spirituality have been separated The mode of application of aromatherapy are as follows:
from healing profession. But, later the positive aspects of • Direct inhalation: Used for respiratory infections,
spirituality in health care were accepted. Patients were asked to decongestant and for psychological effects.
use their own songs, poems and inspirational stories with the • Aerial diffusion: Fragrance the environment.
below segments such as: • Topical application: Used for therapeutic skin care,
• Counting the blessings and saying thanks to the God. massage and baths.
• Requesting the love and protection. Aromatherapy helps to decrease the level of stress and
• Requesting to forgive the self and others for the committed anxiety. It is also helpful for cognitive disorders, insomnia,
mistakes. musculoskeletal disorders and gastrointestinal disorders.
• Requesting the needs for self and others. In psychotherapy, olfactory stimulation is used to elicit the
emotions and memories.
Hypnosis Examples of some aromatherapy oils are rose absolute,
Hypnosis is a trance like state in which the patient has been put sweet almond oil, eucalyptus oil, grapefruit oil, rosewater,
in a heightened focus and concentration. It is useful to reduce chamomile infusion, etc.
the pain due to cancer, burns, irritable bowel syndrome, • Ylang-ylang, clary sage and chamomile reduces insomnia
childbirth, temporomandibular joint problems, fibromyalgia, • Geranium and helichrysum, lavender and rosemary
dental procedures and headache. It is also useful for the reduce the depression.
mental disorders such as phobia, anxiety, post-traumatic stress • Bergamot, neroli, jasmine, and orange oil help to reduce
disorder. Hypnosis is also useful to treat some behavioral anger.
168 Textbook of Psychiatric Nursing for BSc Nursing Students

• Bergamot, grapefruit oils and clary sage reduce fear. The herbs used in therapy have been summarized in Table
• Clary sage, bergamot and patchouli reduce anxiety. 5.26. The benefits and actions have been discussed along with
• Peppermint and cypress improve memory and precautions.
concentration.
Special Diet Therapy
Safety Alert N-Acetyl Cysteine (NAC), an amino acid, is useful to treat
Some essential oils might be affected with the herbicides. individuals with depression, schizophrenia and bipolar
Eucalyptus is a commonly used oil which is highly toxic when disorders. Diet rich in Omega 3 fatty acids like small fish
taken internally. Intake of sage, thuja, cedar oils and hyssop reduces the level of depression. Foods such as walnuts, bananas,
might cause hepatic damage and seizures. Some oils may have pineapples, nut butters and avocados increase the dopamine
interactions with conventional medicine. For example, topical and serotonin. So, these foods create happy mood. Foods
usage of methyl salicylate-heavy oils such as wintergreen and rich in probiotics such as yogurt, kimchi, pickles, sauerkraut,
sweet birch might cause hemorrhage in individuals taking the tempeh, kefler, etc. reduce the social anxiety. Foods rich in
Tab warfarin (anticoagulant). vitamin B12 such as beef, chicken liver, sardines, salmon, trout,
tuna, turkey and lamb increase the neurotransmitter signals.
Herbal Therapy Eating too much of simple sugars or carbohydrates might
Treating the diseases with the use of herbs is herbal therapy. reduce the level of serotonin and thereby it causes depression,
The commonly used herbs to treat the psychiatric disorders are anxiety and insomnia. Eating the complex carbohydrates such
St. John’s wort, Rosemary, Kava Kava, Ginkgo biloba, Valerian, as vegetables, peas, whole grains and beans will increase the
SAMe (S-adenosylmethionine), Passion flower, Guarana and level of serotonin and thereby cause mood elevation. Intake of
5-Hydroxytryptophan (5-HTP). tryptophan (precursor of serotonin) containing foods such as

Table 5.26: Herbal therapy: Benefits, actions and precautions

Herbs Benefits Action and precautions

St. John’s wort Treats mild to moderate depression, Hypericin in the leaves and flower is an active ingredient. Don’t
anxiety, chronic fatigue, immune use the St. John’s wort with antiretroviral drugs, psychotropics
dysfunction syndrome and anorexia such as SSRI, MAOIs, tricyclic antidepressants, etc. in order to
prevent the herb-drug interactions
Rosemary Enhances memory and treat dementia. Acetylcholinesterase Inhibitors
It is an antioxidant, sedative, stabilizes
nerve impulse and reduces headache
Kava Kava Decreases the depression, stress and It has soothing effect on amygdala of brain. It should not be used
insomnia with sedatives, tranquilizers and alcohol. Long term usage might
lead to dry and scaly skin
Ginkgo biloba Decreases short term memory loss It is an antioxidant. Caution to use with blood thinning agents
in elders and increases peripheral (aspirin).
circulation
Valerian Decreases anxiety and insomnia It has sedative and antianxiety effect. It should not be taken with
other sedatives, tranquilizers and alcohol due to drug interactions.
SAMe Treats mild to moderate depression, Regulates the action of serotonin and dopamine. It should
(S-adenosylmethionine) fibromyalgia and arthritis not to be used for bipolar disorder. Folic acid and vitamin B12
supplements along with this herb is beneficial
Passion flower Treats insomnia, nervousness, agitation Central nervous system (CNS) depressant
and restlessness. It causes mild
hypnosis.
Guarana Enhances memory and reduces fatigue CNS stimulant
5-Hydroxytryptophan It is used to treat depression, insomnia 5-HTP is amino acid considered precursor of serotonin. This can be
(5-HTP) taken from and bipolar disorders. given along with drug lithium for patients with bipolar disorder.
Griffonia simplicifolia
seed
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 169

cottage cheese, tuna, turkey, cashews, salmon (wild), halibut, Reiki

oatmeal flakes, shrimp, pork, wheat germ, avocado, eggs, Reiki is an ancient, Buddhist healing method rediscovered
spinach, collards, raisins, chicken, yogurt and sweet potato by Japanese and developed by Tibetans. The term, Reiki is a
increase the level of serotonin. Japanese word which means, ‘Universal life force’. The purpose
of Reiki is direct access to universal, transcendental, radiant
Manipulative and Body-Based Methods and light energies at various levels on energy spectrum. Four
Exercise upper chakras are accessed to get energy for harmony, strength
Physical exercises increase the endorphins and encephalins in and balance in order to promote healing process. Reiki helps to
the brain. They help to reduce the level of stress, anxiety and reduce the stress, recover from illness or injury and decreases
depression. the pain.

Massage Therapy Reflexology

Body tissues, superficial and deeper layer of muscle/connective Dr William Fitzgerald is pioneer of modern reflexology.
tissue are manipulated to enhance the wellness in massage Reflexology is also called ‘Zone therapy.’ It consists of
therapy. It helps to reduce the pain, stress, depression, blood massaging the specific areas of hands or feet in order to reduce
pressure and fatigue. It promotes relaxation, healing process, stress, pain and illness in the corresponding related area in the
body. It creates the physiologic changes and thereby promotes
well-being and immunity.
the overall wellness.
Tai-chi
The term, ‘Tai-chi’ denotes ‘moving meditation’ which consists NURSING RESPONSIBILITY
of series of continuous slow movements along with the
Nurse should understand the importance of Complementary and
mind and breath coordination. Performing this Tai-chi Alternative medicines in the field of psychiatry. She has to assess
helps the patients to connect the universal (above) energy the needs of the patient and should plan the complementary
and the earth (below) energy, thereby it balances the energies therapy which is best suited for the particular patient. She has to
inside the body in an equilibrium state. Tai-chi helps to coordinate with complementary therapy physicians to plan and
execute the therapy successfully. She has to follow-up the patient
enhance the self-awareness, reduces the stress, improves sleep,
regularly and also motivate the patient to practice these therapies
enhances socialization, decreases pain and thereby increases in home settings too after the hospital discharge. She has to teach
the overall quality of life. the patient to report the adverse effects at the earliest stage itself
in order to prevent the complications.
Energy Therapies

Bioelectromagnetic Therapy OCCUPATIONAL THERAPY

Bioelectromagnetic therapy is the usage of electromagnetic
DEFINITIONS
fields (usage of magnets and electric currents) in the body for a
therapeutic purpose. Example: Usage of electromagnetic fields • Occupational therapy is defined as, ‘application of goal-
to enhance the healing effects of non-uniting bone fracture. oriented and purposeful activity for the assessment and
Bioelectromagnetic therapy has two methods: treatment of patients with physical, psychological and
1. Static method: Placing of magnets in shoe inserts, belts developmental disabilities.
and mattresses for 2 hours, extending up to 24 hours. • Occupational therapy is defined as, ‘therapeutic use of
2. Pulse method: Machine is used to direct the alternating work, play activities, self-care to enhance the development
electromagnetic fields. and to prevent disability. It might also include the task
adaptation to obtain the maximum level of independence
Therapeutic Touch and Healing Touch and to improve the quality of life.’
Therapist will direct the energy flow consciously and  —American Occupational Therapy Association
intentionally through the hands of the therapist to the patient • Occupational therapy is defined as, ‘a goal-directed use of
in order to promote the healing process. This will reduce stress, time, interest, energy, attention to get adaptation as well
depression, anxiety, pain, grief. This improves relaxation, as productivity; to decrease the pathology and to enhance
wound healing, psychological wellness, etc. the health status.’ —Kaplan and Sadock
170 Textbook of Psychiatric Nursing for BSc Nursing Students

AIMS OF OCCUPATIONAL THERAPY INDICATIONS

The overall aim is to enhance the level of functioning and • Schizophrenia—paranoid and catatonic
gain independence. It helps in promoting the recovery of the • Substance abuse
patients very soon. It reduces the hospital stay. It increases the • Mood disorders—mania and depression
good habits by involving in the work during leisure time. It • Anxiety disorders
helps the client to gain self-confidence and improve the self- • Dementia
esteem. It acts as diversional technique to come out of stress • Antisocial personality disorders
or depression. • Childhood psychiatric disorders
• Indication for occupational therapy activities are given in
PRINCIPLES OF OCCUPATIONAL THERAPY Table 5.27.

• Activities have to be selected for the patients based on SETTINGS OF OCCUPATIONAL THERAPY
their interest, intelligence, strength and abilities.
• Positive reinforcement for the achievement of small task • Psychiatric hospitals
is so vital. • Nursing home
• Select the task which gives a new experience to the patient • Special schools
and also it would be useful to perform daily activities. • Rehabilitation centers
• Selection of activities for the shorter duration might • Sheltered workshops
provoke the sense of accomplishment and promote the • Half-way homes (or) day care centers
self-confidence in patients. • Group homes
• Utilization of available resources is important to plan and • De-addiction centers
• Community mental health centers
perform the activities.
• Industrial health centers
BASIC ELEMENTS OF PSYCHIATRIC
OCCUPATIONAL THERAPY OCCUPATIONAL THERAPY ACTIVITIES

• Patient: Individual who is seeking help. Task Activities (or) Activities Enhancing Skills
• Therapist: Individual who is rendering or providing help. • Crafts
• Purposeful activity: Occupational therapy activities. • Wood works
• Context: Place where the helping process takes place. • Book binding

Table 5.27: Occupational therapy activities for the specific psychiatric disorders

Disease condition Description of occupational therapy activities Example

Manic disorders Activities are planned to get rid of excess energy and promote Games: Football/Volleyball
emotional expression
Depressive disorders Simple tasks which are achievable Craft works
Paranoid Tasks which are noncompetitive and meaningful which require Crossword puzzles
schizophrenia concentration
Catatonic Simple concrete tasks that involve the clients actively Molding clay
schizophrenia
Anti-social Activities which are expressive and creative, one that promotes Painting or art works
personality disorder self-esteem
Dementia Group tasks that promote the sense of belongingness Cover making and packing things as a group
task
Childhood Activities can be allotted according to the ability of the children Drawing, painting, storytelling, playing, etc.
psychiatric disorders and also as per the interest of the children. The child with For mental retardation children: Candle
Mental retardation are not provided with the competitive making, cover making, etc.
nature of tasks because they can provoke anxiety among them.
Anxiety disorders Simple tasks which have only few steps to perform Washing clothes
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 171

• Chalk making SERVICES GIVEN IN OCCUPATIONAL THERAPY

• Painting
• Mat weaving • Independent living skills (or) self-care: Patients with
• Tailoring the psychiatric disorders might have poor personal
• Operating computer hygiene and self-care. Establishing the good habits
• Gardening (or) horticulture such as personal hygiene, grooming, etc. has to be
• Industrial works done. Psychoeducation is also helpful to develop the
• Candle making independent living skills.
• Leather works • Creative or expressive modalities: Treatment based
• Sewing activities such as craft making, art therapy, drawing, and
• Ceramic works painting might help the patient to express the unconscious
• Clay work motives and also improve the fine motor skills.
• Plastic molding • Sensorimotor including sensory-integrative and
• Printing neuromuscular treatment: Activities such as horticulture,
• Baking cakes domestic skills, industrial works, leather works, etc. will
• Bamboo making improve the sensory and motor function together.
• Domestic skills • Miscellaneous: Therapeutic exercise to improve the
• Basket making functional ability, design and fabrication of orthotic
• Carpentry devices, adaptation to the physical environment, planning
• Collage for discharge and re-entry to community, counseling
and education, pre-vocational training, adjustment with
Activities Enhancing Fine Motor Skills employment/home setting, etc.
• Drawing
• Embroidery OCCUPATIONAL THERAPY PROCESS
• Typing
Occupational therapy process has been illustrated in
Activities Enhancing the Cognition/Memory Figure 5.31.

• Poetry Selecting a Model

• Newspaper reading
• Discussion Occupational therapy is a continuous process, in which
• Puzzles solving choosing a right model will help to obtain the good outcome.

Activities Involving the Communication/Sharing

(or) Social Skills
• Drama
• Social skills training
• Assertiveness training
• Activities of daily living
• Recreational activities

CLASSIFICATION OF OCCUPATIONAL THERAPY

• Diversional: Activities are planned as diversional

techniques aimed to reduce the level of stress and to
promote relaxation. For example, recreational activities,
drama, poetry, etc.
• Remedial: Activities are planned to get a remedy or
solution to a problem. For example, embroidery and
drawing are activities planned to improve fine motor
skills in patients. Figure 5.31: Process of occupational therapy
172 Textbook of Psychiatric Nursing for BSc Nursing Students

There are many factors which influence the selection of model • Develops the positive attitude in patient.
and we can also use more than a single model in a single • Improves the decision making ability in the client.
setting. The commonly used models are listed below: • Reduces the level of stress, anxiety and depression.
• Adaptive performance model: Focus on the activation of • Improves the social skills and learning capacity.
ego-adaptive skills.
• Neurobehavioral model: Focus on sensory motor
NURSES RESPONSIBILITY
integration, cognitive orientation, social skills and body
integration with the environment. Nurse has to be aware of the specific activities assigned to the
• Occupational behavioral model: Focus on personality patient. She has to coordinate with the occupational therapy
development, problem solving, motivation, achievement department in regard with the treatment process and follow-up.
Nurse has to motivate the patient to complete the task successfully.
and social role play. She has to assign the activities as per the interests and needs of
the patient by coordinating with occupational therapist. She has
Assessment to help the client in performing the occupational therapy activities
if required. She has to monitor the prognosis of the patient and
• Initial assessment: Identify the major problems in the treatment plan. The Therapeutic process can be modified along
patient and check out whether the occupational therapy with the occupational therapist if required. She has to ensure
will be helpful for this patient or not. the patient’s safety while the patient is involved in the industrial
• Detailed assessment: Exploring the strength, needs, works or using sharp objects, etc. She has to coordinate with the
interests, short term/intermediate/long term goals, etc. social worker in order to get employment opportunities for the
patient after the discharge.
The basic five methods used in the assessment process are
listed below:
1. Specific observation ELECTROCONVULSIVE THERAPY
2. Interview
3. Standardized test HISTORICAL BACKGROUND
4. Self-rating method
5. Projective tests • Initial—20th century
„ Assumptions that schizophrenia and epilepsy will not
Treatment occur together.
„ So, artificial induction of convulsion is used for
Occupational therapist needs to plan the activities based
treatment of schizophrenia.
on the client’s needs and interest. Planned activities need
• Ladislas Meduna (1896–1964)
to be executed. Patient’s progress needs to be monitored
„ Pioneer of convulsive treatment.
continuously. Treatment reviews should be done, if the
„ He induced seizure with camphor IM and Metrazol  IV.
required treatment plan has to be modified.
„ Ugo Cerletti, an Italian Neurologist, discovered the
Evaluation method of electroconvulsive therapy that is used in
Psychiatry. Lucino Bini assisted Ugo Cerletti in the
Final treatment review takes place in the evaluation. discovery of electroconvulsive therapy (ECT).
Patient prognosis and influence of the occupational therapy
activities in the modification of the behavior need to be DEFINITION
monitored.
Convulsions are induced by passing a brief pulse of electric
ADVANTAGES OF OCCUPATIONAL THERAPY current through brain via electrodes for a therapeutic purpose.

• Guides the patient’s energy toward the work. CLASSIFICATION OF

• Improves the patient’s attention, concentration and ELECTROCONVULSIVE THERAPY
memory.
• Provokes the patient’s interest. The ECT can be classified depending on the treatment involved
• Builds the innovative skills. and thus has been given in Flowchart 5.12.
• Promotes the self-confidence and self-esteem. • ECT is given in the absence of muscle relaxant and
• Helps the patient to perform the daily activities after general anesthesia is termed ‘Direct ECT’ or ‘Unmodified
discharge from hospital. ECT’.
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 173

Flowchart 5.12: Classification of electroconvulsive therapy

• Based on the placement of electrodes, ECT is classified Sine Wave ECT

as Unilateral ECT and Bilateral ECT as shown in
• Continuous stream of electricity which flows in alternative
Flowchart 5.12. In unilateral ECT, electrode has been
direction.
placed at one side of the head whereas in bilateral ECT,
• Number of alternatives in direction are considered one
electrodes are placed at both the sides of head. The positive, and negative current flow is termed frequency of
electrode placement has been identified as midpoint stimulus, measured in Hertz.
between the lateral angle of eye and external auditory
meatus as shown in Figure 5.34. Right unilateral placement Brief Pulse ECT
of electrodes (D’ Elia placement) is better tolerated than
• Series of instant rising and falling of rectangular pulse of
the bilateral ECT and it also has less cognitive impairment.
current with adjacent pulse separated by brief period of
The bilateral ECT such as Bi-temporal ECT, Bi-frontal
no electrical activity.
ECT and Left Anterior Right Temporal (LART) ECT have
more cognitive side effects and also have more treatment
Ultra Brief Pulse ECT
efficiency when compared with unilateral ECT.
• Use of pulse width of 0.3 ms, comparable with 1.0 ms used
Modified ECT in brief pulse ECT.
• Use of smaller dose to induce seizure might reduce
• ECT is provided along with muscle relaxant and general
cognitive side effects.
anesthesia.
• Medications used are as follows:
Indications and Contraindications
„ Anticholinergics: For example, Glycopyrrolate
(0.1–0.4 mg) and Atropine (0.3–0.6 mg). Indications, contraindications and used with precautions of
„ Anesthetics: For example, Methohexital Propofol ECT are enlisted in Table 5.28.
(1 mg/kg).
„ Muscle relaxant: For example, Succinylcholine Criteria to Use ECT
(0.75 mg/kg). Criteria to use ECT are given in Table 5.29.
174 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 5.28: Indications, contraindications and uses with precautions of ECT

Indications Contraindications Uses with precaution

• Major depression • Absolute: • Pregnancy
„ High suicidal risk „ Increased intracranial pressure (ICP) • Patients with cardiac
„ Psychotic depression • Relative: pacemakers
„ Treatment resistance depression „ Recent myocardial infarction

• Catatonic schizophrenia, mania and depression „ Recent stroke/cerebrovascular accident (CVA)

• Postpartum psychosis • Major physical illness:

• Severe neuroleptic malignant syndrome „ Cardiac failure

• Augmentation with Anti-psychotics „ Severe respiratory problems

„ Brain tumor

„ History of Aneurysm

Table 5.29: Criteria to use ECT Mechanism of Action

Primary criteria Secondary criteria Exact mechanism of action is unknown. The effects of
• Poor response of • Adverse effects with
neurotransmitters will get balanced in the monoamine system
psychotropic agents medication is present (serotonin, dopamine and norepinephrine), acetyl choline,
• Need of quick definite • Resistance with GABA, endogenous opioids and adenosine. There is also the
response medications effect on neuroendocrine system and hypothalamic pituitary
adrenal (HPA) axis.
Biological Effects
Frequency of ECT
Biological effects have been mentioned in Table 5.30.
• ECT can be given on alternative days in a week like,
Table 5.30: Biological effects of electroconvulsive therapy 3 times in a week.
• On an average, 6–10 times ECT can be given.
Increase Changes
• Maximum up to 24 ECT is recommended.
• Plasma catecholamines. • 5-hydroxytryptamine or • Depends on the diagnosis:
• Prolactin release. serotonin (5-HT)
• Brain derived neuroleptic • Dopamine receptor binding. „ Mania: >20 times
factor (BDNF). • Gamma-aminobutyric acid „ Depression: 6–12 times
• Permeability of blood (GABA). „ Catatonia: 3–5 times
brain barrier (BBB) • Glutamate neuropeptide Y. Parameters in ECT is shown in Figure 5.32.

Figure 5.32: Diagram highlighting the parameters in electroconvulsive therapy

CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 175

Complications • Cognitive defects (even though it is temporary it is

troublesome)
• Memory loss
• Relapse after the ECT course is over (So, maintenance
• Respiratory Arrest
with drugs/psychotherapy is important).
• Fracture
• Dysthymia Modern ECT Machine
• Monitor electroencephalograms (EEG), electrocar-
Limitations of ECT diogram (ECG) and electromyogram (EMG).
• Anesthesia is needed • Display parameters as shown below:

Date and No of Date and Charge (Mc) Current (A) Pulse width Frequency Stimulus Seizure
time ECT time of (Hz) duration duration
previous ect

ECT Administration
• Twice a week
• 6–12 sessions (for 3–6 weeks)
• Minimum electrical dose is required to induce generalized
seizure.
• Varies from patient to patient.
• Identify seizure threshold in initial session will reduce
cognitive effects rather than administering ECT with the
standard dose because the seizure threshold differs with
every patient.
Rule of Thumb is:
Figure 5.33: Seizure threshold: <100 mc
Type of ECT Electrical dose
Unilateral 1.5 times the seizure threshold (ST) Process
Bilateral 3 times the seizure threshold (ST) Process followed for ECT is shown in Flowchart 5.13.
Seizure threshold varies and is presented in Table 5.31 and Flowchart 5.13: Process followed for ECT
Figure 5.33.
Table 5.31: Seizure threshold in electroconvulsive therapy

Increases Decreases
• Old age • Antipsychotics (increased risk
• Males of hypotension and post–ECT
• Benzodiazepines confusion, clozapine has to be
(or) barbiturates withheld for 24 hours before ECT)
(avoided or given in • Anti-depressants (tricyclic group
lower doses) of drugs has increased risk of
• Anticonvulsants hypotension and post–ECT
(if continued then confusion, moclobemide has to be
higher ECT stimulus withheld for 24 hours before ECT) ECT Procedure
is required) • Lithium (increases the cognitive
Articles required for ECT with rationale are enlisted in
side-effects and neurotoxic effects)
Table 5.32.
176 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 5.32: Articles required for electroconvulsive therapy with rationale

Articles required for ECT Rationale

ECG electrodes and To check the cardiac status during ECT
monitor
EEG electrodes and monitor To check the seizure activity during ECT (Fig. 5.34)
EEG monitoring is the gold standard method to assess ‘spike and wake activity’.
BP cuff (or) cuff technique To monitor the ictal motor duration during ECT
Cuff is used to isolate the forearm or leg from the muscle relaxant by inflating the cuff. So, that motor
seizure will be observed in the particular forearm or leg (seizure has to be at least for 20 seconds that
denotes the treatment efficiency)
Pulse oximetry To monitor oxygen saturation
Peripheral Nerve stimulator To ensure the adequacy of received muscle blocking agents before ECT which is given especially to the
patients with increased musculoskeletal injury.
Stethoscope To check the heart sounds
Reflex hammer To check the reflexes in neurological assessment
Venflon To give intravenous injections
Bite blocks To prevent tongue bite
Stretchers with side rails Side rails to prevent the patient from fall.
Suction device To remove the secretions
Oxygen cylinder To deliver the required oxygen to patients
Artificial manual breathing To provide resuscitation to patient
unit (AMBU) bag
Oral airways To maintain the patent airway
Intubation kit To put endotracheal intubation in case of respiratory arrest
Emergency drugs To save the life of patient in case of any complication arises due to anesthesia or ECT
Electrode paste To paste the EEG and ECG electrodes
Gel For effective conduction of electrodes
Gauze pads To clean the gel applied after ECT
Distilled water Helpful to deliver humidified oxygen
Chart paper To record the ECT procedure

Figure 5.34: Placement of ECT electrodes

CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 177

The medications given during ECT have been given in Table 5.33.
Table 5.33: Categories of medication

Categories Medications
Anesthetic drugs • Thiopental
• Propofol
• Ketamine
• Etomidate
Antihypertensives • β-blockers
„ Atenolol

„ Labetalol

„ Esmolol

• Calcium channel blockers

„ Nicardipine

„ Nifidipine

Narcotics • Fentanyl
• Remifentanyl
• Alfentanyl
Anticholinergic agents • Atropine
• Glycopyrrolate
Neuromuscular blocking agents • Succinylcholine
• Atracurium
• Mivacurium

Electroconvulsive Therapy Checklist

The ECT checklists are given in Tables 5.34 to 5.36.
Table 5.34: Pre-ECT checklist
Name: Age: Sex: Diagnosis: IP No.:
Procedure: Date: Time: Ward:

Checklist Yes No Remarks

Written informed consent
(If psychotic: Consent from care givers
If Neurotic: Both from patient and care givers)
Skin preparation
Hair wash done
Hair combed
Dentures removed
Nails paired
Nail polish removed
Nil per oral (NPO)
Premedications (If any)
Preoperative teaching
Jewels removed
Investigations
• Routine blood test
• Chest X-ray
• ECG
• Echocardiography

Signature of the Staff Nurse

178 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 5.35: Intra-ECT checklist

Name: Age: Sex: IP No.:
Procedure: Date/Time: Diagnosis: ECT Room No.:

Date:
No. of ECT:
Atropine/Glycopyrrolate:
Thiopentone:
Succinylcholine:
Duration:
Frequency:
Pulse width:
Charge (mc):
Seizure duration:
Blood pressure:
Pulse rate:
Remarks:

Signature of the Doctor/Nurse Practitioner

Table 5.36: Post ECT checklist
Name: Age: Sex: IP No.:
Procedure: Date/Time: Diagnosis: ECT Room No.:

Checklist Yes No Remarks

Assessment of memory
Orientation to patient
NPO at least 2 hours after ECT
IV fluids infusion
Pulse rate checked
Blood pressure checked
Any significant complaints elicited
(headache, nausea/vomiting, confusion)
Able to tolerate oral fluids after 2 hours of ECT
Soft diet after 3 hours of ECT

Signature of the Nurse

ECT Procedure Steps

Nurses’ responsibility before ECT, during ECT and after ECT with steps and rationale are given in Tables 5.37, 5.38 and 5.39
respectively.
Table 5.37: Nurses’ responsibility before ECT procedure

Steps Rationale
Get the informed consent To check out the willingness before ECT
Check vital signs It provides the baseline data
Contd…
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 179

Steps Rationale
Get the investigations done as required by anesthetist/doctor It provides the baseline lab reports
Wear comfortable clothing Patient will feel comfortable
Maintain NPO from 12 pm To prevent aspiration
Administer the premedications To prevent gastric irritation and to have a right seizure threshold
during ECT
Remove prosthesis (denture, glasses, contact lens, hearing aids) To prevent interruptions during ECT
Hair should be clean and dry without oil Oiled hair leads to poor conduction of electric impulses.
Make patient to void before ECT To prevent voiding during ECT because the muscle relaxant will relax
the bladder sphincter muscle
Provide Pre-ECT teaching to the care givers To enhance the knowledge about ECT and so it prevents fear
regarding procedure
Advise the client to wear sterile dress To prevent infection
Shift the patient to operating theater or ECT room by wheel To start the ECT procedure
chair or stretcher

Table 5.38: Nurses’ responsibility during ECT procedure

Steps Rationale
Lie the patient in ECT room table Patient will feel comfortable
Remain with the client throughout the procedure To reduce the patient’s level of anxiety
Place the EEG electrodes To monitor the brain activity during seizures.
Clip the oxygen saturation probe To identify the hypoxemia
Give suction in case of oral secretion To prevent aspiration
Administer medications/anesthesia drugs/muscle relaxants as per Minimize the side effects of ECT
doctors order in case of modified ECT
Monitor Blood pressure throughout the ECT To identify hypotension or hypertension
Place the bite block in mouth To prevent tongue bite
Monitor the motor seizure duration To check out the adequacy of ECT delivered
Document the Intra-ECT checklist Act as legal evidence and used for further follow-up

Table 5.39: Nurses’ responsibility after ECT procedure

Steps Rationale
Transfer the patient into recovery room To observe the patient condition
Monitor the oxygen saturation level To identify the hypoxemia
Check vital signs It provides the baseline data
Reorient the patient To reduce cognitive deficits
Allow the patient to sleep Patient will feel comfortable
Put the side rails of the bed To prevent the falls
Maintain NPO at least after 2 hours of ECT and introduce the soft Step by step introduction of diet will prevent aspiration
diet followed by oral fluids
Assess the memory impairment To rule out amnesia as complication of ECT
Document the procedure It act as a legal evidence.
180 Textbook of Psychiatric Nursing for BSc Nursing Students

Figure 5.35: Maintenance of electroconvulsive therapy

Maintenance of ECT Cognitive Symptoms

Administration of ECT below one year duration is termed, • Confusion
‘Acute course of ECT’. Administration of ECT for one year • Memory disturbances
duration is termed, ‘Continuation phase ECT.’ Administration • Poor concentration
of ECT more than one year duration is termed, ‘Maintenance
phase ECT’. Patient has to undergo the regular physical status
Miscellaneous
and mental health status assessment regularly. Patient also • Headache
ensure the proper drug adherence and psychotherapy to elicit • Nausea and vomiting
the good prognosis (Fig. 5.35). • Tongue bite
• Urinary incontinence
Side Effects • Dry mouth
• Drowsiness
More common side effects are as follows:
• Headache
• Confusion
• Memory disturbances (both anterograde and retrograde
amnesia)
• Side effects of general anesthesia and muscle relaxants.
Less common side effects are as follows:
• Muscle weakness/aches
• Nausea
• Anorexia
Side effects are seen prominently immediately after ECT.
It is a temporary or short lasting one and so it will be reduced
after few hours to days (Fig. 5.36).
The side effects of ECT can be categorized as:

Cardiovascular System
• Palpitations Figure 5.36: Duration of the side effects after
• Transient changes in cardiovascular system electroconvulsive therapy
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 181

PSYCHOSURGERY OR FUNCTIONAL NEUROLOGICAL SURGERIES

Psychiatric neurosurgeries are enlisted in Table 5.40.

Table 5.40: Psychiatric neurosurgeries

Name of the Description Indicated psychiatric disorders (treatment

psychosurgery resistant with psychotropics is present)
Anterior Anterior cingulate cortex is targeted. Surgery performed to • Addictive behavior
cingulotomy disconnect the thalamic and posterior frontal regions. • Bipolar disorder/depression
• Obsessive compulsive disorder (OCD)
• Schizophrenia and
• Schizoaffective disorder
Anterior Surgery performed to disconnect the orbitofrontal cortex and • General anxiety disorder and
capsulotomy thalamic nuclei by producing a lesion in anterior limb of internal • Obsessive compulsive disorder (OCD)
capsule
Subcaudate Destruction of bifrontal pathways which is present below and in • Schizophrenia
tractotomy front of the head of caudate nucleus. • Depression and
• Obsessive compulsive disorder (OCD)
Hypothalamotomy Surgical lesions made in the hypothalamus by ultrasonic energy • Addictive behavior
or using knife or by electric impulses or radiation. • Aggression
• Sexual disorders
Thalamotomy The precise destruction is performed in a tiny area of brain Tourette syndrome
called thalamus in order to control the involuntary movements
Amygdalotomy Destruction of part of the amygdala in the brain Aggression associated with psychiatric illness.
Limbic leucotomy It is the combination of anterior cingulotomy and subcaudate tractotomy

DEEP BRAIN STIMULATION • Addiction

• Tourette syndrome
Definition • Chronic pain
Deep brain stimulation is defined as, ‘implanting the electrodes
in certain parts of brain, the electrodes produce the impulses Risk of Surgery
to regulate the abnormal impulses. The amount of stimulation Risks include hemorrhage in the brain, misplacement of
has been controlled with the pacemaker like device which is lead, infection, stroke, breathing difficulty, heart problems,
kept under the skin of the chest’ seizure, etc.

Indications Side Effects

• Parkinson’s disease • Side effects related to stimulation: Speech difficulties,
• Obsessive-compulsive disorder light-headedness, double vision, balance problems,
• Epilepsy numbness, muscle tightness and mood swings.
• Dystonia • Side effects after the surgery: Headache, infection,
• Dementia confusion, difficulty in concentration, stroke, seizure,
• Major depression pain and swelling in implanted site.
• Cluster headache
• Huntington’s disease Targeted Parts of Deep Brain Stimulation for
• Traumatic brain injury Psychiatric Disorders
• Multiple sclerosis Target parts of deep brain stimulation are enlisted in
• Recovery from stroke Table 5.41.
182 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 5.41: Target parts of deep brain stimulation that sensory impairment and memory deterioration are
the reasons for their slow performance and understanding.
Targeted part of brain in Indicated psychiatric disorders
deep brain stimulation The length of the sessions has to be flexible. Nurse needs to
fix the small achievable goals in the small group. Physical
Lateral habenula Depression
and mental health of the elders have to be considered before
Nucleus accumbens Addiction
planning out the psychotherapeutic sessions.
Subcallosal cingulate Anorexia nervosa and depression
Ventral capsule or ventral Addiction Role of Nurse in Psychological Therapies
striatum Obsessive compulsive disorder
Depression Nurse has to provide the trusting therapeutic relationship with
Inferior thalamic peduncle Obsessive compulsive disorder the patient, to ensure the therapeutic alliance. Nurse has to plan
Depression the psychotherapy session in coordination with the therapist
Subthalamic nucleus Obsessive compulsive disorder based on the needs and problems of the patient. Nurse has
Medial forebrain bundle Depression to teach the importance of the particular psychotherapy to
Thalamus Tourette syndrome the patient and his/her family members. Nurse has to work
as a liaison officer between patient, therapist and the family
PSYCHOLOGICAL THERAPIES members of patient.
Nurse has to observe the improvement or deterioration
Geriatric Considerations in Psychological in patient after the few therapy sessions and report the same
Therapies to the psychotherapist. Nurse has to explain every step of the
Nurse has to remember that the psychotherapies will work psychotherapeutic process to the patient in order to prevent
out slow in elders due to ageing. Nurse should consider the unnecessary raise in anxiety.

SUMMARY
• Antipsychotics are medications to treat psychotic disorder and psychosis related to other psychiatric and medical disorders.
• The other names of antipsychotics are D2 receptor blockers, major tranquilizers, neuroleptic agents, ataractics and anti-schizophrenic
drugs.
• Types of antipsychotics are conventional (or) traditional (or) typical antipsychotics and atypical antipsychotics (or) Second generation
antipsychotics.
• Dopamine (D2 receptor) pathways in the brain are Nigrostriatal tract, Tuberoinfundibular tract, Mesolimbic tract and Mesocortical
tract.
• Extrapyramidal symptoms due to antipsychotics are neuroleptic malignant syndrome, pseudo-parkinson’s disease, akathisia, acute
dystonia, Rabbit syndrome, Tardive dyskinesia and abnormal choreoathetoid movements.
• The other terms for antidepressants are Thymoleptics and Mood elevators.
• Types of antidepressants are first generation antidepressants or tricyclic antidepressants (TCA), second generation antidepressants
or selective serotonin reuptake inhibitors (SSRI), serotonin norepinephrine reuptake inhibitors (SNRI), monoamine oxidase inhibitors
(MAOI) and atypical antidepressants.
• The other terms for antianxiety agents are minor tranquilizers and anxiolytics.
• Classification of antianxiety agents are benzodiazepines, barbiturates, nonbarbiturates, non-benzodiazepines anxiolytic agents and
antidepressants causing antianxiety effects.
• The common anti-Parkinson’s agents are classified into Anticholinergics, Antihistamine and Dopaminergic agonists.
• The common mood stabilizers are Lithium, sodium valproate and carbamazepine.
• Stimulants are those which enhance the mental and physical function by increasing the alertness, wakefulness, etc. Example for the
CNS stimulants are Caffeine, Nicotine, Methylenedioxy/methamphetamine (MDMA-Ecstasy), modafinil, Ampakines, etc.
• Psychotherapy is defined as, ‘way to help the people with variety of mental illnesses and emotional difficulties and it also helps to
control or remove the symptoms which trouble the person, function in a better way, increase the sense of well-being and promote
healing.’
• Individual psychotherapy is the interaction process (psychotherapy) between the patient and the mental health professional or
therapist on one to one basis.
• Psychoanalytical psychotherapy is defined as insight therapy which aims to overcome the unconscious conflicts and it also aims to
identify the relationship between the unconscious motivation and the abnormal behavior.
• Cognitive therapy is a form of psychotherapy in which the distorted cognitions are modified into positive cognitions.
• Behavior therapy is defined as ‘form of psychotherapy in which the maladaptive behavior is aimed to change as adaptive behavior.’

Contd…
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 183

• Therapeutic community is a drug free environment in which the individuals with addictive behavior join together in a structured
manner in order to promote drug free society. It forms a miniature of society, staff act as facilitators, residents join together to promote
the transitional process.
• Milieu therapy is the scientific structuring of the environment in order to elicit the behavioral changes and to enhance the psychological
health and functioning of the individual.
• Supportive psychotherapy is defined as a kind of psychotherapy which helps to decrease the psychological conflict and strengthen the
patient’s defenses with the help of techniques such as suggestion, reassurance, counseling and reeducation.
• Play therapy is a form of psychotherapy in which the therapist utilizes the child’s fantasy and symbolic meaning as a medium of play to
have a communication or understanding about the children. It also gives a chance for the child to express the feelings and experiences.
• Family therapy is defined as, ‘a form of psychotherapy in which the issues or problems or conflicts exist among the family members are
addressed and the solution has been identified.’
• Psychodrama is a form of psychotherapy (group therapy), in which the dramatization or dramatic presentation of self helps to gain
self-insight.
• Music therapy is defined as, ‘utilization of music in treatment, training, education and the rehabilitation of children and adults who are
suffering from physical and mental disorder.’
• Dance therapy is defined as, ‘psychotherapeutic use of movement as process, which promotes physical, emotional and cognitive
integration of the individual.’
• Recreational therapy is a systematic process which utilizes the recreation and other activity-based interventions based on the needs of
individuals with illness or disabling conditions which means to psychological/physical health, recovery and well-being.
• Relaxation therapy is a component of body-mind intervention in which the therapist helps the participants at the higher extent of mind
relaxation.
• Light therapy is the use of light with the specified intensity for therapeutic purpose.
• The word, Yoga came from the Sanskrit word ‘Yuj’ which means union or connect or balance or join, i.e., joining of Jivatma with
Paramatma, joining of the individual consciousness with the consciousness in the universe.
• Biofeedback is defined as, ‘psychophysiological therapy in which the individual is able to monitor the physiological changes in the body
due to the psychological stressors.’
• Alternative and complementary medicine is defined as, ‘group of diverse medical/health care system, practices and products that are
not presently considered to be a part of conventional medicine.’
• The major domains of Alternative and complementary medicine are alternative medicine system, mind body interactions, biological
based therapies, manipulative or body based therapies and energy therapies.
• Convulsions are induced by passing a brief pulse of electric current through brain via electrodes for a therapeutic purpose is defined
as ECT.
• Major depression is the most common indication and increased intra-cranial pressure is the absolute contraindication of ECT.
• Poor response of Psychotropic agents is a primary criterion to use ECT.
• Raise in Plasma catecholamines, Prolactin release, BDNF (Brain Derived Neuroleptic Factor), Permeability of blood brain barrier (BBB)
are biological effects of ECT.
• Changes in 5-hydroxytryptamine (5 HT) or serotonin, DA receptor binding, Gamma-aminobutyric acid (GABA), glutamate, neuropeptide
are also the biological effects of ECT.
• Three times the seizure threshold (ST) in Bilateral ECT and 1.5 times the seizure threshold (ST) in unilateral ECT is rule of thumb.
• Benzodiazepines increase seizure threshold (ST). Lithium, antipsychotics and antidepressants might decrease seizure threshold (ST).
• Memory disturbances are most common cognitive side effects of ECT.
• ECT has been classified as direct ECT, modified ECT, brief pulse ECT, sine wave ECT, ultra brief pulse ECT.
• Based on electrode placement, ECT is classified into unilateral ECT and Bilateral ECT.
• On an average, 6–10 times ECT can be given. Maximum times of ECT administration is 24.
• Informed consent, NPO, Pre-medications, hair wash, removal of prosthesis, check out vital signs is important before ECT.
• Monitor vitals, seizure duration is vital during ECT. Administration of anesthetic drugs is essential in case of modified ECT.
• Reorientation, assessment of memory, soft diet, and adequate rest is vital in post-ECT care.

ASSESS YOURSELF
Long Answer Questions 3. Define mood stabilizers. List out the indications,
1. Define antipsychotics. List out the indications, contraindications and their side effects. Classify
contraindications and their side effects. Classify the the mood stabilizers and elaborate the nurse’s
antipsychotics and elaborate the nurse’s responsibility. responsibility.
2. Define antidepressants. List out the indications, 4. Define anti-anxiety agents. List out the indications,
contraindications and their side effects. Classify the contraindications and their side effects. Classify the
antidepressants and elaborate the role of nurse. antianxiety agents and elaborate the role of nurse.
184 Textbook of Psychiatric Nursing for BSc Nursing Students

5. Define psychotherapy. Classify and explain the various 3. Which of the following is the synonymous term of
psychotherapies along with the nurse’s responsibility. antianxiety agents?
6. Define behavior therapy. Classify and explain the various a. Thymolytics b. Major tranquilizers
techniques with appropriate examples. c. Minor tranquilizers d. Neuroleptic agents
7. Define cognitive therapy. Classify and explain the 4. Which of the following is among the eight limbs of
various techniques with appropriate examples. yoga?
8. Define ECT. List out the indications, contraindications a. Yama b. Niyama
and side effects of ECT. Explain the nurse’s responsibility c. Asanas d. None of these
before, during and after ECT.
5. The psychoanalytic technique includes:
Short Answer Questions a. Free association b. Dream analysis
1. What is the role of nurse in managing the side effects of c. Treatment Alliance d. All of these
antipsychotics? 6. Most common side effect of ECT is:
2. Define family therapy. a. Memory impairment b. Hypertension
3. Name the alternative systems of medicine. c. Fracture d. Convulsions
4. Write about nurse’s role in ECT? 7. Which is not considered atypical antipsychotics?
a. Risperidone b. Clozapine
Short Notes
c. Olanzapine d. Haloperidol
Write short notes on:
8. Which type of ECT is highly recommended to prevent
1. CNS stimulants
memory impairment?
2. Extrapyramidal effects
a. Direct ECT b. Modified ECT
3. Tricyclic antidepressants
c. Both of these d. None of these
4. Serotonin syndrome
5. Individual psychotherapy 9. The frequently occurring response (R1) might act as a
6. Psychoanalytical psychotherapy positive reinforcement for the response (R2) which is
7. Supportive psychotherapy occurring less frequently is ____________ of Behavior
therapy.
8. Therapeutic community
a. Systematic desensitization
9. Group therapy
b. Premack principle
10. Play therapy
c. Flooding
11. Psychodrama
d. Assertiveness training
12. Music therapy
13. Dance therapy 10. _____________ is the psychotherapeutic use of
14. Recreational therapy movement as process, which promotes physical,
emotional and cognitive integration of the individual.
15. Light therapy
a. Music therapy b. Dance therapy
16. Relaxation therapies
c. Yoga therapy d. Biofeedback
17. Yoga
18. Meditation 11. _____________ group of drug will cause hypertensive
19. Biofeedback crisis if taken with tyramine derivatives.
20. Classification of ECT a. Tricyclic antidepressants
b. Antianxiety drugs
Multiple Choice Questions c. Monoamine oxidase inhibitors
1. Which of the following is not synonymous term of d. Selective serotonin reuptake inhibitors
Antipsychotics? 12. _____________ group of drug causes extrapyramidal
a. D2 receptor blockers symptoms.
b. Major tranquilizers a. Antipsychotics b. Anti-anxiety drugs
c. Minor tranquilizers c. Stimulants d. Antidepressants
d. Neuroleptic agents
13. What is the minimum seizure duration required for
2. _______ used the ECT at first in modern times. the efficacy of ECT?
a. Egas Moniz b. Kurt Schneider a. 30–90 seconds b. 2 minutes
c. Ladislas Meduna d. Sigmund Freud c. 10–20 seconds d. 20–30 seconds
CHAPTER 5 Treatment Modalities and Therapies used in Mental Disorders 185

14. The proponent of Rationale emotive therapy is: 19. Absolute contraindications of ECT is:
a. Albert Ellis b. Steven C Hayes a. Increased intracranial pressure
c. Marsha M Linehan d. Adrian Wells b. Stroke
15. Most common indication of ECT is: c. Recent MI
a. Mania b. Severe depression d. Cardiac failure
c. Schizophrenia d. Anxiety disorder 20. Drug which decreases seizure threshold is:
16. Which of these comes under the category of relaxation a. Lithium
therapy? b. Antidepressants
a. JPMR b. Autogenic training c. Antipsychotics
c. Guided Imagery d. All of these d. All of the above
17. Breathing practices in the yoga is termed:
Answer Key
a. Pranayama b. Asana
c. Kriyas d. Mudras 1. c 2. c 3. c 4. c 5. d
6. a 7. d 8. b 9. b 10. b
18. Anticholinergic agent can be given before ECT is: 11. c 12. a 13. c 14. a 15. b
a. Succinyl Choline b. Atropine 16. d 17. a 18. b 19. a 20. d
c. Atracurium d. Mivacurium
Notes
 CHAPTER
Nursing Management of
Patients with Schizophrenia
and Other Psychotic Disorders 6
LEARNING OBJECTIVE

After studying this chapter, the student will be able to gain knowledge regarding the schizophrenia and other psychotic disorders in
order to render the nursing care of patient with schizophrenia.

CHAPTER OUTLINE
• Introduction and Meaning • Other Psychotic Disorders
• History • Prognosis of Schizophrenia
• Prevalence and Incidence • Psychosocial Interventions
• Etiology • Treatment
• Diagnosis • Nursing Interventions
• Diagnostic Criteria • Geriatric Considerations
• Differential Diagnosis of Schizophrenia • Follow-up, Home Care and Rehabilitation of Patients with
• Three Phases of Schizophrenia Schizophrenia
• Positive and Negative Symptoms of Schizophrenia

KEY TERMS
Schizophrenia, DiGeorge syndrome, Expressed emotions, Double bind communication, Hallucination, Delusion, Thought broadcasting,
Thought withdrawal, Delusion disorder, Catatonia, Anhedonia, Apathy, Acute and transient psychotic disorder, Brief psychotic
disorder, Schizoaffective disorders, Schizophreniform disorder, Schizotypal (Personality) disorder.

INTRODUCTION AND MEANING HISTORY

The word ‘schizophrenia’ is derived from the Greek word Eugen Bleuler coined the term ‘Schizophrenia’ in 1908.
which means ‘split mind”. Prefix ‘Schizo’ means ‘Split’ and Emil Kraepelin classified the psychiatric disorders into
Suffix ‘Phrenia’ means ‘mind’. The term ‘split mind’ does not Dementia praecox and Manic-depressive illness. The term
denote the split personality or multiple personality disorder,
‘Praecox’ means onset in young age (early onset) and the term
it actually means the split in terms of thought, cognition
and emotions. Hence, schizophrenia is a psychotic disorder ‘Dementia’ denotes gradual decrease in cognitive functions.
(disorder in which client believes that he/she will not have a Kurt Schneider was concerned with improving the method
base of reality) characterized by abnormalities in emotion, of diagnosis in psychiatry. He contributed to diagnostic
thinking and cognition. procedures and the definition of disorders (Fig. 6.1).
188 Textbook of Psychiatric Nursing for BSc Nursing Students

Eugen Bleuler Emil Kraepelin Kurt Schneider

(1857–1939) (1856–1926) (1887–1967)

Figure 6.1: Pioneers in psychiatry

World schizophrenia day is observed on May 24th every year • High rates of schizophrenia are seen in winter season.
with an aim to raise public awareness about schizophrenia and • Twin studies of patient with schizophrenia revealed that
to minimize the disgrace associated with the condition. among twins, monozygotic twins have 47%, dizygotic
twins have 12% and nontwin siblings have 8% chance to
PREVALENCE AND INCIDENCE get schizophrenia as shown in Figure 6.2.
A person is more likely to develop schizophrenia if, someone
• 1% of total population has life time prevalence rate of
in his/her family have Schizophrenia. If, the person with
schizophrenia and the incidence rate is 0.15–0.25/1,000.
Schizophrenia is a parent, brother, or sister, then the chances
• Usual onset of schizophrenia is adolescence/young can go up by 10%. If both the parents are having Schizophrenia,
adulthood. the person can have a 40% chance of getting Schizophrenia.
• Late-onset schizophrenia is at 45 years of age. Mostly females around 30 years of age are affected. Mostly males
Schizophrenia is rarely present before 15 years of age and around 20 years of age are affected. Onset of schizophrenia the
after 45 years of age. chances are early in men.
• Nearly 10% of patients with schizophrenia attempt suicide Males and females are equally affected with schizophrenia
especially young male adults. in general as explained in Table 6.1.

Figure 6.2: Twin studies in schizophrenia

CHAPTER 6 Nursing Management of Patients with Schizophrenia... 189

Table 6.1: Gender and schizophrenia • Neuropathological factors: Enlargement of third and
lateral ventricles of cerebrum along with the decreased
cerebral volume is seen in patient with schizophrenia.
In limbic system, the hippocampus, amygdala and
parahippocampal gyrus are in smaller size. In thalamus,
loss of neurons in medial dorsal nucleus of thalamus is
seen. Anatomical abnormalities in prefrontal cortex, basal
Females Males are affected In general, males and
are affected around 20 years of females are equally ganglia and cerebellum are seen.
around 30 age. Onset is early affected with schizophrenia • Neuropeptides: Imbalance in the neuropeptides such as
years of age in men cholecystokinin, neurotensin, phospholipids, substance
P, dynorphin A, neuropeptide Y and peptide YY is risk
factor for schizophrenia.
ETIOLOGY
• Neuroendocrinology: Imbalance in the hormones such
Factors as growth hormone, prolactin, thyroid-releasing hormone
and oxytocin.
The factors responsible for schizophrenia have been discussed
• Environmental factors: Obstetric complications,
here:
abnormalities in developmental milestones, prenatal
• Neurochemical factors: Dopamine hypothesis states
infections, prenatal malnutrition, advanced paternal
presence of excess dopaminergic activity, high serotonin
age, drug abuse, migrated from native place and season
level and imbalance in other neurochemicals such as
of birth in winter or seasonal spring are environmental
norepinephrine, GABA, glutamate, acetylcholine and
factors might cause schizophrenia.
nicotine.
• Genetic factors: DiGeorge syndrome or Velocardiofacial Theories and Models
syndrome or Shprintzen syndrome or Conotruncal
anomaly face syndrome or Takao syndrome or Other theories and models which explain the etiology of
Sedlackova syndrome or Cayler cardiofacial syndrome schizophrenia have been put forth; some of these are discussed
or 22q11.2 deletion syndrome is defined as deletion of 30 here.
to 40 genes in middle of chromosome 22. The symptoms
Sociocultural Theory
identified on physical examination are wide spaced eyes
(hypertelorism), short broad nose, cardiac malformations, Downward social drift, i.e., lower social economic background
umbilical hernia, intestinal blockage and abnormal pelvis, has high chance of developing schizophrenia.
long forehead, oval shaped low set ears, excess nuchal
Interpersonal Model
thickness and edematous feet (Fig. 6.3).
Sullivan explained the interpersonal model, which is highly
focused on the mother-child relationship. The internal
equilibrium in a body is labeled as self-system. When self-
system feels good there will be low level of anxiety, when self-
system feels bad it will give rise to high level of anxiety and if
self-system feels: it’s not me, then it leads to apocalyptic anxiety
schizophrenia (Fig. 6.4).

Figure 6.3: Symptoms of DiGeorge syndrome Figure 6.4: Interpersonal model of schizophrenia
190 Textbook of Psychiatric Nursing for BSc Nursing Students

Stress-Diathesis Model or Nature-Nurture Model Table 6.2: Dopamine pathways

According to Sandor Rado, genotype (inherited gene) interacts Dopamine pathways Physiology of each pathway
with environment and gives a phenotype namely ‘Schizotype’. Mesolimbic • Motivation
These are individuals who are unable to cope with the repeated • Emotion
stressors. • Reward
• Positive symptoms of schizophrenia
Psychoanalytical Theory Mesocortical • Dorsolateral prefrontal cortex—
In psychoanalytical theory, there is regression to oral stage responsible for cognition and
execution
of psychosexual development, along with use of defense • Ventromedial prefrontal cortex—
mechanism such as denial, projection, reaction formation and responsible for emotions and affect
distortion. • Responsible for negative symptoms
of schizophrenia
Family Theories Nigrostriatal • Constitutes 80% of brain dopamine
• Double bind communication: Unable to identify the • Responsible for motor activity
• Responsible for extrapyramidal
correct choice (For example, mother says child you can go symptoms of schizophrenia
out to play cricket but your shoes and dress should not get
Tuberoinfundibular Hyperprolactinemia
dirty. In this example, mother’s nonverbal cues and facial
expression denote the child to stay at home).
• Dysfunctional family: Hostility between mother and
father can lead a child toward schizophrenia.
• Mother-child relation: If the mother is overprotective
and dominating (try to control the behavior without
understanding the feelings—a parenting style).
• Increased negatively expressed emotion (EE) in family,
i.e., critical comments and emotional over involvement
among family members.

NOTE
Dysfunctional family and Mother-child relation explained above
are older theories and are currently not accepted. Figure 6.5: Dopamine pathways in brain

A’s of Schizophrenia
Dopamine Pathways
Bleuler coined the term ‘Schizophrenia’ in 1908. Four
Dopamine pathways are a set of projection neurons in the brain symptoms are considered primary and fundamental symptoms
that release dopamine responsible for function, execution, of schizophrenia. Four A’s explained by Eugen Bleuler are as
motivation, etc. It has four pathways. Dopamine pathways have follows:
been summarized in Table 6.2 and Figure 6.5. Physiology of 1. Autistic thinking and behavior denote excess fantasy
mesolimbic pathway is responsible for motivation, emotion, thoughts.
reward and positive symptoms of schizophrenia. Physiology of 2. Ambivalence means inability to take decisions due to
mesocortical pathway is responsible for negative symptoms conflicts existing in mind.
of schizophrenia, in which dorsolateral prefrontal cortex 3. Affect is inappropriate to the mood.
is responsible for cognition and execution. Ventromedial 4. Associative loosening (Rapid shifting of one idea to
prefrontal cortex is responsible for emotions and affect. another without any association between those ideas).
Nigrostriatal pathway constitutes 80% of brain dopamine that Five A’s of negative symptoms of schizophrenia are as
is responsible for motor activity and shows extrapyramidal follows:
symptoms of schizophrenia. Tuberoinfundibular pathway 1. Anhedonia (Inability to enjoy the pleasure which seems
increases prolactin level. to be pleasurable before).
CHAPTER 6 Nursing Management of Patients with Schizophrenia... 191

NOTE
Ventricular enlargement is also seen in hydrocephalus, Alzheimer’s
disease and neurodegenerative disorders.

• SPECT/PET scan shows increased D2 receptor density.

• Diffusion tensor imaging reveals the abnormalities in
white matter fiber tracts.
• Functional MRI: If the patient has positive symptoms,
changes can be seen in medial prefrontal cortex and
hippocampus. If the patient has negative symptoms,
changes can be seen in ventrolateral prefrontal cortex
and ventral striatum. If the patient has disorganized
symptoms, changes can be seen in dorsolateral prefrontal
cortex.

Figure 6.6: A’s of schizophrenia

DIAGNOSTIC CRITERIA
2. Alogia (poverty of speech) DSM-5 Diagnostic Criteria for Schizophrenia
3. Flat affect (lack of emotional expression)
4. Avolition (lack of initiation to perform any action) • Two or more of following symptoms present for significant
5. Poor attention. portion of time for 1-month period (or less if successfully
treated).
Four A’s and 5 A’s of negative symptoms of schizophrenia have „ Delusions
been shown in Figure 6.6. „ Hallucinations
„ Disorganized speech (e.g., frequent derailment or
ICD-11 and DSM-5 Code for Schizophrenia incoherence)
6A20 ICD-11 code for schizophrenia „ Grossly disorganized or catatonic behavior.
„ Negative symptoms (i.e., diminished emotional
295.90 DSM-5 code for schizophrenia
expression or avolition)
• Significant impairment in the academic, interpersonal,
DIAGNOSIS occupational and social impairment.
• Continuous signs persist for at least 6 months (at least
• Assessment scales used to identify psychotic symptoms 1 month of symptoms in active phase and then may be
in schizophrenia are as follows: only negative symptoms in the prodromal or residual
„ Brief Psychiatric Rating Scale (BPRS) phase).
„ Scale for Assessment of Negative Symptoms (SANS— • There should not be major depressive or manic episodes.
Andreasen, 1982) • Sign is not due to consumption of any substance.
„ Positive and Negative Syndrome Scale (PANSS—Kay,
1991) Specify if it is:
• Assessment scales used to identify cognitive deficits in • First episode or multiple episodes either with full or
schizophrenia are as follows: partial remission
„ Stroop test • With or without catatonia
„ Trail making test • Severity (use of 5-point scale)
„ Wisconsin card sorting test
„ Wechsler adult intelligence scale (WAIS) ICD-11 Diagnostic Criteria for Schizophrenia
• Assessment scales used to identify personality related • Schizophrenia is characterized by disturbances in multiple
problems in schizophrenia are as follows: mental modalities, including:
„ Rorschach inkblot test „ Thinking (e.g., delusions, disorganization in the form
„ Minnesota multiphasic personality inventory (MMPI) of thought)
• CT scan: Ventricular enlargement and cortical atrophy „ Perception (e.g., hallucinations)
192 Textbook of Psychiatric Nursing for BSc Nursing Students

„ Self-experience (e.g., the experience that one’s feelings, • Schizophreniform disorder or acute transient psychotic
impulses, thoughts, or behavior are under the control disorder or brief psychotic disorder
of an external force) • Delirium and dementia
„ Cognition (e.g., impaired attention, verbal memory, • Body dysmorphic disorder
and social cognition), volition (e.g., loss of motivation) • Schizotypal personality disorder
„ Affect (e.g., blunted emotional expression) and • Schizoid personality disorder
„ Behavior (e.g., behavior that appears bizarre or • Pervasive developmental disorder
purposeless, unpredictable or inappropriate emotional • Obsessive-compulsive disorder
responses that interfere with the organization of • Anxiety disorder
behavior) • Misidentification syndrome
• Psychomotor disturbances, including catatonia, may be • Induced or shared psychotic disorder
present. • Factitious disorder
• Persistent delusions, persistent hallucinations, thought • Bipolar affective disorder
disorder, and experiences of influence, passivity, or
control are considered core symptoms. Symptoms must THREE PHASES OF SCHIZOPHRENIA
have persisted for at least 1 month in order for a diagnosis
Three phases of schizophrenia are as follows: (1) Prodromal
of schizophrenia to be assigned.
phase, (2) Psychotic phase, and (3) Residual phase. Prodromal
• The symptoms are not a manifestation of another health
phase is a first phase that occurs before psychotic episode.
condition (e.g., a brain tumor) and are not due to the
Social withdrawal and irritability occur in prodromal phase.
effect of a substance or medication on the central nervous
The second phase is psychotic phase. In psychotic phase, altered
system (e.g., corticosteroids), including withdrawal (e.g., thought process, disturbances of perception and delusions are
alcohol withdrawal). seen. The third phase is residual phase which occurs between
psychotic episodes in which patient exhibits flat affect (lack of
DIFFERENTIAL DIAGNOSIS OF SCHIZOPHRENIA emotional expression), social withdrawal and odd behavior as
shown in Figure 6.7.
• Schizoaffective disorder
• Delusional disorder
POSITIVE AND NEGATIVE SYMPTOMS OF
• Post-traumatic disorder
SCHIZOPHRENIA
• Hypochondriasis
• Mood disorder with psychotic symptoms The positive symptoms of schizophrenia are hallucination,
• Sleep-related disorder delusion, disorganized thoughts and bizarre behavior which
• Substance-induced psychotic disorder are seen in acute phase and also have good response to
• Psychotic disorder due to general medical condition treatment. The negative symptoms of schizophrenia are apathy,
(Metabolic disorders, endocrine disorders, anatomic flat or blunt affect, anhedonia, alogia, avolition, asociality and
lesions, infectious diseases, vitamin deficiency) attention deficit as described in Table 6.3.

Figure 6.7: Three phases of schizophrenia

CHAPTER 6 Nursing Management of Patients with Schizophrenia... 193

Table 6.3: Positive and negative symptoms of schizophrenia

Positive symptoms Negative symptoms

Hallucination Apathy or Affective flattening or Blunt affect: Blank facial expression
Delusion Anhedonia: Inability to express pleasure which is pleasurable one previously
Disorganized thoughts Alogia: Lack of speech output
Bizarre behavior Avolition: Lack of initiative to act
Asociality: Social withdrawal
Attention deficit: Lack of attention
Seen in acute phase Seen in chronic phase
Have good response to Not having good response to treatment when compared with treatment of patient with positive symptoms
treatment

Schneider’s First-Rank Symptoms: Kurt Schneider, „ Thought block: Interruption in stream of speech
German psychiatrist, enumerated 11 first-rank symptoms of before its completion.
schizophrenia. „ Neologism: Framing new words which do not have
• Three auditory hallucinations: any meaning.
i. Third person voices giving commentary about „ Mutism: Complete absence of speech.
patient actions „ Poverty of ideation: Speech delivered is adequate but
ii. Third person voices arguing or discussing about the content of speech is inadequate.
patient „ Poverty of speech: Decreased production of speech.
iii. Thought Echo—voices are speaking thoughts a loud „ Echolalia: Repetition of words by the patient exactly
• Three-thought phenomenon or thought-alienation what the examiner says.
phenomenon: „ Perseveration or verbigeration: Repetition of words
i. Thought broadcasting: Thoughts escaped into by patient.
outside world and others are experiencing it. „ Delusions: False fixed unshakable belief irrespective
ii. Thought withdrawal: Thoughts have been removed to their sociocultural values.
by an external source. • Disorders of perception
iii. Thought insertion: Thoughts have been inserted by „ Auditory hallucinations: Hearing voices or sounds
an external source. without external stimuli.
• Three made phenomenon (Client experience emotions, „ Visual hallucinations: Visualizing images/shade/
drives and actions influenced by others): something without external stimuli.
i. ‘Made’ actions: Actions performed by outside • Disorders of affect
control. „ Blunt affect: Reduction in intensity of emotional
ii. ‘Made’ feelings: Feelings are not own, due to external response.
source. „ Inappropriate affect: Mood and affect are not
iii. ‘Made’ impulses: Impulses or drives from an external appropriate.
source. „ Apathy: Lack of facial expression.
• Miscellaneous „ Anhedonia: Inability to experience pleasure which
„ Somatic passivity: Passive somatic sensation by seems to be pleasurable before.
external source. • Disorders of motor behavior
„ Delusional perception: Illogical meaning attributed „ Decreased psychomotor activity or Increased
toward normal perception. psychomotor activity.
„ Stereotype behavior: Repetitive strange behavior.
Symptoms of Schizophrenia „ Catatonic features.
• Disorders of thought and speech • Miscellaneous
„ Autistic thinking: Illogical thoughts. „ Reduction in social functioning
„ Loosening of association: Rapid shifting of one idea „ Decreased self-care
to other without any association between those ideas. „ Perplexity in regard to own identity
194 Textbook of Psychiatric Nursing for BSc Nursing Students

„ Multiple somatic complaints Flowchart 6.1: Three dimensions of psychopathology of

„ Suicide if associated with depression schizophrenia
„ No disturbances in attention, concentration, memory,
cognition and intelligence
„ No organic cause
„ No prominent mood symptoms (except schizoaffective
disorder)

Hallucination
It is defined as misperception without any external stimuli.
Common types are auditory, visual, olfactory, tactile and gustatory.
Auditory type of hallucination is most common in schizophrenia.
Types of auditory hallucination are simple and complex. Simple
auditory hallucination is any sound heard whereas complex
hallucination is voice heard by the patient. It also referred as
second person hallucination and third person hallucination.
OTHER PSYCHOTIC DISORDERS
Hearing voice outside the one’s head when the patient is alone
clearly identifies auditory hallucination, if not it might be one’s As per ICD-11 and DSM-5, the classification of other psychotic
own thoughts that refers to pseudo-hallucination. disorders is given in Table 6.4.

Dimensions in the Psychopathology of Acute and Transient Psychotic Disorder

Schizophrenia The term ‘transient’ denotes short lasting. Onset of psychotic
The three dimensions in the psychopathology of schizophrenia symptoms is abrupt and acute with positive symptoms such as
are: (1) Psychotic dimension, (2) Disorganized dimension, and delusion, hallucination, disorganized thoughts and perplexity
(3) Negative dimension. Psychotic dimension denotes positive or confusion. This symptom is not a manifestation of another
symptoms, disorganized dimension denotes disorganized health condition or due to influence or withdrawal of any
speech, disorganized behavior and inappropriate affect, and substances.
negative dimension denotes negative symptoms as explained Duration of the episode: It does not exceed 3 months, and
in Flowchart 6.1. most commonly lasts from a few days to 1 month.

Table 6.4: ICD-11 and DSM-5 classification of other psychotic disorders

ICD-11 DSM-5 Classification of mental disorders

Schizophrenia spectrum and other psychotic disorders
6A21 — Schizoaffective disorder
6A22 301.22 Schizotypal (personality) disorder
6A23 — Acute and transient psychotic disorder
6A24 297.1 Delusional disorder
— 298.8 Brief psychotic disorder
— 295.40 Schizophreniform disorder
— 295.70 Schizoaffective disorder (bipolar type)
— 295.70 Schizoaffective disorder (depressive type)
— 293.81 Psychotic disorder due to another medical condition (with delusions)
— 293.82 Psychotic disorder due to another medical condition (with hallucinations)
6A40 293.89 Catatonia associated with another mental disorder (catatonia specifier)
— 293.89 Catatonic disorder due to another medical condition
6A41 — Catatonia induced by psychoactive substances, including medications
6A4Z 293.89 Unspecified catatonia
— 298.8 Other specified schizophrenia spectrum and other psychotic disorder
— 298.9 Unspecified schizophrenia spectrum and other psychotic disorder
CHAPTER 6 Nursing Management of Patients with Schizophrenia... 195

Epidemiology: It will appear in early adolescence or early Flowchart 6.2: Symptoms of schizotypal disorder
adulthood. Onset may occur anytime throughout the life span.
Average age of onset is around 30 years of age.
Recovery and prognosis: Recovery is within 3 months and
prognosis is usually better than schizophrenia. It does not
fulfill the criteria of schizophrenia so it is categorized as acute
transient psychotic disorders.
Rating scale: Rating scale used for the assessment was
Clinician-rated dimensions of psychotic symptoms severity.
It is 5-point Likert scale with 8 domains such as hallucination,
delusion, disorganized speech, negative symptoms, mania,
depression, impaired cognition and abnormal psychomotor
behavior. patient’s behavior is understood well based on delusions. More
often social and occupational life is not affected.
Peculiar Clinical Features The peculiar clinical features are as follows:
• Types of hallucinations and delusions are seen which are • Duration: Persistent delusions at least for 1 month are
found variable in terms of intensity and nature. longer.
• Marked emotional fluctuations from extreme happiness, • Not prominent hallucinations may be related to the
sadness, irritability and anxiety. delusional theme (sensation of being infested with the
insects might be associated with delusions of infestation).
Specification of Subtypes • No mood disorders, schizophrenia and organic brain
• First episode or multiple episodes disorders.
• Full remission or partial remission • Apart from the impact of the delusion, functioning is not
• Currently symptomatic markedly impaired and behavior is not bizarre or odd
• Unspecified obviously.
• Disturbances is not due to another mental disorder or
Schizotypal (Personality) Disorder medical condition or due to substance abuse/withdrawal.
It is characterized by an enduring pattern (i.e., characteristic • If there is a manic or major depressive episode, it is brief
of the individual’s functioning over several years) of relative to the duration of delusional period.
eccentricities in the behavior, appearance and speech, which Types of delusional disorder on the basis of central theme of
is accompanied by the unusual beliefs, cognitive distortions, delusions have been given in Table 6.5.
perceptual distortions, often having a reduced capacity Specify if it is:
for the interpersonal relationships. The symptoms include • First episode or multiple episodes.
the paranoid ideas, ideas of reference, or other psychotic • Currently in acute or chronic episode.
symptoms including hallucinations in any modality, may occur • Currently in partial or full remission.
(positive schizotypy), and constricted or inappropriate affect, • Continuous presence of symptoms during the course of
anhedonia (negative schizotypy), but are not of sufficient illness: Present/absent.
intensity or duration to meet the diagnostic criteria of • Severity of symptoms: Very severe/moderate/less severe.
schizophrenia, schizoaffective disorder, or delusional disorder. • Mixed type: Lack of any one predominant delusional
The symptoms might cause the significant personal distress theme.
or significant impairment in the personal, family, social, • Unspecified: Dominant delusional belief not be clearly
educational, occupational or other vital areas of functioning determined with any specific type.
(Flowchart 6.2).
Brief Psychotic Disorder
Delusional Disorder Presence of one or more symptoms such as delusions,
Delusions are well systematized and non-bizarre type stable hallucinations, disorganized speech, grossly disorganized or
and chronic in nature. Patient is not able to differentiate catatonic behavior. The duration of an episode of disturbance is
between real and imaginary things. Emotional response and at least 1 day but less than 1 month, with the eventual full return
196 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 6.5: Delusional disorder on the basis of central theme of delusions

Types of delusional Description Example

disorder on the basis of
central theme
Erotomanic type Another person is in love with the Patient verbalizes that, ‘Actor is having love desire toward me’
individual
Grandiose type Conviction of having some great or talent Patient verbalizes that, ‘I am the god’
or having made some vital discovery
Jealous type Spouse or lover is not faithful Patient verbalizes that, ‘My wife is having a love with other guy’
Persecutory type Individual is being cheated, followed, Patient verbalizes that, “My friend is having a plan to kill me”
spied on, poisoned or drugged, harassed
etc.
Somatic type It involves bodily functions or sensations Patient verbalizes that, ‘I feel sound of running water in my
stomach’
With bizarre content Delusions are clearly not understandable Individual strongly believes that a stranger has removed one’s
and not derived from ordinary life internal organs and replaced the same with other without any
experiences scar in the body

toward the premorbid level of functioning. This disturbance is „ Absence of blunted or flat affect.
not well explained by the major depressive or bipolar disorder • Without good prognostic features: Two or more of the
with psychotic features or other psychotic disorder such as above features are absent.
schizophrenia or catatonia, and is not attributable due to the • With catatonia
influence of a substance or any other medical condition. • Specify current severity: Clinician-rated dimensions of
Specify this diagnosis if it is: psychosis symptom severity scale.
• With (brief reactive psychosis) or without stressors
• With postpartum onset (onset is during pregnancy or Schizoaffective Disorder
within 4 weeks’ postpartum) or
• With catatonia. Symptoms: It has both symptoms of schizophrenia and
mood disorders which are prominently seen in same episode.
Schizophreniform Disorder (Schizo + Affective = Schizophrenic symptoms + Mood
symptoms). Mood symptoms may be mania, depression or
Duration of the episode: This is a mental disorder, diagnosed
mixed mania and depression.
when symptoms of schizophrenia are at least 1 month but less
than 6 months. Prognosis: good.
Symptoms: At least one of the following symptoms such as Treatment: Injection lorazepam (IV) and electroconvulsive
delusions, hallucinations, disorganized speech (e.g., frequent therapy.
derailment or incoherence), grossly disorganized or catatonic
Specify if it is:
behavior, negative symptoms (i.e., diminished emotional
• Bipolar type: Manic episode is part of the presentation.
expression or avolition). This symptom is not a manifestation
Major depressive episodes may also occur.
of another health condition or due to influence or withdrawal
• Depressive type: Major depressive episode is part of the
of any substances.
presentation.
Specify if it is:
• With good prognostic features: Presence of at least two of • With or without catatonia.
the features: • First episode or multiple episodes.
„ Onset of prominent psychotic symptoms within • Full remission (a period of time after a previous episode
4 weeks of the first noticeable change in usual behavior during which no disorder-specific symptoms are present)
or functioning. or partial remission (a time period during which an
„ Confusion or perplexity improvement after a previous episode is maintained and
„ Good premorbid social and occupational functioning in which the defining criteria of the disorder are only
and partially fulfilled).
CHAPTER 6 Nursing Management of Patients with Schizophrenia... 197

Psychotic Disorder due to Another Mental Symptoms: Table 6.6 (3 or more following symptoms should
Disorder be present as per DSM-5 criteria).
It may be diagnosed in the context of certain mental
There will be presence of prominent hallucinations or delusions
disorders: Schizophrenia, mood disorders and autism
with the clear diagnostic evidence states it is due to the direct
spectrum disorder.
pathophysiological consequence of another mental disorder.
Potential risk of catatonia: Malnutrition, Hyperpyrexia,
This disturbance causes clinically significant personal distress
Exhaustion, self-inflicted injury and harming others
and impairment in social, occupational or other vital areas of
Specify if it is:
functioning.
• Associated with another mental disorder.
• Due to another medical condition.
Psychotic Disorder due to Another Medical
• Induced by psychoactive substances, including
Condition
medications.
There will be presence of prominent hallucinations or delusions • Unspecified (full criteria for the catatonia not met or due
with the clear diagnostic evidence states it is due to the direct to insufficient information to have a specific diagnosis—
pathophysiological consequence of another medical condition. for example, patient admitted in emergency room
The disturbance is not better explained by another mental situations).
disorder and does not occur during the course of a delirium.
This disturbance causes clinically significant personal distress Other Specified Schizophrenia Spectrum and
and impairment in social, occupational or other vital areas of Other Psychotic Disorder
functioning.
Symptoms of a schizophrenia spectrum and other psychotic
Specify if it is:
disorder which cause significant distress or impairment in
• With hallucinations social, occupational functioning but do not meet full criteria
• With delusions. for any of disorders in the schizophrenia spectrum and other
psychotic disorders. When there is presence of specific reason
Catatonia
for the presentation such as:
It is a marked disturbance in the voluntary control of • Persistent auditory hallucinations happen in the absence
movements which is characterized by extreme slowness or of other features.
absence of motor activity, purposeless motor activity unrelated • Delusions with predominant overlapping mood episodes.
to external stimuli, mutism, maintenance of rigid or unusual • Attenuated psychosis syndrome: Psychotic-like symptoms
or bizarre postures, resistance to the instructions or attempts below a threshold for full psychosis (symptoms are less in
to be moved, or automatic compliance with instructions. severity, transient and presence of insight).

Table 6.6: Symptoms of catatonia

Symptoms of catatonia Description

Stupor Absence of psychomotor activity or not actively relating to environment
Catalepsy Passive induction of a posture held against gravity
Waxy flexibility Slight, even resistance to positioning by examiner
Mutism Absence or very little verbal response (exclude if there is known aphasia)
Negativism Opposition or no response to the instructions or external stimuli
Posturing Spontaneous and active maintenance of a posture against gravity
Mannerism Odd, circumstantial caricature of normal actions
Stereotypy Repetitive abnormally frequent non-goal-directed movements
Echolalia Mimicking another’s speech
Echopraxia Mimicking another’s movements
Grimacing Fixed facial expression
Agitation A sense of excitement which is not influenced by external stimuli
198 Textbook of Psychiatric Nursing for BSc Nursing Students

• Delusional symptoms present in the individual with PSYCHOSOCIAL INTERVENTIONS

delusional disorder.
Psychosocial interventions for schizophrenia have been given
Unspecified Schizophrenia Spectrum and Other in Table 6.8.
Psychotic Disorder Table 6.8: Psychosocial interventions for schizophrenia
Symptoms of a schizophrenia spectrum and other psychotic
Psychosocial Description
disorder which cause significant distress or impairment in interventions
social, occupational functioning but do not meet full criteria for
for any of disorders in the schizophrenia spectrum and other schizophrenia
psychotic disorders. When there is presence of insufficient Psychoeducation • Regarding the nature and course of
information to make a more specific diagnosis (for example, in schizophrenia
emergency room settings). • Treatment of schizophrenia
Social skills • Patient with negative symptoms of
PROGNOSIS OF SCHIZOPHRENIA training schizophrenia will have lack of social skills
• Social skills such as maintaining eye to
eye contact, shaking hands with others,
The prognosis of schizophrenia is given in Table 6.7.
making ward rounds, social interaction
Table 6.7: Prognosis of schizophrenia with others are said to be implied
Cognitive Cognitive deficits such as lack in attention/
Aspects Good prognosis Poor prognosis training/Cognitive concentration/memory should be targeted
Onset Acute/abrupt Insidious remediation and appropriate training should be provided
to improve it
Age of onset Late Early
Supportive Promotion of vocational guidance and
Duration <6 months >2 years
employment placement in a right job helps the client to
Episode First episode Previous history or Vocational cope up with the situation well
of schizophrenia rehabilitation
Gender Female Male Token economy • Acts as a positive reinforcement in case
Stressor Absent Present of desired positive behavior
• One token will be issued for one desirable
Depression Absent Present positive behavior
Symptoms Positive symptoms Negative • If a number of tokens have been collected
symptoms by a patient, then a particular gift can be
provided to motivate the client
Social support Good Poor
Family Steps taken to avoid ‘Expressed Emotions’
Types Acute catatonia Disorganized,
interventions in family (i.e., to avoid critical comments,
(Paranoid has undifferentiated
hostile behavior and high emotional
intermediate and simple
involvement)
prognosis)
Psychosocial • Research data states that tablet
Relapse of Absent Present weight Olanzapine might cause increase in
symptoms management weight up to 5 kg within 1 week
Drug adherence Present Absent • Even other antipsychotics might increase
the weight
Nature of Outpatient basis/ Inpatient/
• So, balanced high fiber diet has to be
treatment community based hospitalization
maintained
CT scan Normal Enlargement of
Interventions to • Important cause of relapse of symptoms
ventricles
enhance drug is drug nonadherence
Premorbid Good Poor compliance • So, education in regard to drug
functioning compliance is needed

Antipsychotics: Discussed in Chapter 5.

CHAPTER 6 Nursing Management of Patients with Schizophrenia... 199

TREATMENT NURSING INTERVENTIONS

Psychotherapy for Schizophrenia • Disturbed thought process related to neurochemical

factors as evidenced by delusion of persecution
Individual psychotherapy, group psychotherapy, supportive
psychotherapy and cognitive behavior therapy are the first line Nursing interventions Rationale
of treatment which should be started in the patient’s suffering Assess the intensity, content, To obtain baseline data about
from schizophrenia. frequency and duration of delusion
delusion
Treatment-Resistant Schizophrenia Assess the environmental To reduce the environmental
Clozapine is a drug of choice for the treatment of resistant triggering factors triggering factors
schizophrenia. If it fails, it can be treated with amisulpride, Communicate with client Since the client is having
calmly and gently suspiciousness therefore,
risperidone, aripiprazole, lamotrigine, topiramate, benzodia-
he/she might have fear of
zepines, depot preparations and antidepressants (for negative everything
symptoms) (Fig. 6.8).
Avoid arguing about delusion Argument about delusion
might put the delusion
Repetitive Transcranial Magnetic Stimulation stronger
In this noninvasive technique, changing magnetic field is Monitor the client carefully Clients with delusions might
used to cause electric current to the brain (specific area) harm to self and others
through electromagnetic induction. It is a brain stimulation Encourage the client to To reduce the stress
technique and is mainly used to treat depression when ventilate the distressing
thoughts
applied in prefrontal cortex. However, research evidence
suggests auditory hallucination reduces when applied in Encourage the client for group To promote self-esteem
activities
temporoparietal cortex.
Educate the client and To enhance the drug
caregivers regarding the adherence and to prevent the
Assertive Community Treatment and Intensive importance of psychotropic relapse of symptoms
Psychiatric Rehabilitation drugs
Assertive community treatment is defined as group of Do’s To promote trust
psychiatric health team workers joins together to render the • Assign the same staff for
taking care of the patient
care to mentally ill patients in a community setup and they do
• Be truthful to the client
regular follow-ups to promote the holistic mental well-being • Be assertive with patient
of patients. Don’ts
Intensive psychiatric rehabilitation is defined as the • Touch the client
structured measures taken for the promotion of mental health unnecessarily
• Laughing, murmuring or
of the person (he/she) before the onset of mental illness.
whispering in front of client

• Disturbed sensory perception related to genetic or

biochemical factors as evidenced by hallucinatory
behavior

Nursing interventions Rationale

Assess the intensity, content, To obtain baseline data about
frequency, duration and type hallucination
of hallucination
Ask the client, ‘What the voices To explore whether the
saying to you?’ commanding voices will cause
any harm to the patient or not
Avoid arguing about Argument about hallucination
Figure 6.8: Medications for the treatment-resistant hallucination might put the hallucination
schizophrenia stronger
Contd…
200 Textbook of Psychiatric Nursing for BSc Nursing Students

Nursing interventions Rationale Nursing interventions Rationale

Identify the triggering factors To reduce the severity of Assess the nutritional status of To obtain the baseline data
hallucination the patient
Interrupt the hallucination by It helps to divert the patient Monitor the food intake It provides a pathway of
diverting or calling the patient from hallucination regularly continuous assessment
Encourage the client to It helps to deal the If client is suspicious about It helps to decrease the
say ‘stop’ or ‘go away’ or hallucination effectively the food is poisonous, ask the suspiciousness
whistle slowly to dismiss the client himself/herself to get
hallucination the food from shop
Educate the client regarding It helps to improve the health
• Social isolation related to negative symptoms of the nutritious diet status
schizophrenia as evidenced by social withdrawal Provide the menu plan to the Guide the client to eat the food
patient at proper time
Nursing interventions Rationale
Provide food that the client Motivate the client to eat
Convey the acceptance To promote the feeling of self- likes
attitude to the patient worth
Involve the client for group To enhance social skills • Risk of violence related to command hallucination as
activities
evidenced by destruction of nearby objects
Promote positive reinforcement To motivate the client to
if the client performs voluntary perform task Nursing interventions Rationale
interaction to others Observe the client carefully To obtain baseline data
Provide social skills trainings To improve social skills and frequently
such as maintaining eye Remove the sharp and To ensure the client’s safety
contact while interacting, dangerous objects from the
shaking hands, talking in polite client’s room
way, providing a leadership
role, etc. Provide scheduled daily To make the client being
activities to patient committed with daily activities
• Self-care deficit related to cognitive impairment or lack Provide physical restraints to Restraints prevent harm to
the client. Check the distal oneself and also to others.
of trust or anxiety as evidenced by inability to do the
pulse rate and color of skin Monitoring pulse and skin
tasks such as bathing, grooming, eating, toileting and every 15 minutes once color will ensure the proper
sleeping blood circulation
Encourage the client to To reduce the aggression
Nursing interventions Rationale
ventilate the distressing
Assess the patient ability to To obtain baseline data thoughts
perform the self-care activities
Administer relaxation therapy To reduce the stress
Assist the client to perform To promote the comfort and
Redirect the violent behavior To redirect the violence into
self-care activities safety
into physical outlet. For fruitful activity
Encourage the patient Helps to promote the behavior example, involve the patient in
to perform the task by motivation outdoor sports
independently
Demonstrate the activities Helps to guide the client how • Impaired verbal communication related to unrealistic
need to be performed in to perform the task step by thoughts as evidenced by flight of ideas
simple steps step
Allow enough time to perform Patient might take more time Nursing interventions Rationale
the self-care activities due to shorter attention span Use therapeutic techniques Helps to have clear
Withdraw the assistance It promotes the sense of of communication, e.g., communication between nurse
gradually and supervise the independence clarification—can you clarify it and patient
patient’s self-care activities still better
Assign the staff nurse Promote empathy and
• Ineffective health maintenance related to poor dietary consistently with the patient verbalize the feeling to the
intake or lack of trust or suspiciousness that food is who feels reluctant to talk with nurse after gaining trust
poisonous as evidenced by significant loss of weight other staff nurse
Contd…
CHAPTER 6 Nursing Management of Patients with Schizophrenia... 201

Nursing interventions Rationale the psychotic symptoms so necessary psychoeducation has to

be given to the family members. Patient has to be motivated for
Talk in a simple language It will help the client to
understand properly the right behavior and family members should not express the
negative emotions about patient.
Motivate the client to talk to It will help the patient to
other patients improve the communication
skills Rehabilitation of Patient with Schizophrenia
The term ‘Rehabilitation’ denotes restoring the health status of
• Ineffective family coping related to conflicts among mentally ill individuals as early as possible. Nurses can refer
family members, impaired communication among to the self-help group or rehabilitative centers in order to
family members and more concern on illness promote mental health of patient and to prevent the relapse
Nursing interventions Rationale of psychotic symptoms. The rehabilitative services are as
follows:
Assess the communication To have a baseline data
pattern, conflicts and importance • Day hospitals
of patient among family • Half-way homes
members • Long-term homes
Give psychoeducation to the It will help to reduce the • Occupational therapy
family members regarding the problems among family • Social skills training
treatment process and prognosis members • Monetary management skills
Educate the family members that Helps to promote the unity • Recreational therapy
the conflicts occurring in your among them • Cognitive training
family will affect prognosis of the
patient
Facilitate the proper Useful to prevent the issues EXTRA EDGE
communication among family among family members
ICD-10 Classification of Schizophrenia
members
• F20.0: Paranoid schizophrenia
• F20.1: Hebephrenic schizophrenia
GERIATRIC CONSIDERATIONS • F20.2: Catatonic schizophrenia
• F20.3: Undifferentiated schizophrenia
• F20.4: Post-schizophrenic depression
Late-onset schizophrenia (onset after 45 years of age)
• F20.5: Residual schizophrenia
characterized by paranoid ideations along with varying degrees • F20.6: Simple schizophrenia
of impairment can be observed in older patients. Psychosis • F20.8: Other types of schizophrenia
in elderly may be comorbid with depression or dementia. • F20.9: Schizophrenia, unspecified
Antipsychotics and psychotherapy will be helpful for elders to
reduce the psychotic symptoms.
EXTRA EDGE
FOLLOW-UP, HOME CARE AND REHABILITATION Types of Schizophrenia
OF PATIENTS WITH SCHIZOPHRENIA Paranoid Schizophrenia
It is most common type of schizophrenia. Onset is late and has
Follow-up of Patients with Schizophrenia good prognosis. Personality is said to be preserved, i.e., client
is able to perform activities of daily living (ADLs) and has good
Regular follow-up by the psychiatric nurse is found vital to
social interaction. Hallucination, delusion and thought disorders
prevent the relapse of psychotic symptoms. Follow-up can be are peculiarly seen. Examples of hallucinatory themes are
done either by home visits or through telephone to provide the commenting, arguing, threatening, body sensations/movements.
necessary guidance and counseling to the patient and family Examples of thought disorders are irrelevant, incoherent and
members. Proper documentation of follow-up helps the nurse neologisms in speech. Prognosis is good in case of earlier
treatment. Minimal deterioration of personality is seen.
to promote the quality nursing care.
Examples of delusional themes are persecution, grandiose,
jealousy and reference.
Home Care of Patients with Schizophrenia
• Delusion of persecution means patient having strong
Taking care of patients in home settings will promote the suspiciousness of being cheated, poisoned, spied on,
mental health in far better way. Family members have to harassed, etc.
understand that negatively expressed emotions might provoke
Contd…
202 Textbook of Psychiatric Nursing for BSc Nursing Students

• Delusion of reference denotes that the irrelevant or Undifferentiated Schizophrenia

innocent events happen in the surroundings refer to oneself. Schizophrenia not conforming any subtypes will come under the
For example, patient believes that others are talking about category of undifferentiated schizophrenia.
him/her. Postschizophrenic Depression
• Delusion of jealousy means unfaithfulness with individual’s Depressive episode develops after the resolution of schizophrenic
sexual partner. symptoms in post-schizophrenic depression. Patient might be at
• Delusion of grandiosity means irrational ideas in regard to high suicidal risk.
talent, power or knowledge.
Schizophreniform Disorder
Hebephrenic or Disorganized Schizophrenia Features of schizophrenia are present, but when the duration
Behavior is aimless and not goal directed in hebephrenic is less than 6 months then it is labeled as schizophreniform
schizophrenia. Hallucinations and delusions are not prominent. disorder.
Inappropriate and incongruent affects are seen. Speech is Pseudoneurotic Schizophrenia
incoherent. Early and insidious onset is associated with poor Hoch and Polatin explained this type. Prominent neurotic
premorbid personality. symptoms are present in initial phase. Classical triad of
Catatonic Schizophrenia pseudoneurotic schizophrenia includes pan-anxiety, pan-neurosis
Motor symptoms are present predominantly. Types of catatonic and pan-sexuality as explained in Figure 6.9. Pan-anxiety denotes
schizophrenia are stuporous, excited and periodic are explained free floating anxiety which will not subside easily. Pan-neurosis
in Flowchart 6.3. Prognosis is good. Treatment includes injection includes the predominant neurotic symptoms. Pan-sexuality
lorazepam (IV) and electroconvulsive therapy. denotes that patient with pseudoneurotic schizophrenia is
preoccupied with sexual desires.
Simple Schizophrenia
Simple schizophrenia shows prominent negative symptoms of Pfropf Schizophrenia
schizophrenia such as amotivation, apathy, social withdrawal, It occurs with the presence of mental retardation. Behavior
flat or blunt affect and poverty of speech. Positive symptoms disturbance is more prominent than thought disorder. It differs
are absent. Social functioning gets reduced. Onset is early and from schizophrenia due to unsystematized delusions and poverty
insidious. Course is progressive. Prognosis is worst. of ideation.

Residual Schizophrenia Van Gogh Syndrome

Progression is from early stage (hallucination and delusions Self-mutilation or self-injurious behavior is seen in this type of
are predominant) to late stage (hallucination and delusions are schizophrenia. Van Gogh was a famous painter, he cuts his ear in
minimal). Negative symptoms are present. state of acute illness and hence this term is named after him.

Flowchart 6.3: Types of catatonic schizophrenia

Contd…
CHAPTER 6 Nursing Management of Patients with Schizophrenia... 203

after attack and polymorphous symptoms. Remission takes place

within 3 months even without any treatment. It occurs mainly due
to consequences of urbanization and westernization.
According to ICD-10, required duration to diagnose schizophrenia
is given in Table 6.10.
Table 6.9: Type I and type II schizophrenia

Aspects Type I Type II

schizophrenia schizophrenia
Symptoms Positive symptoms Negative symptoms
Course of illness Acute Chronic
Cognitive deficit Absent Sometimes present
Ventricles Normal Dilated
Figure 6.9: Classical triad of pseudoneurotic schizophrenia
Response to drugs Good Poor
Late Paraphrenia Prognosis Better Poor
Sir Martin Roth explained this type. Onset is too late. It is common Table 6.10: Required duration to diagnose schizophrenia as per
in unmarried or widow women. Delusion of persecution with ICD-10
bizarre/fantasy is present. Visual, auditory, olfactory, gustatory
and tactile hallucinations are seen. Types of schizophrenia Duration
Oneiroid Schizophrenia Paranoid schizophrenia 1 month
Mayer-Gross explained this type. Onset is acute and usually
the episode is brief. Term ‘Oneiroid’ means ‘dream’ so client Hebephrenic or Disorganized 1 month
remains in dream like state. Symptoms are such as clouding of schizophrenia
consciousness, perceptual disturbances and disorientation. Catatonic schizophrenia ½ month or 2 weeks
Type I and Type II Schizophrenia Simple schizophrenia 12 months
TJ Crow is classified schizophrenia as type I and type II. Symptoms,
course of illness, cognitive deficit, condition of ventricles, Induced Delusional Disorder or Shared Psychotic Disorder
response to medications and prognosis of type I and type II are An uncommon delusional disorder in which the delusions have
explained in Table 6.9. been shared between two individuals due to the emotional
bonding is termed folie à deux. If those persons got separated
Bouffée Délirante then the dependent individual might be free of the delusions.
It is a French term for ‘short-lived psychosis’. It is mainly So, the individual with true delusions has to be treated properly
characterized by hallucination, delusion, confused state, amnesia (Fig. 6.10).

Figure 6.10: Concept map to understand induced delusional disorder

SUMMARY
• Schizophrenia is a psychotic disorder (disorder in which the client believes that he/she not have a basis of reality) characterized by
abnormalities in emotion, thinking and cognition.
• 6A20 is ICD-11 code and 295.90 is DSM-5 code for schizophrenia.

Contd…
204 Textbook of Psychiatric Nursing for BSc Nursing Students

• Dopamine pathways are mesolimbic, mesocortical, tuberoinfundibular and nigrostriatal.

• 4 A’s of schizophrenia by Bleuler are autistic thinking, ambivalence, affect is inappropriate and associative looseness.
• Positive symptoms of schizophrenia are hallucination, delusion, disorganized thoughts and bizarre behavior.
• Negative symptoms of schizophrenia are anhedonia, alogia, affect (flat), avolition and attention (poor).
• Kurt Schneider’s first-rank symptoms of schizophrenia are three auditory hallucinations, three thought phenomenon or thought
alienation phenomenon, three made phenomenon, somatic passivity and delusional perception.
• Other psychotic disorders are delusional disorder, acute and transient psychotic disorder, schizotypal (personality) disorder, brief
psychotic disorder, schizoaffective disorder (bipolar or depressive type), schizophreniform disorder, psychotic disorder due to another
medical condition (with delusions or hallucinations), catatonia associated with another mental disorder, catatonia induced by
psychoactive substances, including medications, unspecified catatonia, other specified schizophrenia spectrum and other psychotic
disorder and unspecified schizophrenia spectrum and other psychotic disorder.
• The rehabilitative services are day hospitals, half-way homes, long-term homes, occupational therapy, social skills training, monetary
management skills, recreational therapy and cognitive training.

ASSESS YOURSELF
Long Answer Questions 4. ICD-11 code for schizophrenia is ________.
1. Explain the types, etiology, psychopathology, diagnosis, a. 6A20 b. 5A20
clinical manifestations and management of patients c. 5A21 d. None of these
with schizophrenia. 5. Most common type of hallucination in psychiatric
2. Explain the types, etiology, psychopathology, diagnosis, disorders is ________.
clinical manifestations and management of patients a. Visual b. Auditory
with catatonia.
c. Tactile d. Olfactory
Short Answer Questions 6. Schizophrenia occurs due to __________ in dopamine
1. Define schizophrenia. level.
2. Define catatonia. a. Increased
b. Decreased
Short Notes c. Neither increase nor decrease
Write short notes on: d. Fluctuate
1. First-rank symptoms of schizophrenia 7. Which of the following are positive symptoms of
2. Delusional disorder schizophrenia; except:
3. Nursing interventions of patient with schizophrenia a. Hallucination b. Delusion
4. Etiology of schizophrenia c. Anhedonia d. Disorganized thoughts
5. Clinical features of schizophrenia
6. Psychosocial interventions of schizophrenia 8. Drug of choice for treatment-resistant schizophrenia
7. ICD-11 classification of schizophrenia is:
8. ICD-11 and DSM-5 diagnostic criteria of schizophrenia a. Haloperidol b. Risperidone
c. Clozapine d. Olanzapine
Multiple Choice Questions 9. Thought has been removed by an external source
1. Who first coined the term ‘schizophrenia’? means:
a. Eugen Bleuler b. Emil Kraepelin a. Thought insertion b. Thought withdrawal
c. Sigmund Freud d. None of the above c. Thought broadcasting d. None of these
2. Which dopamine pathway constitutes 80% of brain 10. Peculiar symptom identified in mental status
dopamine? examination among patients with schizophrenia is:
a. Mesolimbic b. Mesocortical
a. Delusion b. Delirium
c. Nigrostriatal d. Tuberoinfundibular
c. Sundowning syndrome d. Cogwheel rigidness
3. Which dopamine pathway might cause
hyperprolactinemia? Answer Key
a. Mesolimbic b. Mesocortical 1. a 2. c 3. d 4. a 5. b
c. Nigrostriatal d. Tuberoinfundibular 6. a 7. c 8. c 9. b 10. a
 CHAPTER
Nursing Management of
Patients with Mood Disorders 7
LEARNING OBJECTIVE

After studying this chapter, the student will be able to gain knowledge regarding mood disorders in order to render the nursing care
of patient with mood disorders.

CHAPTER OUTLINE
• Introduction • Nursing Management
• Mood Disorders—Meaning/Definition • Nursing Diagnosis and Interventions
• Diagnostic Criteria for Bipolar I Disorder • Depression
• Diagnostic Criteria for Bipolar II Disorder • Classification of Depressive Disorders
• Diagnostic Criteria for Cyclothymic Disorder • Diagnostic Criteria for Depressive Disorder
• Lithium • Persistent Mood Disorder
• Treatment of Bipolar Disorder • Geriatric Considerations

KEY TERMS
Mood, Affect, Bipolar affective disorder, Depression, Mania, Euphoria, Elation, Exaltation, Ecstasy, Dysthymia, Cyclothymia, Euthymia,
Hypomania, Delirious mania, Lithium toxicity, Endogenous depression, Exogenous depression, Involutional melancholia, Seasonal
affective disorder, Social skill training, Antidepressants, Mood stabilizers, Electroconvulsive therapy (ECT), Light therapy (or)
Phototherapy.

INTRODUCTION with others. Before studying mood disorders, it is better to

know the differences between mood and its affect, definitions
Mood is a persistent and sustained emotional feeling. It is not and meaning.
triggered by a particular experience or event. Mood can be
affected by different factors, including fatigue, stress, social MOOD DISORDERS—MEANING/DEFINITION
interactions, world events, hormones, weather, hunger, and
general health. It is also known as ‘affective disorders’. It is classified as unipolar
Mood can leave its impact on different aspects of life, disorder (Depression) and bipolar disorder. In depression,
including how people think, feel, and behave. These affective client may experience one or more episodes of low level of
states can affect motivational levels and decision-making. mood known as unipolar disorder. In bipolar disorder, client
They can also affect relationships and how people interact may experience:
206 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 7.1: Concept of mood and affect

Aspects Mood Affect

Meaning It is a sustained and persistent emotional feeling It is outward expression feelings
Comparable with Climate (being persistent) Weather (Keep changing)
Types • Flat affect—No emotional expression
• Constricted or restricted affect-reduction in the
individual’s emotional response
• Blunt/shallow affect—Lack of affect is more severe
than constricted or restricted affect but less severe
Elevated mood can range from mild to very severe than flat affect
state as mentioned below. • Labile affect (or) Pseudobulbar affect (PBA) (or)
(Refer to Table 7.5) Involuntary Emotional Expression Disorder (IEED)—
Emotional incontinence, i.e., immediate and urge in
expression of emotions
• Affect which is appropriate to mood (or) affect which
is not appropriate to mood
• Affect which if congruent (or) noncongruent to
thought

• Both the low mood (depression) and elevated mood Incidence and Prevalence
(Mania or hypomania).
• Age: Onset is usually at 25 years of age in bipolar disorder.
• Two or more episodes of elevated mood (Mania or
• Gender: Mania and depression both are more common in
hypomania).
females. First episode as depression is common in females
Concept of mood and affect is listed in Table 7.1 and continuum and first episode as mania is common in men. As per the
of affect (Continuum ranges from no emotion expression to National Mental Health Survey Report, conducted by
emotional incontinence) is shown in Figure 7.1. It also exhibits National Institute of Mental Health and Neurosciences
explanation of flat affect, constricted affect, blunt affect and (NIMHANS), Bengaluru in 2016 explored the life
labile affect. time prevalence rate of Mood disorders: (Male—5.19,
Female—6.00); Bipolar Affective disorder (Male—0.58,
History Female—0.42); and Depressive disorder (Male—4.75,
Hippocrates coined the term ‘Mania’ and ‘Depression’. He Female—5.72). This report also states that the prevalence
identified that mania and depression can occur in the same rate of mood disorders in urban metro cities is double
individual. Emil Kraepelin classified psychiatry as dementia than the prevalence rate in rural area.
praecox and manic-depressive psychosis. King Saul found • Sociocultural: Incidence is high among unmarried
that hearing music will help the individual to recover from individuals.
depression. Onset, gender and prevalence of bipolar and cyclothymic
disorder have been depicted in Table 7.2.
Comorbid illness of mood disorders has been shown in
Flowchart 7.1.
Table 7.2: Onset, gender and prevalence of bipolar and cyclothymic
disorder

Aspects Onset Gender Prevalence

(Approx.) (%)
Bipolar I type Males = Females 0.1
25 years
Bipolar II type Females > Males 0.5
Cyclothymic Males = Females 0.4–1.0
18–25 years
Figure 7.1: Continuum of affect disorder
CHAPTER 7 Nursing Management of Patients with Mood Disorders 207

Flowchart 7.1: Comorbid illness with mood disorders Flowchart 7.2: Types of bipolar disorder

ICD-11 and DSM-5 Classification of bipolar related disorders

has been shown in Table 7.4

Stages of Mania
Duration required for the diagnosis of mood disorder has been Stage I—Hypomania
depicted in Table 7.3. Stage II—Acute mania
Table 7.3: Duration of the persisting symptoms required for Stage III—Delirious mania
diagnosis of mood disorder as per DSM-5
Hypomania
Disorder Duration of the persisting
symptoms required for diagnosis of The mood disorder in which symptoms are not severe to cause
mood disorder as per DSM-5 significant impairment in social or occupational functioning is
Hypomanic episode 4 days known as hypomania. Psychotic features are absent.
Manic episode 1 week
Acute Mania
Depressive episode 2 weeks
When intensified manic symptoms are present in a patient,
Cyclothymia 2 years
the disorder is known as hypomania and if patient requires
Dysthymia 2 years hospitalization it is known as acute mania. It is characterized
by euphoria (or) elation, frequent mood variation, thinking
Bipolar Disorder that may have psychotic features, raised sexual interest with
Either of two poles consists of mania or hypomania in one pole poor control of impulse, high energy level and the patient may
and depression on opposite pole (Flowchart 7.2). deny grooming.

Table 7.4: ICD-11 and DSM-5 classification of bipolar related disorders

ICD-11 DSM-5 Bipolar and related disorders

Bipolar I disorder
— 296.41 Current or most recent episode manic (Mild)
— 296.42 Current or most recent episode manic (Moderate)
— 296.43 Current or most recent episode manic (Severe)
6A60.5 296.44 Current or most recent episode manic (With psychotic features)
6A60.B 296.45 Current or most recent episode manic (In partial remission)
6A60.F 296.46 Current or most recent episode manic (In full remission)
6A60.E 296.40 Current or most recent episode manic (Unspecified)
Bipolar II disorder
6A61 296.89 Bipolar II disorder
6A62 301.13 Cyclothymic disorder
6A6Y 296.89 Other specified bipolar and related disorder
6A6Z 296.80 Unspecified bipolar and related disorder
208 Textbook of Psychiatric Nursing for BSc Nursing Students

• Thought
„ Grandeur (strong unshakable belief that client has
acquired a supreme power)
„ Persecution (suspiciousness)
„ Mood congruent psychotic features: Grandiose
delusion is present. In auditory hallucination, patient
might hear voices verbalizing that the patient has
supreme power.
„ Mood incongruent psychotic symptoms: Delusion of
persecution, delusion of reference and voices heard in
auditory hallucinations might be telling that, ‘you are
Figure 7.2: Classical triad of mania unworthy and deserve punishment’, i.e., the patient is
in manic episode, but the psychotic symptoms elicited
Delirious Mania are not congruent with the patient’s mood.
Severe clouding of consciousness with confusion or „ Hallucinations (Auditory and visual)
disorientation or stupor, extreme labile mood, delusion with • Speech: Mental status examination reveals the flight of
grandiosity or religiosity or persecution, auditory or visual ideas that leads to incoherence (rapid shift from one idea
hallucinations, increased psychomotor activity which has risk to other) and increased pressure of speech (Flight of ideas
of harming to self or others. If left untreated, death may occur. without pressure is termed prolixity).
Classical triad of mania has been given in Figure 7.2. • Perception: Raised perceptual sensitivity can be seen in
patients such as hyperacusis (Little sounds has been heard
Types of Bipolar and Related Disorders in higher volume) and seeing vivid colors.
• Bipolar I disorder (current or recent manic episode)— • Miscellaneous: Patient will have decreased need for sleep
mild or moderate or severe; with or without psychotic and absence of insight. There is no relation with any
features; full or partial remission or unspecified. organic cause. Patient will have a severe interference in
• Depressive episode. personal functioning and sometimes exhibit irresponsible
• Bipolar II disorder—cyclothymic disorder, other specified behavior, e.g., spending too much of money for
disorder and Unspecified disorder. unnecessary things.

Comparison of hypomania and mania is given in Table 7.5. Etiology of Mood Disorders
Table 7.5: Comparison of hypomania and mania Neurotransmitter
Aspects Hypomania Mania Levels of norepinephrine, serotonin and dopamine are found
Duration of symptoms 4 days >1 week to be decreased in depression and increased in mania as shown
Psychotic features Absent May or may not
in Figure 7.3.
Social and occupational Absent Present Biopsychosocial Factors
dysfunction
Biological causes include imbalance in neurotransmitters and
Insight into illness Present Absent
hereditary factors (Primary relatives with mood disorders
Manic Episode (Table 7.5) and monozygotic twins). The psychological causes are
hopelessness, helplessness and worthlessness. Social causes
• Persistent elated, expansive (non-stop and unselective
are social pressure, stressful life events, loss of loved ones and
high-level enthusiasm to interact with others) and
social isolation as shown in Figure 7.4.
irritable mood (easily provoke anger for silly things).
• Increased goal directed activity.
• Psychomotor activity increased: Manic patients will
be overactive and restless (On the toe—On the Go),
excessive planning/doing many activities at the same
time, performing high risk activities (Reckless driving in
a heavy traffic) and do playful activities (cracking jokes,
talking loud, jumping, etc.). Figure 7.3: Neurotransmitters in mania
CHAPTER 7 Nursing Management of Patients with Mood Disorders 209

Figure 7.4: Biopsychosocial model

Psychological Factors DIAGNOSTIC CRITERIA FOR BIPOLAR I DISORDER

• Psychodynamic theory: Ambivalence tendency toward
DSM-5 Diagnostic Criteria for Bipolar I Disorder
the loss of loved object as actual loss or perceived loss
(Manic Episode)
leads to emotional conflict which in turn leads to mood
disorder. • Abnormal, persistent, elevated, expansive or irritable
„ In depression, introjection of ambivalence into the mood with the increased goal-directed activity at least
lost object. one week and present most of the day or every day.
„ In mania, inadequacy and worthlessness convert • Three or more of the below symptoms:
into denial, reaction formation and projection to i. Inflated self-esteem (or) grandiosity
grandiose feeling. ii. Reduced need for sleep
• Psychoanalytical theory: Id, ego, superego (rigid super iii. More talkative
ego might lead to aggressiveness and the sexual impulses iv. Flight of ideas
at unconscious state will lead to punishment or suicide). v. Distractibility
vi. Purposeless increase in goal-directed activity or
• Cognitive triad of depression: It includes negative
psychomotor agitation
view of self, negative view of future and negative view of
vii. Involvement in risk taking activities
environment as shown in Figure 7.5.
• Marked impairment in social or occupational functioning
• Learned helplessness: Individual undergoes repeated
or to proceed hospitalization in order to prevent harm to
painful or aversive stimuli, from which the individual is
self and others.
unable to avoid or escape.
• The episode is not due to the physiological effects of a
• Stressor: Factors which cause stress might induce the
substance.
depression.
DSM-5 Diagnostic Criteria for Bipolar I Disorder
(Hypomanic Episode)
• A distinct period of abnormally and persistently elevated,
expansive, or irritable mood and abnormally and
persistently increased activity or energy, lasting at least
four consecutive days and present most of the day, nearly
every day.
• During the period of mood disturbance and increased
energy and activity, three (or more) of the following
symptoms (four if the mood is only irritable) have
persisted, represent a noticeable change from usual
Figure 7.5: Cognitive triad of depression behavior, and have been present to a significant degree:
210 Textbook of Psychiatric Nursing for BSc Nursing Students

i. Inflated self-esteem or grandiosity. v. Psychomotor agitation or retardation nearly every day

ii. Decreased need for sleep (e.g., feels rested after only (observable by others; not merely subjective feelings of
3 hours of sleep). restlessness or being slowed down).
iii. More talkative than usual or pressure to keep talking. vi. Fatigue or loss of energy nearly every day.
iv. Flight of ideas or subjective experience that thoughts vii. Feelings of worthlessness or excessive or inappropriate
are racing. guilt (which may be delusional) nearly every day (not
v. Distractibility (i.e., attention too easily drawn to merely self-reproach or guilt about being sick).
unimportant or irrelevant external stimuli), as viii. Diminished ability to think or concentrate, or
reported or observed. indecisiveness, nearly every day (either by subjective
vi. Increase in goal-directed activity (either socially, account or as observed by others).
at work or school, or sexually) or psychomotor ix. Recurrent thoughts of death (not just fear of dying),
agitation. recurrent suicidal ideation without a specific plan, or a
vii. Excessive involvement in activities that have a high suicide attempt or a specific plan for committing suicide.
potential for painful consequences (e.g., engaging in The symptoms cause clinically significant distress or
unrestrained buying sprees, sexual indiscretions, or impairment in social, occupational, or other important areas
foolish business investments). of functioning.
• The episode is associated with an unequivocal change Episode is not attributable to the physiological effects of a
in functioning that is uncharacteristic of the individual substance or another medical condition.
when not symptomatic.
• Disturbance in mood and the change in functioning are ICD-11 Diagnostic Criteria for Bipolar I Disorder
observable by others.
• Bipolar type I disorder is an episodic mood disorder
• Episode is not severe enough to cause marked impairment
defined by the occurrence of one or more manic or mixed
in social or occupational functioning or to necessitate
episodes.
hospitalization. If there are psychotic features, the episode
• A manic episode is an extreme mood state lasting at least
is, by definition, manic.
one week unless shortened by a treatment intervention
• Episode is not due to the physiological effects of a
characterized by euphoria, irritability, or expansiveness,
substance (e.g., a drug of abuse, a medication, other
and by increased activity or a subjective experience of
treatment).
increased energy, accompanied by other characteristic
symptoms such as rapid or pressured speech, flight of
DSM-5 Diagnostic Criteria for Bipolar I Disorder
ideas, increased self-esteem or grandiosity, decreased
(Major Depressive Episode)
need for sleep, distractibility, impulsive or reckless
Five or more of the following symptoms seen during behavior, and rapid changes among different mood states
the same two-week period and represent a change from (i.e., mood lability).
previous functioning; at least one of the symptoms is either • A mixed episode is characterized by either a mixture or
(1) Depressed mood or (2) Loss of interest or pleasure. very rapid alternation between prominent manic and
i. Depressed mood most of the day, nearly every day, as depressive symptoms on most days during a period of at
indicated by either subjective report (e.g., feels sad, least two weeks.
empty, or hopeless) or observation made by others (e.g., • Although the diagnosis can be made based on evidence
appears tearful). (Note: In children and adolescents, can of a single manic or mixed episode, typically manic or
be irritable mood.) mixed episodes alternate with depressive episodes over
ii. Markedly diminished interest or pleasure in all, or almost the course of the disorder.
all, activities most of the day, nearly every day (as indicated
by either subjective account or observation). DIAGNOSTIC CRITERIA FOR BIPOLAR II DISORDER
iii. Significant weight loss when not dieting or weight gain
(e.g., a change of more than 5% of body weight in a DSM-5 Diagnostic Criteria for Bipolar II Disorder
month), or decrease or increase in appetite nearly every • Criteria have been met for at least one hypomanic episode
day. (Note: In children, consider failure to make expected (criteria A–F under ‘Hypomanic Episode’ above) and at
weight gain.) least one major depressive episode (criteria A–C under
iv. Insomnia or hypersomnia nearly every day. ‘Major Depressive Episode’ above).
CHAPTER 7 Nursing Management of Patients with Mood Disorders 211

• There has never been a manic episode. a hypomanic episode and numerous periods with
• The occurrence of the hypomanic episode(s) and depressive symptoms that do not meet criteria for a major
major depressive episode(s) is not better explained by depressive episode.
schizoaffective disorder, schizophrenia, schizophreniform • During the above 2-year period (1 year in children and
disorder, delusional disorder, or other specified or adolescents), the hypomanic and depressive periods have
unspecified schizophrenia spectrum and other psychotic been present for at least half the time and the individual
disorder. has not been without the symptoms for more than 2
• The symptoms of depression or the unpredictability months at a time.
caused by frequent alternation between periods of • Criteria for a major depressive, manic, or hypomanic
depression and hypomania causes clinically significant episode have never been met.
distress or impairment in social, occupational, or other • The symptoms in criterion A are not better explained by
important areas of functioning. schizoaffective disorder, schizophrenia, schizophreniform
Specify current or most recent episode: disorder, delusional disorder, or other specified or
• Hypomanic unspecified schizophrenia spectrum and other psychotic
• Depressed disorder.
• The symptoms are not attributable to the physiological
Specify if:
effects of a substance or another medical condition.
• With anxious distress
• The symptoms cause clinically significant distress or
• With mixed features
impairment in social, occupational, or other important
areas of functioning.
ICD-11 Diagnostic Criteria for Bipolar II Disorder
Specify if: With anxious distress
• Bipolar type II disorder is an episodic mood disorder
defined by the occurrence of one or more hypomanic
ICD-11 Diagnostic Criteria for Cyclothymic
episodes and at least one depressive episode.
Disorder
• A hypomanic episode is a persistent mood state
characterized by euphoria, irritability, or expansiveness, • Cyclothymic disorder is characterized by a persistent
and excessive psychomotor activation or increased instability of mood over a period of at least 2 years,
energy, accompanied by other characteristic symptoms involving numerous periods of hypomanic (e.g., euphoria,
such as grandiosity, decreased need for sleep, pressured irritability, or expansiveness, psychomotor activation)
speech, flight of ideas, distractibility, and impulsive or and depressive (e.g., feeling down, diminished interest in
reckless behavior lasting for at least several days. activities, fatigue) symptoms that are present during more
• The symptoms represent a change from the individual’s of the time than not.
typical behavior and are not severe enough to cause • The hypomanic symptomatology may or may not
marked impairment in functioning. A depressive episode be sufficiently severe or prolonged to meet the full
is characterized by a period of almost daily depressed definitional requirements of a hypomanic episode (see
mood or diminished interest in activities lasting at least Bipolar type II disorder), but there is no history of manic
two weeks accompanied by other symptoms such as or mixed episodes (see Bipolar type I disorder).
changes in appetite or sleep, psychomotor agitation or • The depressive symptomatology has never been
retardation, fatigue, feelings of worthless or excessive or sufficiently severe or prolonged to meet the diagnostic
inappropriate guilt, feelings or hopelessness, difficulty requirements for a depressive episode (see Bipolar type II
concentrating, and suicidality. disorder).
• There is no history of manic or mixed episodes. • The symptoms result in significant distress or significant
impairment in personal, family, social, educational,
DIAGNOSTIC CRITERIA FOR CYCLOTHYMIC occupational or other important areas of functioning.
DISORDER
Treatment
DSM-5 Diagnostic Criteria for Cyclothymic • Lithium (0.6–1.2 mEq/L*)
Disorder „ Tab. Lithium carbonate (Eskalith, Lithobid) 40 mg
• For at least 2 years (at least 1 year in children and „ Syrup Lithium citrate 300 mg
adolescents) there have been numerous periods with • Carbamazepine (6–12 mg/L*)
hypomanic symptoms that do not meet criteria for • Sodium Valproate (50–125 mg/L*)
212 Textbook of Psychiatric Nursing for BSc Nursing Students

• Anticonvulsants
„ Gabapentin 300 mg/day at bed time
„ Topiramate (Topamax) 250–500 mg/day
„ Lamotrigine (Lamictal) 100–200 mg/day at bed
time
• Calcium channel blockers—Verapamil (Isoptin)
40–360 mg
• Agitated or psychotic patient—Administration of second-
generation antipsychotics (olanzapine, risperidone) and Figure 7.6: Fundamental concepts of lithium
benzodiazepines (lorazepam, clonazepam)
Mechanism of Action
• Electroconvulsive Therapy (ECT)
*Therapeutic drug level in blood Lithium acts on macroscopic (anatomy of brain) as well as on
microscopic level (intracellular) (Fig. 7.7). Lithium is related
LITHIUM with neuroprotective effect (or) factors such as:
• Brain-Derived Neurotrophic Factor (BDNF)
Discovery of Lithium • B-cell lymphoma 2 (BCL2)—Inhibit the apoptosis in
various cells
Dr John Frederick Joseph Cade AO (1912–1980) an Australian
psychiatrist discovered Lithium in 1948. He explored the Changes in structure of brain during lithium intake are seen
in anterior cingulate cortex, ventral prefrontal cortex, hippo­
effects of lithium carbonate as a mood stabilizer and it is also
campus and amygdala. Lithium modulates the neurotransmitters
useful in treatment of bipolar disorder.
such as dopamine, glutamate and Gamma aminobutyric
acid (GABA). Lithium shows effects at intracellular level by
Basic Information about Lithium (Fig. 7.6)
inhibiting proteins such as Phosphoinositol/Protein Kinase
The half-life of the drug is 24 hours. It is not metabolized in C (PKC), Myristoylated Alanine-Rich C Kinase Substrate
liver and gets excreted by kidneys. Lithium does not bind or (MARCKS) and Glycogen Synthase Kinase-3 (GSK-3).
minimally bind with protein. The usual dosage is 600–900 mg/ Categories of lithium level in blood has been depicted
day and is given in divided or single dose initially with the below in Table 7.6:
maintenance serum level of 0.6–1.2 mmol/L. Table 7.6: Categories of lithium level in blood

Pharmacokinetics Categories Lithium level in blood

Therapeutic 0.6–1.2 mEq/L
The absorption takes place within 30 minutes and reaches
Prophylactic 0.8–1.2 mEq/L
at peak in 3 hours. Antipsychotics/antidepressants might
decrease the absorption. Toxic >2 mEq/L

Figure 7.7: Mechanism of action for lithium

CHAPTER 7 Nursing Management of Patients with Mood Disorders 213

Drug Interactions with Lithium

Drug interactions with lithium are categorized into minor
categories, moderate categories and major categories have
been summarized in Table 7.8.

Table 7.8: Drug interactions with lithium

Categories Drugs interact with

lithium
Minor interaction with lithium Carbonic anhydrase
inhibitors
sympathomimetic
medications
Moderate interaction with lithium • ACE inhibitors
• Metrogyl
• Methyldopa
Figure 7.8: Side effects of lithium • Benzodiazepines
• NSAID
Side effects of lithium have been given in Figure 7.8. • Caffeine
• Carbamazepine
• Clozapine
Mnemonic • Thiazide diuretics
Mnemonic to remember lithium side effects are “LITHUM” • Loop diuretics
• Succinylcholine
L : Leukocytosis
• Theophylline
I : Insipidus (Nephrogenic diabetes insipidus) • Phenothiazines
T : Tremors (or) thirst (or) taste as metallic (or) teratogenic • Fluoxetine
(Teratogenics–Ebstein anomaly) • Tricyclic
H : Hypothyroidism antidepressants
U : Urinary (Polyuria) Major interaction with Haloperidol
M : Miscellaneous (ECG changes—T wave flattening, QRS lithium
widening and sinus node dysfunction, rashes, gastrointestinal
(GI) upset, weight gain, fatigue, rashes, ataxia, nystagmus,
Management of Lithium Toxicity
muscle weakness, delirium, hair loss, psoriasis, peripheral
neuropathy, intracranial hypertension, myasthenia gravis like Gastric lavage can be given to remove the contents from
syndrome, lower seizure threshold, neuromuscular irritability, gastrointestinal tract. Charcoal helps to bind with lithium.
Memory disturbances, dysphoria and slow reaction time) Tab. propranolol decreases the tremors. Sodium and water
Factors which increase/decrease serum lithium level have been retention must be avoided. Patients are advised to take more
depicted below in Table 7.7: oral fluids/water.
Table 7.7: Factors which increase or decrease serum lithium level Electrolyte abnormalities have to be corrected. IV fluids
can be administered. If the patient has consumed lithium
Factors increasing serum lithium Factors decreasing
level serum lithium level
extended-release tablets in last 2–4 hours, in that case, whole
bowel irrigation is advisable in order to prevent absorption of
Drugs Drugs
• Thiazide diuretics • Acetazolamide lithium. In case of severe lithium toxicity, hemodialysis is the
• Nonsteroidal anti-inflammatory drugs • Mannitol only option. Grades of lithium toxicity with its manifestations
(NSAIDs) • Theophylline and management are given in Table 7.9.
• Angiotensin-converting enzyme (ACE) Miscellaneous
inhibitors • Caffeine
• Angiotensin II receptor antagonists • Pregnancy NOTE
• Metronidazole
Miscellaneous Lithium has more chance of toxicity since the drug has narrow
• Low sodium diet • Dehydration therapeutic index (i.e., little variation exists between the
• Elderly • Renal disease therapeutic drug level and toxic drug level).
214 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 7.9: Grades of lithium toxicity with its manifestations and NURSING MANAGEMENT
management
Assessment
Level mEq/L Clinical manifestations Management
Young mania rating scale (YMRS): It is the scale used to assess
Grade-1 1.5–2.5 • Nausea Hydration
• Vomiting Kayexalate manic symptoms. It is an observer rated scale which has
• Tremor 11 items. 4 items rated from 0 to 8 and 7 items rated from 0 to 4.
• Hyperreflexia Another mood disorder questionnaire was developed by
• Ataxia Hirschfeld, Williams, Spitzer, Calabrese, et al. (2000). It is a
• Agitation
• Muscular weakness screening tool with13-item checklist. It’s efficiently lies in the
fact that it helps to identify 7 out of 10 patients in case of bipolar
Grade-2 2.5–3.5 • Stupor Hydration
disorder. It also effectively screens out 9 out of 10 patients who
• Rigidity Kayexalate
• Hypertonia Dialysis as may be without bipolar disorder.
• Hypotension (if needed) Semantic Differential Feelings and Mood Scales (SDFMS)
Grade-3 >3.5 • Coma Hemodialysis is developed by Maurice Lorr and Richard A Wunderlich.
• Seizures It helps to measure the state of mood. It has 35 differential
• Myoclonus items which has one-to-five-point scale and they help in
• Collapse assessing and determining the mood. It has five factors as
listed below:
1. A = Elated-Depressed
TREATMENT OF BIPOLAR DISORDER 2. B = Relaxed-Anxious
3. C = Confident-Unsure
Anticonvulsants Used to Treat Bipolar Disorder
4. D = Energetic-Fatigue
The action and side effects of mood stabilizers sodium 5. E = Good Natured-Grouchy
valproate, carbamazepine, lamotrigine and topiramate have
Assess the client’s mood, level of anxiety and thoughts in
been given in Table 7.10.
regard to harming oneself or others.
Antipsychotics Used to Treat Bipolar Disorder
NURSING DIAGNOSIS AND INTERVENTIONS
Aripiprazole, risperidone, olanzapine, quetiapine, ziprasidone
and clozapine. Risk for self-directed violence related to suicidal feelings.

Table 7.10: Mood stabilizers with their actions and side effects

Mood Actions Side effects

stabilizers
Sodium • Dissociates the valproate ion in gastrointestinal tract (GI) • Alopecia
valproate • Increases GABA levels in brain either by reducing reuptake or by reducing • Pancreatitis
the metabolism of GABA • Thrombocytopenia
• Suppress the influx of calcium through specified calcium channels • Hyperammonemia
• Inhibition of liver enzymes
Carbamazepine • Sodium channel blocker (binds with voltage-gated sodium channel and • Agranulocytosis
thereby prevents sustained firing of action potential) • Ataxia
• It is a serotonin releasing agent and serotonin reuptake inhibitor. • Induces liver enzymes
• Analgesics • Hyponatremia
• Antiepileptics • Stevens-Johnson syndrome (SJS)
• Mood stabilizing agent • Toxic epidermal necrosis (TEN)
Lamotrigine • Inhibits • Maculopapular skin eruptions
• Voltage sensitive sodium ions • Stevens-Johnson syndrome (SJS)
• Excitatory amino acids (glutamate and asparate) • Toxic epidermal necrosis (TEN)
Topiramate • Increases GABA • Cognitive dulling
• Block voltage gated sodium and calcium channels
• Inhibits excitatory neurotransmitters especially glutamate
CHAPTER 7 Nursing Management of Patients with Mood Disorders 215

Interventions Rationale
Determine the suicidal risk with the standard tool It helps to estimate the suicidal risk
Obtain the suicidal contract from the client It develops in client the feelings of self-realization, not to commit
suicide
Decrease the environment stimuli by allotting the single silent Because the patients are easily distracted even with a slight
room with less lightening effect. stimulus
Remove sharp objects It prevents the self-harm
Provide recreational activities It helps to divert the patient’s mind and decreases the level of stress
When hyperactivity of the patient increases, stay with the client Staying with the patient might give secure feelings.

Risk for violence directed toward others related to manic excitement, delusion and hallucinations.
Interventions Rationale
Maintain the low environment stimuli To reduce anxiety and suspicious ideas
Keep observing the client every 15 minutes To ensure the patient’s safety
Encourage the client to talk To reduce the bottled-up negative emotions and thereby reduce
stress
Divert the client when he/she experiencing hallucination It acts as diversional technique to reduce hallucination
Involve the client in sports or other activities (e.g., kicking football) It helps the client to express his violent behavior in a positive way

Impaired nutrition, less than body requirement may be related to refusal of food as evidenced by weight loss.
Interventions Rationale
Assess the client’s likes and dislikes It provides the client’s baseline data
Provide them high calorie diet Since the client is excited, the level of energy loss will be high in manic patient
Foods has to be colorful and attractive It motivates the manic patient to eat well
Advice the patient’s caregiver to follow small frequent It helps to maintain the nutritional status of the patient
diet as suggested in menu plan
Give more oral fluids and salt adequately to the patient. To prevent the lithium toxicity
Monitor the weight regularly To assess the improvement in patient’s weight.

DSM versions are listed below:

DO YOU KNOW • DSM-I is depressive reaction
• DSM-II is depressive neurosis
Some Indian celebrities who spoke boldly that they were
suffering from mood disorders were Manisha Koirala, Yo Yo • DSM-III, IV and DSM-5 are depressive disorder
Honey Singh, Shahrukh Khan, Deepika Padukone, Anushka
Sharma, Varun Dhawan, Randeep Hooda and Ileana D’Cruz. Etiology
• Brain anatomy: Neuron loss is present in frontal lobe,
cerebellum and basal ganglia.
DEPRESSION • Genetics: First degree relatives of a depression patient
have a threefold risk of depression. Abnormality in
Introduction chromosomes 12 and 15 has been identified in such
patients. Polymorphism of serotonin transporter gene
The term ‘Depression’ originated from Latin word ‘deprimere’
in chromosome 17 and chromosomes with short allele
which means to press down. Hippocrates found the term of homozygosity or heterozygosity increase the risk of
‘Melancholia’ to address the depression initially. Emil depression.
Kraepelin said that ‘Depressive state is a part of manic- • Neurochemical: Decreased norepinephrine and
depressive psychosis.’ Henry Maudsley used the term, serotonin are seen in depression. Acetylcholine and
‘Affective disorders’. Kurt Schneider classified the depression as Gamma-Aminobutyric Acid (GABA) regulations are
endogenous (melancholic) and reactive (Neurotic) depression. impaired.
216 Textbook of Psychiatric Nursing for BSc Nursing Students

• Endocrine theory: Hypothalamic-pituitary-adrenal certain time each year, usually in the fall or winter. During
(HPA) axis induce stress and thereby cortisol level too light therapy, you sit or work near a device called a light
increases as shown in Figure 7.9. Nonadrenergic receptors therapy box. The light emitted by it reduces depression by
of pineal gland secrete melatonin. Decreased level of decreasing level of melatonin.
melatonin leads to depression. Administration of light • Psychosocial causes: Chronic stressors, lack of social
therapy will increase the level of melatonin and thereby it support, chronic pain, loneliness, loss of loved ones, poor
decreases the level of depression as shown in Figure 7.10. coping skills, repeated failures, anxious and obsessional
• Circadian rhythm: Dysregulation of sleep-wake cycle personality, family conflicts, use of alcohol or substance
will lead to depression. abuse and negative view of self or future or environment.
• Psychoanalytical model: As per Freud (1957) depression • Medications: Psychotropic agent, oral hypoglycemic
is due to loss of ‘loved object’ and fixed oral sadistic phase agents, antihypertensive drugs, anti-Parkinson’s
of development. medications, antimicrobials, chemotherapeutic drugs,
• The hypothalamic pituitary adrenal (HPA) axis is our cimetidine, cardiovascular medications, narcotics and non-
central stress response system. ACTH binds to receptors narcotic analgesics.
on the adrenal cortex and stimulates adrenal release of • Organic causes: Secondary depression is due to various
cortisol. In response to stressors, cortisol will be released physical disorders listed here:
for several hours after encountering the stressor. „ Anemia
• Light therapy is a way to treat seasonal affective disorder „ Cardiovascular diseases: Heart failure
(SAD) and certain other conditions by exposure to „ Cancer (mainly carcinoma in pancreas)
artificial light. SAD is a type of depression that occurs at a „ Endocrine disorder: Diabetes mellitus, Cushing
syndrome, hypothyroidism and hyperparathyroidism.
„ Gastrointestinal disorder: Irritable bowel syndrome
„ Genitourinary disorder: Urine incontinence and
chronic renal failure.
„ Metabolic disturbances: Hypercalcemia, hypoxia
and Wilson’s disease.
„ Viral and bacterial infections: Influenza, pneumonia,
encephalitis, infectious mononucleosis, miliary
tuberculosis and brucellosis.
„ Musculoskeletal disorders: Arthritis.
„ Neurological disease: Alzheimer’s disease, Parkinson’s
disease.
„ Vascular: Stroke and coronary artery disease.
Figure 7.9: Hypothalamic-Pituitary-Adrenal (HPA) „ Nutritional deficiency: Iron, folic acid, protein,
Axis and cortisol
niacin, vitamin C, thiamine (B1), pyridoxine (B6) and
cyanocobalamin (B12).

Clinical Features
Physical Symptoms
Blurred vision, dry mouth, giddiness, fatigue, headache, chest
pain, breathlessness, numbness, tingling sensation, abdominal
discomfort, anorexia, increased urinary frequency, sexual
disturbances and constipation (Fig. 7.11).

Psychological and Emotional Symptoms

Depressed mood that is clearly visible abnormal to the
individual, anhedonia (Unable to enjoy the events which are
considerably joyful before), feel of guilt, anergia, insomnia,
Figure 7.10: Concepts of light therapy psychomotor retardation, decreased concentration, lack of
CHAPTER 7 Nursing Management of Patients with Mood Disorders 217

interest, crying spells, avoiding socialization, diurnal variation

(worsening of symptoms in morning), suicidal ideation, feel of
hopelessness/helplessness/worthlessness
Mood congruent psychotic symptoms are as follows:
• Delusion of guilt
• Nihilistic delusion
• Delusion of hypochondriasis
• Voices accusing/condemning the client
Mood incongruent psychotic symptoms are as follows:
• Delusion of persecution
• Delusion of reference
• Voices speaks about affectively neutral topic

CLASSIFICATION OF DEPRESSIVE DISORDERS

ICD-11 and DSM-5 classification of depressive disorders is

Figure 7.11: Physical symptoms in depression shown in Table 7.11.

Table 7.11: ICD-11 and DSM-5 classification of depressive disorders

ICD-11 DSM-5 Depressive disorders

— 296.99 Disruptive mood dysregulation disorder
6A70.0 296.21 Single episode depression (mild)
— 296.22 Single episode depression (moderate)
6A71.1 — Single episode depression (moderate without psychotic features)
6A71.2 — Single episode depression (moderate with psychotic features)
6A71.3 — Single episode depression (severe without psychotic features)
6A71.4 — Single episode depression (severe with psychotic features)
— 296.23 Single episode depression (severe)
— 296.24 Single episode depression (with psychotic features)
6A70.6 296.25 Single episode depression (in partial remission)
6A70.7 296.26 Single episode depression (in full remission)
6A70.Z 296.20 Single episode depression (unspecified)
6A71.0 296.31 Recurrent episode depression (mild)
— 296.32 Recurrent episode depression (moderate)
6A71.1 — Recurrent episode depression (moderate without psychotic features)
6A71.2 — Recurrent episode depression (moderate with psychotic features)
— 296.33 Recurrent episode depression (severe)
6A71.3 — Recurrent episode depression (severe without psychotic features)
6A71.4 — Recurrent episode depression (severe with psychotic features)
— 296.34 Recurrent episode depression (with psychotic features)
6A71.6 296.35 Recurrent episode depression (in partial remission)
6A71.7 296.36 Recurrent episode depression (in full remission)
6A71.Y 296.30 Recurrent episode depression (unspecified)
6A7Z 300.4 Persistent depressive disorder (dysthymia)
— 625.4 Premenstrual dysphoric disorder
— 293.83 Depressive disorder due to another medical condition
218 Textbook of Psychiatric Nursing for BSc Nursing Students

DIAGNOSTIC CRITERIA FOR DEPRESSIVE „ Inability to concentrate almost every day.

DISORDER „ Frequent thoughts of death.
• Above symptoms cause the significant social and
DSM-5 Diagnostic Criteria for Disruptive Mood occupational impairment.
Dysregulation Disorder • Above symptoms are not due to consumption of any
Criteria in Regard to the Recurrent Temper Outbursts substances.
• There should not be any manic episode.
• Severe recurrent temper outbursts manifested either
• Occurrence of depressive episode might not be explained
verbally (verbal rages) and/or behaviorally (physical
as other psychotic disorders.
aggression toward other persons or property) that are not
proportionate in intensity or the duration to the situation Specify if it is:
• Temper outbursts are not consistent with the • With anxious distress
developmental level. • With atypical features
• Mood between temper outbursts is persistently irritable • With melancholic features
most of the day or nearly every day. • With mood-congruent psychotic features
• Severe recurrent temper outbursts need to be present in • With mood-incongruent psychotic features
at least two of the three settings (i.e., at home, at school, • With seasonal pattern
with peers) and need to be severe in at least one of
these. ICD-11 Diagnostic Criteria for Single Episode
Depression
Duration • It is characterized by the presence or history of one
• On average, temper outbursts happen three or more times depressive episode when there is no history of prior
in a week. depressive episodes.
• All the above criteria’s need to present for one year or • Depressive episode is characterized by the period of
above. almost daily depressed mood or lack of interest in
• Individual should not be present without all of the activities lasting at least for 2 weeks along with other
symptoms for more than three months symptoms such as feelings of worthlessness or excessive or
• Diagnosis should not be made for first time before 6 years inappropriate guilt, difficulty concentrating, hopelessness,
of age or after 18 years. recurrent thoughts of suicide or death, psychomotor
agitation or retardation, changes in appetite or sleep and
Miscellaneous decrease in the energy or fatigue.
• Symptoms should not reflect any other mental disorders. • No prior manic, hypomanic, or mixed episodes, which
• Symptoms are not due to the effects of a substance use or indicate the presence of bipolar disorder.
due to another medical condition.
Specify if it is:
• Mild: Less intensity, not considerable difficulty in
DSM-5 Diagnostic Criteria for Single Episode
continuing with work, social, or domestic activities and
Depression
no delusions or hallucinations.
• Five or more of the following symptoms present for • Moderate: Symptoms of depression for at least 2 weeks
significant portion of time for 2 weeks period. and presence difficulty in continuing with work, social, or
„ Depressed mood presents almost most of the day and domestic activities.
every day. • Severe: Severe depressive symptoms cause significant
„ Lack of interest or pleasure. distress and have social or occupational impairment.
„ Significant weight loss (without dieting) or weight • With or without psychotic features.
gain—5% of body weight loss or gain in a month. • Partial remission: Full definitional requirements for a
„ Fatigue or energy loss almost every day. depressive episode are no longer met but some significant
„ Hypersomnia or Insomnia almost every day. mood symptoms remain.
„ Psychomotor retardation or agitation almost every • Full remission: Full definitional requirements for a
day. depressive episode has met.
„ Feel or worthlessness or inappropriate guilt. • Unspecified.
CHAPTER 7 Nursing Management of Patients with Mood Disorders 219

ICD-11 Diagnostic Criteria for Recurrent Episode Specifications on the basis of onset:
Depression Early onset: If onset is before at age 21 years.
Late onset: If onset is at age 21 years or older.
• Recurrent depressive disorder is characterized by a history
Specifications on the basis of Severity: Mild or Moderate or
or at least two depressive episodes separated by at least
Severe.
several months without significant mood disturbance.
• A depressive episode is characterized by a period of Other Specifications
almost daily depressed mood or diminished interest in
activities lasting at least two weeks accompanied by other • With intermittent major depressive episodes, with or
symptoms such as difficulty in concentrating, feelings without current episode
of worthlessness or excessive or inappropriate guilt, • With pure dysthymic syndrome
hopelessness, recurrent thoughts of death or suicide, • With persistent major depressive episode.
changes in appetite or sleep, psychomotor agitation or
retardation, and reduced energy or fatigue.
ICD-11 Diagnostic Criteria for Persistent
• There have never been any prior manic, hypomanic, or Depressive Disorder (OR) Dysthymic Disorder
mixed episodes, which would indicate the presence of a • Dysthymic disorder is characterized by a persistent
bipolar disorder. depressive mood (i.e., lasting 2 years or more), for most of
the day, for more days than not.
DSM-5 Diagnostic Criteria for Persistent • In children and adolescents depressed mood can
Depressive Disorder (OR) Dysthymic Disorder manifest as pervasive irritability. The depressed mood is
• Depressed mood for most of the day, for more days accompanied by additional symptoms such as markedly
than not, as indicated by either subjective account or diminished interest or pleasure in activities, reduced
observation by others, for at least 2 years. (In children and concentration and attention or indecisiveness, low self-
adolescents, mood can be irritable and duration must be worth or excessive or inappropriate guilt, hopelessness
at least 1 year). about the future, disturbed sleep or increased sleep,
• Presence, while depressed, of two (or more) of the diminished or increased appetite, or low energy or
following: fatigue. During the first 2 years of the disorder, there has
i. Poor appetite or overeating. never been a 2 weeks period during which the number
ii. Insomnia or hypersomnia. and duration of symptoms were sufficient to meet the
iii. Low energy or fatigue. diagnostic requirements for a depressive episode.
iv. Low self-esteem. • There is no history of manic, mixed, or hypomanic
v. Poor concentration or difficulty making decisions. episodes.
vi. Feelings of hopelessness.
• During the 2 years period (1 year for children or ICD-11 Diagnostic Criteria for Recurrent
adolescents) of the disturbance, the individual has never Depressive Disorder
been without the presence of depressive symptoms. • Recurrent depressive disorder is characterized by a
• There has never been a manic episode or a hypomanic history or at least two depressive episodes separated
episode, and criteria have not met for cyclothymic by at least several months without significant mood
disorder. disturbance.
• The disturbance is not better explained by other medical or • A depressive episode is characterized by a period of
mental disorder or not due to influence of any substances. almost daily depressed mood or diminished interest in
• Symptoms cause clinically significant distress or activities lasting at least two weeks accompanied by other
impairment in social, occupational, or other important symptoms such as difficulty in concentrating, feelings
areas of functioning. of worthlessness or excessive or inappropriate guilt,
Specifications on the basis of features: Anxious distress or hopelessness, recurrent thoughts of death or suicide,
mixed features or melancholic features or atypical features changes in appetite or sleep, psychomotor agitation or
or mood-congruent psychotic features or mood-incongruent retardation, and reduced energy or fatigue.
psychotic features or peripartum onset. • There have never been any prior manic, hypomanic, or
Specifications on the basis of remission: Partial or full mixed episodes, which would indicate the presence of a
remission. bipolar disorder.
220 Textbook of Psychiatric Nursing for BSc Nursing Students

DSM-5 Diagnostic Criteria for Premenstrual Hamilton Rating Scale for Depression
Dysphoric Disorder Max Hamilton published the scale in 1960 which was later
• Presence of at least five symptoms must be present in revised. Original scale had 17 items, later 21 item version of
the final week before the onset of menses, commence to this scale was included. Score inference has been given in
improve within the few days after the onset of menses, Table 7.13.
and become less or absent in the week post menses. Table 7.13: Score interpretation of Hamilton rating scale
• One (or more) of the following peculiar depressive
symptoms must be present: Score interpretation Inference
i. Mood swings 0–7 Normal
ii. Marked anger or irritability or interpersonal conflicts. 20 or higher Moderate to severe (Require treatment)
iii. Marked depressed mood and feelings of hopelessness.
iv. Marked anxiety and tension. Dexamethasone Suppression Test
• One or more of the following additional symptoms Cortisol level usually decreases with dexamethasone but it will
present to reach a total of five symptoms when combined not reduce in patients with depressive disorder.
with peculiar depressive symptoms:
i. Decreased interest in usual activities Differences between Endogenous and
ii. Difficulty in concentration. Exogenous Depression
iii. Lethargy or marked lack of energy.
The differences between endogenous and exogenous
iv. Marked change in appetite–overeating or craving to
depression are given in Table 7.14.
eat specific food.
v. Hypersomnia or insomnia.
Differences between Endogenous and Atypical
vi. A sense of being out of control.
Depression
vii. Physical symptoms such as tenderness or swelling in
breast, joint or muscle pain, a sensation of ‘bloating’, The differences between endogenous and atypical depression
or weight gain. are given in Table 7.15.
• Symptoms are associated with clinically significant
distress or interference with usual social activities or Treatment Modalities
relationships with others. Individual Psychotherapy
• Symptoms are not attributable to the physiological effects When treatment is administered as psychoanalytical oriented
of a substance or other medical condition or other mental manner then the patient develops insight in regard to the
disorder. factors responsible for depression.

Diagnosis Family Therapy

Beck Depression Inventory Interpersonal and intrafamilial conflicts in the life of patient
It is a self-rating scale that consists of 21 items rated on are addressed to reduce the level of depression.
scale of 0–3. Lowest score is 0 and highest score is 63. Score
Cognitive Therapy
interpretation has been given in Table 7.12.
Cognitive therapy helps to modify the unrealistic or unhelpful
Table 7.12: Score interpretation of beck depression inventory
(BDI)
thoughts into realistic or helpful thoughts. By driving or
walking in the morning hours, the individual will feel hopeful,
Score interpretation Inference helpful and worthful as shown in Figure 7.12.
Up to 10 Normal
11–16 Borderline depression
Behavioral Therapy
17–20 Mild depression
Social Skills Training
21–30 Moderate depression It helps to maintain interpersonal relationship with others. Eye
to eye contact has to be maintained while speaking to others.
31–40 Severe depression
Involving the depression, patients in ward rounds can improve
>40 Extreme depression the social skills of the patient.
CHAPTER 7 Nursing Management of Patients with Mood Disorders 221

Table 7.14: Differences between endogenous and exogenous depression

Aspects Endogenous depression Exogenous depression

Meaning Prefix ‘Endo’ means within (due to Prefix ‘Exo’ means outside (caused by external factors—
hereditary or biochemical imbalance) unemployment, divorce, sudden death of loved ones)
Other name • Psychotic depression • Neurotic depression
• Autogenous depression • Reactive depression
• Biological depression
Predominant factors Biological factor Environmental factor
Stress Present Present
Premorbid personality • Cyclothymic personality • Anxious personality
• Dysthymic personality • Obsessive personality
Insomnia Early morning awakening Struggle in getting into sleep
Psychotic feature • Psychomotor retardation • Psychomotor agitation
• Suicidal attempt is seen • Suicidal attempts are not common
• Delusions is present • Psychotic features are absent
Individual feeling Better when alone Better in group
Mood Sad in morning Sad in evening
Treatment Antidepressants and ECT Antidepressants and psychotherapy
Relapse Common Not common

Table 7.15: Differences between endogenous and atypical depression

Aspects Endogenous depression Atypical depression

Appetite Decreased Increased
Weight Loss of weight Gain of weight
Worsening of symptoms Morning Evening
Insomnia Insomnia is present in middle Patient may have insomnia at initial phase of sleep and
or late phase of sleep sometimes the patient may have hypersomnia
Interpersonal hypersensitivity (fear of Absent Present
being rejected by others)

Assertiveness Training
Training is provided to verbalize one’s own willingness in
polite manner in order to protect one’s own rights. Important
technique is ‘Broken Record’—Speaking the same phrase again
and again to another person.

Problem Solving and Decision-Making Skills

Patient is advised to identify the multiple solutions to the
problem and to seek help from experts. Patient is thought to
check out the benefit–loss ratio for any sort of problem and
take decision accordingly.

Activity Schedule
Schedule the activities/daily routines of patient so that the
Figure 7.12: Concepts of cognitive therapy patient occupied. It increases self-esteem of the client.
222 Textbook of Psychiatric Nursing for BSc Nursing Students

Psychopharmacology “Happiness doubles when you share and sorrow

reduces to half when you share. Keep sharing to a
Antidepressant therapy: Monoamine oxidase inhibitors
(MAOIs), tricyclics and selective serotonin reuptake right person”
inhibitors (SSRIs). Antidepressants are explained in Chapter 5
Occupational Therapy
(Page No. 111).
Involve the client in activities, so that patient is socialized.
Supportive Measures It will enhance the cognition, attention, concentration and
Reassurance decision-making skills.

Nurse has to promote the right psychological support to the Relaxation Therapy
patient. Reassurance differs from the false reassurance as it is
(Explained in Chapter 5, Page No. 156).
a wrong assurance (For example, nurse verbalize to the HIV
• Jacobson progressive muscle relaxation therapy (JPMR)
patient that, ‘HIV will be cured soon’ is an example of false
• Autogenic training
reassurance, instead the nurse is expected to say to the patient
that, ‘if you take antiretroviral drugs, it will improve your life
Miscellaneous
span’ which is reassurance).
• Electroconvulsive therapy (ECT) (Explained in Chapter 5,
Mental Ventilation Page No. 172).
If an individual who feels depressed, shares his/her emotional • Light therapy (or) phototherapy (Explained in Chapter 5,
burden with others, then half of the depressed feelings are Page No. 154).
reduced. Bottled up emotions have to be ventilated. • Deep Brain (Explained in Chapter 5, Page No. 181).

Nursing Diagnosis and Interventions for Patient with Mania (Tables 7.16A to E)
Table 7.16A: Risk of injury related to more hyperactivity and impulsive behavior evidenced by performing purposeless and injurious
movements

Interventions Rationale
Have a decreased environmental stimulus Client is easily distractible and responds even to a slight stimulus
Remove the hazardous objects Client might harm self
Assist the patient in performing some activities To relieve from tension
Be with a client when hyperactivity increases To provide psychological support
Administer psychotropics as per physician’s order For rapid relief of hyperactivity

Table 7.16B: Risk of violence directed to self and others, related to manic excitement

Interventions Rationale
Maintain the low level of environmental stimuli To decrease the anxiety
Observe the patient every 15 minutes once To ensure the patient’s safety
Encourage the patient to ventilate the feeling To relieve the mental tension
Use diversional techniques and engage them in activities To divert the patients from agitation
Talk to the patient with calm attitude To prevent anxiety
Apply restraints if the client is harming to self or others To prevent injury to self or others
Observe the restraints every 15 minutes once To ensure the patient’s safety
Remove the restraints one at a time To observe the patient’s risk of becoming violent and to prevent
self-harm
Administer minor tranquilizers as per physician’s order To control the violent behavior
CHAPTER 7 Nursing Management of Patients with Mood Disorders 223

Table 7.16C: Impaired nutritional status less than body requirement, related to inability to sit in a place or to eat as evidenced by
significant weight loss

Interventions Rationale
Calculate the patient’s body mass index (BMI) To get the baseline data
Obtain the information about the patient’s To encourage the patient to eat the food based on the patient’s likes and dislikes
likes and dislikes
Give high protein and high caloric finger foods To enable the patient eat the foods ‘on the run’ since the patient will not sit in a place
which is highly nutritious to eat
Maintain intake output chart To monitor the food intake regularly
Stay with patient when he/she eats To provide psychological support
Give plenty of fluids/juices/snacks to the To help compensate the caloric requirements which has been lost due to hyperactivity
patient

Table 7.16D: Impaired social interactions related to narcissistic behavior as evidenced by manipulation and inability to sustain the
relationship with others

Interventions Rationale
Identify the manipulative behavior To obtain the baseline data
Usage of ‘Limit setting’ as a psychotherapeutic technique (For example, nurse says to the To prevent the violation of limits
patient that, ‘you should not do like this and this is not an acceptable behavior’)
Provide positive reinforcement of the acceptable behavior Motivate the patient to do right behavior
Advise the patient about the consequences of manipulative behavior Help the patient to realize one’s mistake
Help the patient to identify the positive aspect of life To promote self-esteem

Table 7.16E: Impaired family coping skills related to grandiose ideas and manipulative behavior as evidenced by family disputes

Interventions Rationale
Identify the feelings of the family members such as anger, Living along with manic patient might affect the interpersonal
despair, hostility and powerlessness, etc. relationship among family members
Observe the communication among family members Helps to identify the undergoing problems among family members
Identify the role of patient in family If the role was not performed by the patient as per expectation, then
family disintegration occurs
Provide family therapy if required Enhances the family coping skills

Nursing Diagnosis and Interventions for Patient with Depression (Tables 7.16F to J)
Table 7.16F: Risk for suicide related to suicidal ideation as evidenced by suicidal risk determination

Interventions Rationale
Assess suicidal risk Provides the baseline data and helps to explore whether the client
belongs to mild or moderate or severe risk of suicide
Do not allow the client alone Monitors the client
Remove the sharp objects from room Helps to prevent suicidal attempts
Observe the client regularly Monitoring prevents the suicide
Do not allow the client to put bolt in the door of rest room For security concern, since the patient is having risk to commit suicide
Ask openly about suicidal ideas To identify the suicidal thoughts
Allow the client to talk about his/her emotional burden Expression of negative feeling will reduce the level of depression
Administer antidepressants as ordered To reduce the level of depression
224 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 7.16G: Dysfunctional grieving related to actual or perceived loss as evidenced by inappropriateness in expression of anger and not
performing the daily activities

Interventions Rationale
Identify the stage of grief in which patient is fixed To obtain the baseline data
Show unconditional positive regard on patients To develop a therapeutic relationship
(accept the patient as he/she is)
Advice the patient to ventilate the feeling of anger To reduce the emotional burden
Encourage the patient to perform simple activities An effective way to relieve anger and being involved

Table 7.16H: Self-care deficit related to lack of energy as evidenced by lack of doing activities

Interventions Rationale
Assess the client’s interest and capacity to To know about the patient’s ability to perform self-care activities
perform self-care activities
Help the client to do the activities by self Helping the client will promote interest to do the activities
Assign the daily activities with time schedule Keep scheduling will make the client to have clear idea about what activity is to be
performed at what time
Simple task can be done by the client with Accomplishment of simple task will motivate the client to perform further activities
supervision
Do not rush the client to do activities It increases the level of anxiety
Reinforce the client to perform activities Reinforcement will act as a motivation factor to perform the task

Table 7.16I: Hopelessness related to negative view of self as evidenced by mental status assessment

Interventions Rationale
Nurse has to assess the patient’s actual loss and perceived loss It provides the baseline data about the patient
Reinforce the client supporting system to help the client Motivate the client to feel that there are supporting systems that will
help to get rid of problems
Maintain the therapeutic nurse patient relationship To maintain basic trust with client
Provide counseling/cognitive behavior therapy Negative distorted thoughts will be changed into positive way

Table 7.16J: Impaired social interactions related to social isolation as evidenced by poor interpersonal relationship with others

Interventions Rationale
Nurse has to accept the patient and maintain good To promote trust with patient
interpersonal relationship with client
Provide social skill training To encourage the socialization
Involve in group activities To motivate the client to feel the pleasure in talking to others
Help the client to gradually socialize with others To improve social skills
Avoid competitive tasks To client may feel discouraged and demotivated

PERSISTENT MOOD DISORDER Cyclothymia

It involves the period of depressive symptoms and hypomania.
ICD-10 Classification includes:
Exact cause is unknown.
F34.0 Cyclothymia
F34.1 Dysthymia • Onset: Usually in early adulthood and late childhood.
F34.8 Other persistent mood disorders • Epidemiology: Males and females are equally affected.
F34.9 Persistent mood disorder, not specified
The prevalence is 0.7% at some point of life.
CHAPTER 7 Nursing Management of Patients with Mood Disorders 225

DSM-5 Criteria includes: During the second year, above symptoms are never absent
• Periods with elevated mood and depressive symptoms for more than two months. Patient does not have manic/
have been persisting for half of the time since last two hypomanic/mixed episode. Patient will not the criteria of
years (for adults) and one year for teenagers. cyclothymia. Depression does not exist as part of psychosis/
• Stable mood might last only for two months (mostly). schizophrenia/delusion disorder. Symptoms are not caused
• Symptoms cause significant distress. by medical conditions or influence of any substance use.
• Symptoms not meeting the criteria of major depression, Depression causes significant personal distress and also social/
bipolar disorder or other psychiatric conditions. occupational impairment.
• Symptoms not caused by medical conditions or influence Treatment includes selective serotonin reuptake inhibitors
of any substance use. (SSRI) and tricyclic antidepressants (TCA).

Differential diagnosis includes borderline personality disorder, GERIATRIC CONSIDERATIONS

bipolar disorder and substance use disorder.
Treatment includes psychotherapy and mood stabilizers. Depression is a common psychiatric problem among elders.
Geriatric depression scale is used to quantify the severity of
Dysthymia depression. Elders residing in old age homes are more prone
to depression than elders who stay along with their family
It is a persistent depressive disorder in which the mild
members. Empty nest syndrome (loneliness in elderly is
depressive symptoms persist for at least two years (one year in
common causative factor for depression) is a factor that
case of children).
should be rectified by social skills training. Treatment measure
Pathophysiology: Brain structural changes in corpus callosum
includes psychotherapy and antidepressants which are helpful
and frontal lobe are seen. Increased activity in amygdala and
for elders to recover from depression.
cingulate gyrus of the brain.
DSM-IV criteria include: Follow-up, Home Care and Rehabilitation
Depressive symptoms persist at least for two years for most of Psychological therapies rendered to elders with mood disorders
the days. During depression, patient has two or more of the have to be followed at regular intervals for higher level of
following symptoms: efficiency. Negative expression emotions have to be avoided
• Changes in appetite (increased or decreased) in home settings to prevent depression. Preventive measures
• Sleep disturbances (insomnia or hypersomnia) of elderly abuse (physical abuse—beating, emotional abuse—
• Fatigue scolding elders, sexual abuse or granny bashing, economical
• Reduced self-esteem abuse) will also prevent the depression. Rehabilitation helps
• Decreased concentration to restore the elders to live with peace and it helps them to
• Feel of hopelessness perform the activities of daily living.

EXTRA EDGE
ICD-10 Classification of Mood Disorders • F31 Bipolar affective disorder
• F30 Manic episode „ F31.6 Bipolar affective disorder, current episode mixed

• F31 Bipolar affective disorder • F32 Depressive episode

• F32 Depressive episode „ F32.0 Mild depressive episode
• F33 Recurrent depressive disorder „ F32.1 Moderate depressive episode
• F34 Persistent mood (affective) disorders „ F32.2 Severe depressive episode without psychotic
• F38 Other mood (affective) disorders symptoms
• F39 Unspecified mood (affective) disorders „ F32.3 Severe depressive episode with psychotic symptoms

„ F32.8 Other depressive episode—atypical depression

ICD-10 Classification for Bipolar Affective Disorder
„ F32.9 Depressive episode, unspecified
• F30 Manic episode
„ F30.0 Hypomania • F33 Recurrent depressive disorder
„ F30.1 Mania without psychotic symptoms

„ F30.2 Mania with psychotic symptoms

ICD-10 Classification of Depression
„ F30.8 Other manic episode • F32 Depressive episode
„ F30.9 Manic episode unspecified „ F32.0 Mild depressive episode

Contd…
226 Textbook of Psychiatric Nursing for BSc Nursing Students

◆ .00 Without somatic syndrome ◆ .10 Without somatic syndrome

◆ .01 With somatic syndrome ◆ .11 With somatic syndrome
„ F32.1 Moderate depressive episode „ F33.2 Recurrent depressive disorder, current episode is
◆ .10 Without somatic syndrome severe without psychotic symptoms
◆ .11 With somatic syndrome „ F33.3 Recurrent depressive disorder, current episode is
„ F32.2 Severe depressive episode without psychotic severe with psychotic symptoms
symptoms „ F33.4 Recurrent depressive disorder, currently in remission
„ F32.3 Severe depressive episode with psychotic „ F33.8 Other recurrent depressive disorders
symptoms „ F33.9 Recurrent depressive disorder, unspecified
„ F32.8 Other depressive episodes • F34 Persistent mood [affective] disorders
„ F32.9 Depressive episode, unspecified „ F34.0 Cyclothymia

„ F34.1 Dysthymia
• F33 Recurrent depressive disorder
„ F34.8 Other persistent mood [affective] disorders
„ F33.0 Recurrent depressive disorder, current episode is
„ F34.9 Persistent mood [affective] disorder, unspecified
mild
„ F38.1 Other recurrent mood [affective] disorders
◆ .00 Without somatic syndrome
◆ .01 With somatic syndrome ◆ .10 Recurrent brief depressive disorder
„ F38.8 Other specified mood [affective] disorders
„ F33.1 Recurrent depressive disorder, current episode is

moderate • F39 Unspecified mood [affective] disorder

EXTRA EDGE
Types of Depression
Endogenous (or) psychotic depression, exogenous (or) neurotic depression (or) reactive depression, mild depression, moderate
depression, severe depression. Masked depression, melancholic (or) involutional melancholia, seasonal affective depression, postpartum
depression, agitated depression, acute depression, recurrent depression, secondary depression, double depression, atypical depression
and mixed anxiety and depressive disorder is shown in Flowchart 7.3.

Flowchart 7.3: Types of depression

CHAPTER 7 Nursing Management of Patients with Mood Disorders 227

SUMMARY
• Mood disorders are also called ‘Affective Disorders’.
• Mood disorders are classified as unipolar disorders (depression) and bipolar disorders.
• Mania and depression are bipolar I disorder.
• Hypomania and depression are bipolar II disorder.
• Norepinephrine, serotonin and dopamine—decrease in depression and increase in mania.
• Stages of mania are stage I—Hypomania, Stage II—Acute mania, Stage III—Delirious mania.
• Treatment includes lithium (0.6–1.2 mEq/L), Carbamazepine (6–12 mg/L), sodium valproate (50–125 mg/L), anticonvulsants, calcium
channel blockers, antipsychotics and benzodiazepines (lorazepam, clonazepam) and Electroconvulsive Therapy (ECT).
• The term “depression” came from Latin word ‘deprimere’ which means to press down.
• Beck depression Inventory (BDI) and Hamilton Rating Scale for depression is the most common rating scales used to assess depression.
• Decreased levels of norepinephrine and serotonin are observed in depression.
• Acetylcholine and Gamma-aminobutyric acid (GABA) regulations are impaired in depression.
• Cortisol level usually decreases with dexamethasone in general but it will not decrease in patients with depressive disorder.
• Behavior therapy includes social skills training, assertiveness training, problem-solving, decision-making skills and activity schedule.
• Antidepressant therapy includes Monoamine Oxidase Inhibitors (MAOIs), tricyclics and Selective Serotonin Reuptake Inhibitors (SSRIs).
• Electroconvulsive therapy (ECT), light therapy (or) phototherapy and repetitive Transcranial Magnetic Stimulation (TMS) and Vagus
Nerve Stimulation (VNS) are also helpful to reduce depression.

ASSESS YOURSELF
Long Answer Questions 14. Diagnostic criteria of mania and depression
1. Explain the classification, etiology, psychopathology, 15. Types of depression
diagnosis, clinical manifestations and management of
patients with mania. Multiple Choice Questions
2. Explain the classification, etiology, psychopathology, 1. Who coined the term mania and depression?
diagnosis, clinical manifestations and management of a. Hippocrates b. Emil Kraepelin
patients with depression. c. Aretus d. King Saul
2. Stage 3 mania is also called _______.
Short Answer Questions
a. Hypomania b. Acute mania
1. Define Mania. c. Delirious mania d. None of these
2. Define depression.
3. Drugs which increase the serum lithium level are ___.
Short Notes a. Acetazolamide b. Mannitol
c. Theophylline d. Metrogyl
Write short notes on:
1. Lithium 4. Hypomania and depression is _______.
2. Lithium toxicity and its management a. Bipolar I disorder b. Bipolar II disorder
3. BPAD c. Both a and b d. None of these
4. Stages of mania 5. Decreased Norepinephrine and Serotonin is present
5. Nursing interventions of patient with mania in _________.
6. Nursing interventions of patient with depression a. Mania
7. Etiology of mood disorders b. Depression
8. Clinical features of mania c. Both mania and depression
9. Symptoms of depression d. None of the above
10. Management of depression 6. Light therapy is indicated for _________.
11. Behavioral therapy for depression a. Mania
12. Differences between endogenous and exogenous b. Seasonal affective disorder
depression c. Both a and b
13. ICD-11 classification of bipolar related disorders d. None of the above
228 Textbook of Psychiatric Nursing for BSc Nursing Students

7. Stevens-Johnson Syndrome (SJS) is a side effect of a. 6A60.5 b. 6A61

_________. c. 6A62.5 d. 6A62
a. Sodium valproate b. Carbamazepine 10. Value of Grade-2 lithium toxicity is _________.
c. Lamotrigine d. Both b and c
a. 1.5–2.5 mEq/L b. 2.5–3.5 mEq/L
8. Mania is more common in _________. c. >3.5 mEq/L d. 0.5 mEq/L
a. Male b. Female
c. Both male and female d. None of these Answer Key
1. a 2. c 3. d 4. b 5. b
9. ICD-11 code for current manic episode with psychotic
features is _________. 6. b 7. d 8. b 9. a 10. b
Nursing Management of CHAPTER
Patients with Neurotic,
Stress-related and
Somatoform Disorders
8
LEARNING OBJECTIVE

After studying this chapter, the student will be able to understand the basic concepts of neurotic disorders. The student will also be
able to render the quality nursing care to patients with neurotic, stress-related and somatoform disorders.

CHAPTER OUTLINE
• Neurotic Disorder • Dissociative Disorder
• Anxiety Disorders • Somotoform or Somatic Symptom and Related Disorders
• Obsessive-Compulsive Disorder and its Related Disorders • Other Neurotic Disorders
• Trauma- and Stressor-Related Disorders • Geriatric Considerations

KEY TERMS
Anxiety disorder, Obsessive-compulsive disorder, Adjustment disorder, Dissociative or conversion disorder, Somatic symptom
disorder, Illness anxiety disorder (Hypochondriasis/Health Phobia/Health anxiety disorder), Post-traumatic stress disorder, Somatic
autonomic dysfunction, Factitious disorder or Munchausen syndrome by proxy, Malingering, Flashbacks, Trait anxiety, State anxiety,
Signal anxiety, Free-floating anxiety, Phobia, Panic attacks, Social phobia, Specific phobia, Agoraphobia, Fear network, Systematic
desensitization, Modeling, Exposure/response prevention, Thought-stopping technique, Nightmares, Hyperarousal, Briquet’s
syndrome or Somatoform disorder, Conversion disorder, Body dysmorphic disorder, Persistent somatoform pain disorder, Dissociative
amnesia, Multiple personality disorder, Trance or possession disorder, Ganser syndrome, Dissociative convulsion, Neurasthenia,
Depersonalization-derealization syndrome.

NEUROTIC DISORDER

Neurotic disorder is a less severe form of psychiatric disorder, in which the patients exhibit excess or prolong emotional response
to the stressors and it is not due to organic brain disease. The major causes of neurotic disorder are overwork, lack of rest, and
inability to relax. Neurotic diseases are caused by a disruption in the metabolism of neurotransmitters, hormones, vitamins, and
other biologically active chemicals necessary for the regular functioning of the central nervous system.

ANXIETY DISORDERS
Historical Perspectives
In 1871, Jacob Da Costa explained that chronic cardiac syndrome had been included in psychological and somatic symptoms
among soldiers. In 1900, Sigmund Freud introduced the concept of anxiety.
230 Textbook of Psychiatric Nursing for BSc Nursing Students

Definition or social distress, interference with normal functioning,

disproportionate with the threat and presence of significant
Anxiety is defined as ‘feelings of uncertainty, apprehension,
avoidance as shown in Flowchart 8.1.
uneasiness or tension that an individual shows in a given
situation’.
Etiological Factors
Epidemiology of Anxiety Disorders Genetic Factors

• Anxiety disorders are more common in females. These factors are enlisted in Table 8.3.
• Lifetime prevalence of anxiety disorders is 25% in females Biological Theory
and 15% in males.
• Increased serotonin activity: Thalamus, raphe nucleus,
• Common anxiety disorder in female is specific phobia
hypothalamus, basal ganglion and limbic system.
followed by social phobia.
• Increased tidal volume in panic attack.
• Common anxiety disorder in male is social phobia.
• Greater activation of amygdala (diamond-shaped
• In general, anxiety disorders are early in onset when
structure in limbic system).
compared with psychotic or mood disorders.
• Hyperactivity of insula (portion of cortex buried under
Onset of anxiety disorders: These are enlisted in Table 8.1.
lateral sulcus).
• Not activated anterior cingulate cortex (ACC).
Types of Anxiety Disorders
• These three structures—amygdala, ACC and insula
Types of anxiety disorders are summarized in Table 8.2. constitute to form fear network as shown in Figure 8.1.
When there is a dangerous situation, an individual • Abnormalities in cortico-striatal-thalamo-cortical
may fight or flight (escape) or fright (fear) toward the danger. (CSTC) circuit and glutamate transporter gene.
He/she becomes adaptive if there is a presence of coping skills. • Deficit in sensory gating, i.e., threat-related stimuli are
It may become pathological if it causes significant personal not filtered out.

Table 8.1: Onset of anxiety disorders

Disorders Onset of the disorder

Specific phobia Childhood
Social phobia Early teenage
Obsessive-compulsive disorder Mid to late teenage
Agoraphobia Early 20s age group
Panic disorder Mid 20s age group
Generalized anxiety disorder Around 30 years of age
Post-traumatic stress disorder (PTSD) Depends on the exposure of trauma

Table 8.2: Types of anxiety disorders

Types Description Example

Trait anxiety This type of anxiety is a component of personality and persists Individual with anxious personality disorder
for longer duration
State anxiety Anxiety which is more specific to the situation Student becomes anxious during examination
Signal anxiety Any response to anticipating event Mother who is relaxed but feels anxious when
sending the child to the school for the first time
Free-floating Individuals with generalized anxiety disorder often Ms Sudha having strong worries about her poor
anxiety characterize their feelings as ‘free-floating anxiety’. Here, the academic performance, when it gets solved, now
individuals will worry about one thing and when that worry she is worrying about her financial constraints.
resolves, the individuals might worry about other thing. It is She is having a racing thought, inability to
difficult to identify the absolute triggering point. concentrate or focus on one thing.
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 231

Flowchart 8.1: Concept of various responses in anxiety situation

Table 8.3: Genetic factors responsible for anxiety disorder

Chromosome Linkage of development

1, 9, 11, 13q Panic disorder
14q Specific phobia, social phobia, agoraphobia and
panic disorder
3q Agoraphobia
16q Social and simple phobia

• Neurotransmitters: GABA (gamma-aminobutyric acid)

underactivity and serotonin dysfunction.
• Neuroendocrine: HPA (hypothalamic-pituitary-adrenal) Figure 8.1: Parts involved in fear network
axis overactivity.
• Neuropeptides: Creatine phosphokinase (CPK), Psychoanalytic Theory
neuropeptide-Y (NPY), arginine vasopressin (AVP).
Anxiety is due to unconscious conflicts that exist between
• Childhood obsessive-compulsive disorder (OCD) occurs
impulses of aggressiveness and ego gratification. Example: Child
as a part of pediatric autoimmune neuropsychiatric
disorders associated with Streptococcus (PANDAS) might have unconscious conflict of losing the mother’s love.
syndrome; due to antistreptococcal antibodies acting on
Cognitive Behavioral Theory
basal ganglia.
• Positron emission tomography (PET): Raised metabolic Aaron Beck states that anxiety is a conditioned or learned
activity and blood flow in frontal lobe, cingulum and response toward the stressors. Anxiety is a learned trait for
basal ganglia are seen in patients with OCD. children from anxious parents.
232 Textbook of Psychiatric Nursing for BSc Nursing Students

Figure 8.2: Continuum or levels of anxiety

Sociocultural Theory
An individual is unable to meet social or cultural demands due
to his low self-concept. For example, if a student is weak in all
subjects, he is unable to perform well in academics as good as
Figure 8.3: Concept of panic anxiety
others.
ICD-11 and DSM-5 Classification of Anxiety
Etiology Based on the Types
Disorders
• Social phobia: Individual feels humiliated in public places.
As per ICD-11 and DSM-5, the classification of anxiety
• Specific phobia: Evolutionary phenomenon (Example:
disorders is given in Table 8.4.
Fear of dog—individual might have been exposed to dog
bite earlier or seen someone who suffered from the same Table 8.4: ICD-11 and DSM-5 classification of anxiety disorders
situation). ICD-11 DSM-5 Classification of anxiety disorders
• Post-traumatic stress disorder (PTSD): History of
6B00 300.02 Generalized anxiety disorder
exposure to traumatic event/events.
6B01 300.01 Panic disorder

Continuum or Levels of Anxiety 6B02 300.22 Agoraphobia

6B03 300.29 Specific phobia
The levels of anxiety include normal level, euphoria, mild
6B04 300.23 Social anxiety disorder (social phobia)
anxiety, moderate anxiety, severe anxiety and panic anxiety as
6B05 309.21 Separation anxiety disorder
shown in Figure 8.2.
• Normal: Individual may experience threat, but he/she 6B06 312.23 Selective mutism
might take necessary steps to reduce the threat. — 293.84 Anxiety disorder due to another
medical condition
• Euphoria: Exaggerated feel of well-being which is not
6B0Y 300.09 Other specified anxiety disorder
appropriate to the situation. It is an onset of mild level of
anxiety. 6B0Z 300.00 Unspecified anxiety disorder
• Mild anxiety: Increased alertness toward inner feelings.
Client might be restless, unable to relax, maintain rigid
Symptoms of Anxiety
posture and tremulous motor activity. They include physiological symptoms, psychological or
• Moderate anxiety: Signs like lack of concentration, emotional symptoms, behavioral symptoms and cognitive
tremors in voice, physiological changes, pacing and symptoms. Symptoms of anxiety disorders have been presented
verbalizing about danger are observed. in Table 8.5.
• Severe anxiety: Decreased intelligence, inability to
perform the task and inability to communicate clearly, Clinical Features of Generalized Anxiety
lack of concentration and decreased ability to perceive Disorder
things. • Prominent, persistent and exaggerated worry or tension
• Panic anxiety: Altered physiological, intellectual and or apprehension about day-to-day problems or events.
emotional changes take place. Physiological changes • Restlessness.
peak up and get back to normal within shorter duration • Inability to relax.
followed by a stressor as shown in Figure 8.3. • Irritable.
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 233

Table 8.5: Symptoms of anxiety disorder Clinical Features of Agoraphobia

Aspects Symptoms • Marked fear or anxiety about two or more of the following
Physiological • Headache five situations:
symptoms • Tachycardia 1. Using public transportation (e.g., automobiles, buses,
• Increased blood pressure trains, ships, planes)
• Increased respiration 2. Being in open spaces (e.g., parking lots, marketplaces,
• Blurred vision
bridges)
• Diaphoresis
• Dilated pupils 3. Being in enclosed places (e.g., shops, theaters,
• Vertigo cinemas)
• Nausea and vomiting 4. Standing in line or being in a crowd
• Anorexia 5. Being outside of the home alone
• Frequent urination
• Agoraphobic situations are actively avoided or almost
• Increased sweat in palms
• Sleep disturbances always provoke fear or anxiety.
• Tightness of chest • Agoraphobic situations cause significant distress or
• Dyspnea occupational impairment for at least 6 months or more.
• Weakness or muscle tension
Psychological • Depression Simple or Specific Phobia
or emotional • Irritability
symptoms • Social isolation Types of simple phobia are enumerated in Table 8.6.
• Lack of interest Table 8.6: Types of simple phobia
• Anger
• Crying spells Types of simple phobia Description
Behavioral • Hypervigilance Ablutophobia Fear of washing or bathing
symptoms • Restless
• Pacing Acarophobia Fear of itching or of the insects that
cause itching
Cognitive • Lack of concentration
symptoms • Inability to perform a task as expected Acerophobia Fear of sourness
• Memory loss Achluophobia Fear of darkness
• Unresponsive to external stimuli Acousticophobia Fear of noise
• Slow in performance
• Preoccupied with something Acrophobia or Altophobia Fear of heights
Aeronausiphobia Fear of vomiting secondary to air
sickness
• Difficult to concentrate.
Aerophobia Fear of drafts, air swallowing, or
• Initial insomnia (delay in falling into sleep due to
airborne noxious substances
continuous worry).
Agraphobia Fear of sexual abuse
Clinical Features of Panic Disorder Agrizoophobia Fear of wild animals
Agyrophobia Fear of streets or crossing the street
Episodes of panic attacks are characterized by:
Aichmophobia Fear of needles or pointed objects
• Acute onset of severe anxiety without an obvious trigger.
• Anxiety symptoms and physiological changes might Ailurophobia Fear of cats
reach at peak within few minutes and get back to normal Albuminurophobia Fear of kidney disease
within few minutes. Alektorophobia Fear of chickens
• Autonomic symptoms like palpitation, increased heart Algiophobia or Fear of pain
rate, sweating, tremors, etc. Algophobia
• Physical symptoms like chest tightness, breathing Alliumphobia Fear of garlic
difficulty, abdominal discomfort, difficult to swallow, Allodoxaphobia Fear of opinions
hot flushes, cold chills, lump in the throat, numbness or
Amathophobia Fear of dust
tingling sensation, etc.
Amaxophobia Fear of riding or traveling in a car
• Fear of dying, fear of losing control, fear of fainting,
depersonalization and derealization may also be present. Ambulophobia Fear of walking
Contd…
234 Textbook of Psychiatric Nursing for BSc Nursing Students

Types of simple phobia Description Types of simple phobia Description

Amnesiphobia Fear of amnesia Coitophobia Fear of coitus
Amychophobia Fear of scratches or being scratched Contreltophobia Fear of sexual abuse
Anablephobia Fear of looking up Coprastasophobia Fear of constipation
Androphobia Fear of men Coprophobia Fear of aversion of feces
Anemophobia Fear of air drafts or wind Cyberphobia Fear of computer or working with
Anginophobia Fear of angina, choking or use of computer
narrowness Cynophobia Fear of dogs/rabies
Angrophobia Fear of becoming angry Cypridophobia Fear of venereal disease
Ankylophobia Fear of immobility of a joint Decidophobia Fear of making decisions
Anthophobia Fear of flowers Dermatophobia Fear of skin lesions
Anthropophobia Fear of people in the society Dentophobia Fear of dentist
Antlophobia Fear of floods Dextrophobia Fear of objects/things at right side of
Anuptaphobia Fear of staying single the body

Apeirophobia Fear of infinity Levophobia Fear of objects/things at left side of

the body
Aphenphosmphobia or Fear of being touched
chiraptophobia Diabetophobia Fear of diabetes
Diplophobia Fear of double vision
Apiphobia Fear of bees
Didaskaleinophobia Fear of going to school
Arachnophobia Fear of spiders
Dipsophobia Fear of drinking
Asthenophobia Fear of fainting or weakness
Siderodromophobia Fear of train travel
Astrapophobia/ Fear of thunder and lightening
brontophobia Domatophobia Fear of houses or being in a home
Dromophobia Fear of crossing streets
Atelophobia Fear of imperfection
Dystychiphobia Fear of accidents
Automysophobia Fear of being dirty
Ecclesiophobia Fear of church
Autophobia Fear of being alone
Eisoptrophobia Fear of mirror or seeing oneself in
Bibliophobia Fear of books
mirror
Bromidrosiphobia Fear of body smells
Emetophobia Fear of vomiting
Cainotophobia Fear of newness or novelty
Electrophobia Fear of electricity
Cancerophobia Fear of cancer
Enissophobia/ Fear of having committed sin
Carnophobia Fear of meat enosiophobia
Kathisophobia Fear of sitting down Entomophobia or Fear of insects
Catoptrophobia Fear of mirrors Insectophobia
Chaetophobia Fear of hair Epistaxiophobia Fear of nose bleeding
Cheimatophobia Fear of cold Eosophobia Fear of daylight
Chemophobia Fear of chemicals Epistemophobia Fear of knowledge
Chorophobia Fear of dancing Ergophobia Fear of work
Chromatophobia Fear of colors Euphobia Fear of hearing good news
Chrematophobia Fear of money Gamophobia Fear of marriage
Chronophobia Fear of time Geliophobia Fear of laughter
Cibophobia Fear of food Genophobia Fear of sex
Claustrophobia Fear of closed spaces Gerascophobia Fear of growing old
Climacophobia Fear of stairs/climbing or falling Geumaphobia Fear of taste
downstairs Graphophobia Fear of writing
Clinophobia Fear of going to bed Gynephobia Fear of women
Contd… Contd…
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 235

Types of simple phobia Description Types of simple phobia Description

Hadephobia Fear of hell Olfactophobia Fear of smells
Harpaxophobia Fear of being robbed Oneirophobia Fear of dreams
Hedonophobia Fear of feeling pleasure Ombrophobia Fear of rain
Heliophobia Fear of sun Ornithophobia Fear of birds
Helminthophobia Fear of worm infestation Pantophobia Fear of everything
Hematophobia Fear of blood Papyrophobia Fear of paper
Heterophobia Fear of opposite sex Ouranophobia Fear of heaven
Hippophobia Fear of horses Parasitophobia Fear of parasites
Hobophobia Fear of beggars Parthenophobia Fear of virgins
Hodophobia Fear of road travel Pathophobia Fear of disease
Hyelophobia Fear of glass Pharmacophobia Fear of taking medications
Hylephobia Fear of fits Pedophobia Fear of children
Hylophobia Fear of forest Pediophobia Fear of dolls
Hypnophobia Fear of sleep Peniaphobia Fear of poverty
Hypengyophobia Fear of responsibility Pentheraphobia Fear of mother-in-law
Latrophobia Fear of doctors Phasmophobia Fear of ghost
Ideophobia Fear of ideas Philemaphobia Fear of kissing
Iophobia Fear of poison Photophobia Fear of light
Kakorrhaphiophobia Fear of failure Plutophobia Fear of wealth
Kopophobia Fear of dust Poinephobia Fear of punishment
Laliophobia Fear of speaking Polyphobia Fear of many things
Lachanophobia Fear of vegetables Psychophobia Fear of mind
Leukophobia Fear of white color Pyrexiophobia Fear of fever
Melanophobia Fear of black color Pyrophobia Fear of fire
Porphyrophobia Fear of purple color Radiophobia Fear of radiation
Xanthophobia Fear of yellow color Scabiophobia Fear of scabies
Ligyrophobia Fear of loud noises Soceraphobia Fear of parents
Logophobia Fear of words Sophophobia Fear of learning
Lygophobia Fear of darkness Soteriophobia Fear of dependent on others
Maieusiophobia Fear of childbirth Stasiphobia Fear of standing or walking
Mageirocophobia Fear of cooking Technophobia Fear of technology
Maniaphobia Fear of insanity Telephonophobia Fear of telephones
Meningitophobia Fear of brain disease Thermophobia Fear of heat
Microbiophobia Fear of microbes Thalassophobia Fear of sea
Methyphobia Fear of alcohol Thaasophobia or Fear of sitting or idleness
Microphobia Fear of small things Thassophobia

Nephophobia Fear of clouds Tomophobia Fear of surgery

Noctiphobia Fear of night Trichophobia Fear of hair

Nosocomephobia Fear of hospitals Traumatophobia Fear of injury

Nosophobia Fear of becoming ill Triskaidekaphobia Fear of number 13

Numerophobia Fear of numbers Trypanophobia Fear of injection

Obesophobia Fear of gaining weight Urophobia Fear of urine

Odynephobia Fear of pain Verminophobia Fear of germs

Contd… Contd…
236 Textbook of Psychiatric Nursing for BSc Nursing Students

Types of simple phobia Description Differential Diagnosis

Virginitiphobia Fear of rape • Prodrome or first episode of schizophrenia.
Vestiphobia Fear of clothes • Behavioral and psychological symptoms of dementia
Xenophobia Fear of strangers (BPSD).
Xerophobia Fear of dryness
• Delirium tremens of alcohol withdrawal.
• Anxiety seen in bipolar disorder.
Zelophobia Fear of jealousy
• Hyperthyroidism may mimic anxiety symptoms.
Zeusophobia Fear of God
Zoophobia Fear of animals Duration of the Persisting Symptoms Required
for Diagnosis
Clinical Features of Social Anxiety Disorder
Duration of the persisting symptoms required for the diagnosis
• Marked fear or anxiety about one or more social situations. of anxiety disorder is given in Table 8.7.
• Social situations provoke the fear or anxiety always.
Table 8.7: Duration of the persisting symptoms required for the
• Fear or anxiety is out of proportion to the actual threat
diagnosis of anxiety disorder
posed by the social situation.
• This disturbance is not related to the any other medical or Disorder DSM-5 ICD-11
mental disorder. Generalized anxiety At least 6 months For several months
• Duration of this disturbance—at least 6 months or more disorder
• Muscle tension or tension headache. Phobia At least 6 months For several months
• Autonomic symptoms like palpitation, increased heart Panic disorder At least 1 month Not mentioned
rate, sweating, tremors, etc.
• Physical symptoms like abdominal discomfort, difficult Obsessive- Not mentioned
to swallow, lump in the throat, hot flushes, numbness or compulsive disorder
tingling sensation, etc. Post-traumatic At least 1 month At least several weeks
stress disorder
Clinical Features of Separation Anxiety Disorder
• Recurrent excessive distress when anticipating or Assessment of Anxiety Disorder
experiencing separation from the major attachment Rating scale in anxiety disorders has been summarized in
figures or from home. Table 8.8.
• Persistent and excessive worry of losing the attachment
Table 8.8: Rating scale in anxiety disorders
figure.
• Persistent and excessive worry of experiencing the Anxiety disorder Rating scale
untoward events.
Generalized • Hamilton Rating Scale for Anxiety
• Repeated nightmare with the themes of separation anxiety disorder (HAM-A)
• Repeated complaints of physical symptoms when • State Trait Anxiety Rating Scale
separation from the attachment figures happens. Panic disorder • Panic Disorder Severity Scale (PDSS)
• Reluctance or refusal to go away from home or sleep away • Panic and Agoraphobia Scale (PAS)
from home. Social phobia • Social Phobia Inventory (SPIN)
• Duration involves 4 weeks for children and 6 months for • Liebowitz Social Anxiety Scale (LSAS)
adults. Obsessive- • Yale-Brown Obsessive-Compulsive Scale
compulsive (Y-BOCS)
Clinical Features of Selective Mutism disorder • Maudsley Obsessive-Compulsive
Inventory (MOCI)
• Consistent failure to speak in specific social situations
(e.g., at school). Post-traumatic • Impact of Events Scale (IES)
stress disorder • Clinician-Administered PTSD Scale (CAPS)
• This disturbance interferes with the educational and
(PTSD)
occupational achievement.
• This disturbance is not better explained in the • Routine blood investigations: Complete blood count,
communication disorder or autism or psychotic disorder glucose, liver function test, thyroid function test, etc.
• Duration of this disturbance—at least 1 month. • Baseline ECG
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 237

• It is important to be aware of the anxiety symptoms may stress management strategies, maintaining the
also be present in the major psychiatric illness such as: panic diary or journal writing and special training
„ Unipolar depression to enhance the coping skills are useful.
„ Mixed states of bipolar depression ◆ Phobia
„ Behavioral and psychological symptoms of dementia ¾ Systematic desensitization: It is developed by
„ Delirium tremens of alcohol withdrawal Joseph Wolpe. It has three steps:
„ During the prodrome phase in the first episode of 1.  Relaxation training: Relaxation gives the
schizophrenia. physiological effects which is opposite to
• Hyperthyroidism may resemble the symptoms of anxiety the anxiety.
disorder. So, the features of hyperthyroidism like heat 2.  Hierarchy construction: Arrange the
intolerance, tachycardia, etc. need to be checked. conditions in order of increasing anxiety.
3.  Desensitization of stimulus: Gradual
Treatment exposure of the individual from least to
Drugs most anxiety provoking state. In fact, it is
a behavior modification technique that
• Benzodiazepines: Useful in simple or specific phobia,
is used especially in treating phobias, in
e.g., lorazepam and diazepam.
which panic or other undesirable emotional
• Antidepressants: Selective serotonin reuptake inhibitors
response to a given stimulus is reduced
(SSRIs) are the first-line treatment for all anxiety disorders
or extinguished, especially by repeated
(except simple or specific phobia), e.g., fluoxetine and
exposure to that stimulus. For example,
escitalopram.
to understand the concept of systemic
• Beta-blockers: Useful for somatic symptoms of
desensitization in an individual having fear
anxiety such as tremors, tachycardia, etc., for example,
of crossing roads you can discuss the road
propranolol.
signals, show the picture of road, show the
real road, assist the person to cross the road
NOTES and at last ask the individual to cross the
• For OCD, tablet clomipramine can be given. In case of road alone.
treatment resistant OCD and SSRI augmented with low dose ◆ Flooding: It is also called implosive therapy. It is
antipsychotics can be given. used to desensitize the persons to phobic stimuli.
• Benzodiazepines might be useful in short-term treatment and It differs from systemic desensitization. Instead of
SSRI might be used in long-term/maintenance treatment.
working out in hierarchy of anxiety and instead of
provoking stimuli, the person is ‘flooded’ with the
Psychotherapy continuous presentation of phobic stimuli until
• Cognitive behavioral therapy: Maladaptive cognition/ the anxiety comes down. Flooding does not exist
imaginary threat has been identified and maladaptive in practice because this intense anxiety might be
behavior (escape and avoidance to overcome anxiety) has dangerous to the individuals and it may lead to
to be changed. heart attack or death. For example, if the individual
„ Cognitive strategies is having the fear of insect, then the individual is
◆ Help the client to have realistic perception of put into the room with a greater number of insects
anxiety. in order to reduce the phobia.
◆ Educate the client that anxiety will not persist • Cognitive behavioral therapy for post-traumatic stress
forever and it might not kill. disorder
◆ Advise the client, avoidance of anxiety may help „ Identify the cognitive distortions
for short-term reduction of symptoms but for long „ Discussion about the trauma
run it won’t help the individual, instead facing the „ Exposure to remind the traumatic incidents (place,
anxiety presently may worsen the symptoms but in activities, person, etc.)
long run it might help to overcome the anxiety. ◆ By imagination or
„ Behavioral strategies ◆ Direct confrontation
◆ Panic disorder: Cognitive behavioral therapy, „ Development of skills to deal with future trauma
systematic desensitization, relaxation training, • Eye movement desensitization and reprocessing for PTSD
238 Textbook of Psychiatric Nursing for BSc Nursing Students

• Self-monitoring technique: Ask the patient to monitor Table 8.10: ICD-11 and DSM-5 classification of obsessive-
oneself when he/she becomes anxious compulsive disorder and its related disorders
• Relaxation training: Mindfulness meditation, exercise,
ICD-11 DSM-5 Classification of obsessive-compulsive
yoga, progressive muscle relaxation, breathing exercises disorder and its related disorders
and autogenic training
6B20 300.3 Obsessive-compulsive disorder
• Psychoeducation
• Problem-solving skill training — 300.7 Body dysmorphic disorder
• Support group 6B24 300.3 Hoarding disorder
• Bibliotherapy—self-help books
6B25.0 312.39 Trichotillomania (hair-pulling disorder)
Prognosis of Anxiety Disorder 6B25.1 698.4 Excoriation (skin-picking) disorder
Prognosis of anxiety disorder is given in Table 8.9. — 294.8 Obsessive-compulsive and related disorder
due to another medical condition
Table 8.9: Prognosis of anxiety disorder
— 300.3 Other specified obsessive-compulsive and
Aspects Good prognosis Poor prognosis related disorder
Onset Late Early
6B20.Z 300.3 Unspecified obsessive-compulsive and
Severity Mild/Moderate anxiety Severe anxiety related disorder
Comorbidity Absent Present
Drug adherence Present Absent Etiology
Previous unsuccessful Absent Present Genetic Factors
treatment
• Family studies: 35% of first-degree relatives of OCD
clients might suffer from this disorder.
OBSESSIVE-COMPULSIVE DISORDER AND ITS
RELATED DISORDERS • Twin studies: Monozygotic twins are more prone to it as
compared to dizygotic twins.
Definition
• Obsession: Repetitive thoughts, images and doubts Psychodynamic Theory
which make a person absolutely senseless and irrational. Fixation of anal-sadistic phase in childhood might lead
Individual tries to resist but finds unable to do so because to reaction formation and when it fails it might cause the
that restriction might increase the level of anxiety. obsessional personality traits. Anxiety due to oedipal conflicts
• Obsession versus delusion: Obsession is ego-alien or might lead to regression and when it fails it might cause the
ego-dystonic, i.e., opposite to individual’s personality aggressive impulses reinforced. Isolation affect (ego removes
whereas delusion is said to be ego-syntonic. affect from anxiety occurring thoughts) fails, it might lead
• Obsession versus thought insertion: Obsession is to obsessional thoughts. If undoing (prevent the feared
one’s own idea/thought whereas in thought insertion, consequences of obsession) fails, it might lead to compulsive
someone’s idea gets inserted in one’s mind. acts and if displacement fails, it might lead to phobia
• Compulsion: Repetitive actions are performed followed (Flowchart 8.2).
by obsession in order to avoid the marked distress even Flowchart 8.2: Psychodynamic theory of
though the client knows that behavior is unrealistic, obsessive-compulsive disorder
senseless and irrational.

Epidemiology
• Worldwide lifetime prevalence is 2–3%
• Common among unmarried males
• Common with upper socioeconomic individuals
• Onset is late 20s in India.

Classification of Obsessive-Compulsive
Disorder and its Related Disorders
As per ICD-11 and DSM-5, the classification of obsessive-
compulsive disorder and its related disorders is given in
Table 8.10.
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 239

Behavioral Theory • Checkers

Compulsions are said to be learned behavior to reduce the „ Obsession: Feeling of doors is not locked properly.
„ Compulsive act: Checking again and again whether
anxiety related to obsessions.
door is locked.
Biological Theory • Pure obsessions
„ Obsessive ruminations: Preoccupied thoughts/
• Lesions in hypothalamus, basal ganglia and third ventricles.
images/impulses which ruminate in one’s mind.
• Abnormalities in serotonin (5-HT) system, cortico-
• Primary obsessive slowness
striatal-thalamo-cortical circuit and glutamate transporter „ Marked slowness in repetitive thoughts will lead to
gene. slowness in daily activities.
• Dysfunction of caudate nucleus (part of striatum).
• OCD secondary to tics and encephalitis. Clinical Features of Body Dysmorphic Disorder
• Pediatric autoimmune neuropsychiatric disorders • Preoccupation with the perceived defects in physical
associated with Streptococcus syndrome might cause appearance which are not observable by others.
childhood OCD because of antistreptococcal antibodies • During the course of the disorder, the person does
which act on basal ganglia of brain. repetitive behaviors such as mirror checking, skin
picking, excessive grooming and seeking reassurance or
Hormonal Factors
the mental acts such as comparing his or her appearance
Increased incidence during menarche and increased severity with others.
of symptoms following the birth of the child. • This preoccupation causes clinically significant distress
and impairment in social, occupational, or other vital
Psychological Risk Factors
areas of functioning.
Personality traits such as guilt, excessive doubt, perfectionism, • These symptoms will not meet the diagnostic criteria for
more sense of responsibility, etc. an eating disorder.

Types of Obsessive-Compulsive Disorder Clinical Features of Hoarding Disorder

(Flowchart 8.3)
• Persistent difficulty in discarding or parting with
• Washers possessions, regardless of the actual value.
„ Obsession: Feeling of dirty hands/clothes/rooms. • Perceived need to save the items and having distress
„ Compulsive act: Washing again and again. associated with the discarding them.

Flowchart 8.3: Types of obsessive-compulsive disorder

240 Textbook of Psychiatric Nursing for BSc Nursing Students

• Hoarding behavior causes the clinically significant • Behavior therapy

distress or impairment in social, occupational or other „ Thought-stopping technique
vital areas of functioning. ◆ Joseph Wolpe developed this technique.
• Hoarding behavior is not attributable to another medical ◆ When client gets repetitive thoughts while being
condition or other mental disorder. alone, then client can shout ‘STOP’.
◆ When client gets repetitive thoughts in a group,
Clinical Features of Trichotillomania then client can say ‘STOP’ slowly to oneself.
• Recurrent pulling out of one’s hair which results in hair ◆ Rubber band method: Individual might tie
loss. a rubber band in wrist, when he/she gets the
• Repeated attempt to stop hair pulling. repeated thoughts, then strike the rubber band to
avoid those distressing thoughts.
• Hair pulling behavior causes the clinically significant
„ Exposure and response prevention
distress or impairment in social, occupational or other
◆ For example, soil the patient’s hand visibly dirty
vital areas of functioning.
(exposure) and ask the client not to perform hand
• Hair pulling behavior is not attributable to another
wash (response prevention).
medical condition or other mental disorder.
„ Systematic desensitization: Step by step graded
Clinical Features of Excoriation (Skin-Picking) exposure of fearful stimuli.
Disorder „ Modeling: Demonstrate the method what has to be
done (expected) during obsessions and ask the client
• Recurrent skin picking behavior results in lesions and to repeat it immediately.
repeated attempt to stop the same. • Electroconvulsive therapy
• Skin picking behavior causes the clinically significant Indications are as follows:
distress or impairment in social, occupational or other „ If the client has depression along with OCD
vital areas of functioning. „ Poor response to drug therapy
• Skin picking behavior is not attributable to influence of „ OCD patient with high suicidal risk
substance or another medical condition or other mental • Psychosurgery
disorder. „ Stereotactic limbic leukotomy
„ Stereotactic subcaudate tractotomy
Course and Prognosis
• Good prognosis with social and family support. TRAUMA- AND STRESSOR-RELATED DISORDERS
• Poor prognosis includes early onset of OCD, more • The term ‘trauma’ means injury. Here it denotes the
severity of symptoms, bizarre compulsions along with the psychological trauma.
presence of comorbid illness can be seen. • Stressor is something which causes stress. Stressor can
be internal (which is present inside) or external (from
Treatment outside).
• Drug therapy
„ Benzodiazepines: Clonazepam, lorazepam, alprazolam Classification of Trauma- and Stressor-Related
„ Antidepressants: Selective serotonin reuptake Disorders
inhibitors As per ICD-11 and DSM-5, the classification of trauma- and
◆ Fluoxetine: 20–80 mg/day stressor-related disorders is given in Table 8.11.
◆ Clomipramine: 75–300 mg/day
◆ Fluvoxamine: 50–200 mg/day Post-Traumatic Stress Disorder
◆ Sertraline: 50–200 mg/day Definition
„ Antipsychotics: Haloperidol, olanzapine, risperidone,
Post-traumatic stress disorder (PTSD) is an anxiety disorder,
pimozide
in which the individual might develop the re-experiencing
„ Buspirone
symptoms or arousal symptoms or avoidance symptoms
• Psychotherapy after witnessing or experiencing an extreme, overwhelming
„ Psychoanalytic psychotherapy for patients traumatic event during which the individual felt intense fear or
„ Supportive psychotherapy for family members helplessness in the past.
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 241

Table 8.11: Classification of trauma- and stressor-related disorders

ICD-11 DSM-5 Classification of trauma- and stressor-related disorders

6B40 309.81 Post-traumatic stress disorder
6B41 — Complex post-traumatic stress disorder
6B42 — Prolonged grief disorder
6B43 — Adjustment disorders
6B44 313.89 Reactive attachment disorder
6B45 313.89 Disinhibited social engagement disorder
— 308.3 Acute stress disorder
— 309.0 Adjustment disorders (with depressed mood)
— 309.24 Adjustment disorders (with anxiety)
— 309.28 Adjustment disorders (with mixed anxiety and depressed mood)
— 309.3 Adjustment disorders (with disturbance of conduct)
— 309.4 Adjustment disorders (with mixed disturbance of emotions and conduct)
— 309.9 Adjustment disorders (unspecified)
6B4Y 309.89 Other specified trauma- and stressor-related disorder
6B4Z 309.9 Unspecified trauma- and stressor-related disorder

Etiological Factors Avoidance Features

• Neurochemical factors: Increased sensitivity of • Efforts are made to avoid the thoughts or feelings
hypothalamic-pituitary-adrenal axis and increased associated with traumatic event/events.
sensitivity to cortisol receptors. • Efforts are made to avoid activities, places, situations
• Biological factors: Increased function of sympathetic or people which arouse the recollection of traumatic
nervous system, imbalance in dopamine and norepineph- event.
rine. • Inability to recall the vital aspect of the trauma
• Cycle of violence: Witnessing the child abuse. (psychological amnesia).
• Miscellaneous • Markedly diminished interest in significant activities.
„ Actual or threatened serious injury or death. • Feelings of detachment from others.
„ Threat to one’s physical integrity. • Restricted range of effect: Not able to have lovable
„ Witnessing an event and perceived as life-threatening feelings for others.
one, e.g., war, natural disaster, road traffic accident. • Sense of foreshortened future: Not expected to have
„ Learning about unexpected serious harm or violent marriage, children, career, or to lead a normal life span.
death or threat of death or injury experienced by a
family members or friends. Persistent Symptoms of Increased Arousal (Not Present
Before Trauma)
Symptoms of PTSD • Difficulty in falling asleep or staying asleep
Re-experiencing Symptoms • Irritable (progress to rage) or outburst of anger
• Difficulty in concentrating on any events
• Recurrent and distressing recollection of the events
• Hypervigilance—resembles like paranoia
(flashback).
• Recurrent dreams of that particular event (nightmares). • Exaggerated startle response—highly fearful in nature
• Sudden feeling or acting as if the traumatic event is even for small noise.
recurring.
Diagnostic Criteria for PTSD as per DSM-5
• Intense psychological distress at exposure to things which
symbolize or resemble an aspect of the trauma. • One or more re-experiencing symptoms
• Physiological reactivity when exposed to the internal or • Two or more increased arousal symptoms
external cues of event. • Three or more avoidance symptoms
242 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 8.13: Examples of the post-traumatic events

Witnessed Traumatic events Events experienced

traumatic experienced by others that are
events directly learned about
• Witnessing the • Being kidnapped • Learned about
serious injury • Being taken violent personal
or unnatural hostage assault, serious
death of a • Terrorist attack injury or serious
person due • Torture accident,
to road traffic • Violent personal experienced by or
accident, assault a close friend or a
violence, • Natural or man- family member
assault, made disasters • Learned about
disaster or war • Severe accidents a sudden,
• Unexpectedly • Being diagnosed unexpected death
Figure 8.4 Predominant symptoms of PTSD witnessing a with a life- of a close friend or
body part or a threatening family member
dead body illness • Learned about
All the symptoms must be present for more than 1 month
one’s children have
duration and clinically cause the significant distress or a life-threatening
impairment in social, occupational, or other important areas disease
of functioning.
Predominant symptoms of PTSD have been described in Types of PTSD
Figure 8.4.
The other common clinical manifestations of PTSD are Types of PTSD have been displayed in Flowchart 8.4. Traumatic
restlessness, aggressiveness, clinical depression, nightmares, events might occur for individual and group are given in
insomnia, memory loss, avoidance, dissociation, hyperarousal, Table 8.14.
anorexia, anxiety, irritability, hypervigilance, extreme distress
and intrusions. Flowchart 8.4: Types of PTSD

ICD-11 Diagnostic Criteria for PTSD

• Significant evidence of traumatic events
• Onset within 6 months of a traumatic event
• Significant emotional detachment
• Numbness of feelings
• Daytime imagery
• Repetitive, intrusive recollection of the events in memories

Differences between immediate and delayed onset PTSD have

been mentioned in Table 8.12. Examples of the post-traumatic
events are given in Table 8.13.
Table 8.12: Differences between immediate and delayed onset PTSD Table 8.14: Traumatic events might occur for individual and group

Aspects Immediate onset Delayed onset PTSD Traumatic events might Traumatic events might
PTSD occur to an individual occur for group or whole
population
Response to Better Poor
treatment • Strong threat from stranger • Natural disaster
• Victim of sexual abuse • Earthquake
Prognosis Better Worse • Physical abuse • Tsunami
Associated Fewer More • Witness the severe • Hurricane
symptoms or accident • Drought
complications • Involved in life-threatening • Man-made disaster
accident • Bomb threat
Symptoms are Within 6 months More chances to
• Domestic violence from life • War
resolved develop into chronic
partner
state
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 243

Assessment of PTSD • Depressive disorders: Emotional numbness and

• Interviews avoidance features are present in both depression and
„ Clinician-Administered PTSD Scale (CAPS) PTSD whereas hyperarousal or intrusive symptoms are
not seen in depression but they are present in PTSD.
„ Anxiety Disorder Interview Schedule (ADIS)
• Others: Anxiety disorders and substance abuse disorders.
„ PTSD Symptom Scale Interview (PSS-I)
„ Structured Interview for PTSD (SI-PTSD)
• Self-report questionnaires NOTE
„ Impact of Event Scale-Revised (IES-R) Sometimes, the above differential diagnosis might be present as
„ The Post-traumatic Diagnostic Scale (PDS) the comorbid conditions of post-traumatic stress disorder.
„ Mississippi Scale for Combat-related PTSD and
Mississippi Scale for Civilians
Treatment
„ Keane PTSD Scale of the MMPI-2
„ PTSD checklist—it has two versions: • Exposure therapy: Repeated exposure to the past-
◆ Version 1: Civilians traumatic events in gradual manner which is aimed to
◆ Version 2: Military personnel and veterans. remember the traumatic event without the anxiety.
• Cognitive therapy: Separating the intrusive thoughts
• For children from the associated anxiety. Therapist will work out to
„ Child PTSD Symptom Scale (CPSS) reduce the distress-enhancing cognitions.
„ Trauma Symptom Checklist for Children (TSCC) • Stress inoculation training: Helps the patient to relax
„ Trauma Symptom Checklist for Young Children while thinking about the traumatic event.
(TSCYC) • Medications
„ Parent Report of Child’s Reaction to Stress „ Selective serotonin reuptake inhibitors: Sertraline
„ Child Post-traumatic Stress Reaction Index (CPTS- (zoloft), escitalopram (lexapro), paroxetine (paxil
RI) fluoxetine (prozac), fluvoxamine (luvox).
„ Children’s Impact of Traumatic Events Scale-Revised „ Tricyclic antidepressants: Clomipramine (Anafra-
(CITES-R) nil), maprotiline (Ludiomil), nortriptyline (Aventyl),
„ Clinician-Administered PTSD Scale for Children and amitriptyline (Elavil), doxepin (Sinequan), desipra-
Adolescents (CAPS-CA) mine (Norpramin).
„ Antianxiety agents: Benzodiazepines, e.g., lorazepam
NOTE „ Antihypertensive agents: For example, propranolol,
clonidine.
In children, the symptoms of PTSD are expressed as night- „ Mood stabilizers: For example, lithium carbonate,
mares, disturbances in going to sleep, acting out behavior,
carbamazepine.
developmental regression, clinging behavior, withdrawal from
friends, poor attention, decline in academic performance, fighting • Treatment for children
with peers, etc. „ Critical incident stress management: Intervention
that addresses the traumatic incident to decrease the
traumatic effects.
Differential Diagnosis „ Cognitive behavioral therapy: Cognitive restructur-
• Acute stress disorder: Symptoms might occur within ing and anxiety management can be done.
4 weeks of traumatic event and it might come to an end „ Group therapy
within that period, when the symptoms persist for more „ Play therapy
than 4 weeks then it is termed PTSD. „ Involvement of parents in treatment
• Obsessive-compulsive disorder: Repeated thoughts will „ Medications: Fluoxetine (prozac) for depression in
be there but not related toward the post-traumatic events children and sertraline (zoloft) for OCD in children.
in OCD.
• Adjustment disorder: Stressor is going to be within Complex Post-Traumatic Stress Disorder
the normal human experience in adjustment disorder In addition to the core features of post-traumatic stress
whereas in PTSD, stressor is a post-traumatic event. disorder, the below features will be present:
244 Textbook of Psychiatric Nursing for BSc Nursing Students

• Severe and pervasive problems in affect regulation History

• Persistent beliefs about oneself as worthless, accompanied Adjustment disorders were previously a part of personality
by the pervasive feelings of shame, guilt or failure related
disorder. After 19th century, it is termed ‘intrinsic monomania’
to the traumatic event
(fire setting and kleptomania—uncontrolled impulse of
• Persistent difficulties in sustaining relationships with others.
stealing things).
Adjustment disorders occur due to the repeated
Prolonged Grief Disorder
stressors which are experienced by a normal human being
(Refer to Grief and Bereavement Topic in Psychiatric
such as sudden job loss, marriage, childbirth, divorce,
Emergency Unit)
economic problems and not interested in studies which give
Definition of Grief a maladaptive response to a stressful life event. Emotional
and behavioral responses occur within 3 months from the
It is the normal process of reacting to the loss of beloved
onset of stressors. These emotional and behavioral responses
ones. (Example: At the time of grieving process, any sort of
may be present with depression, anxiety, conduct disturbances,
actions or emotions or expressions to loss such as anger, shock,
mixed depression and anxiety. Adjustment disorders may
disbelief, depression, resentment, etc. is elicited).
be acute (with 6 months) or chronic (more than 6 months)
Subtype (Flowchart. 8.5).
Prolonged grief disorder is a subtype of morbid grief or Epidemiology
complicated grief.
Adjustment disorders might occur at any age group. Incidence
ICD-11 Diagnostic Criteria rate is higher in adolescence and women. Approximately 2–3%
• The disturbance happens following the death of life of people in general population have adjustment disorder. This
partner or parent or child or another close person to be disorder is more common in individuals with poor coping
bereaved. skills/abilities.
• Persistent and pervasive grief response characterized by
Etiology
longing for the deceased.
• Persistent preoccupation with the deceased accompanied • Genetic factors: Over reacting to the stressor and high
by intense emotional pain (e.g., blame, sadness, denial, anxiety temperament.
guilt, anger, feeling one has lost a part of one’s self, negative • Biological factors: History of serious medical illness or
mood, emotional numbness, difficulty in engaging in disability.
activities). • Psychosocial factors: Poor care from parents and loss
• Grief response presents atypically long period of time of parents in infancy. Decreased frustration tolerance in
following the loss (6 months and above at a minimum). adult might be due to lack of basic needs in infancy.
• Grief reactions that have persisted for longer periods
that are within a normative period of grieving given Differential Diagnosis
the person’s cultural and religious context are viewed as • Acute post-traumatic stress disorder: It is outside the
normal bereavement responses. range of human experience (e.g., disasters, war or any
• Disturbance causes significant impairment in personal, catastrophic incidents) whereas in adjustment disorder it
family, social, educational, occupational or other is within the range of human experience.
important areas of functioning. • Brief psychotic disorder: Brief psychotic disorder
delusion, hallucination and disorganized behavior are
Nursing Management
present whereas these are absent in adjustment disorders.
Nurse needs to provide the bereavement counseling to the • Uncomplicated bereavement: Symptoms occur after
patient (counseling provided to address the practical issues of the death of beloved ones in case of uncomplicated
living without the loved one who has been dead recently). bereavement but they occur within the range of human
experience in adjustment disorder.
Adjustment Disorder
• Anxiety and mood disorders: Anxiety and mood
Definition disorders do not have direct relation with stressor,
Presence of significant behavioral or emotional symptoms in whereas adjustment disorder occurs due to the repeated
response to the psychosocial stressors. stressors.
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 245

Flowchart 8.5: Concept map of adjustment disorder

Course and Prognosis Epidemiology

The individual might return to the previous level of functioning It is seen in severely neglected children (less than 10% of such
within 3-month period. The individual might develop mood children).
disorder or substance abuse disorder in future. Prognosis of
DSM-5 Diagnostic Criteria
adolescence is later than adults.
The above-mentioned definition criteria are met but the criteria
Treatment for autism spectrum disorder are not met. The disturbance is
• Psychological: Psychotherapy such as biofeedback, evident before age 5 years and the child has a developmental
relaxation techniques and hypnosis might be helpful. age of at least 9 months. (Specify as ‘Persistent’ if the symptoms
Crisis intervention such as supportive techniques, present more than 12 months).
suggestion, reassurance and environment manipulation
Functional Consequences
might be helpful. Coping skills training and stress
management training are essential. Interpersonal relations with the adult and peers will be greatly
• Drugs: Antianxiety and antidepressants. impaired.

Nursing Management
Reactive Attachment Disorder
Nurse has to teach the parents in regard to the importance
Definition
of the primary caregiver for the children and functional
A consistent emotionally withdrawn behavior toward adult consequence if the quality of caregiving environment
caregivers such as rarely seeks or responds to comfort when consistently compromised. Ask the caregiver to monitor
distressed, persistent emotional or social disturbances such whether the baby seeks or responds to comfort when distressed
as irritability, sadness, fearfulness, etc. and child experiences and so the progress can be identified.
the extremes of ineffective care such as social neglect, repeated
change of primary caregiver, limited opportunity to get Prognosis
attached with primary caregiver, etc. It depends on the quality of caregiving environment.
246 Textbook of Psychiatric Nursing for BSc Nursing Students

Comorbid Disorders Epidemiology

• Psychological disorders: Cognitive delay, stereotype It is common in females, first exposure to traumatic event and
behavior, language delay, depressive disorders. individuals with poor coping skills.
• Medical disorders: Malnutrition.
Clinical Manifestations
Disinhibited Social Engagement Disorder Anger, depression, anxiety, social withdrawal, despair and
Definition constricted level of consciousness. Symptoms might resolve
within few hours if the individual from stressful environment
A consistent pattern of behavior in which a child actively has been removed. If the stress continues, the symptoms may
approaches and interacts with unfamiliar adults, not limited resolve within 1–3 days. Description of the symptoms is given
to impulsivity (as in attention-deficit/hyperactivity disorder). in Table 8.15.
Child experiences the extremes of ineffective care such as
Table 8.15: Symptoms of acute stress disorder
social neglect, repeated change of primary caregiver, limited
opportunity to get attached with primary caregiver, etc. Symptoms of acute Description of the symptoms
stress disorder
Epidemiology
Intrusion symptoms • Recurrent, involuntary and intrusive
It is seen in severely neglected children (less than 20% of such distressing memories of traumatic
children). event
• Recurrent distressing dreams
DSM-5 Diagnostic Criteria • Dissociative reactions (e.g., flashbacks)
about the traumatic event
The above-mentioned definition criteria are met but the criteria • Prolonged psychological distress or
for autism spectrum disorder are not met. The disturbance is marked physiological reactions in
response to internal or external cues
evident before age 5 years and the child has a developmental
in regard to the traumatic event
age of at least 9 months. (Specify as ‘Persistent’ if the symptoms
Negative mood Persistent inability to experience positive
present more than 12 months). emotions
Functional Consequences Dissociative • Altered sense of the reality of one’s
symptoms surroundings or oneself
Interpersonal relations with the adult and peers will be greatly • Inability to remember the vital aspect
impaired. of the traumatic event (typically due
to dissociative amnesia)
Nursing Management Avoidance • Efforts to avoid distressing memories,
Nurse has to teach the child in regard to the negative symptoms thoughts, or feelings associated with
the traumatic event
consequences of having more interaction with the unfamiliar • Efforts to avoid external reminders
adults. Necessary treatment advice is required to treat the associated with the traumatic event
comorbid disorder at the earliest. Arousal symptoms • Sleep disturbances
• Irritable behavior and angry outbursts
Prognosis • Hypervigilance
It depends on the quality of caregiving environment. • Problems with concentration
• Exaggerated startle response
Comorbid Disorders
Treatment
Cognitive delay, stereotype behavior, language delay and
Antianxiety drugs (benzodiazepines, e.g., diazepam) to reduce
attention-deficit/hyperactivity disorder.
the agitation.
Acute Stress Disorder
DISSOCIATIVE DISORDER
Definition
An immediate and clear relation exists between the stressor Definition
(e.g., accident, sudden job loss, disaster) and the onset of Dissociative disorder is defined as lack of integration of
symptoms such as anger, depression, etc. consciousness, memory and identity.
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 247

History Table 8.16: ICD-11 and DSM-5 classification of dissociative disorders

• Mr Pierre Janet (19th century), French Physician and ICD-11 DSM-5 Classification of dissociative
Psychologist, is the first person to identify the concept of disorders
dissociation. 6B60 — Dissociative neurological symptom
• Freud (1962) viewed that the dissociation is an active disorder
mechanism of repression. 6B61 300.12 Dissociative amnesia
— 300.13 Dissociative amnesia (with dissociative
Epidemiology
fugue)
Dissociative amnesia (formerly psychogenic amnesia) is the 6B62 — Trance disorder
most common type of dissociative disorder. The prevalence of
6B63 — Possession trance disorder
dissociative fugue is 0.2%; however, it is increased during the
time of disaster, accidents and war. 6B64 300.14 Dissociative identity disorder
6B65 Partial dissociative identity disorder
Etiology 6B66 300.6 Depersonalization-derealization
• Biological/neurophysiological dysfunction: Amygdala, disorder
hippocampus, frontal cortex, mammillary bodies and 6B6Y 300.15 Other specified dissociative disorder
thalamus. 6B6Z 300.15 Unspecified dissociative disorder
• Psychodynamic factors: Intrapsychic conflict, sublima-
tion, projection and repression (Flowchart 8.6).
• Social factors/learning theory: Nonverbal means of Dissociative Neurological Symptom Disorder or
controlling/managing others. Conversion Disorder (Functional Neurological
• Behavioral—reinforcement by: System Disorder as per DSM-5)
„ Primary gain: Protect from painful emotional (Refer to the Conversion Disorder in the Same Chapter for
experience. Full Description)
„ Secondary gain: Gratifying response of having a sick It is characterized by presentation of motor, sensory
role. or cognitive symptoms which lead to the involuntary
discontinuity with the normal integration of motor, sensory
Classification of Dissociative Disorders
or cognitive functions and not consistent with disease of the
As per ICD-11 and DSM-5, the classification of dissociative nervous system, other mental or behavioral disorder or other
disorders is given in Table 8.16. diseases.

Flowchart 8.6: Psychodynamic factors of dissociative disorder Dissociative Identity Disorder

Individual is dominated with two or more personalities, in
which one personality is manifested at a time. One personality
is not aware about the other personality (amnesia is present
between the personalities). Onset and termination of
personalities are sudden in nature.

Partial Dissociative Identity Disorder

One personality state is dominant and normally functions
in daily life, but the dominant personality intruded upon by
one or more nondominant personality states (dissociative
intrusions). This intrusion can be cognitive, affective,
motor, perceptual or behavioral. Due to the interfering
with the functioning of the dominant personality state may
provoke aversiveness. Nondominant personality state will
not recurrently take an executive control of individual’s
consciousness and functioning.
248 Textbook of Psychiatric Nursing for BSc Nursing Students

Dissociative Amnesia Possession Trance Disorder

It is the most common type of dissociative disorder. It is most It is characterized by trance states in which the individual’s
commonly seen in young adults and it has been observed customary sense of personal identity is replaced by an external
that females are more affected as compared to males. Mostly ‘possessing’ identity and in which the individual’s movements
dissociative amnesia has the following stages: or behaviors are experienced as being controlled by possessing
• Before amnesia: Stressor or traumatic life event. agent.
• During amnesia: Clouding of consciousness.
• Post amnesia: Aware of disturbances in memory. Miscellaneous Dissociative Disorder
• Ganser syndrome or hysterical pseudodementia:
Types of Dissociative Amnesia
Symptom commonly seen in prison inmates and has
• Localized amnesia: Unable to recall for specific time a characteristic feature of ‘Vorbeireden’ called ‘saying
period after the event. approximate answer’.
• Selective amnesia: Unable to recall certain incidents with • When client is questioned 6 + 5 = ___. Client might
traumatic event. verbalize 10 or 12 but not 11.
• Continuous amnesia: Unable to recall from a specific
time till date. Clinical Features of Dissociative Disorder
• Generalized amnesia: Unable to recall entire lifetime
The clinical features of dissociative disorder have been given
incidence including the personal identity.
in Table 8.17.
• Systematized amnesia: Unable to recall events with
specific category (e.g., any particular person/event/
ICD-11 Diagnostic Criteria for Dissociative
family).
Disorder
Dissociative Fugue • Predominant symptoms should match the description
of the specific subtype of dissociative disorder such
It is characterized by episodes of wandering away from home.
as dissociative identity disorder or partial dissociative
During the wandering, individual assumes new identity along
identity disorder or trance or procession trance
with complete amnesia of previous life. Onset is sudden with
disorder or dissociative amnesia or dissociative fugue or
presence of stress. Termination is abrupt with remembrance
depersonalization-derealization disorder or dissociative
of previous life. Differential diagnosis includes the complex
fugue or other specified or unspecified disorder.
partial seizure and temporal lobe epilepsy (in which
• Symptoms are not better explained by another psychiatric,
assumption of new identity is absent).
behavioral or the neurodevelopmental disorder.
• Disorder is not due to the influence of any substances or
Depersonalization-Derealization Disorder
medication on the central nervous system or disease of
Depersonalization-derealization disorder is persistent or the nervous system or sleep wake disorder.
recurrent experiences of depersonalization, derealization, or
both. Table 8.17: Clinical features of dissociative disorder
• Depersonalization is experiencing the self as strange or
unreal, or feeling detached from, or as though one were an Motor symptoms Sensory deficits Visceral symptoms
outside observer of, one’s thoughts, feelings, sensations, • Involuntary • Anesthesia of • Psychogenic
body, or actions. movements extremities vomiting
• Derealization is characterized by experiencing other • Tics • Blindness • Pseudocyesis
• Blepharospasm • Midline • Urinary retention
persons, objects, or the world as strange or unreal or • Seizures anesthesia • Diarrhea
detached from the surroundings. • Abnormal gait • Tunnel vision • Globus hystericus
• Torticollis • Deafness • Swooning or
Trance Disorder • Opisthotonos syncope
• Falling
It is characterized by trance states in which there is a marked • Weakness
alteration in the person’s state of consciousness or a loss of • Aphonia
the individual’s sense of personal identity. Trance state is not • Astasia-abasia
replaced by an alternate identity. • Paralysis
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 249

• Symptoms of this disorder will lead to the significant • Drug therapy: Short-acting barbiturates (amobarbital)
impairment in personal, family, educational, social, and benzodiazepines.
occupational or other vital areas of functioning.
SOMOTOFORM OR SOMATIC SYMPTOM AND
Differential Diagnosis RELATED DISORDERS
• Delirium/Dementia Introduction
• Epilepsy
• Amnesia with general medical disorder In the word, ‘Somatoform’ prefix ‘soma’ came from Greek
• Transient global amnesia word, ‘body’. It is a mental illness in which multiple body signs
• Substance-induced amnesia and symptoms are elicited but, the medical evaluation does
• Wernicke-Korsakoff syndrome not reveal any abnormalities. Patients will visit a number of
• Acute stress doctors (Doctor shopping), when the doctor says that there is
• Somatoform/somatization/conversation disorder no health problems, then the patient might get face issues like
• Malingering frustration, anxiety and depression.

Course and Prognosis Classification of Somatic Symptom and Related

Disorders
• Usually, acute onset.
• Recovery is complete, few relapses might be there. DSM-5 classification of somatic symptom and related disorders
• Duration is prolonged if dissociation is due to secondary is given in Table 8.18.
gain.
• Symptoms might terminate abruptly. Somatic Symptom Disorder
• Prognosis is good when onset is acute and the individual Definition
has above average intelligence. Presence of one or more somatic symptoms which cause
The continuum of dissociation has been presented in significant personal distress in patient.
Figure 8.5.
Epidemiology
Treatment It begins in teenage usually before 30 years of age. It is more
• Behavior therapy common in women. Depression and anxiety are the common
„ Aversion therapy—pressure in tragus of ear comorbid illnesses. The common personality traits are paranoid,
• Psychotherapy with abreaction (Bringing to conscious avoidant, self-defeating and obsessive- compulsive trait.
awareness/thoughts/memories for first time)
„ Hypnosis Etiology
„ Free association Psychodynamic factors.
„ Intravenous barbiturates (thiopentone/diazepam)
• Supportive psychotherapy Table 8.18: DSM-5 classification of somatic symptom and related
• Insight-oriented supportive or behavior therapy disorders
• Psychodynamic psychotherapy
• Psychoanalysis DSM-5 code Somatic symptom and related disorders
300.82 Somatic symptom disorder
300.7 Illness anxiety disorder
300.11 Conversion disorder (functional neurological
symptom disorder)
316 Psychological factors affecting other medical
conditions
300.19 Factitious disorder
300.89 Other specified somatic symptom and related
disorder
300.82 Unspecified somatic symptom and related
Figure 8.5: Continuum of dissociation disorder
250 Textbook of Psychiatric Nursing for BSc Nursing Students

• Learning theory psychotherapy. Assist the patient to express the underlying

• Social/cultural factors emotions and also help the patient to develop alternative
• Biological factors strategies to express feelings of the patient.
• Genetic factors
• Cytokines Nursing Diagnosis
• Ineffective coping skills related to unresolved
Differential Diagnosis psychological conflicts as evidenced by the verbalized
• True medical illness somatic symptoms.
• Psychiatric disorders such as depression and anxiety • Anxiety related to extreme concern about physical illness/
• Life stressors with associated psychophysiological symptoms.
symptoms. • Low self-esteem related to perceived threat to perform
• Other somatic symptom-related disorders. daily functional activities.
• Powerlessness related to perceived lack of ability to
Course of Illness improve the physical health as evidenced by high level
It is usually chronic and relapsing in nature. dependency.
• Social isolation related to lack of ability to participate in
DSM-5 Diagnostic Criteria social events.
• One or more somatic symptoms which can be distressing • Interrupted family process related to the assumption of
or result in the significant disruption of daily life. sick role.
• Excessive feelings or thoughts or behaviors related to Ineffective coping skills related to unresolved psychological
somatic symptoms or which are associated with health conflicts as evidenced by the verbalized somatic symptoms
concerns are manifested by at least one of the following: have been given in Table 8.19.
„ Disproportionate and persistent thoughts about the
Table 8.19: Ineffective coping skills
seriousness of one’s symptoms.
„ Persistently high levels of anxiety about health or Nursing intervention Rationale
symptoms. Discuss with the patient It helps the client to recognize the
„ Excessive time and energy are devoted to these to explore the triggering triggering factor and manage one’s
symptoms or health concerns. factors own behavior
• State of being symptomatic persists for more than Show empathy in the To gain the trust from patient
6 months. patient’s distress
Individual appears with many physical symptoms which Teach the client to It helps to enhance the coping ability
occur over a period of years. It leads to multiple medical develop coping strategies
consultations and other attempts for seeking treatment. It must Perform insight-oriented To promote the insight into behavior
cause significant impairment in social, occupational, or other therapy patterns
areas of functioning. In spite of appropriate investigations
done, the symptoms cannot be fully explained by a known Anxiety related to the extreme concern on physical illness/
general medical condition. The symptoms are not produced symptoms has been given in Table 8.20.
intentionally. There will be four pain symptoms which are Table 8.20: Anxiety related to physical illness
related to at least four different sites or functions which are as
follows: Nursing intervention Rationale
• Two gastrointestinal symptoms other than pain Assess the level of anxiety It gives the baseline data
• One sexual or reproductive symptom and the triggering factor
which is provoking anxiety
• One pseudoneurological symptom
Provide stress management To reduce the level of stress
Treatment training

Nurse has to help the patient to have a regular monthly visit to Teach the relaxation techniques To decrease the level of anxiety
the same psychiatrist. Advise the patient to avoid the diagnostic Encourage the client to It helps to involve in activities,
investigations. Raise awareness of these symptoms being participate in the activities of thereby the patient’s concern
responses to psychological pressure. Improve the coping skills/ daily living (ADLs) on his/her physical symptoms
might reduce
abilities with these symptoms. Provide individual or group
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 251

Illness Anxiety Disorder (Hypochondriasis/ Diagnostic Test

Health Phobia/Health Anxiety Disorder) All laboratory investigations will reveal the patient’s condition
Definition is normal. Minnesota Multiphasic Personality Inventory
It is an anxiety disorder which is characterized by being (MMPI) shows the five components on hysteria scale such
preoccupied with health concerns that might cause significant as poor physical health, shyness, cynicism, headache and
impairment or personal distress in one’s life. neuroticism and it will reveal higher score. More color
responses in the Rorschach test might be present and denote
Epidemiology the emotional liability.
• Males and females are equally affected.
Nursing Management
• Common in all age groups
• In males, symptoms peak around 30 years of age and in Supportive systemic approach with love and care is beneficial.
females around 40 years of age. Stress reduction program (deep breathing exercises, relaxation
training, healthy lifestyle measures) and enhancement of
Etiology coping skills are important. Assist the client in performing
• Psychodynamic factors: Projection, intrapsychic the daily activities. Do not give any false reassurance to the
conflict, pain or suffering as a punishment of guilt and patient. Support the patient in rehabilitation and refer him/her
displacement of anger toward self. to the appropriate self-help groups. Inquire the client directly
• Social learning model/Learning theory/Social factors: whether he/she is having a suicidal tendency. Group therapy
Symptoms often learned from past experiences or have might be helpful to get good social support from others.
related medical illness. Regular follow-up of the patients is important. Antidepressants
• Biological factors: Low threshold and low tolerance of and antianxiety agents are used.
physical discomfort.
Course and Prognosis
DSM-5 Diagnostic Criteria It is usually chronic in nature. The prognosis is good if the
• Preoccupation with having or acquiring a specific illness. individual has a good premorbid personality and prognosis is
• Usually, somatic symptoms are absent though mild poor if the individual is superimposed with the physical disorder.
symptoms may be present sometimes. The descriptions of somatoform autonomic dysfunction
• Excessive health concern if another medical condition is have been given in Table 8.22. It also shows the symptoms and
present or the individual is at high-risk. treatment method of this dysfunction.
• High level of anxiety about health, easily alarmed about The physiology of hyperventilation syndrome has been
personal health status. shown in Flowchart 8.7.
• Performs excessive health-related behaviors or exhibits
maladaptive avoidance. Conversion Disorder
• Symptoms last for 6 months or more. Definition
• Preoccupation with health concerns might cause
It is a somatic symptom-related disorder which characterized
significant impairment or distress in a person’s life.
by the presence of one or more symptoms of altered voluntary
Table 8.21 shows differences between medical and psychiatric motor or sensory function. There is an incompatibility between
disorders. the symptom and recognized neurological or medical conditions.
Table 8.21: Differences between medical and psychiatric disorders
Other Names
Medical disorders Psychiatric disorders • This disorder is also called “functional neurological
• Degenerative diseases of • Depression symptom disorder”.
neurons • Anxiety • As per ICD-11, this is named as “dissociative neurological
• Myasthenia gravis • Panic disorder symptom disorder”.
• Acquired • Sexual dysfunction
immunodeficiency • Malingering Epidemiology
syndrome (AIDS) • Factitious disorder
• Systemic lupus • Persistent conversion symptoms are estimated to be
erythematosus (SLE) 2–5/100,000 per year.
• Two to three times more common in females.
252 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 8.22: Descriptions of somatoform autonomic dysfunction

Somatoform autonomic Description Symptoms Treatment

dysfunction
Hyperventilation syndrome Hyperventilation (loss of • Mild hyperventilation syndrome • Relaxation therapy
(HVS) (Flowchart 8.7) too much carbon dioxide) • Headache • Breathing techniques
because of fast breathing • Fatigue • Antidepressants
due to psychosocial • Chest pain • Antianxiety agents
stressors • Sweating • Breathing-in-bag technique
• Palpitation (client rebreathes the
• Feel of lightheadedness Moderate to expired air to increase the
severe hyperventilation syndrome pCO2)
• Paresthesia
• Loss of consciousness
• Carpopedal spasm (tetany)

Irritable bowel syndrome (IBS) Disturbances in bowel • Discomfort, pain or cramps of • Antidepressants
or irritable colon syndrome motility are due to abdomen • Antianxiety
or nervous diarrhea or spastic psychological factors. It • Disturbed bowel habits (diarrhea/ • Prokinetic agents (e.g.,
colitis or colon neurosis or may be hypomotility or constipation) cisapride)
mucus colitis hypermotility • Feel of incomplete evacuation • Supportive psychotherapy

Premenstrual syndrome or Presence of physical, • Psychological Symptoms • Thiazide diuretics (e.g.,

premenstrual tension behavioral and • Anxiety spironolactone)
psychological symptoms • Restlessness • Oral/Parental progesterone
occurs in the second half of • Depression • Treatment-resistant
menstrual cycle (few days • Crying spells premenstrual syndrome
after ovulation) due to fault • Irritability can be treated with
in luteinization increased • Physical Symptoms antidepressants,
estrogen and decreased • Fatigue antianxiety drugs,
progesterone level • Headache bromocriptine and lithium
• Gastroenterological changes • Supportive psychotherapy
• Pedal edema
• Sense of bloating abdomen
• Swelling of breast

Flowchart 8.7: Physiology of hyperventilation syndrome

CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 253

Etiology or Risk Factors Associated features:

• Temperamental: Maladaptive personality traits are • La belle indifference—lack of concern about the nature or
commonly associated with this disorder. implications of the symptom.
• Environmental: History of childhood abuse or neglect, • Secondary gain—derive external benefits such as money
stressful life event may be present. or release from responsibilities.
• Genetic and physiological: Presence of neurological disease
may cause similar symptom (for example, nonepileptic
seizure is more common in patients who have epilepsy). NOTE
The associated features are additional but not specific symptom
Clinical Features to diagnose the conversion disorder.
Motor symptoms:
• Weakness or paralysis.
Comorbid Disorders
• Gait abnormalities and abnormal limb posturing.
• Abnormal movements such as tremors or dystonic Anxiety disorders (especially panic disorders, depressive
movements. disorders and personality disorders are more common
Sensory symptoms: comorbid disorders.
• Altered, reduced or absent skin sensation, vision or hearing
Nursing Management
• Episodes of abnormal generalized limb shaking with
apparent impaired or loss of consciousness may resemble Relaxation program such as deep breathing exercises,
epileptic seizures (also called psychogenic or nonepileptic relaxation training, healthy lifestyle measures is important.
seizures)—given in Table 8.23. Assist the client in performing the daily activities. Motivate
Other symptoms: the patients to ventilate the emotions. Support the patient
• Altered articulation (dysarthria). in rehabilitation and refer him/her to the appropriate self-
• Reduced or absent speech volume (dysphonia/aphonia) help groups. Teach the coping strategies to patients. Regular
• Diplopia (double vision). follow-up of the patients is important. Antidepressants and
• Sensation of a lump in the throat (globus). antianxiety agents are used.

Table 8.23: Differences between epileptic seizures and psychogenic nonepileptic seizures or hysterical fits

Aspects Epileptic seizures Psychogenic nonepileptic seizures or hysterical fits

Clinical pattern Stereotyped Purposive body movements
Place of incident Anywhere Safe place
Time of day Anytime. Even happen during sleep Never happen during sleep
Speech Absent May present
Tongue bite May present Absent
Injury May occur Very rare
Urine and fecal incontinence May occur Very rare
Turning duration Shorter Prolonged
Turing of head Unilateral Side to side turning is present
Eye gaze Staring gaze if the eyes are open Avoidant gaze
Neurological signs Present Absent
Amnesia Complete Partial
Stress 25% of patients have stress Majority of them have stress
Postictal confusion Present Absent
EEG Abnormal Normal
Serum prolactin Raised in postictal period Normal
254 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 8.24: Other specified neurotic disorders (culture-bound syndromes)

Syndromes Regions commonly affected Description

Dhat syndrome India Belief that there will be presence of semen in urine. There
may be sexual dysfunction, depression, anxiety, multiple somatic complaints
and asthenia (physical/mental exhaustion)
Amok Southeast Asia Sudden onset of rage and killing the persons those who are coming on the way
Koro Asia Belief that penis is shrinking and will disappear into abdominal wall
Wihtigo (Windigo) American-Indians Belief that the individual is being transferred into cannibal monster mainly
during the time of starvation
Piblokto (Arctic Eskimos living in green land Women might tear off clothes and throw oneself into ice. She might cry like
hysteria) arctic circle bird/animal. It is a type of dissociative disorder and the episode lasts for
1–2 hours followed by amnesia
Latah (Startle Japan and Southeast Asia Presence of echolalia, echopraxia and automatic obedience.
reaction)

Psychological Factors Affecting Other Medical differential diagnosis, in which individual has a soft physical
Conditions sign (present in mild) without the significant medical or
psychiatric disorder. Individual with neurasthenia might have
Presence of physical medical condition due to the psychological
any two of these complaints:
or behavioral factors may influence the course of the medical
• Sleep disturbances
condition (exacerbation or delayed recovery), treatment of the
medical condition, health risks for the individual, underlying • Muscle aches
pathophysiology and the precipitating or exacerbating • Tension/headache
symptoms which seek the medical attention. • Inability to relax
• Dyspepsia
Categories • Fatigue/dizziness
• Mild category: Presence of increased medical risk. • Irritability
• Moderate category: Aggravates the underlying medical Other specified neurotic disorders (culture-bound syndromes)
condition. have been listed in Table 8.24.
• Severe category: Results in hospitalization.
• Extreme category: Results in life-threatening risk. GERIATRIC CONSIDERATIONS

The common anxiety disorders seen in elders are general

Factitious Disorders or Munchausen Syndrome
by Proxy anxiety disorders and phobia. In general, anxiety disorders are
comorbid condition of depression, physical illness, dementia
Falsifications of physical or psychological symptoms which and drug toxicity. Drug of choice in geriatrics is selective
project the individual as an ill person. The deception happens serotonin reuptake inhibitor group of antidepressants. Drugs
even in the absence of obvious external reward. It may happen have to be initiated in lower dosage in order to check the
as a single episode or in a recurrent episode. tolerating capacity among elders.
In malingering (psychiatric disorder), patient plays a
similar sick role with the intention of secondary gain (avoiding Follow-Up, Home Care and Rehabilitation
work, escape from the criminal cases, unwilling to pay the
amount, etc.) whereas in factitious disorder playing of sick role • Teach the stress management techniques and coping skills
is not for the secondary gain. among patients.
• Encourage the family members to utilize the available
OTHER NEUROTIC DISORDERS community resources.
• Teach the patient to identify the stressors which exacerbate
Neurasthenia: Individual has persistent and distressing the anxiety and to avoid them.
complaints of body weakness and he feels exhausted even after • Teach the family members about drug compliance.
a minimal effort. Chronic fatigue syndrome (CFS) is the main • Encourage the patient to express the feelings.
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 255

• Teach the patient in regard with the lifestyle modifications

such as balanced diet, regular exercises, avoidance of EXTRA EDGE
smoking and alcoholism.
• Advise the patient and family members to have a regular DSM-IV Classification of Somatoform Disorders
follow-up in psychiatric OPDs or in community clinics. • Somatization disorders or Briquet’s syndrome: Multiple organ
system involvement is present.
• Conversion disorders: Neurological complaints.
EXTRA EDGE • Hypochondriasis: Worried about being sick with a particular
illness rather than to focus on physical symptoms (now,
ICD-10 Classification of Neurotic, Stress-related and hypochondriasis is termed ‘illness anxiety disorder’ in DSM-5).
Somatoform Disorder (F40-F49) • Body dysmorphic disorder: Dissatisfaction with any of the
body part (now, body dysmorphic disorder has been shifted to
• F40: Phobic anxiety disorder
obsessive disorders in the DSM-5).
• F41: Other anxiety disorder • Persistent somatoform pain disorder: Pain is the main
• F42: Obsessive-compulsive disorder complaint (now, persistent somatoform pain disorder is the
• F43: Reaction to severe stress and adjustment disorder part of somatic symptom disorder in DSM-5).
• F44: Conversion or dissociative disorder • Undifferentiated somatoform disorder.
• F48: Other neurotic disorder • Somatoform disorder not otherwise specified.

SUMMARY
• In 1900, Sigmund Freud introduced the concept of anxiety.
• Anxiety is defined as ‘feelings of uncertainty, apprehension, uneasiness or tension that individual shows in any situation’.
• Anxiety disorders are more common in females.
• Lifetime prevalence of anxiety disorders in females is 25% and in males it is 15%.
• Types of anxiety disorders: Trait anxiety, state anxiety, signal anxiety and free-floating anxiety.
• When there is a dangerous situation, individual may fight, flight (escape), fright (fear) toward the danger.
• Biological factors for anxiety disorders: Increased serotonin activity in thalamus, raphe nucleus, hypothalamus, basal ganglion
and limbic system, greater activation of amygdala (diamond-shaped structure in limbic system), hyperactivity of insula (portion of
cortex buried under lateral sulcus), not activated anterior cingulate cortex, three structures (amygdala, anterior cingulate cortex and
insula) constitute ‘fear network’, abnormalities in cortico-striatal-thalamo-cortical circuit and glutamate transporter gene, deficit in
‘sensory gating’, i.e. threat-related stimuli are not filtered out, neurotransmitters—GABA underactivity and serotonin dysfunction,
neuroendocrine—hypothalamic-pituitary-adrenal axis overactivity, neuropeptides—CPK, NPY, AVP.
• Anxiety is due to unconscious conflicts that exist between impulses of aggressiveness or gratification with ego.
• The levels of anxiety include normal level, euphoria, mild anxiety, moderate anxiety, severe anxiety and panic anxiety.
• Symptoms of anxiety include physiological symptoms, psychological or emotional symptoms, behavioral symptoms and cognitive
symptoms.
• Types of phobias: Simple or specific phobia, social phobia, agoraphobia, panic disorder with agoraphobia.
• ICD-11 and DSM-5 classifications of anxiety disorder are separation anxiety disorder, selective mutism, specific phobia, social anxiety
disorder, panic disorder, agoraphobia, generalized anxiety disorder, other specified and unspecified anxiety disorder.
• Anxiety disorders in DSM-5 are generalized anxiety disorder, panic disorder, specific phobia/social phobia/agoraphobia, obsessive-
compulsive disorder and post-traumatic stress disorder.
• Differential diagnosis of anxiety disorders is prodrome or first episode schizophrenia, behavioral or psychological symptoms of
dementia, delirium tremens of alcohol withdrawal, anxiety seen in bipolar disorder and hyperthyroidism may mimic anxiety symptoms.
• Hamilton Rating Scale for Anxiety (HAM-A) and State Trait Anxiety Rating Scale are used for assessment of generalized anxiety disorder.
Panic Disorder Severity Scale (PDSS) are Panic and Agoraphobia Scale (PAS) are used to assess panic disorder. Social Phobia Inventory
(SPIN) and Liebowitz Social Anxiety Scale (LSAS) are used to assess social phobia. Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and
Maudsley Obsessive-Compulsive Inventory (MOCI) are used to assess obsessive-compulsive disorder. Impact of Events scale (IES) and
Clinician Administered PTSD Scale (CAPS) are used to assess post-traumatic stress disorder.
• Drugs used in anxiety disorders are benzodiazepines, beta-blockers and antidepressants—selective serotonin reuptake inhibitors are
first-line treatment for all anxiety disorders.
• Psychotherapy for anxiety disorders: Cognitive behavioral therapy, behavior strategies, systematic desensitization or graded exposure
and flooding for phobia, cognitive behavioral therapy for post-traumatic stress disorder (PTSD), eye movement desensitization and
reprocessing for PTSD, self-monitoring technique, relaxation training (mindfulness meditation, exercise, yoga, progressive muscle
relaxation, breathing exercises and autogenic training), psychoeducation, skill training to solve the problems, support group and
bibliotherapy.
• Obsession is the repetitive thoughts, images and doubts that one will feel which are absolutely senseless and irrational, individual
tries to resist but is unable to do so because that restriction might increase the level of anxiety. Obsession is ego-alien or ego-dystonic.
Obsession is one’s own idea/thought whereas in thought insertion, someone’s idea is inserted in one’s mind.

Contd…
256 Textbook of Psychiatric Nursing for BSc Nursing Students

• Compulsion is repetitive action performed followed by obsession in order to avoid the marked distress even though the client knows
that behavior is unrealistic, senseless and irrational.
• Worldwide lifetime prevalence of OCD is 2–3%, common among unmarried males, common with upper socioeconomic individuals and
the onset is late 20s in India.
• Etiology of OCD includes genetic factors, psychodynamic theory, behavioral theory, biological theory, hormonal factors and
psychological risk factors.
• Types of obsessive-compulsive disorder include predominantly obsessive thoughts, predominantly compulsive acts and mixed
obsessional thoughts and compulsive acts.
• Good prognosis of OCD is with social or family support. Poor prognosis of OCD is with early onset, severity of symptoms, bizarre
compulsions and presence of comorbid illness.
• Drug therapy of OCD includes benzodiazepines (clonazepam, lorazepam, alprazolam), antidepressants—selective serotonin reuptake
inhibitors (fluoxetine 20–80 mg/day, clomipramine 75–300 mg/day, fluvoxamine 50–200 mg/day and sertraline 50–200 mg/day),
antipsychotics (haloperidol, olanzapine, risperidone, pimozide) and buspirone.
• Psychotherapy of OCD includes psychoanalytic psychotherapy for patients and supportive psychotherapy for family members.
• Behavior therapy of OCD includes thought-stopping technique, systematic desensitization—step by step graded exposure of fearful
stimuli, modeling, exposure and response prevention.
• Electroconvulsive therapy can be administered if the client has depression along with OCD, poor response to drug therapy and OCD
patients have high suicidal risk.
• Psychosurgery of OCD includes stereotactic limbic leukotomy and stereotactic subcaudate tractotomy.
• Acute stress reaction is defined as ‘immediate and clear relation exists between the stressor (e.g., accident, sudden job loss, disaster)
and the onset of symptoms’.
• Post-traumatic stress disorder is an anxiety disorder in which the individual might develop intense fear or helplessness after witnessing
or experiencing an extreme, overwhelming traumatic event.
• Etiological factors of PTSD include neurochemical factors (increased sensitivity of hypothalamic-pituitary-adrenal axis and
increased sensitivity to cortisol receptors) and biological factors (increased functions of sympathetic nervous system, imbalance in
neurotransmitters such as dopamine and norepinephrine).
• Symptoms of PTSD are classified as re-experiencing symptoms, avoidance features and persistent symptoms of increased arousal (not
present before trauma).
• ICD-11 Diagnostic Criteria for PTSD include the significant evidence of traumatic events, onset is within the 6 months of a traumatic event,
significant emotional detachment, numbness of feelings, daytime imagery, repetitive or intrusive recollection of the events in memories.
• Types of PTSD are acute, chronic and delayed onset type.
• Assessment of PTSD includes interviews such as Clinician Administered PTSD Scale (CAPS), Anxiety Disorder Interview Schedule revised
(ADIS-R), PTSD Symptom Scale Interview (PSS-I), Structured Interview for PTSD (SI-PTSD). Self-report questionnaires such as Impact of
Event Scale-Revised (IES-R), the Post-traumatic Diagnostic Scale (PDS), Mississippi Scale for Combat-related PTSD and Mississippi Scale
for Civilians, Keane PTSD Scale of the MMPI-2 and PTSD Checklist Scales used to assess PTSD for Children are Child PTSD Symptom Scale
(CPSS), Trauma Symptom Checklist for Children (TSCC), Trauma Symptom Checklist for Young Children (TSCYC), Parent Report of Child’s
Reaction to Stress, Child Post-traumatic Stress Reaction Index (CPTS-RI), Children’s Impact of Traumatic Events Scale-Revised (CITES-R)
and Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA).
• Differential diagnosis for PTSD include acute stress disorder, obsessive-compulsive disorder (OCD), adjustment disorder, depressive
disorders, anxiety disorders and substance abuse disorders.
• Treatment for PTSD includes exposure therapy, cognitive therapy and stress inoculation training—helps the patient to relax while
thinking about the traumatic event.
• Medications for PTSD are SSRIs, tricyclic antidepressants, antianxiety agents and antihypertensive agents and mood stabilizers.
• Treatment for PTSD in children includes critical incident stress management, cognitive behavioral therapy, group therapy, play therapy,
involvement of parents in treatment and medications: fluoxetine (Prozac) for depression in children and sertraline (Zoloft) for OCD in
children.
• Adjustment disorders are defined as ‘presence of significant behavioral or emotional symptoms in response to the psychosocial
stressors’.
• Etiology of adjustment disorders includes genetic factors, biological factors and psychosocial factors.
• Differential diagnosis of adjustment disorder includes acute post-traumatic stress disorder, brief psychotic disorder, uncomplicated
bereavement, anxiety and mood disorders.
• Treatment of adjustment disorders includes psychotherapy such as biofeedback, relaxation techniques and hypnosis might be helpful.
Crisis intervention such as supportive techniques, suggestion, reassurance and environment manipulation might be helpful. Coping
skills training and stress management training are essential. Antianxiety and Antidepressants can be administered.
• Somatoform disorder is a mental illness in which a multiple body signs and symptoms are elicited but the medical evaluation does not
reveal any abnormalities.
• DSM-5 classification of somatic symptom-related disorders includes somatic symptom disorder, illness anxiety disorder (hypochondriasis),
conversion disorder (functional neurological symptom disorder), psychological factors affecting other medical conditions, factitious
disorders, other specified somatic symptoms disorders (pseudocyesis), unspecified somatic symptom and related disorder.

Contd…
CHAPTER 8 Nursing Management of Patients with Neurotic, Stress-related... 257

• Dissociative disorder is defined as lack of integration of consciousness, memory and identity.

• Types of dissociative disorders are dissociative amnesia (selective amnesia continuous amnesia, generalized amnesia, systematized
amnesia), dissociative fugue, multiple personality (dissociative identity) disorder, trance or possession disorder and other dissociative
disorder (Ganser syndrome or hysterical pseudodementia).
• Treatment of dissociative disorders includes behavior therapy, abreaction, hypnosis, free association, intravenous barbiturates,
supportive psychotherapy, insight-oriented supportive or behavior therapy, psychodynamic psychotherapy and psychoanalysis.
• DSM-5 Criteria for illness anxiety disorder are preoccupation with having or acquiring a specific illness, somatic symptoms are
absent usually or mildly present sometimes. Excessive health concern if another medical condition is present or the individual at high
risk, high level of anxiety about health, easily alarmed about personal health status, performs excessive health-related behaviors or
exhibits maladaptive avoidance, symptoms last for 6 months or more and preoccupation with health concerns might cause significant
impairment or distress in a person’s life.
• Somatoform autonomic dysfunction includes hyperventilation syndrome (HVS), irritable bowel syndrome (IBS) or irritable colon
syndrome or nervous diarrhea or spastic colitis or colon neurosis or mucus colitis and premenstrual syndrome or premenstrual tension.
• Factitious disorder is the falsification of physical or psychological symptoms which project the individual as an ill person. The deception
happens even in the absence of obvious external reward.
• Other neurotic disorders are neurasthenia, depersonalization disorder or depersonalization-derealization syndrome. Other specified
neurotic disorders (culture-bound syndromes) include Dhat syndrome, Amok, Koro, Wihtigo, Piblokto and Latah.

ASSESS YOURSELF

Long Answer Questions a. State anxiety b. Trait anxiety

c. Signal anxiety d. Free-floating anxiety
1. Explain its types, etiology, psychopathology, clinical
manifestations and management of patient with anxiety 4. Drug of choice for anxiety disorder is _________.
disorder. a. Chlorpromazine b. Risperidone
2. Explain its types, etiology, psychopathology, clinical c. Haloperidol d. Lorazepam
manifestations and management of patient with 5. Another name for irritable bowel syndrome (IBS) is:
obsessive-compulsive disorder. a. Nervous diarrhea b. Colon neurosis
c. Mucus colitis d. All of these
Short Answer Questions
6. ICD-11 code for dissociative amnesia is:
1. Define anxiety disorder. a. 6B61 b. 6B63
2. Define obsessive-compulsive disorder. c. 6B62 d. 6B64
Short Notes 7. Fear of road travel is:
a. Acrophobia b. Hydrophobia
Write short notes on:
c. Hematophobia d. Zoophobia
1. Post-traumatic stress disorder
2. Specific phobia 8. Peculiar symptom of PTSD is:
3. Somatic symptom disorder a. Nausea b. Fatigue
4. Dissociative disorder c. Flashback d. Crying spells
5. Adjustment disorder 9. __________ is characterized by episodes of wandering
6. Hypochondriasis away from home.
a. Dissociative fugue
Multiple Choice Questions b. Dissociative identity disorder
c. Trance and possession disorder
1. __________ is the repetitive thoughts, images and
d. Dissociative amnesia
doubts that one will feel it’s absolutely irrational one.
a. Obsession b. Compulsion 10. _______ has characteristic feature of ‘Vorbeireden’.
c. Anxiety d. Phobia a. Ganser syndrome or hysterical pseudodementia
b. Fatigue
2. Which neurotransmitters underactivity might cause c. Free-floating anxiety
anxiety disorder? d. None of the above
a. Dopamine b. GABA
c. Norepinephrine d. Substance-P Answer Key
3. Anxiety which is more specific to the situation is 1. a 2. b 3. a 4. d 5. d
termed ___________. 6. a 7. b 8. c 9. a 10. a
Notes
 CHAPTER
Nursing Management of
Patients with Substance
Use Disorders 9
LEARNING OBJECTIVE

After studying this chapter, the student will be able to gain knowledge regarding the substance abuse in order to render the nursing care
of patient with substance use disorders.

CHAPTER OUTLINE
• Common Substance Abuse in India • Cocaine
• Modified Mann’s Index of Addiction • Nicotine Abuse
• ICD-11 Classification of Substance Use Disorders • Hallucinogens
• DSM-5 Classification of Substance Use Disorders • Caffeine
• Stages of Adolescent Substance Abuse • Synthetic Cathinones
• Stages of Craving • Disorders Due to Use of Methylenedioxymethamphetamine
• Etiology of Substance Abuse or Related Drugs
• Complications of Substance Abuse • Disorders Due to Use of Dissociative Drugs Including
• Alcohol Ketamine and Phencyclidine
• Disulfiram Ethanol Reaction • Inhalants (or) Volatile Solvents
• Various Approaches to Quit Alcohol Nursing Diagnosis and Interventions for Patient with
• Alcohol Withdrawal Syndromes Substance Abuse
• Alcoholics Anonymous • Nursing Care in Acute Episode
Sedatives, Hypnotics and Antianxiety Agents • Nursing Care in Withdrawal
• Introduction • Nursing Diagnosis and Interventions
Cannabis • Prevention of Substance use Disorder
• Introduction • Rehabilitation
• Opioids • Geriatric Considerations
• Central Nervous System Stimulants

KEY TERMS
Tolerance, Dependence, Abuse, Harmful use, Withdrawal, Intoxication, Detoxification, Codependency, Cross tolerance, Alcohol,
Cannabis, Amphetamines, Barbiturates, Cocaine, Hallucinogens, Hypnotics, Sedatives, Opioids, Antianxiety drugs, Addiction reward
pathway, Alcoholic anonymous, Stages of change model.
260 Textbook of Psychiatric Nursing for BSc Nursing Students

COMMON SUBSTANCE ABUSE IN INDIA Flowchart 9.1: Concept of dependence and abuse

• Alcohol
• Cannabis
• Hypnotics, sedatives and antianxiety drugs
• Amphetamines
• Barbiturates
• Cocaine
• Hallucinogens
• Inhalants
• Nicotine
• Opioids—heroin, morphine and meperidine
• Phencyclidine
• Polysubstance abuse
• Other or unknown substance abuse.
Continued substance use might lead to recurrent interpersonal
problems as shown in Flowchart 9.1.

MODIFIED MANN’S INDEX OF ADDICTION

Modified Mann’s Index of Addiction denotes the addiction

level of various substances which has been arranged from
• 6C43 Disorders due to use of opioids
lower to higher, for example, caffeine has low addiction index
• 6C44 Disorders due to use of sedatives, hypnotics or
and heroin is a synthetic opioid derivative with a high addition
anxiolytics
index as shown in Figure 9.1.
• 6C46 Disorders due to use of stimulants including
amphetamines, methamphetamine or methcathinone
ICD-11 CLASSIFICATION OF SUBSTANCE USE
DISORDERS • 6C47 Disorders due to use of synthetic cathinones
• 6C48 Disorders due to use of caffeine
• 6C40 Disorders due to use of alcohol • 6C49 Disorders due to use of hallucinogens
• 6C41 Disorders due to use of cannabis • 6C4A Disorders due to use of nicotine
• 6C42 Disorders due to use of synthetic cannabinoids • 6C4B Disorders due to use of volatile inhalants

Figure 9.1 Modified Mann’s index of addiction

CHAPTER 9 Nursing Management of Patients with Substance Use Disorders 261

• 6C4C Disorders due to use of MDMA or related drugs, Stimulant-related disorders

including MDA.
305.70 Stimulant use disorder, mild amphetamine-type
• 6C4D Disorders due to use of dissociative drugs including substance use (or) use of unspecified substances
ketamine and phencyclidine [PCP].
305.60 Stimulant use disorder, mild cocaine substance use
• 6C4E Disorders due to use of other specified psychoactive
304.40 Stimulant use disorder, moderate or severe
substances, including medications. Amphetamine-type substance use (or) use of
• 6C4F Disorders due to use of multiple specified psycho- unspecified substances
active substances, including medications. 304.20 Stimulant use disorder, moderate cocaine substance
• 6C4G Disorders due to use of unknown or unspecified use
psychoactive substances. 292.89 Stimulant intoxication
• 6C4H Disorders due to use of nonpsychoactive substances.
292.0 Stimulant withdrawal
• 6C4Y Other specified disorders due to substance use.
Tobacco
• 6C4Z Disorders due to substance use, unspecified.
305.1 Tobacco use disorder, mild
DSM-5 CLASSIFICATION OF SUBSTANCE USE 305.1 Tobacco use disorder, moderate
DISORDERS 305.1 Tobacco use disorder, severe
292.0 Tobacco withdrawal
Alcohol
292.9 Unspecified tobacco-related disorder
305.00 Alcohol use disorder (mild)
Miscellaneous
303.90 Alcohol use disorder (moderate or severe)
305.90 Other (or unknown) substance use disorder, mild
303.00 Alcohol intoxication
304.90 Other (or unknown) substance use disorder,
291.81 Alcohol withdrawal moderate
291.9 Unspecified alcohol-related disorder 304.90 Other (or unknown) substance use disorder, severe
Caffeine 292.89 Other (or unknown) substance intoxication
305.90 Caffeine intoxication 292.0 Other (or unknown) substance withdrawal
292.0 Caffeine withdrawal 292.9 Unspecified other (or unknown) substance-related
292.9 Unspecified caffeine-related disorder disorder
Cannabis
Classification of Substance abuse Based on
305.20 Cannabis use disorder (mild)
Psychological Effects
304.30 Cannabis use disorder (moderate or severe)
It is classified as CNS depressants and CNS stimulants as
Inhalants
shown in Flowchart 9.2.
292.89 Inhalant intoxication
292.9 Unspecified inhalant-related disorder Patterns of Substance Dependance as per ICD-11
Opioids • Current use, continuous—consumption of substance
305.50 Opioid use disorder (mild) almost daily for at least one month.
304.00 Opioid use disorder (moderate or severe) • Current use, episodic—intermittent heavy consumption
292.89 Opioid intoxication of substance with the period of abstinence during the past
292.0 Opioid withdrawal
one year.
• Early full remission—period of abstinence from substance
292.9 Unspecified opioid-related disorder
consumption for 1–12 months after the treatment.
Sedative, hypnotic or anxiolytic related disorders
• Sustained Partial remission—significant reduction in
305.40 sedative, hypnotic, or anxiolytic use disorder (mild) substance consumption for more than 12 months.
304.10 sedative, hypnotic, or anxiolytic use disorder • Sustained Full remission—abstinent from substance
(moderate or severe) consumption for 12 months or longer.
292.89 sedative, hypnotic, or anxiolytic intoxication
292.0 sedative, hypnotic, or anxiolytic withdrawal STAGES OF ADOLESCENT SUBSTANCE ABUSE
292.9 unspecified sedative-, hypnotic-, or anxiolytic-related
disorder Stages of adolescent substance abuse are shown in Flowchart 9.3.
Contd…
262 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 9.2: Substance abuse based on psychological effects

Figure 9.2: Stages of craving

STAGES OF CRAVING

There are four stages of craving. These stages are shown in

Figure 9.2. These are as follows:
1. Normal craving: It will not cause any distress to
individual.
2. Excessive craving: It will cause significant distress to
Flowchart 9.3: Stages of adolescent substance abuse individual and not socially acceptable behavior.
3. Obsessional craving: Repeated thoughts to consume a
particular substance.
4. Compulsive craving: With repeated consumption of
drug an individual finds difficult to control the behavior
of consuming drug.

ETIOLOGY OF SUBSTANCE ABUSE

Etiology of substance abuse is shown in Bio-psychosocial

model (Fig. 9.3). Due to repeated consuming of drugs
(addictive behavior) an individual becomes stereotyped and it
gets difficult for him/her to control an urge to consume the
—Mac Donald (1987)
same drug.

Figure 9.3: Etiology of substance abuse

CHAPTER 9 Nursing Management of Patients with Substance Use Disorders 263

COMPLICATIONS OF SUBSTANCE ABUSE ALCOHOL

Local Effects (In Case of Intravenous Injection) Introduction

Thrombophlebitis, vasculitis, skin lesions, abscess and Alcohol is a natural product obtained by the reaction of
gangrene. fermented sugar with yeast spores. It is classified as food
because it gives calories but there is no nutritive value in it.
Systemic Effects
• Neurological complications: Seizure, Korsakoff ’s
Pharmacokinetics of Alcohol
syndrome, Wernicke’s encephalopathy, peripheral Alcohol absorption is fast and it mostly happens in small
neuropathy, high blood pressure leads to hemorrhagic intestine. It is highly fat soluble in nature. Its absorption might
stroke, subdural hematoma (common in road traffic delay due to food specifically milk. It crosses placenta. It is found
accidents, and occur due to influence of alcoholism), in all body fluids such as blood, urine, saliva, cerebrospinal
intracranial hemorrhage, dementia and delirium fluid and milk. Ethanol is metabolized by Microsomal Ethanol
tremens. Oxidizing System (MEOS). Binge drinking of alcohol will
• Cardiopulmonary complications: Hypertension, affect the absorption of other medications.
arrhythmia, cardiomyopathy, subacute bacterial
endocarditis, pneumonia, Acute Respiratory Distress Pharmacodynamics of Alcohol
syndrome (ARDS), respiratory arrest, respiratory Ethanol is central nervous system depressant. It inhibits
infections, pulmonary emboli and chronic obstructive cerebral cortex, cerebellum, spinal cord and medulla. It also
pulmonary disease (COPD). inhibits antidiuretic hormone of posterior pituitary and
• Musculoskeletal disorders: Osteoporosis may lead thereby causes diuresis. It interferes with the cutaneous
to fracture, osteoarthritis, rheumatoid arthritis, vasoconstriction as a response toward cold, so hypothermia
musculoskeletal injury and gout. develops. The toxic level of alcohol will inhibit regulation
• Gastrointestinal disturbances: Esophagitis, esophageal of temperature by hypothalamus. Alcohol stimulates the
varices, peptic ulcer, duodenal ulcer, gastritis, gastric juice along with pepsin and HCl, thereby increasing
malabsorption syndrome, pancreatitis, hemorrhoids, appetite when consumed in small quantities. However, it is
gastric bleeding leads to hematemesis (or) occult blood contraindicated with acid peptic disease.
(blood in stools), carcinoma of mouth, larynx, throat,
esophagus, stomach and intestines. Addiction Reward Pathway
The major parts involved are ventral tegmental area (VTA),
Reproductive Complications nucleus accumbens, and prefrontal cortex shown in
• Men: Sexual dysfunctions such as impotence, decreased Figure 9.4. The VTA is connected with both the nucleus
libido, oligospermia, decreased sperm motility and accumbens and prefrontal cortex. Through this pathway,
infertility. it sends information to neurons. Neurons of VTA contains
dopamine (neurotransmitter), which has been released in
• Women: Miscarriage, stillbirth, premature birth and low
nucleus accumbens and prefrontal cortex.
birth weight babies.

Psychological Effects
Psychosis, depression, amotivational syndrome (lack of
desire to complete task, sense of apathy about future, lack of
concentration, reduced interest in social and other activities),
suicidal ideation, multiple substance abuse, impaired social
and occupational dysfunction.

Miscellaneous
Fetal alcohol syndrome, beriberi, foot ulcer, decrease in
blood glucose level, domestic violence, accidents, involving in
criminal activities and hypoglycemia. Figure 9.4: Regions of brain related to addiction reward pathway
264 Textbook of Psychiatric Nursing for BSc Nursing Students

DSM-IV Classification of Alcoholism II. Early alcoholic: Individual drinks alcohol alone
and remains preoccupied with thoughts of alcohol.
• Alcohol use disorder
Individual experiences black out (memory loss of past
• Alcohol dependence syndrome
events after drinking alcohol) and eye opener (strong
• Alcohol intoxication
desire to drink alcohol immediately by after awakening
• Alcohol withdrawal syndrome
from bed). Individual might use defense mechanism,
• Alcohol induced dementia
‘Denial’, and he/she may refuse the dependency toward
• Alcohol induced amnesia
alcoholism.
• Alcohol induced mood disorder
III. True alcoholic: Individual loses control over drinking
• Alcohol induced anxiety disorder
(physiological dependence). There will be a binge
• Alcohol induced sexual disorder
drinking episodes (continuous and routine drinking of
• Alcohol induced sleep disorder
alcohol). Individual might be willing to lose anything for
• Alcohol induced psychosis:
alcohol.
„ With delusion
IV. Chronic alcoholic: Emotional and physical disintegration
„ With hallucination
of the individual might lead to psychosis. Presence of life-
Common Alcoholic Beverages threatening complications such as cirrhosis, hepatitis,
cardiac myopathy, Wernicke’s encephalopathy, Korsakoff ’s
Common alcoholic beverages with its source and percentage psychosis, ascites, leukopenia, thrombocytopenia,
of alcohol are given in Table 9.1. pancreatitis, gastritis, depression, suicidal tendencies
Table 9.1: Common alcoholic beverages with its source and might develop.
percentage of alcohol

Common Source Percentage of alcohol Table 9.2: Blood alcohol concentration with its effects in body
alcoholic (approximate)
Blood alcohol Effects of alcohol in body
beverages
concentration (mg/dL)
Beer Malted barley 3–6%
20–30 • Slow motor activity
Wine Grapes/berry Fortified: 16–24% • Slow thinking process
Unfortified: 14–16%
30–80 Decline in cognition
Whisky Malted grains 36–50%
80–200 • Lack of coordination
Rum Molasses 36–50% • Decline in cognition
Scotch Malted barley 40–45% • Poor judgment
Gin Distilled spirit 36–50% 200–300 • Alcohol black out
with Juniper • Slurring of speech
berries aromatic • Nystagmus
botanicals
300–350 Hypothermia, dysarthria
Vodka Grains (Russian 40–95%
350–400 Coma, respiratory depression
vodka from
potatoes) >400 Death might occur

Blood Alcohol Concentration

Various categories of blood alcohol concentration with its
effects on body have been presented in Table 9.2. Urine alcohol
concentration >200 mg% might be used for diagnostic purpose
of alcohol consumption which is equivalent to 150 mg% of
blood alcohol concentration.

Phases of Alcoholism (Fig. 9.5)

I. Prealcoholic: Individual starts to drink alcohol
occasionally. Figure 9.5: Phases of alcoholism
CHAPTER 9 Nursing Management of Patients with Substance Use Disorders 265

Table 9.3: Cloninger’s classification based on genetics and environmental factors

Aspects Type I alcoholism Type II alcoholism

Causes Genetic and environmental Mostly genetic and environmental influence
is limited
Gender Both male and female Common in male
Usual onset of age >25 years <25 years
Family history May be present Commonly present
Loss of control Present Absent
Premorbid personality traits Avoidance of harm and reward seeking nature Novelty seeking behavior
Features Psychological dependence and guilt present Aggression followed by drinking alcohol

Table 9.4: Jellinek’s, five species of alcohol dependence based on usage pattern

Alpha Beta Gamma (or) malignant alcoholism Delta Epsilon

Increased consumption Increased consumption Physical dependence, psychological Inability to stop Dipsomania
of alcohol to come out of alcoholism lead to dependence tolerance, inability to alcohol completely (uncontrollable
of physical or emotional physical complications but control and withdrawal symptoms but it can be craving of
pain no dependence to alcohol are present controlled alcohol)

Classification of Alcoholism • Hematologic studies: Anemia, thrombocytopenia, raised

prothrombin and partial prothrombin time (PPT).
Cloninger’s classification based on genetics and environmental
• Serum glucose level: Decreased in case of severe liver
factors has been given in Table 9.3. Jellinek’s, five species
disease.
of alcohol dependence based on usage pattern are shown in
• Urine toxicology: To screen out other diseases.
Table 9.4.
• Serum electrolyte analysis: To analyze the electrolyte
ICD-11 Diagnostic criteria for alcohol dependence imbalance due to alcohol use.
• Strong desire to drink alcohol • ECG: Cardiac problems due to alcoholism are screened
• Unable to control alcohol intake behavior out.
• Development of tolerance
• Withdrawal symptoms are present if alcohol consumption is
stopped Assessment Tools for Problem Drinkers of
• Increasing priority given to use alcohol over other activities Alcoholism
despite its negative consequences
• Repeated use of alcohol in spite of harmful complications • CAGE questionnaire: It is given in Table 9.5
• Features of dependence present for at least 1 year and the Table 9.5: CAGE questionnaire
diagnosis is made if features present continuously almost
daily for 1 month Mnemonics Aspects Questions
C Cut down Have you ever felt to stop (cut
Diagnosis of Alcohol Abuse down) alcohol?

• Blood alcohol level: Accepted legal limit in regard to A Annoyance Did you feel anger (annoyed) due
to other’s criticism about your
blood alcohol level (India) is <30 mg/dL (or) 0.03% g/dL.
drinking?
• Gamma glutamyl transferase (GGT): >40 IU/L (seen
in 80% of cases and return to normal if alcohol is not G Guilt Have you ever felt guilt about
drinking?
consumed (abstinence) >48 hours.
• Mean corpuscular volume (MCV): >92 fL/red cell in E Eye opening Have you ever felt drinking
adult (seen in 60% of cases and it takes few weeks to show immediately after awakening
from bed (eye opening) in early
as normal value in case of abstinence). morning?
• Liver function test (LFT): Increased serum glutamic
oxaloacetic transaminase (SGOT), serum glutamic Interpretation Score >2 denotes problem drinkers (possibility
of alcoholism dependence and needs further
pyruvic transaminase (SGPT), alanine aminotransferase
investigations)
(ALT) and ammonia.
266 Textbook of Psychiatric Nursing for BSc Nursing Students

• Michigan alcoholism screening test (MAST): Used in

courts to screen the individuals who met alcohol related
offences.
• Alcohol use disorders identification test (AUDIT):
Developed by World Health Organization (WHO).
• Paddington alcohol test (PAT): Screening tool to assess
alcohol-related problems among patients attending
emergency department.

Categories of Alcohol Withdrawal

Categories such as mild, moderate and severe is explained
in Table 9.6. It is also categorized into complicated alcohol
withdrawal and uncomplicated alcohol withdrawal.

Stages of Alcohol Withdrawal

There are three stages of alcohol withdrawal as presented in
Figure 9.6.

ICD-11 Diagnostic Criteria for Alcohol Withdrawal

• Clinically significant cluster of symptoms present in the Figure 9.6: Stages of alcohol withdrawal
varying degree of severity and duration, that happens after
the cessation or reduction of use of alcohol in individuals
disorientation, delusion and prolonged hallucinations
following the alcohol dependence.
(separate diagnosis of alcohol-induced delirium has to be
• Presenting features are autonomic hyperactivity, tremor,
assigned in such cases).
nausea, vomiting, insomnia, psychomotor agitation,
anxiety, transient visual or tactile or auditory hallucinations • Specify it is:
and distractibility. „ Uncomplicated
• Alcohol withdrawal state is complicated by seizures less „ Complicated with seizures
commonly. „ Complicated with perceptual disturbances
• Alcohol withdrawal state may progress to a very severe „ Complicated with seizures and perceptual distur-
form of delirium which is characterized by confusion, bances.

Table 9.6: Categories of alcohol withdrawal

Signs/Symptoms Mild Moderate Severe

Appetite Impaired Impaired Complete rejection of all foods
Blood pressure Normal/slightly raised Increased systolic BP Both systolic and diastolic BP is increased
systolic BP usually
Confusion and disorientation Absent Varies Present
Dry heaving/retching/ Only nausea present Nausea and vomiting Nausea and vomiting present
retroperistalsis/nausea and present
vomiting
Hallucinations Absent Auditory and visual (fearful or threatening
Auditory and visual (vague, transient and nocturnal in in nature); delusional misidentification
nature) syndrome present
Motor disturbances Fine motor disturbances Obvious motor restlessness Extreme restlessness, agitation and gross
(tremors only seen in hands) with hand tremors motor disturbances
Pulse Increased 100–120 beats/min 120–140 beats/min
Seizure Absent Present Commonly seen
Sweating Absent Sometimes Increased (hyperhidrosis)
CHAPTER 9 Nursing Management of Patients with Substance Use Disorders 267

Assessment of Alcohol Withdrawal

• Modified Selective Severity Assessment (MSSA)
• Clinical Institute Withdrawal Assessment for Alcohol
Revised (CIWA-AR)

Treatment of Alcohol Withdrawal

Emergency Management
Treatment of trauma, gastrointestinal bleeding and infection.

Symptomatic Management
Give respiratory support in order to maintain airway
and administer oxygen. Provide fluid replacement with
intravenous normal saline. Intravenous dextrose is
administered if hypoglycemia is present. If nutritional
deficiency is present, vitamin B supplements (or) Inj.
thiamine needs to be administered. If withdrawal symptoms
are present, chlordiazepoxide (librium), lorazepam can be Figure 9.7: Mechanism of action—disulfiram
given. Antiemetics can be given as required. Psychosis and
hyperactivity can be treated with antipsychotics. personality disorder, severe cardiac diseases, severe renal
problems and severe hepatic dysfunction.
Psychological Management
• Aversion therapy (or) antabuse: Treatment to arouse the Mechanism of Action
unlikeness or feel likely to be hated of alcoholism. Types The drug action of disulfiram is alcohol dehydrogenase
include: Inhibitors. In general, ethanol or alcohol gets converted into
„ Electrical aversion acetaldehyde in liver. Acetaldehyde will convert it to acetate.
„ Chemical aversion (or) disulfiram therapy The acetate is converted into carbon dioxide and water. Intake
„ Aversion through emesis of disulfiram will inhibit the enzyme alcohol dehydrogenase so
„ Covert sensitization (or) covert conditioning the conversion of ethanol to acetaldehyde doesn’t takes place.
• Electrical aversion: Ask the client to smell the desired This concept has been represented in Figure 9.7.
brand of alcohol. Low volt electrical stimuli will be • Side effects: Metallic or garlic taste, headache,
administered immediately when he smells alcohol. drowsiness/fatigue, dermatitis, halitosis, nausea/vomiting
Alcohol intake (desired response) will be changed by and impotence/lack of libido/sexual dysfunction.
undesired electrical stimuli. • Adverse reactions: Polyneuritis, hepatotoxicity, optic
• Chemical aversion (or) disulfiram therapy (or) deterrent neuritis and peripheral neuritis.
therapy • Drug interactions with disulfiram: Phenytoin,
Dosage: Usual dosage of disulfiram is 250 mg/day. warfarin, ethanol (cause disulfiram ethanol reaction),
metronidazole (flagyl), tricyclic antidepressants
Indications of Disulfiram Usage in Patients with (particularly amitriptyline) and benzodiazepines
Alcohol Dependence (increase sedative effect).
Abstinence more than 48 hours of alcohol intake, failure or
contraindicated with naltrexone, previous good response DISULFIRAM ETHANOL REACTION
to disulfiram and client has both cocaine as well as alcohol
dependence. Meaning
When client takes disulfiram along with alcohol it might lead
Contraindications to disulfiram ethanol reaction.
Suspected alcohol intake, rubber/cobalt/nickel allergy,
psychotic patients, hypersensitivity, pregnancy/breast feeding, Symptoms of Disulfiram Ethanol Reaction (DER)
cognitive impairment, uncontrolled hypertension, high It includes facial flushing, nausea, vomiting, hypotension,
suicidal risk, history of stroke/myocardial infarction, severe shock, fatigue, general malaise, epigastric pain, sweating,
268 Textbook of Psychiatric Nursing for BSc Nursing Students

excessive thirst, blurred vision, shortness of breath, liver failure, centered approach is followed to improve the readiness
heart attack, abnormal heart beat and throbbing headache. to change (quit alcoholism) by resolving ambivalence. It
is a technique for motivating the client to quit alcoholism.
Food and Drug Administration (FDA) • Cognitive therapy: Aaron T. Beck introduced this
Recommendations therapy. Unrealistic thoughts in regard to alcoholism
Client has to avoid alcohol 12 hours before taking disulfiram, might change into realistic thoughts.
during and until completion of treatment for 14 days. Alcohol • Behavioral therapy: Reward for desirable behavior
has to be avoided 48 hours before and after treatment in order and punishment for undesirable behavior motivates the
to avoid Disulfiram Ethanol Reaction (DER). patient to quit alcohol.
• Contingency management: Anker and Crowley
Instruction for Patients described the concepts of contingency management. Use
predetermined positive consequences of the abstinence
Not to use any alcohol content products such as cough syrups, of alcoholism and teach the consequences of continued
fermented vinegar, sauces, after shave lotions, mouth wash, drinking in order to change the undesired behavior.
back rubs, etc. • Group therapy: Group of alcohol dependents with
5–10 members was involved in the group therapy sessions
Treatment
in order to:
Give reassurance and advice to take adequate oral fluids for „ Enhance motivation
mild Disulfiram Ethanol Reaction (DER). In case of severe „ Promote abstinence
Disulfiram Ethanol Reaction (DER) intravenous infusions, „ Establish the stable social and occupational
antihistamines and dopamine infusions are advisable. functioning.
„ Prevention of relapse
Drugs Causing Disulfiram Like Reactions with „ Address any specific psychosocial issue, comment to
Ethanol the group members
• Sulfonylureas (or) antidiabetic agents: Chlorpropamide, „ Psychoeducation
tolazamide, tolbutamide, glipizide, glyburide, gliclazide It helps to observe patient’s problems on others in order to
and glibenclamide. work out good ways of coping with problems.
• Antimicrobial agents: Cephalosporin (cefoperazone, • Cue exposure therapy: Nurse might give exposure to
moxalactam, cefamandole, cefotetan), isoniazid, sulfon- the alcoholics with craving, inducing cue and guide the
amides, nitrofurantoin, ketaconazole, chloramphenicol, patient, how to prevent the use of alcohol as shown in
beta-lactams, metrogyl and griseofulvin. Figure 9.8.
• Antiviral agents: Lopinavir (or) ritonavir. • Relapse prevention: Marlatt and Gordon first explained
• Antihypertensive agents: Beta blockers, vasodilators the concept of relapse prevention. It focuses on cognitive
(Nitrates). behavior approach to attain a great self-control so that
• Anticoagulants: Warfarin. the patients who quit alcohol should never get back into
drinking behavior by following guidelines provided with
VARIOUS APPROACHES TO QUIT ALCOHOL cue exposure therapy.

Aversion through emesis: Administer alcohol along with

emetics which will induce vomiting after alcohol intake,
thereby the client develops aversion.

Covert Sensitization (or) Covert Conditioning

Enhance the mental imagination of undesired habits and
thereby promote aversion. Success rate of aversion presents
with combination of two or more techniques of aversion.
• Motivational interviewing in alcohol addiction: It is
a form of counseling approach first explained by Prof.
William Miller in 1983. It is also called Motivational
Enhancement Therapy (or) Brief Intervention. A client- Figure 9.8: Concept of cue exposure therapy
CHAPTER 9 Nursing Management of Patients with Substance Use Disorders 269

Ethanol Challenge Test

It is performed to create cognitive awareness of disulfiram-
ethanol reaction (DER). This test has to be done after informed
consent. Patient has to take in 250 mg of disulfiram as initial dose
for 5 days. Alcohol has to be administered approximately 40 mL
(15 mL for every 15 minutes) as maximum of 90 mL can be given. Figure 9.9: Phases of Wernicke-Korsakoff’s syndrome
Monitor the vital signs and keep IV line open so that, if blood
pressure drops, vasopressor can be administered.

ALCOHOL WITHDRAWAL SYNDROMES

• Delirium tremens: It occurs within 48–72 hours of

stopping alcohol. Clinical features are as follows:
„ Clouding of consciousness
„ Disorientation
„ Visual hallucination
„ Illusion Figure 9.10: Classical triad of Wernicke’s encephalopathy
„ Poor attention span
„ Insomnia syndrome as shown in Figure 9.9. Damage to neuron
„ Autonomic disturbances occurs secondary to thiamine deficiency so parenteral
„ Dehydration thiamine for a week of 50–100 mg is helpful.
„ Electrolytes imbalance „ Wernicke’s encephalopathy (Fig. 9.10): Wernicke’s
Treatment includes Tab. chlordiazepoxide 100 mg/day Encephalopathy is characterized by cerebellar
in divided doses and Inj. Lorazepam 0.1 mg/kg at ataxia, mental confusion, palsy of 6th cranial
2 mg/min (give lorazepam as slow IV because the nerve, hypothermia, cardiac problems, vestibular
intravenous administration of diazepam in a rapid dysfunction and peripheral neuropathy.
manner might lead to respiratory arrest). ◆ Confusion/encephalopathy:
• Alcohol withdrawal seizures (or) ‘Rum Fits’: It occurs ¾ Disorientation
within 6–48 hours after the intake of alcohol. It is usually ¾ Poor attention span
Grand mal type. Around 3–15% of untreated alcohol ¾ Loss of consciousness in 5% of patients
withdrawal clients might develop seizures and less than ◆ Occulomotor dysfunction/ophthalmoplegia:
3% of patients will develop status epilepticus. ¾ Unequal pupil
• Alcoholic hallucinosis: Hallucinations are present even ¾ Nonreactive pupil
in period of abstinence after the regular alcohol intake. It ¾ Nystagmus (involuntary eye ball movements)
commonly occurs with clear consciousness. ¾ Lateral rectus palsy
• Alcoholic pellagra: The main cause is niacin deficiency ¾ Conjugate gaze palsy
due to alcoholism. Initial symptoms include mood ¾ Light near dissociation (impaired pupillary
changes and neurasthenia. Confusion and lethargy occurs light reaction but the nearer reaction to light
in middle stages of alcoholism. Myoclonus and spastic accommodation remains intact)
paresis occur in later stages of alcoholism. ◆ Gait ataxia:
The mechanism behind this alcoholic pellagra is: ¾ Stance and gait disturbances are seen as
„ Nutritional: Vitamin B, protein and zinc deficiency. primary symptoms.
„ Biochemical: Inhibition of liver tryptophan and ¾ Wernicke’s encephalopathy will not have upper
niacin precursors. limb ataxia as seen in cerebellar dysfunction.
„ Physiological: Disturbances in GABA and Glutamate „ In postmortem of Wernicke’s encephalopathy, patients
Neuronal function. might have petechial hemorrhage in mammillary
• Wernicke-Korsakoff syndrome: Patient with acute phase body in brain at third ventricle.
of Wernicke-Korsakoff syndrome will have Wernicke’s „ Korsakoff ’s syndrome: It is characterized by
encephalopathy and patient with chronic phase of gross memory disturbances (severe retrograde and
Wernicke-Korsakoff ’s syndrome will have Korsakoff ’s anterograde amnesia) with a preserved long-term
270 Textbook of Psychiatric Nursing for BSc Nursing Students

memory, cognition and social skills. Other symptoms • Speaker meeting: Participants can speak their own stories.
are confabulation (False filling of memory gaps), • Discussion meeting: Narration of brief experiences with
confusion, disorientation, poor attention span, easily detailed discussion.
distractible in nature. The client may be unaware of • Step meeting: Any one of 12 steps of alcoholic anonymous
illness. is discussed.
• Marchiafava bignami disease: It is a neurological disease
of alcoholism which occurs due to demyelination of Ideology of Alcoholics Anonymous
corpus callosum, optic tract and cerebellar peduncles. Theory of alcoholics anonymous focuses on addiction,
Symptoms include ataxia, disorientation, epilepsy, which means the individual is being powerless over the drug.
dysarthria and hallucinations. Abstinence (quitting alcohol) is the primary goal focus on
• Morbid jealousy (Othello syndrome): Morbid jealousy ‘emotional sobriety’ rather than physical sobriety.
is a delusion that the life partner is not faithful (i.e.,
suspiciousness that life partner is having extramarital Dynamics of Alcoholics Anonymous
relationship). If it persists, it might lead to domestic
violence. Antipsychotics are the drugs of choice with Alcoholics anonymous is nonjudgmental, which means
abstinence from alcohol. unconditional way of accepting alcoholics. Work out with
• Alcohol induced disorders 12 steps of alcoholic anonymous to stimulate the cognition
„ Amnesia (black out): Transient short term memory which was previously unfocused. Elements of group therapy
loss may be complete or partial in relation with such as group cohesiveness, learning social skills, sharing their
intoxication state. It doesn’t indicate dementia. experiences and instillation of hope to achieve sobriety are
„ Hallucinations: It is rare with alcohol abuse. The being involved.
common type is auditory. Voices are derogatory in
Efficacy of Alcoholics Anonymous
nature.
„ Mood disorders: Alcoholism might lead to persistent Efficacy depends on the following factors such as periodical
depression. assessment of achievement, retention of members, active
„ Anxiety disorders: Panic attacks that occur during participation of members, active religious life and social
acute withdrawal, especially in first 4–6 weeks of adjustment.
abstinence are known as anxiety disorders.
• Fetal alcohol syndrome: Alcohol might affect the fetus Assumptions in Regard with Alcoholics
when consumed by pregnant women. It is a third leading Anonymous
cause of mental retardation and it can be prevented. Alcoholics anonymous will help the alcoholics to:
Risk also depends on the amount and percentage of • Get accurate information about the disease
alcohol consumed by expecting mother. Signs include • Obtain guidance and support
microcephaly and mental retardation. • Learn from others to maintain sobriety
• Recognize feelings of everyone
ALCOHOLICS ANONYMOUS • Provide therapeutic altruism
• Promote group cohesiveness
Alcoholics anonymous (AA) was founded in 1935 by Bill • Develop social skills
Wilson and Dr Bob Smith. AA helps people suffering • Involve in activities which could divert them from the use
from alcohol addiction disorder. Alcoholics Anonymous of alcohol.
Program works under the recovered alcoholics who explain
the process of sobriety that they have found in AA, and Twelve Steps of Alcoholics Anonymous
welcome the newcomers with similar disorder (alcoholics) to 1. Members admit oneself that they were powerless to control
join the group. alcohol drinking and their lives were not manageable.
2. They believe that a power greater than themselves might
Types of Alcoholics Anonymous Meetings restore them to normal mental health.
• Closed meeting: Person only with alcohol problems will 3. Decisions are taken to change their lives under the care of
participate in this meeting. God and in their understanding of him.
• Open meeting: Nonalcoholics can also participate in this 4. They (alcoholics) will keep searching and following moral
meeting. values by themselves.
CHAPTER 9 Nursing Management of Patients with Substance Use Disorders 271

5. Admit themselves to God, and to another person in

regard to their mistakes.
6. Request the God to remove all defects in their character.
7. Request the God to remove their shortcomings.
8. Prepare the list of all individuals whom they have harmed
before and they will try to amend for the harm that
happened because of them.
9. Perform direct amendments to people who are
psychologically injured.
10. Continue to take self-monitoring and when they found
that they were wrong, they will admit it.
Figure 9.11: Stages of change model
11. Do prayer and meditation to enhance their conscious
contact with God to have blessings and power to carry
out the right behavior. Stages of Change Model
12. With spiritual awakening as the result of above steps, Precontemplation, contemplation, preparation, determination,
we will try to carry out the message to alcoholics and to action, maintenance and relapse are the stages of change model
practice these principles in our lives. as shown in Figure 9.11. Description of each stage, patient’s
response and nursing interventions are given in Table 9.8.
Limitations of Alcoholics Anonymous
Alcoholics anonymous does not provide hospitalization, any SEDATIVES, HYPNOTICS AND
modalities of treatment, follow-up of the patients, control of ANTIANXIETY AGENTS
drop outs or deal individuals with multiple substance abuse.
Al-anon and Alateen (Table 9.7): INTRODUCTION
Table 9.7: Al-anon and alateen
Sternbach, discovered chlordiazepoxide (1957): Benzo-
Al-anon Alateen diazepines was replaced with sedatives-hypnotics.
It is a mutual support It is a subgroup of Al-anon. It is a mutual Classification of sedatives, hypnotics and antianxiety agents
group for families and support group for family members are shown in Flowchart 9.4. Classification of barbiturates with
friends of alcoholics. and friends of alcoholics especially the duration of action and examples explained in Table 9.9 along
teenagers are involved in this group. with street names.

Table 9.8: Stages of change model with description and nursing interventions

Stages of change Explanation Patient’s response Nursing interventions

Precontemplation Patient is unaware of problem “I don’t know what problem I Nurse must create awareness in a patient
have” about one’s own problem
Contemplation Patient had awareness of the “I know that, I am so much Motivate the patient to quit alcohol.
problem but not interested to addicted to alcohol but I don’t
change want to stop it”
Preparation Patient is willing to change and is “I am willing to quit alcohol” Refer to alcoholic anonymous
prepared to change
Determination Patient seeks help from others “I expect the health team members Nurse offers professional help to come
for change process will help me from addiction” out of addiction
Action Patient is abstaining “I am not drinking alcohol now a Guide and monitor the efficacy of
days” treatment
Maintenance Patient takes steps to avoid “I am avoiding contacts with my Promote coping skills and assertive
relapse friends who drink alcohol” behavior
Relapse Patient returns to drink alcohol “I would like to drink alcohol and Identify the factors which caused relapse
again so I drank yesterday” and discuss the steps to prevent it
272 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 9.4: Classification of sedatives, hypnotics and • These experiences are often accompanied by a subjective
antianxiety agents sensation of urge or craving to use these substances.
• Physiological features of dependence may also be
present, including tolerance to the effects of sedatives,
hypnotics or anxiolytics, withdrawal symptoms following
cessation or reduction in use, or repeated use of sedatives
or pharmacologically similar substances to prevent or
alleviate withdrawal symptoms.
• The features of dependence are usually evident over a
period of at least 12 months but the diagnosis may be
made if sedative use is continuous (daily or almost daily)
for at least 1 month.

Intoxication Effects
Table 9.9: Classification of barbiturates These are categorized into psychological effects and physical
Classification Duration Generic Street names effects as shown in Flowchart 9.5.
of barbiturates of action name
Long acting >8 hours Phenobarbital Purple hearts,
ICD-11 Diagnostic Criteria for Sedatives,
goof balls Hypnotics and Anxiolytic Intoxication
Intermediate 5–8 hours Amobarbital Downers, blue • A clinically significant transient condition that develops
acting Pentobarbital heavers, blue during or shortly after the consumption of sedatives,
velvet, blue
hypnotics or anxiolytics that is characterized by
devils
Nembies yellow disturbances in consciousness, cognition, perception,
jeckets abbotts affect, behavior, or coordination.
mexican yellows • These disturbances are caused by the known
Short acting 1–5 hours Secobarbital Reds, red birds, pharmacological effects of sedatives, hypnotics or
red devils, lily, anxiolytics and their intensity is closely related to the
F-40s, Pinks, pink amount of sedatives, hypnotics or anxiolytics consumed.
ladies, seggy
• They are time-limited and abate as sedatives, hypnotics or
Ultra short <1 hour Thiopentone Rainbow, reds anxiolytics are cleared from the body.
acting sodium and blues,
tooies, double
trouble gorills Flowchart 9.5: Intoxication effects of sedatives, hypnotics and
pills, F-66s. antianxiety agents

Pattern of Usage
• Pattern I: Prescribed drug by doctor is used with
increased dosage and frequency.
• Pattern II: Due to bad company of friends or drugs
obtained illegally.

ICD-11 Diagnostic Criteria for Sedatives,

Hypnotics and Anxiolytic Dependence
• Disorder of regulation of sedative use arising from
repeated or continuous use of these substances.
• The characteristic feature is a strong internal drive to use
sedatives, hypnotics, or anxiolytics, which is manifested
by impaired ability to control use, increasing priority
given to use over other activities and persistence of use
despite harm or negative consequences.
CHAPTER 9 Nursing Management of Patients with Substance Use Disorders 273

Flowchart 9.6: Withdrawal effects of sedatives, hypnotics and • In such cases, a separate diagnosis of sedative, hypnotic,
antianxiety agents or anxiolytic-induced delirium should be assigned.

Treatment
• Treatment of benzodiazepine overdose
„ If conscious it could induce vomiting before
absorption.
„ Give activated charcoal to decrease absorption.
„ Symptomatic management.
• Treatment of benzodiazepine dependence
„ Tapering the drug as 10% per day.
„ Benzodiazepine substitution: Long-acting benzodi-
azepines can be substituted with short acting ones.
„ Phenobarbital substitution therapy: Short-acting
barbiturates are used.
• Presenting features may include somnolence, impaired „ Antidote of benzodiazepine dependence: Flumazenil.
judgment, slurred speech, impaired motor coordination, • Treatment of benzodiazepine withdrawal
unsteady gait, mood changes, as well as impaired memory, „ Carbamazepine to attenuate the withdrawal effects of
attention and concentration. Nystagmus (repetitive, Benzodiazepines.
uncontrolled eye movements) is a common physical sign.
CANNABIS
Withdrawal Effects
These are categorized into psychological effects and physical INTRODUCTION
effects as shown in Flowchart 9.6.
Cannabis is derived from ‘hemp plant’, Cannabis sativa
ICD-11 Diagnostic Criteria for Sedatives, and it produces more than 400 chemicals in which 50 are
Hypnotics and Anxiolytic Withdrawal cannabinoids (active ingredient of 9-tetrahydrocannabinol)
• A clinically significant cluster of symptoms, behavior and/ Inhibitory G protein linked with cannabinoid receptors
or physiological features, varying in degree of severity can be substituted in basal ganglion, cerebellum and
and duration, that occurs upon cessation or reduction of hippocampus of the brain. Anandamide is endogenous
use of sedatives, hypnotics or anxiolytics in individuals cannabinoid. Tetrahydrocannabinol absorption rate varies
who have developed dependence or have used sedatives, depending on the route—Oral (2–3 hours) and smoke
hypnotics or anxiolytics for a prolonged period or in large (30 minutes), in which effect of single dose lasts for 4–8 hours.
amounts.
• Sedative, hypnotic or anxiolytic withdrawal can also Common Preparations of Cannabis
occur when prescribed sedatives, hypnotics or anxiolytics Common preparation of cannabis with percentage of
have been used in standard therapeutic doses. Tetrahydrocannabinol concentration and street names is given
• Presenting features of sedative, hypnotic or anxiolytic in Table 9.10.
withdrawal may include anxiety, psychomotor agitation, • Intoxication effects: Shown in Flowchart 9.7.
insomnia, increased hand tremor, nausea or vomiting,
• Complications of cannabis: Shown in Flowchart 9.8.
and transient visual, tactile or auditory illusions or
hallucinations. Treatment
• There may be signs of autonomic hyperactivity, or
postural hypotension. For detoxification, Inj. lorazepam 1–4 mg/day (or) diazepam
• The withdrawal state may be complicated by seizures. 2–10 mg/day can be given. If cannabis induced psychosis is
• Less commonly there may be progression to a more present, Inj. chlorpromazine 50–100 mg IM (or) haloperidol
severe form of delirium characterized by confusion and 5–10 mg slow IV is advisable. To prevent extrapyramidal
disorientation, delusions, and more prolonged visual, symptoms, trihexyphenidyl (THP) 2–6 mg is administered.
tactile or auditory hallucinations. Psychotherapy and family therapy are helpful.
274 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 9.10: Common preparations of cannabis

Common preparations Percentage of Prepared from Street names

of cannabis tetrahydrocannabinol
concentration
Marijuana 0.5–1 Leaves, flowers and stem Mary Jane, joint, weed, locoweed, hay
stick, MJ, pot, grass, texas tea
Hashish 2–10 Resin from flowery tops Ganja, charas, hash, bhang
Hashish oil 15–50 Extract of resin

Flowchart 9.7: Intoxication effects of cannabis

Flowchart 9.8: Complications of cannabis abuse

OPIOIDS Table 9.11: Natural and synthetic opioid derivatives

It is the exudate from dried seeds of Papaver somniferum. The Natural opioid derivatives Synthetic opioid derivatives
street name is smack and brown sugar. Phenanthrene derivatives • Heroin
Synthetic opioid derivatives (Table 9.11) cause more • Morphine • Methadone
dependence tendency than natural. The withdrawal effects of • Codeine • Pethidine
synthetic opioids are more severe than the natural. Heroin and • Thebaine • Nalorphine
• Levallorphan
morphine are commonly high dependence producing agents. Isoquinoline derivatives
• Hydromorphone
Opioid receptors (Table 9.12) have been evenly distributed in • Noscapine
• Diphenoxylate
central nervous system. However, high density of these receptors • Papaverine
• Cyclazocine
is seen in limbic system, neural area and thalamic nucleus.
CHAPTER 9 Nursing Management of Patients with Substance Use Disorders 275

Table 9.12: Opioid receptors with its significance Diagnosis

Opioid receptors Significance Naloxone challenge test, urine opioid test (radioimmunoassay,
Mu Most dependent producing opioids thin layer chromatography, pressure liquid chromatography
bind with Mu receptor and gas liquid chromatography).
Kappa E.g., enkephalin
ICD-11 Diagnostic Criteria for Opioids
Sigma E.g., phencyclidine
Dependence
Epsilon and lambda —
• Disorder of regulation of opioid use arising from repeated
Acute Intoxication Effects of Opioids or continuous use of opioids.
• The characteristic feature is a strong internal drive to
Decreased heart rate, temperature, blood pressure and pulse,
use opioids, which is manifested by impaired ability to
pinpoint pupil, apathy, delay in reflexes, coma and mydriasis
control use, increasing priority given to use over other
due to hypoxia are present in a patient in case of severe
activities and persistence of use despite harm or negative
intoxication.
consequences.
• These experiences are often accompanied by a subjective
Withdrawal Effects of Opioids
sensation of urge or craving to use opioids.
Withdrawal effects like increase in heart rate/temperature/ • Physiological features of dependence may also be present,
respiration/pulse, dilated pupil, lacrimation, sweating, including tolerance to the effects of opioids, withdrawal
rhinorrhea, muscle cramps, body ache, anxiety, nausea/ symptoms following cessation or reduction in use of
vomiting, piloerection, anorexia and insomnia can be observed. opioids, or repeated use of opioids or pharmacologically
Complications of opioids dependence: Shown in similar substances to prevent or alleviate withdrawal
Flowchart 9.9. symptoms.
• The features of dependence are usually evident over a
Pharmacodynamics period of at least 12 months but the diagnosis may be
Opioids depress cerebral cortex, medulla and hypothalamus. made if opioid use is continuous (daily or almost daily)
They suppresses pain, vomiting center, respiratory center, for at least 1 month.
cough center and chemoreceptor trigger zone (CTZ). Opioid
stimulates vagus nerve and causes bradycardia. It stimulates Treatment of Opioid Dependence
nucleus of oculomotor nerve and causes miosis. Activation of • Overdose of opioids: Narcotic antagonist (intravenous
dorsal horn of spinal cord and decrease in release of substance administration of naloxone or naltrexone and it can be
P (pain transmitter) decreases the level of pain. It decreases the repeated after 5–10 minutes).
secretion of HCl, decreases peristaltic movement and leads to • Detoxification
constipation. „ Use of substitute: E.g., methadone.

Flowchart 9.9: Complications of opioids dependence

276 Textbook of Psychiatric Nursing for BSc Nursing Students

„ Clonidine (0.3–1.2 mg/day): Inhibit the release of Acute Intoxication Effects of Amphetamine
norepinephrine in presynapse. It might lead to excess
• Neuropsychiatric manifestations: Panic anxiety, restless,
sleepiness and orthostatic hypotension. So, taper it off
irritability, hostile behavior and bruxism.
within 10–14 days.
• Cardiovascular manifestations: Hypertension, cardiac
„ Naltrexone with clonidine
failure, cardiovascular shock, tachycardia and hemor-
„ Levo-Alpha-Acetyl-Methadol (LAAM)
rhage.
„ Propoxyphene
• Psychiatric manifestations: Prominent visual halluci-
„ Buprenorphine
nations, phobia, euphoria, hypervigilance, hyperactivity,
„ Diphenoxylate
anger, impaired judgment, confused state, talkativeness,
„ Lofexidine
absence of thought disorder, paranoid hallucination
• Maintenance: Methadone maintenance (agonist
syndrome and tactile hallucination (present in chronic
substitution)—20–50 mg/day is helpful to shift out from
usage).
hard drugs. Opioid antagonist—nalorphine (partial
• Miscellaneous: Ataxia, hyperpyrexia, convulsions, tetany,
antagonist) 100 mg/day.
mydriasis and coma.
• Miscellaneous: Individual psychotherapy, behavior
therapy, cognitive therapy, interpersonal therapy,
Withdrawal Effects of Amphetamine
motivational interviewing, self-control measures,
family therapy, group therapy, narcotic anonymous and Depression with suicidal ideation, apathy, fatigue, dysphoria,
psychosocial rehabilitation. agitation, increased appetite, unpleasant dreams, psychomotor
agitation or retardation, hypersomnia alternative with
CENTRAL NERVOUS SYSTEM STIMULANTS insomnia and hyperphagia.

Central nervous stimulants are categorized in two types: Drug Interactions

1. Psychomotor stimulants: Augmentation of norepineph-
Decongestants and hay fever medications contain stimulants
rine, dopamine and serotonin
like sodium bicarbonate (urine alkalinizing agent which
2. Cellular stimulants: Exert the cellular activity (E.g.,
decrease amphetamine elimination). Urine acidifying agent
caffeine and nicotine).
increases amphetamine elimination.
Caffeine inhibits phosphodiesterase enzyme so adenosine
3, 5-cyclin phosphate of cellular metabolism will increase.
ICD-11 Diagnostic Criteria for Amphetamine
Nicotine acts at ganglionic synapse so acetylcholine stimulates
Dependence
the nerve impulses toward activation of autonomic nervous
system. • Disorder of regulation of stimulant use arising from
Common CNS stimulants are as follows: repeated or continuous use of stimulants.
• Amphetamines: Amphetamine sulfate, dextroamphet- • The characteristic feature is a strong internal drive to use
amine, methamphetamine. stimulants, which is manifested by impaired ability to
• Nonamphetamines: Benzphetamine, phendimetrazine, control use, increasing priority given to use over other
pemoline, methylphenidate, sibutramine and phentermine. activities and persistence of use despite harm or negative
• Miscellaneous: Cocaine, caffeine and nicotine. consequences.
Amphetamine is a stimulant of central nervous system. • These experiences are often accompanied by a subjective
Its primary action is to release norepinephrine along with sensation of urge or craving to use stimulants.
dopamine and serotonin. In 1932, amphetamine was • Physiological features of dependence may also be
introduced in medicine as amphetamine sulfate (benzedrine present, including tolerance to the effects of stimulants,
inhaler) for treating rhinitis, asthma and coryza. Street names withdrawal symptoms following cessation or reduction
of amphetamines are ecstasy, XTC, speed, meth, ice, crank and in use of stimulants, or repeated use of stimulants or
crystal. As per the metabolism, the oral amphetamines are pharmacologically similar substances to prevent or
absorbed well in gastrointestinal tract and excreted by kidneys. alleviate withdrawal symptoms.
At present, common clinical indications of amphetamines are • The features of dependence are usually evident over a
attention deficit hyperactive disorder (ADHD), narcolepsy, period of at least 12 months but the diagnosis may be
obesity (rarely used), mild depression among students and made if stimulant use is continuous (daily or almost daily)
sports personnels and post encephalitic Parkinson’s disease. for at least 1 month.
CHAPTER 9 Nursing Management of Patients with Substance Use Disorders 277

Treatment presynaptic neurons. Cocaine is commonly used with opioids

Management of Amphetamine Intoxication and amphetamines. Cocaine mixed up with heroin is called
speedball. The preparation of cocaine in various forms is given
Induce vomiting as a first aid measure when you suspect in Table 9.13.
amphetamine intoxication. Acidification of urine and
diuresis is helpful. If convulsion is there, Inj. diazepam is Acute Intoxication Effects of Cocaine
administered. In case of psychotic symptoms, haloperidol and
chlorpromazine can be given. If hypertension is present beta Pupil dilatation, nausea, vomiting, tachycardia, increase or
blockers can be given. Administer Tab. paracetamol and give decrease in temperature/blood pressure/pulse/respiration,
cold sponging if the patient has hyperpyrexia. Nurse should increased sweating, loss of appetite, weight loss, impaired
also facilitate the urinary clearance of amphetamines. thinking, seizure, agitation, chest pain, hypomanic state and
coma.
Management of Withdrawal Effects of Amphetamine
Symptomatic treatment can be done. Amino acid Chronic Effects of Cocaine
catecholamine precursors such as phenylalanine and tyrosine Psychosis, perforated nasal septum (when snorting is present),
is used. Dopamine agonist (For example, bromocriptine) disturbances in biological functions, paranoia, crack babies—
is used to manage withdrawal symptoms of amphetamine. cause damage to fetus and pseudohallucination.
Tricyclic antidepressants and psychotherapy is also helpful.
Withdrawal Effects of Cocaine
COCAINE Phases of cocaine withdrawal include crash phase, postcrash
It is alkaloid derived from coca bush, Erythroxylum coca. Karl and extinction phase as explained in Table 9.14.
Koller used this as first effective local anesthetic agent in 1884.
Street Name; Coca, Crack, gold dust, coke, cecil, toot, blow,
Complications
happy dust, snow, dust and flake. It exerts physiological effects • Psychological: Anxiety, psychotic symptoms such as
on both central and peripheral nervous system which prevents tactile hallucination/persecutory delusion, compulsive
the reuptake of norepinephrine, serotonin and dopamine into behavior and out of control behavior.

Table 9.13: Preparation of cocaine in various forms

Final preparation Mode of administration Content of cocaine (%) Content in addition to leaves of Erythroxylum coca
Coca Chewable 0.5–1.5% Lime
Coca paste Smoked 40–90% Gasoline or kerosene
Sniffed 12–75%
Cocaine HCl Intravenous >98% HCl
Smoke with glass pipe
Free base or alkaloid Inhale with glass pipe Varies Alkali

Table 9.14: Withdrawal effects of cocaine

Phases of cocaine Duration after Substages Symptoms

withdrawal discontinuation of cocaine
Crash 9 hours–4 days I Anorexia, agitation, depression and severe craving
II Depression, fatigue, sleepiness and moderate craving
III Hyperphagia, excessive day time sleepiness with intermediate
awareness and mild craving
Postcrash 4 days–1 week I Normal sleep, may or may not have craving
II Anergia, anxiety, cocaine blues (depression), anhedonia and
moderate craving
Extinction 1 week–10 days Absence of withdrawal symptoms
278 Textbook of Psychiatric Nursing for BSc Nursing Students

• Intranasal: Nasal septum perforation, mucosal vasocon- NICOTINE ABUSE

striction and anosmia.
• Systemic: Gastrointestinal necrosis, respiratory depression, Nicotine is addictive substance present in tobacco products.
coronary artery disease, arrhythmias, convulsions and Tobacco smoke has around 4,000 chemicals. Available forms
fetal anoxia. are cigarette smoking, pipe smoking, tobacco chewing, snuff
and cigar smoking.
ICD-11 Diagnostic Criteria for Cocaine
Dependence Mechanism of Nicotine Dependence
• Regulation of cocaine use arising from repeated or • Biomolecular: Nicotine binds with their specified
continuous use of cocaine. nicotinic receptors in brain and release dopamine or
• Characteristic feature is a strong internal drive to use other neurotransmitter which gives pleasure; thereby the
cocaine, which is manifested by impaired ability to control dependence to nicotine develops.
use, increasing priority given to use over other activities and • Psychosocial: Taking nicotine as a coping mechanism
persistence of use despite harm or negative consequences. with negative mood or stress.
• These experiences are often accompanied by a subjective
sensation of urge or craving to use cocaine. ICD-11 Diagnostic Criteria for Nicotine
• Physiological features of dependence may also be present, Dependence
including tolerance to the effects of cocaine, withdrawal • Disorder of regulation of nicotine use arising from
symptoms following cessation or reduction in use of repeated or continuous use of nicotine.
cocaine, or repeated use of cocaine or pharmacologically • The characteristic feature is a strong internal drive to
similar substances to prevent or alleviate withdrawal use nicotine, which is manifested by impaired ability to
symptoms. control use, increasing priority given to use over other
• The features of dependence are usually evident over a activities and persistence of use despite harm or negative
period of at least 12 months but the diagnosis may be consequences.
made if cocaine use is continuous (daily or almost daily) • These experiences are often accompanied by a subjective
for at least 1 month. sensation of urge or craving to use nicotine.
• Physiological features of dependence may also be present,
Treatment including tolerance to the effects of nicotine, withdrawal
symptoms following cessation or reduction in use of
• For overdose of cocaine:
nicotine, or repeated use of nicotine or pharmacologically
„ Administration of oxygen
similar substances to prevent or alleviate withdrawal
„ Muscle relaxants
symptoms.
„ Antidote is amyl nitrite
• The features of dependence are usually evident over a
„ Diazepam (or) thiopentone IV for seizure (or) severe
period of at least 12 months.
anxiety
Intoxication effects of nicotine: Lung carcinoma,
„ Propranolol IV—antagonist of cocaine induced
oropharyngeal carcinoma, emphysema, heart disease, diabetes,
sympathomimetic effect
macular degeneration of eye, cataract, premature ageing,
„ Haloperidol (or) pimozide for treating psychosis
infertility or impotence, stroke, miscarriage in pregnancy,
• For chronic use of cocaine: peptic ulcer, osteoporosis, cancer of kidney, bladder cancer,
„ Dopaminergic agonist—bromocriptine pancreatic carcinoma, cervical cancer and leukemia.
„ Antiparkinson agent—amantadine Withdrawal effects of nicotine: Irritability, headache,
„ Antidepressants—desipramine, imipramine and insomnia, lack of concentration, memory loss, restlessness,
trazodone increased appetite, depression, weight gain and decreased
„ Supportive psychotherapy heart rate.
„ Behavior therapy Nicotine replacement therapy: Nicotine chewing gum
„ Relapse prevention (2 mg dose/gum has to be chewed and kept between the
CHAPTER 9 Nursing Management of Patients with Substance Use Disorders 279

cheek and gums for effective release of nicotine). Nasal Five Major Steps of Intervention (5 A’s)
spray, inhaler and transdermal patch is also recommended (Flowchart 9.10)
to use. Bupropion hydrochloride (zyban) can be used, but
Flowchart 9.10: Five major steps to intervention—
contraindicated with seizure/eating disorders. The second line smoking cessation
of treatment is clonidine (antihypertensive) and nortriptyline
(antidepressant). Psychosocial interventions include individual
and group psychotherapy. Complementary therapies include:
acupuncture, yoga, herbs and hypnosis. Tablet varenicline
(Trade name: Champix, Chantix)—high affinity partial agonist
for nicotinic acetylcholine receptor (nACh) which leads to
dopamine release in nucleus accumbens so that nicotine
craving is reduced.
Behavior modification (6 D technique): It includes the
determination of oneself to quit smoking, deep breathing
exercises, drink more water, healthy, diet, daily exercises and
diversional techniques as shown in Figure 9.12.

5 R’s for Patients Unwilling to Quit Nicotine

(Flowchart 9.11)
Flowchart 9.11: Five R’s for patients unwilling to quit smoking

Determine oneself to quit Drink plenty of water

smoking

Diet should be healthy and

Deep breathing exercises balanced

Benefits of smoking cessation: Shown in Figure 9.13

HALLUCINOGENS

Hallucinogens are substances which alter the individual’s

sensory perception of reality and induce hallucinations. They
fall in two categories:
1. Natural hallucinogens: Mescaline, Psilocybin, Psilocin
Divert yourself when you get
and Ololiuqui.
Daily exercises
thoughts to smoke 2. Synthetic hallucinogens: Lysergic acid diethylamide
(LSD), dimethytryptamine (DMT), diethyltryptamine
(DET), phencyclidine (PCP), methoxyamphetamine
Figure 9.12: Smoking cessation—6 D technique (MDA) and 3, 4-Methylene-dioxyamphetamine (MDMA).
280 Textbook of Psychiatric Nursing for BSc Nursing Students

Figure 9.13 Benefits of smoking cessation from 20 minutes to 10 years

ICD-11 Diagnostic Criteria for Hallucinogens Treatment

Dependence Symptomatic management, antidepressants, antianxiety agents–
• Disorder of regulation of hallucinogen use arising diazepam; antipsychotics-haloperidol and psychotherapy.
from repeated or continuous use of hallucinogens. The
characteristic feature is a strong internal drive to use CAFFEINE
hallucinogens, which is manifested by impaired ability
Caffeine intoxication is a clinically significant transient
to control use, increasing priority given to use over other
condition that develops during or shortly after the consumption
activities and persistence of use despite harm or negative
of caffeine.
consequences.
• Intoxication effects: Disturbances in consciousness,
• These experiences are often accompanied by a subjective
cognition, perception, affect, behavior or coordination.
sensation of urge or craving to use hallucinogens.
• Presenting features: Restlessness, anxiety, excitement,
• The features of dependence are usually evident over a insomnia, flushed face, diuresis, gastrointestinal
period of at least 12 months but the diagnosis may be disturbances, muscle twitching, psychomotor agitation,
made if hallucinogens use is continuous (daily or almost perspiration or chills, and nausea or vomiting and panic
daily) for at least 1 month. attacks may occur.
• Withdrawal effects of caffeine: Headache, fatigue or
Intoxication Effects of Hallucinogens drowsiness, anxiety, dysphoric mood, nausea or vomiting,
It includes bad trips [Fear of dying (or) going mad (or) feeling and difficulty in concentrating.
panicky], synesthesia—confusion with sensory modalities • Complications on very high doses: Respiratory distress
(e.g., sound being seen, colors being heard), impaired and seizures
judgment, paranoid ideas, alertness, full wakefulness, • Treatment: Symptomatic management, antidepressants,
depersonalization, derealization. Physical symptoms such antianxiety agents and psychotherapy.
as tachycardia, sweating, palpitation, blurring of vision,
pupillary dilatation, tremors, incoordination and raised blood SYNTHETIC CATHINONES
pressure.
• Synthetic cathinones have dependence-inducing properties,
resulting in synthetic cathinone dependence and also causes
Withdrawal Effects of Hallucinogens
withdrawal symptoms when stopped or reduced.
No specific withdrawal symptoms. However, flash back • Intoxication effects:
phenomenon (repeated occurrence of hallucinogenic state „ Presenting features: Anxiety, anger, hypervigilance,
without taking the drug) is seen. psychomotor agitation, panic, confusion, paranoid
CHAPTER 9 Nursing Management of Patients with Substance Use Disorders 281

ideation, auditory hallucinations and changes in • Complications: Delirium, psychotic features and mood
sociability, perspiration or chills and nausea or disorder.
vomiting. • Treatment: Symptomatic management, antidepressants,
„ Physical signs: Tachycardia, increased blood pressure, antipsychotics, antianxiety agents and psychotherapy.
hyperthermia and pupillary dilatation. Seizure may
occur rarely. INHALANTS (OR) VOLATILE SOLVENTS
• Withdrawal effects: Dysphoric mood, irritability, fatigue,
insomnia or hypersomnia, increased appetite, anxiety and The commonly used inhalants (or) volatile solvents are
craving for cathinones. aerosols, varnish remover, thinners, petrol and solvents used
• Treatment: Symptomatic management, antidepressants, in industrial areas.
antianxiety agents and psychotherapy. • Intoxication effects: Euphoria, apathy, slurring of speech,
belligerence, excitement and impaired judgment.
DISORDERS DUE TO USE OF • Withdrawal effects: Anxiety and depression.
METHYLENEDIOXYMETHAMPHETAMINE OR • Complication: Kidney/liver damage, brain damage,
RELATED DRUGS peripheral neuropathy and disturbances in perception.
• Treatment: Antianxiety agents, antidepressants and
Methylenedioxymethamphetamine (MDMA) causes a wide
psychotherapy.
range of harms affecting most organs and systems of the body.
It also has dependence-inducing properties and withdrawal
symptoms when stopped or reduced. NURSING DIAGNOSIS AND INTERVENTIONS FOR
• Intoxication effects: Anxiety, Increased or inappropriate PATIENT WITH SUBSTANCE ABUSE
sexual interest and activity, restlessness, agitation and
sweating. Dystonia and seizure may happen rarely. NURSING CARE IN ACUTE EPISODE
• Withdrawal effects: Lethargy, fatigue, hypersomnia or
insomnia, anxiety, depressed mood, irritability, difficulty • Monitor vital signs.
in concentrating craving and appetite disturbance. • Intake output chart is need to be maintained.
• Treatment: Symptomatic management, antidepressants, • Observe the complications of drug overdose and
antianxiety agents and psychotherapy. withdrawal.
• Take precautions to prevent suicide and use restraints
DISORDERS DUE TO USE OF DISSOCIATIVE if patient is violent/potential for injury to self and
DRUGS INCLUDING KETAMINE AND others.
PHENCYCLIDINE • Use limit setting, a psychotherapy technique in order
to control the manipulative behavior. Maintain seizure
The use of dissociative drugs including ketamine and precaution.
phencyclidine (PCP) will harm the health due to the direct or • Administer intravenous fluids and medications as per
secondary toxic effects on body organs and systems, behavior physician order.
related to intoxication, by the harmful route of administration.
It also has dependence-inducing properties and withdrawal NURSING CARE IN WITHDRAWAL
symptoms when stopped or reduced.
• Intoxication effects: • Observe and monitor the withdrawal symptoms.
„ Presenting features: Aggression, unpredictability, • Administer medications as per the doctor’s order to
impulsiveness, anxiety, altered judgment, psycho- reduce the withdrawal symptoms and ensure that the
motor agitation, numbness, slurred speech and patient has swallowed the medication properly.
dystonia. • Provide calm environment since noise may agitate the
„ Physical signs: Nystagmus, tachycardia, raised blood patient.
pressure, numbness, ataxia, dysarthria, and muscle
rigidity. NURSING DIAGNOSIS AND INTERVENTIONS
• Withdrawal effects: Dysphoric mood, irritability,
fatigue, insomnia or hypersomnia, increased appetite and • Imbalanced nutrition less than body’s requirements
anxiety. due to the effects of drug dependence.
282 Textbook of Psychiatric Nursing for BSc Nursing Students

Nursing interventions Rationale • Risk of injury related to acute intoxication effects of

drug as evidenced by disorientation and confused state
Assess the nutritional Provide the baseline data about
requirements of the client client’s nutritional status
Nursing interventions Rationale
and Body mass index
Allot the patient’s bed near to nurses’ To have direct
Assess the client likes and To prepare diet menu accordingly
station observation
dislikes
Monitor the client’s need of restraint To promote safety
Plan the adequate To improve the health status with
measures
and realistic calorie adequate calorie
requirement Promote seizure precautions (raise the To prevent injury of
side rails, airway kept ready, padded client
Describe the importance To improve the knowledge regarding
tongue blade to prevent tongue fall
of adequate nutrition to nutritious diet thereby weight loss
back)
the client and anemia (physiological effects of
drugs) will be corrected Reorient the client to time, place and To orient the patient
person
Provide the menu plan to To execute the diet plan effectively
client into practice Reduce the environment stimuli (switch To promote the client
off the bright lights, restrict the visitors) to take adequate rest
• Ineffective coping identified by the patient verbalization
that he consumes drug to relieve stress • Altered health maintenance related to seeking help
from others to maintain health as evidenced by feeling
Nursing interventions Rationale
exhausted and presence of more physical symptoms
Assess the situations in Provide the baseline data about due to drug withdrawal.
which client feels stressful client’s stressful situation
Explore the internal and Help to identify the stressor Nursing interventions Rationale
external stressors causing stress Assess the client health Provide the baseline data about
Teach the various right To cope the stressful situations status client’s health status
coping skills Provide bland diet Easily tolerable food for the client
Encourage the good It helps to express the feelings with substance abuse
relationship with family and bottled up emotions to family Maintain fluid and To rectify the fluids and electrolytes
members members instead of consuming electrolyte balance imbalance since, it’s common among
drug patients with substance abuse
Refer the client to alcoholic Self-help group will guide the disorder.
anonymous, narcotic client to enhance the coping skills Ensure the adequate Hepatic dysfunction is common
anonymous, Al-anon, etc. protein in diet among patients with substance use
Assist the client to plan the Proper adherence with disorder so protein metabolism is
schedule daily the schedule will avoid the said to be problematic among these
unnecessary stress clients
Promote small, frequent To promote the nutritional status
• Ineffective denial related to underdeveloped ego as and balanced diet
evidenced by failure to accept the responsibility and
lack of insight
PREVENTION OF SUBSTANCE USE DISORDER
Nursing interventions Rationale
Follow the psychiatric nursing Unconditional acceptance Primary Prevention
Principle ‘Accept the patient as of client will promote self- Social changes or governmental measures such as:
he/she is’. esteem
• Control the sales of alcohol within the limited hours
Identify the maladaptive behavior To reduce denial, relation
might decrease the availability.
and find out how drug act as between drug usage and
contributing factor for such personal problem has to be • Increase in the price of alcohol is helpful to reduce the use
behavior identified of alcohol.
Don’t allow the client to blame Helps to promote insight and Health education to the public and school/college students:
others thereby it reduces denial • Educating in regard with the harmful effects of substance
Give positive reinforcement To promote the desirable use will be helpful to prevent the usage.
when client exhibits insight in his behavior • Consider the cultural belief is important, i.e., tribal group
behavior people (Lambani group) might feel ‘arrack’ manufacture
CHAPTER 9 Nursing Management of Patients with Substance Use Disorders 283

is said to be normal and certain cultures consider that anonymous, al-anon, al-ateen, narcotic anonymous) and
alcohol consumption in postnatal mother might speedup relapse prevention.
the retroversion of uterus and some foreigners also
consider that drinking little amount of alcohol daily is REHABILITATION
good for health and to improve the heart function. So,
these cultural beliefs have to be addressed properly during Measures are taken to improve the new social contacts
the time of health teaching. and avoid the previous contacts who drink alcohol or use
substances. Provide them a good social and family support.
Doctors can restrict the over prescription of
Engage the patients in work and social activities.
benzodiazepines: The benzodiazepines have risk of
dependence so, it can be either avoided or prescribed in the
GERIATRIC CONSIDERATIONS
low doses based on the patient’s needs.
Training to enhance the social and personal skills which in Late onset substance abuse is rare, but if it is present it has to
turn develops the self-esteem. be treated properly because it will increase the grief, stress,
depression and social isolation. History of substance use by the
Secondary Prevention same individual with absenteeism might have a chance to use
Counseling and motivational interviewing (Identify the factors again in old age due to social isolation. Hence, good social and
which promote the motivation toward change, i.e., motivation family support are essential.
to quit substances).
Detoxification with the benzodiazepines (e.g., Lorazepam, EXTRA EDGE
diazepam) will control the withdrawal symptoms and help
ICD-10 Classification of Substance Abuse
them to recover from substance abuse.
F10–F19: Mental and behavioral disorders due to psychoactive
substance use and mental and behavioral disorder due to the
Tertiary Prevention use of
• F10 — Alcohol
Holistic approach of treatment modalities is considered such
• F11 — Opioids
as assertiveness training, training to promote coping skills, • F12 — Cannabinoids
psychotherapy, anger control measures, time management, • F13 — Hypnotics or sedatives
monetary management, stress management, recreation, sleep • F14 — Cocaine
hygiene, family counseling, referral to the agencies (alcoholic • F16 — Hallucinogens

SUMMARY
• Dependence means compulsive and repeated use of substance, which results in tolerance toward the substance and also leads to
withdrawal symptoms, when it is commenced to quit or decrease the dosage of the substance.
• Common substance abuse in India is alcohol, cannabis, hypnotics, sedatives, antianxiety drugs, amphetamines, barbiturates, cocaine,
hallucinogens, inhalants, nicotine and opioids.
• Modified Mann’s index of addiction denotes the addiction level of various substances which has been arranged from lower level of
addiction to higher level of addiction.
• Substance abuse can also be classified based on the psychological effects as depressants and stimulants.
• The major parts involved in addiction reward pathway are ventral tegmental area (VTA), nucleus accumbens and prefrontal cortex.
• DSM-5 classification of alcoholism includes the alcohol use disorder (mild or moderate or severe), intoxication, withdrawal and
unspecified alcohol related disorder.
• Cloninger’s classified alcoholism as type I and II based on genetic and environmental factors. Jellinek’s, five species of alcohol
dependence based on usage pattern is alpha, beta, gamma, delta and epsilon.
• CAGE Questionnaire, Michigan Alcoholism Screening Test (MAST), Alcohol Use Disorders Identification Test (AUDIT) and Paddington
Alcohol Test (PAT) are the tool used to assess problem of alcoholism.
• Alcohol withdrawal is categorized as mild, moderate and severe. It is also categorized as complicated and uncomplicated.
• Aversion therapy or Antabuse means treatment to arouse unlikeliness.
• Usual dose of disulfiram is 250 mg per day.
• When client takes alcohol along with disulfiram it will cause disulfiram ethanol reaction.
• Ethanol challenge test is done to create the cognitive awareness of disulfiram ethanol reaction.
• Alcoholic anonymous works by the recovered alcoholics to sustain the process of sobriety.
• Precontemplation, contemplation, preparation, determination, action, maintenance and relapse are the stages of change model.
Contd…
284 Textbook of Psychiatric Nursing for BSc Nursing Students

• Sedatives, hypnotics and antianxiety agents are classified as barbiturates and nonbarbiturates.
• Flumazenil is antidote of antianxiety agents.
• Cannabis is derived from hemp plant, Cannabis sativa.
• Opioids are exudates from dried seeds of Papaver somniferum. It is classified as natural and synthetic derivatives. Naltrexone is used
to treat the overdose of opioids. Methadone maintenance is the agonist substitution.
• CNS stimulants are two categories—cellular and psychomotor. Common CNS stimulants are classified as amphetamines,
nonamphetamines, cocaine, caffeine and nicotine.
• Cocaine is an alkaloid derived from coca bush, Erythroxylum coca. Phases of cocaine withdrawal are crash, postcrash and extinction
phase. Amyl nitrite is an antidote for cocaine overuse.
• Nicotine is an addictive substance in tobacco product. Mechanism of nicotine dependence is classified as biomolecular and psychosocial.
Nicotine replacement therapy is helpful for patients with nicotine dependence.

ASSESS YOURSELF

Long Answer Questions 2. ICD-11 code for mental and behavioral disorders due
1. Explain the classification, etiology, psychopathology, to psychoactive substance use is ______.
diagnosis, clinical manifestations of intoxication and a. 6C40 b. 6C41
management of patients with alcohol dependence syndrome. c. 6C42 d. 6C43
2. Explain the classification, etiology psychopathology, 3. The major part involved in addiction reward pathway
diagnosis, clinical manifestations and management of are _____________.
patients with opioids abuse. a. Ventral tegmental area (VTA)
b. Nucleus accumbens
Short Answer Questions c. Prefrontal cortex.
1. Define substance abuse. d. All of the above
2. Write about opioids abuse in brief. 4. Usual dose of disulfiram is _____ per day.
a. 250 mg b. 500 mg
Short Notes c. 750 mg d. 1 g
Write short notes on: 5. ___________ is a first stage in change model.
1. Cannabis abuse a. Contemplation b. Precontemplation
2. Alcohol withdrawal syndrome c. Preparation d. Determination
3. Complications of alcoholism 6. _________ works by the recovered alcoholics to
4. Assessment tools used to assess the patient with sustain the process of sobriety.
substance abuse a. Rehabilitation Center b. Alcoholic anonymous
5. Treatment of alcohol withdrawal c. Psychotropic drugs d. None of these
6. Disulfiram 7. _________is antidote of antianxiety agents.
7. Aversion therapy a. Flumazenil b. Lorazepam
8. Disulfiram ethanol reaction c. Haloperidol d. Amyl nitrite
9. Alcoholic anonymous 8. _________ is a antidote for cocaine overuse.
10. Sedatives, hypnotics and antianxiety agents a. Flumazenil b. Lorazepam
11. Opioids dependence c. Haloperidol d. Amyl nitrite
12. CNS stimulants 9. ________ are exudates from dried seeds of Papaver
13. Cocaine dependence somniferum.
14. Nicotine abuse a. Cannabis b. Opioids
15. Nursing management of patient with substance abuse c. Nicotine d. Alcohol
10. _____________is tool used to assess problem drinkers
Multiple Choice Questions of alcoholism.
1. _________ is a compulsive and repeated use of a. CAGE questionnaire b. AUDIT
substance, which results in tolerance toward the c. MAST d. All of these
substance and also leads to withdrawal symptoms
when it is commenced to quit. Answer Key
a. Dependence b. Abuse 1. a 2. a 3. d 4. a 5. b
c. Tolerance d. Codependence 6. b 7. a 8. d 9. b 10. d
Nursing Management CHAPTER
of Patients with
Sexual, Personality
and Eating Disorders
10
LEARNING OBJECTIVE

After studying this chapter, the students will be able to gain knowledge regarding the personality disorders, eating disorders and sexual
disorders which will help them in nursing care of patient suffering from personality disorders, eating disorders and sexual disorders.

CHAPTER OUTLINE
Sexual Disorders • Antisocial Personality Disorder
• ICD-11 and DSM-5 Classification of Sexual Disorders • Borderline Personality Disorder
• Gender Identity Disorder or Gender Dysphoria or Gender • Geriatric Considerations
Incongruence Eating Disorders
• Disorders Related to Sexual Maturation and Development • Etiology of Eating Disorder
• Disorders of Sex Preference/Deviation/Perversions/ • Comparison of Anorexia Nervosa and Bulimia Nervosa
Paraphilic Disorders • Complications of Eating Disorders
• Sexual Dysfunction • Categories of Eating Disorders
Personality Disorders • Assessment of Eating Disorders
• Introduction • Nursing Diagnosis
• Definition of Personality Disorder • Signs and Symptoms of Eating Disorders Revealed During
• Incidence and Prevalence Physical Assessment
• Significant Features of Personality Disorders • Treatment of Eating Disorders
• Etiology of Personality Disorders • Eating Disorders of Infancy and Childhood
• Classification of Personality Disorders • Obesity
• Protective and Risk Factors of Personality Disorders

KEY TERMS
Transsexualism, Dual-role transvestism, Gender identity disorders, Fetishism, Fetishistic transvestism, Exhibitionism, Sadomasochism,
Multiple disorders of sexual preference, Exhibitionism, Frotteurism, Sadism, Masochism, Pedophilia, Zoophilia (Bestiality), Klismaphilia,
Urophilia, Coprophilia, Necrophilia, Telephone or mail scatologia, Voyeurism/Scopophilia, Paranoid personality disorder, Schizoid
personality disorder and schizotypal personality disorder, Antisocial personality disorder, Borderline personality disorder, Histrionic
personality disorder and Narcissistic personality disorder, Avoidant personality disorder, Dependent personality disorder and Obsessive-
compulsive personality disorder, Anorexia nervosa, Bulimia nervosa, Binge eating, Pica, Rumination disorder, Obesity.
286 Textbook of Psychiatric Nursing for BSc Nursing Students

SEXUAL DISORDERS Paraphilic Disorders

Sexual disorders are classified as gender identity disorders, 6D30 302.4 Exhibitionistic disorder
disorders of sex preference/deviation/perversion, disorders 6D31 302.82 Voyeuristic disorder
related to sexual maturation or development and sexual 6D32 302.2 Pedophilic disorder
dysfunction as shown in Flowchart 10.1. 6D33 302.84 Sexual sadism disorder
6D34 302.89 Frotteuristic disorder
ICD-11 AND DSM-5 CLASSIFICATION OF SEXUAL — 302.83 Sexual masochism disorder
DISORDERS
F65.0 302.81 Fetishistic disorder
Sexual Dysfunctions — 302.3 Transvestic disorder
HA00 302.71 Hypoactive sexual desire disorder 6D35 and 302.89 Other specified paraphilic disorder
6D36
HA01.0 302.72 Female sexual interest/arousal disorder
6D3Z 302.9 Unspecified paraphilic disorder
HA01.1 302.72 Erectile disorder
HA02 302.73 Female orgasmic disorder
HA03.0 302.75 Premature (early) ejaculation GENDER IDENTITY DISORDER OR GENDER
HA03.1 302.74 Delayed ejaculation
DYSPHORIA OR GENDER INCONGRUENCE
— 302.76 Genito-pelvic pain/penetration disorder Transsexualism or Gender Dysphoria
HA03.Y 302.79 Other specified sexual dysfunction
Transsexual people experience gender identity crisis, which is
Gender Dysphoria (DSM-5) and Gender Incongruence (ICD-11)
expressed in feeling of discomfort with one’s own anatomical
HA60 302.85 Gender dysphoria in adolescents and
sex organs. Individual has preoccupied ideas that he/she
adults
will feel better to have opposite sex organs and the person
HA61 302.6 Gender dysphoria in children
feels marked significant distress. There will be a presence of
HA8Y 302.6 Other specified gender dysphoria
social and occupational dysfunction. This disorder is being
HA6Z 302.6 Unspecified gender dysphoria diagnosed after puberty (Table 10.1).

Flowchart 10.1: Classification of sexual disorders

CHAPTER 10 Nursing Management of Patients with Sexual, Personality... 287

Table 10.1: Primary and secondary transsexualism DISORDERS RELATED TO SEXUAL MATURATION
AND DEVELOPMENT
Aspects Primary transsexualism Secondary
transsexualism
Sex Maturation Disorder
Onset Early childhood Late
Uncertainty with regard to gender identity and sexual
Prognosis Good Poor
orientation (homosexual, heterosexual, bisexual) leads to
Category Homogenous Heterogenous anxiety or depression. Usual onset of this disorder is in
Types • Male to female primary Majority are male adolescence.
transsexualism to female secondary
• Female to male/ transsexualism Egodystonic Sexual Orientation
primary transsexualism Disorder/Homosexuality
Common Wish to change anatomical
feature sex organ
Individual wishes to change the sexual orientation because
it causes significant distress (egodystonic: Opposite to that
of ego, unwillingness to ego). Previously homosexuality
Differential Diagnosis
was classified as egosyntonic (no distress with regard to
Cross-gender homosexuality or Pseudotranssexualism: homosexual behavior) and egodystonic (distress with regard
Male or female homosexuals sometimes need sex change and to homosexual behavior) (Table 10.2).
even wear the dress of opposite gender.
Table 10.2: Types of homosexuality
Transvestism or fetishistic transvestism: Wearing the dress
of opposite gender for purpose of sexual excitement is mostly Types of homosexuality Description in regard to
seen in males (transsexuals wear dress of opposite gender the desire to have sex
because they feel that they are a part of other gender. This is not Obligatory homosexuality Only homosexuals
because of sexual excitement). Preferred homosexuality Predominant homosexuals
and occasionally
Treatment heterosexuals
• Counseling and psychotherapy: It is to promote Bisexuality Both homosexuals and
satisfaction with one’s own gender (This has been done heterosexual
previously but as per the newer concept, this is no longer Situational homosexuality Predominant heterosexual
advocated if the diagnosis is clear). and occasionally homosexual
„ Sex reassignment surgery (if psychotherapy fails). Latent homosexuality Only heterosexual and
„ Hormonal therapy. fantasy of homosexuals
„ Mastectomy: Surgical removal of partial or complete
removal of one or two breasts. The main objective of Treatment
mastectomy is to create an aesthetically pleasing male
• To change sexual orientation: Psychoanalytic
chest by removing glandular tissue while minimizing
psychotherapy, behavior therapy (systematic
chest wall scars.
desensitization, aversion therapy and covert sensitization),
• Castration or testiclectomy or oophorectomy: Action
androgen therapy was practiced previously but, it is not
performed to lose the function of the testis or ovaries is
practiced nowadays because these methods are considered
known as castration. It can be done either surgically or
to provoke the anxiety in patients.
with the use of chemicals.
• To remove psychological distress: Psychotherapy and
• Phalloplasty: Surgical reconstruction or artificial
psychotropics (antidepressants and benzodiazepines) are
modification of penis.
used.
• Hysterectomy with salpingo-oophorectomy: Removal
of uterus and cervix. Bilateral salpingo-oophorectomy is
DISORDERS OF SEX PREFERENCE/DEVIATION/
the removal of both ovaries and fallopian tubes.
PERVERSIONS/PARAPHILIC DISORDERS
Gender Dysphoria of Childhood Disorders of sex preference/deviation/perversions/paraphilic
Onset of transsexualism can be seen in age group of 2–4 years. disorders have been described in Table 10.3.
288 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 10.3: Disorders of sex preference/deviation or paraphilic

disorders

Disorders of Description
sex preference/
deviation/perversion
Exhibitionism Showing of sex organs to stranger
Frotteurism Sexual pleasure with rubbing others
Sadism Sexual pleasure with humiliating others
Masochism Sexual pleasure with getting or being
humiliated
Sadomasochism Sexual pleasure with humiliating others Figure 10.1: Normal human sexual response cycle
and getting or being humiliated
Pedophilia Sexual pleasure with children orgasmic phase and resolution phase as shown in Figure 10.1
Zoophilia (bestiality) Sexual pleasure with animal and male/female sexual response in each phase is described
Klismaphilia Sexual pleasure with enema in Table 10.4. Sexual dysfunction denotes a significant
Urophilia Sexual pleasure with urine dysfunction in a human sexual response cycle which is not due
Coprophilia Sexual pleasure with feces
to an organic cause.
Necrophilia Sexual pleasure with dead bodies Table 10.4: Phases of normal human sexual response cycle
Telephone or mail Sexual pleasure attained by sending Phases of Male Female
Scotologia sexual pictures normal
Fetishism Sexual pleasure with objects human
sexual
Fetishistic Sexual pleasure with clothes of
response
Transvestism opposite sex
Appetitive Sexual fantasies and desire of sexual activity
Voyeurism/scopophilia Sexual pleasure with observing the
phase
sexual activity of opposite sex/watching
naked, etc. (visualizing pornography is Excitement • Penile erection • Clitoris and nipple
not included in this category) phase • Elevation of erection
(true phase testis in scrotum • Thickening of labia
of sexual majora
Treatment for Disorders of Sex response • Vagina gets lubricated
Preference/Deviation cycle) with transudate
• Psychoanalysis: The aim of psychoanalysis is to release Plateau • Autonomic • Autonomic
repressed emotions and experiences, that is make the phase hyperactiveness hyperactiveness
(intermediate • Erection/ • Lengthening and
unconscious conscious.
state of enlargement of ballooning of vagina
• Behavior therapy: Aversion therapy is used to quit excitement penis and testis • Breast and labia
undesirable behavior. and orgasm) majora enlarged
• Drugs: Antipsychotics are given for aggression with Orgasmic • Contraction of • Contractions of lower
paraphilias and antiandrogens (e.g., cyproterone phase penis, urethra, vagina, cervix and
acetate and medroxyprogesterone acetate) are used for (peak state prostate and uterus
suppressing androgen production. of sexual seminal vesicles • Contractions of
excitement) • Ejaculation takes external and internal
• Psychosurgery: Amygdalotomy involves surgical place sphincters
removal or destruction of amygdala or parts of amygdala.
Resolution General state of relaxation and vanish of sexual
It is mostly last-resort. phase flush

SEXUAL DYSFUNCTION
Disorders Related to Appetitive Phase
Normal Human Sexual Response Cycle (Sexual Desire Disorders)
There are five phases in normal human sexual response cycle • Sexual aversion disorder or lack of sexual enjoyment:
such as appetitive phase, excitement phase, plateau phase, Avoidance of sexual activity with life partner or sexual partner.
CHAPTER 10 Nursing Management of Patients with Sexual, Personality... 289

Thoughts of sexual activities will provoke anxiety and attain sexual arousal or to maintain arousal until the
negative feelings. completion of a sexual activity. This may be due to
• Hypoactive sexual desire disorder: Decreased sexual biological (postmenopausal) or psychological factors.
desire to initiate sexual activity.
• Excessive sexual desire disorder: Excess sexual desire Disorders Related to Orgasmic Phase
in male is termed ‘Satyriasis’ and excess sexual desire in • Male orgasmic disorder or male anorgasmia: Male feels
female is termed ‘Nymphomania’. difficult to have orgasm during the coitus. This may be
due to biological (drug-induced or after prostate surgery)
Disorders Related to Excitement and or psychological factor.
Plateau Phase (Sexual Arousal Disorders) • Female orgasmic disorder or female anorgasmia:
• Male erectile disorder: Lack of ability to sustain the Female feels difficult to have orgasm during the coitus.
penile erection in males. It is classified on the basis of This may be due to biological (drug-induced or endocrine
onset, context and etiology factors. Based on onset, disorders like hypothyroidism) or psychological factor.
it is classified as life-long or acquired (happened few • Premature ejaculation: Ejaculation of sperm occurs
months/years ago). Based on the context, it is classified before the satisfactory sexual activity. This may be due
into generalized (all the time) and situational (only in a to biological (not common) or/and psychological factors
particular situation). Based on the etiology, it is classified (performance anxiety).
into biogenic, psychological and combination of both
biogenic and psychological as shown in Flowchart 10.2. Sexual Pain Disorders
Previously, it was termed impotence. Tab Sildenafil and • Nonorganic vaginismus: Spasm of lower vagina will
Tab Tadalafil might be helpful to treat this disorder. cause interference with the coitus.
• Female sexual arousal disorder: It is a disorder • Nonorganic dyspareunia: Male or female may have pain
characterized by a persistent or recurrent inability to in genital area during coitus.

Flowchart 10.2: Classification of male penile erection disorder

290 Textbook of Psychiatric Nursing for BSc Nursing Students

Miscellaneous all (approximately 75–100%) occasions of sexual activity

(in identified situational contexts or, if generalized, in all
• Sexual disorders related to general medical condition:
contexts).
Above disorders which occur secondary to general
• The symptom in criterion A causes clinically significant
medical conditions come under this category.
• Substance-induced sexual dysfunction: Sexual distress in the individual.
dysfunctions due to substances like nicotine, alcohol • The sexual dysfunction is not better explained by a
dependence or other substances. The drug user loses nonsexual mental disorder or as a consequence of severe
interest or desire to have sex. relationship distress or other significant stressors and is
• Sexual dysfunction not otherwise specified (NOS): not attributable to the effects of a substance/medication
Sexual dysfunctions which have not been discussed above or another medical conditions.
come under this category.
Delayed Ejaculation
DSM-5 Diagnostic Criteria • At least one of the following symptoms must be
experienced on almost all or all (approximately
Erectile Disorder
75–100%) occasions of sexual activity (in identified
• At least one of the following symptoms must be situational contexts or, if generalized, in all contexts) such
experienced on almost all or all (approximately as marked delay in ejaculation, marked infrequency or
75–100%) occasions of sexual activity (in identified absence of ejaculation.
situational contexts or, if generalized, in all contexts) • Symptation of 6 months.
such as marked difficulty in obtaining an erection • Symptoms cause clinically significant distress in
during sexual activity, marked difficulty in maintaining individual.
an erection until the completion of sexual activity and • Sexual dysfunction is not better explained by a
marked decrease in erectile rigidity. nonsexual mental disorder or as a consequence of severe
• Symptoms are present for minimum duration of 6 months.
relationship distress or other significant stressors and is
• Symptoms cause clinically significant distress in
not attributable to the effects of a substance/medication
individual.
or another medical condition.
• Sexual dysfunction is not better explained by a
• Specify whether
nonsexual mental disorder or as a consequence of severe
„ Lifelong or acquired
relationship distress or other significant stressors and is
„ Generalized or situational
not attributable to the effects of a substance/medication
„ Mild or moderate or severe
or another medical condition.
• Specify whether Female Sexual Interest /Arousal Disorder
„ Lifelong or acquired
• Lack of, or significantly reduced, sexual interest/arousal,
„ Generalized or situational
as manifested by at least three of the following:
„ Mild or moderate or severe
i. Absent/reduced interest in sexual activity.
Premature or Early Ejaculation ii. Absent/reduced sexual/erotic thoughts or fantasies.
iii. No/reduced initiation of sexual activity, and typically
• A persistent or recurrent pattern of ejaculation occurring
during partnered sexual activity within approximately unreceptive to a partner’s attempts to initiate.
1 minute following vaginal penetration and before the iv. Absent/reduced sexual excitement/pleasure during
individual wishes it. sexual activity in almost all or all (approximately
75–100%) sexual encounters (in identified situational
contexts or, if generalized, in all contexts).
NOTE
v. Absent/reduced sexual interest/arousal in response
Although the diagnosis of premature (early) ejaculation may be to any internal or external sexual/erotic cues
applied to individuals engaged in nonvaginal sexual activities, (e.g., written, verbal, visual).
specific duration criteria have not been established for these
vi. Absent/reduced genital or nongenital sensations
activities.
during sexual activity in almost all or all (approximately
• The symptom in criterion A must have been present for at 75–100%) sexual encounters (in identified situational
least 6 months and must be experienced on almost all or contexts or, if generalized, in all contexts).
CHAPTER 10 Nursing Management of Patients with Sexual, Personality... 291

• Symptoms present with the minimum duration of Flowchart 10.3: Concept of personality disorders
6 months.
• Symptoms cause clinically significant distress in individual.
• Sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of severe
relationship distress (e.g., partner violence) or other
significant stressors and is not attributable to the effects
of a substance/medication or another medical condition.

Gender Dysphoria in Adults/Adolescents

• Marked incongruence between one’s experienced/
expressed gender and assigned gender, of at least 6 months
duration, as manifested by at least two of the following:
i. A marked incongruence between one’s experienced/
expressed gender and primary and/or secondary
sex characteristics (or in young adolescents, the
anticipated secondary sex characteristics).
ii. A strong desire to get rid of one’s primary and/or
secondary sex characteristics because of a marked
incongruence with one’s experienced/expressed
gender (or in young adolescents, a desire to prevent NOTE
the development of the anticipated secondary sex Personality is a combination of traits. Abnormal traits do not
characteristics). denote abnormal personality until an abnormal personality trait
iii. A strong desire for the primary and/or secondary sex reaches a particular threshold with certain number, severity and
characteristics of the other gender. impairment to label it as ‘personality disorder.’
iv. A strong desire to be of the other gender (or some
alternative gender different from one’s assigned
gender). DEFINITION OF PERSONALITY DISORDER
v. A strong desire to be treated as the other gender (or
• Personality disorder is defined as, “Characteristic and
some alternative gender different from one’s assigned
gender). enduring pattern of inner experience or behavior as a
vi. A strong conviction that one has the typical feelings whole marked deviation from level of expectation and
and reactions of the other gender (or some alternative acceptable range of individual’s culture.”
gender different from one’s assigned gender.  —International Classification of Diseases (ICD-10)
• The condition is associated with clinically significant • Personality disorder is defined as, “Enduring pattern of
distress or impairment in social, occupational, or other inner experience and behavior has marked deviation
important areas of functioning. from expectation individual’s culture.”
 —Diagnostic Static Manual (DSM-5)
PERSONALITY DISORDERS
INCIDENCE AND PREVALENCE
INTRODUCTION
Around 5–10% of general population suffers from personality
Personality is defined as enduring qualities of a person in disorders. Borderline personality disorder is more common in
various circumstances. These qualities develop into personality psychiatric setups. Antisocial personality is common among
traits (characters). When these traits become abnormal, prison inmates. Mixed personality disorder is more common
inflexible and maladaptive, they cause significant personal than single type. Common personality disorders in females
distress and cause social/occupational impairment which may and males separately and common in both genders are shown
lead to personality disorders as shown in Flowchart 10.3. in Figure 10.2.
292 Textbook of Psychiatric Nursing for BSc Nursing Students

DSM-5 Classification of Personality Disorders

In addition to the above 3 clusters, 25 maladaptive traits are
divided into five domains:
1. Negative affectivity
2. Detachment Reliable to identify the
3. Antagonism functional impairment in
4. Disinhibition Vs. personality disorders
Compulsivity
Histrionic Schizoid Obsessive-compulsive 5. Psychoticism
Dependant Paranoid schizotypal Classification based on maturity is given in Table 10.5.
Borderline Antisocial Comparison of ICD-10 and DSM-IV/5 Classification of Personality
Avoidant disorders has been given in Table 10.6.
Narcissistic
ICD-11 and DSM-5 Classification of personality disorders
Figure 10.2: Common personality disorders in females, ICD-11 DSM-5
male and both gender 6D10 — Personality disorders
6D10.0 — Personality disorders, mild
SIGNIFICANT FEATURES OF PERSONALITY 6D10.1 — Personality disorders, moderate
DISORDERS
6D10.2 — Personality disorders, severe
Maladaptive, persistent and inflexible patterns of: 6D10.Z — Personality disorders, unspecified
• Thinking (about self and others) severity
• Feeling (intensity/range of emotions) 6D11 — Predominant personality traits
• Behavior 6D11.0 — Negative affectivity in personality
• Interpersonal relationship disorder
6D11.1 — Detachment in personality disorder
They cause significant personal distress and impairment
6D11.2 — Dissociality in personality disorder
in interpersonal or self-functioning. Onset is stable since
childhood or adolescence. They do not meet criteria to 6D11.3 — Disinhibition in personality disorder
diagnose other psychiatric disorder or organic disorder. 6D11.4 — Anankastic personality disorder
6D11.5 — Borderline pattern personality
ETIOLOGY OF PERSONALITY DISORDERS disorder
Cluster A personality disorders
Increased levels of testosterone, 17-estradiol and estrone — 301.0 Paranoid personality disorder
and increased level of dopamine and serotonin will cause
— 301.20 Schizoid personality disorder
aggression, impulsivity and change in electrical conductance
— 301.22 Schizotypal personality disorder
on EEG seen in antisocial or borderline personality disorder.
Cluster B personality disorders
CLASSIFICATION OF PERSONALITY DISORDERS — 301.7 Antisocial personality disorder
— 301.83 Borderline personality disorder
ICD-11 Classification of Personality Disorders — 301.50 Histrionic personality disorder
It focuses on core personality dysfunction, while allowing the — 301.81 Narcissistic personality disorder
classification on three levels as mild, moderate and severe Cluster C personality disorders
personality disorders.
Prominent personality traits or patterns: Trait domain applied — 301.4 Obsessive-compulsive personality
to the personality is most prominent which contributes to disorder
personality disturbance. Traits are continuous and represent a — 301.82 Avoidant personality disorder
set of dimensions which correspond to underlying structure of
— 301.6 Dependent personality disorder
personality. There may be many trait domain qualifiers that are
applied to describe personality functioning. Persons with more Other personality disorders
severe personality disturbance tend to have a greater number of 310.1 Personality changes due to another
prominent trait domains. medical condition
Contd… 301.89 Other specified personality disorder
CHAPTER 10 Nursing Management of Patients with Sexual, Personality... 293

Table 10.5: Classification of personality disorders based on maturity

Immature personality disorder Mature personality disorder

• Antisocial/Dissocial • Anankastic/Obsessive compulsive
• Borderline/Emotionally unstable • Anxious/Avoidant
• Histrionic • Paranoid
• Dependent • Schizoid
• Narcissistic • Schizotypal

Table 10.6: Comparison of ICD-11 and DSM-5 classification of personality disorders

Types of personality disorders DSM-5 (Cluster) ICD-11

Paranoid personality disorder A —
Schizoid personality disorder A —
Schizotypal personality disorder A —
Antisocial personality disorder B —
Borderline personality disorder B Yes (borderline pattern personality disorder)
Histrionic personality disorder B —
Narcissistic personality disorder B Yes (dissociality in personality disorder)
Avoidant personality disorder C Yes (detachment in personality disorder)
Dependent personality disorder C —
Obsessive -compulsive personality disorder. C Yes (anankastic personality disorder)

PROTECTIVE AND RISK FACTORS OF PERSONALITY DISORDERS

Protective and risk factors of personality disorders are summarized in Table 10.7.
Table 10.7: Protective and risk factors of personality disorders

Risk factors of personality disorders Protective factors of personality disorder

• School drop outs • Establishing a strong trusting relationship with parents
• Unemployment • Married
• Divorced/separated • Employed
• Unmarried • Good interpersonal relationship
• History of child abuse • Individuals who are extrovert
• Neglect from parents

Types of personality disorders have been given in Table 10.8.

Table 10.8: Types of personality disorders

Types of Psychodynamic factor Signs and symptoms/criteria for diagnosis Differential

personality (defense mechanism) diagnosis/comorbid
disorders illness
Paranoid personality Projection • Suspiciousness/mistrust • Paranoid
disorder • Excess sensitive to criticism schizophrenia
• Doubts the loyalty of friends • Persistent
• Suspicious of sexual partner fidelity delusional disorder
• Interpret remarks as threatening
• Hold ‘grudges’ (Unable to forget/forgive)
• Become angry and threaten when he/she perceives as
being attacked by someone
Contd…
294 Textbook of Psychiatric Nursing for BSc Nursing Students

Types of Psychodynamic factor Signs and symptoms/criteria for diagnosis Differential

personality (defense mechanism) diagnosis/comorbid
disorders illness
Schizoid personality Emotional detachment • Emotional coldness • Simple
disorder (to relieve from • Blunted or flat affect schizophrenia
emotional pain) • Lack of humor sense • Negative symptoms
• Prefer solitary activities of schizophrenia
• Introspective • Depression
• Indifference with praise or criticism • Autism spectrum
• Inability to express both positive and negative feelings disorder
• Lack of desire to enjoy relationships
• Aloof (loneliness)
• Prefer to have social distance even with own family
members
Schizotypal Fantasy (escape from • Odd, eccentric behavior • Schizophrenia
personality disorder reality) • Social withdrawal • Unspecified
• No close relation with others psychosis
• Inappropriate and constricted affect
• Magical thinking
• Paranoid ideation
• Ruminations with violence and sexual themes
• Vague and circumstantial speech
• Depersonalization
• Derealization
• Illusions
Antisocial personality • Denial • Violates rules and regulations/social norms • Schizophrenia
disorder • Acting out • Fails to maintain relationship • Unspecified
• Externalization • Impulsive action psychosis
• Low frustration tolerance
• Absence of guilt
• Manipulation in activities to get self-gratification
• Unconcern with safety of others
• Not able to learn from punishment
• Blame others for one’s own antisocial activities
• Deceitfulness: Frequent lying or cheating others to gain
profit as well as pleasure
Borderline • Projection • Impulsivity • Acute transient
personality disorder • Projective • Chronic feel of emptiness Psychosis
or Borderline pattern identification • Unstable affect (intense anxiety/irritable within few • Adult attention
personality disorder • Dissociation hours) deficit hyperactive
• Splitting • Unstable relationships disorder
• Unstable self-image • Mixed state bipolar
• Self-mutilation (threats of self-harm) disorder
• Unable to control anger • Cyclothymia
• Transient dissociative symptoms during stress • Rapid cycling
• Paranoid ideas bipolar disorder
• Tendency to act out impulsivity without considering the
consequences (e.g., driving very fast, binge eating)
Histrionic personality • Regression • Self-dramatization • Hypomania
disorder • Somatization • Attention-seeking behavior • Somatization
• Labile affect disorder
• Exaggerated way of expressing emotions • Narcissistic
• More concern in regard to physical attractiveness personality
• Emotional blackmail/suicide attempts disorder
• Crave for excitement
• Impulsive behavior
• Uncomfortable with situations when other persons are
around/being a guest
• Easily influenced by others
Contd…
CHAPTER 10 Nursing Management of Patients with Sexual, Personality... 295

Types of Psychodynamic factor Signs and symptoms/criteria for diagnosis Differential

personality (defense mechanism) diagnosis/comorbid
disorders illness
Narcissistic • Reaction formation • Attention seeking • Hypomania
personality disorder • Self-importance • Arrogance • Histrionic
or Dissociality in • Denial • Strong belief that, he/she is special personality
Personality disorder • Omnipotence • Feel to have relation with high status people disorder
• Fragile self-esteem • Envious of others but, verbalizes that others are envious
to self
• No empathy
• Difficulty to face criticism of others
• Preoccupied with fantasy world of success, beauty and
power
Avoidant personality • Fixation at oral stage • Avoid activities which need to done in interpersonal • Social phobia
disorder or • Parenting style relationship • Obsessive
Detachment in (over-rigid/over- • Continuous tension and apprehension compulsive
personality disorder protective) • Fear of criticism/rejection disorder
• Childhood • Feel inferior than others • Somatoform
attachment • Not willing to get along with others disorder
problems • Preoccupied with criticism/rejection by others • Schizophrenia
• Anxiety
• Depression
• Schizoid
personality
disorder
Dependent • Regression • Depend on others more for psychological support • Dysthymia
personality disorder • Idealization of others • Inability to take decision • Depressive
• Devaluation of self • Allow others to take important decisions in life disorder
• Subordinating the one’s own needs than to the others
needs
• Difficult to express unwillingness due to fear
• Not willing to make reasonable demands to others
• Low self esteem
• Feel helpless by being alone
• Lack of self-confidence
Obsessive-compulsive • Fixation at oral stage • Preoccupied with perfectionism Obsessive compulsive
personality disorder • Reaction formation • Thinking of orderliness always disorder
or Anankastic • Undoing • Excessive doubtfulness
personality disorder • Rigid and stubborn
• Preoccupied with rules, list, details, schedules, etc. which
interfere with the daily routines
• Tendency to hoard/unable to throw the useless object
even though he/she doesn’t have any sentimental value

Miscellaneous Personality Disorder as per Common manifestations include distractibility, impulsivity,

ICD-11 recklessness irresponsibility and lack of planning.
Comparative diagnostic criteria of mild, moderate and Negative Affectivity in Personality Disorder or
severe personality disorders as per ICD-11 are presented in Personality Difficulty
Table 10.9. Core feature of this trait domain is the tendency to
experience negative emotions. Common manifestations
Disinhibition in Personality Disorder or Personality include experiencing a broad range of negative emotions
Difficulty with a frequency and intensity out of proportion to the
Core feature of this trait domain is the tendency to act situation, negativistic attitude, emotional lability and poor
rashly based on immediate external or internal stimuli emotion regulation, low self-esteem or self-confidence and
without consideration of the possible negative consequences. mistrustfulness.
296 Textbook of Psychiatric Nursing for BSc Nursing Students

Table: 10.9: Comparative diagnostic criteria of mild, moderate and severe personality disorders as per ICD-11

Diagnostic criteria as per ICD-11 Mild personality Moderate personality Severe personality disorder
disorder disorder
Diagnostic requirements of personality Yes Yes Yes
disorder are met
Disturbances which affect personality In some areas In multiple areas Severely affected in the
functioning functioning of the self
Problems in the Interpersonal relationships Present Marked problems in most Seriously affected
cases
Specific manifestations of personality Mild degree Moderate degree Severe degree
disturbances
Substantial harm to self or others Absent Sometimes Often
Personal, family, social, educational, Mild impairment Marked impairment Severe impairment
occupational or other important areas of
functioning

ANTISOCIAL PERSONALITY DISORDER Flowchart 10.4: Concept of conduct disorder develops into
antisocial personality disorder
Patients with antisocial personality disorder mainly violate
the social norms and lead to criminal activity. Concept of
conduct disorder develops into antisocial personality disorder
as shown in Flowchart 10.4. Previously, antisocial personality
disorder had four clinical types such as aggressive psychopath,
inadequate psychopath, creative psychopath and sexual
psychopath.
According to Theodore Millon, five subtypes of antisocial
behavior:
1. Nomadic: Schizoid and avoidant
2. Malevolent: Sadistic and paranoid
3. Covetous: Pure form of antisocial behavior
4. Risk taking: Histrionic • Psychodynamic factors: Use of defense mechanism such
5. Reputation defending: Narcissistic as denial, acting out and externalization.

NOTE DSM-5 Criteria for Antisocial Personality

Disorder
All of the above-mentioned other terms of antisocial personality
disorders have been used previously, but are not used these • A pervasive pattern of disregard for violation of the rights
days. The other terms of antisocial personality disorder include of others, occurring since age 15 years, as indicated by
psychopathic personality, sociopathic personality, semantic
three (or more) of the following:
disorder, dangerous and severe personality.
i. Failure to conform to social norms with respect
to lawful behaviors, as indicated by repeatedly
Etiology performing acts that are grounds for arrest.
• Psychological factors: Family having a criminal offender, ii. Deceitfulness, as indicated by repeated lying, use
single parenthood, alcoholism, family disputes, lack of of aliases, or conning others for personal profit or
supervision, and history of child abuse. pleasure.
• Biological factors: Presence of monoamine oxidase A iii. Impulsivity or failure to plan ahead.
(MAO-A) gene, smoking during pregnancy, decreased iv. Irritability and aggressiveness, as indicated by
function of right brain hemisphere and decreased resting repeated physical fights or assaults.
heart rate. v. Reckless disregard for safety of self or others.
CHAPTER 10 Nursing Management of Patients with Sexual, Personality... 297

vi. Consistent irresponsibility, as indicated by repeated was previously known as ambulatory schizophrenia and
failure to sustain consistent work behavior or honor pseudoneurotic schizophrenia was previously considered
financial obligations. subtype of schizophrenia.
vii. Lack of remorse, as indicated by being indifferent to „ Ambulatory schizophrenia is a mild level of
or rationalizing having hurt, mistreated, or stolen schizophrenia in which the individual can be managed
from another. well in community without hospitalization.
• The individual is at least 18-year-old. „ Pseudoneurotic schizophrenia is presence of two
• There is evidence of conduct disorder with onset before or more psychiatric illnesses such as phobia, anxiety,
age 15 years. hysteria and obsessive-compulsive neurosis.
• The occurrence of antisocial behavior is not exclusively
during the course of schizophrenia or bipolar disorder. Etiology
• Psychological factors: History of child abuse,
Treatment for Antisocial Personality Disorder neglect during childhood, family disputes and lack of
Individual psychotherapy, group psychotherapy, psychoanalysis supervision.
and use of drugs: Antipsychotics like pericyazine are used for • Biological factors: Hypothalamic-pituitary-adrenal
this purpose. axis dysfunction and serotonin dysfunction lead to
impulsivity. Other reasons may be the presence of
Nursing Interventions for Antisocial Personality serotonin transporter (5-HTT), tryptophan hydroxylase
Disorder (TPH) gene, dopamine and noradrenaline dysfunction.
• Psychodynamic factors: Defense mechanism such as—
Nurse has to accept the patient as he/she is. Nurse can
projection, projective identification, dissociation, and
maintain calm attitude with patient and convey the message
splitting
clearly to the patient that he/she is acceptable whereas his
abnormal behavior is not acceptable. Nurse has to remove the ICD-11 Diagnostic Criteria for Borderline Pattern
sharp objects which is present near the patient. Nurse has to Personality Disorder
set limits with patient when the behavior is found to be out of
boundaries. Nurse should provide physical restraint, if patient Pervasive pattern of instability of interpersonal relationships,
harms self or others. Nurse can explore the numerous ways of self-image, and affects, and marked impulsivity, as indicated by
expressing his/her negative emotions in a constructive way many of the following:
and encourage the patient to ventilate hostile feelings. Nurse • Frantic efforts to avoid real or imagined abandonment.
should show helping attitude to patient and also a positive • A pattern of unstable and intense interpersonal
reinforcement. Nurse can help patient to gain insight into one’s relationships.
behavior and administer sedatives as prescribed, if necessary. • Identity disturbance, manifested in markedly and
persistently unstable self-image or sense of self.
BORDERLINE PERSONALITY DISORDER • A tendency to act rashly in states of high negative affect,
leading to potentially self-damaging behaviors.
Tendency to act out of impulsivity without considering • Recurrent episodes of self-harm; Emotional instability
the consequences along with unstable effects. Borderline due to marked reactivity of mood; Chronic feelings of
personality disorder is also called borderline pattern emptiness.
personality disorder as per ICD-11 and emotionally unstable • Inappropriate intense anger or difficulty controlling anger
personality disorder as per ICD-10. Emotionally unstable • Transient dissociative symptoms or psychotic-like
personality disorder has two subtypes such as: features in situations of high affective arousal.
1. Impulsive type is characterized by unstable emotions and
unable to control impulses. Anger outburst and violent DSM-5 Diagnostic Criteria for Borderline
behavior in response to criticism are common. Personality Disorder
2. Borderline type is characterized by unstable emotions A pervasive pattern of instability of interpersonal relationships,
along with disturbed self-image. Feeling of emptiness and self-image, and affects, and marked impulsivity, beginning
lack of stability in relationship cause emotional crisis and by early adulthood and present in a variety of contexts, as
further lead to suicidal threats. Borderline personality indicated by five (or more) of the following:
298 Textbook of Psychiatric Nursing for BSc Nursing Students

1. Frantic efforts to avoid real or imagined abandonment. GERIATRIC CONSIDERATIONS

2. A pattern of unstable and intense interpersonal
relationships characterized by alternating between Personality disorder is not going to be the first diagnosis in old
extremes of idealization and devaluation. age period. It will be present from young adulthood onwards.
3. Identity disturbance: Markedly and persistently unstable Individuals with personality disorders will experience more
self-image or sense of self. difficulties in late period of life. Elders with personality
4. Impulsivity in at least two areas that are potentially self- disorders are unable to take decisions in regard to their health,
damaging (e.g., spending, sex, substance abuse, reckless finance and their living pattern. They are found dissatisfied
driving, binge eating). with life, difficult to maintain relationships, alienation from
5. Recurrent suicidal behavior, gestures, or threats, or self- friends, relatives and care givers. Constant support and holistic
mutilating behavior. care will be required for taking care of the elders.
6. Affective instability due to a marked reactivity of mood
Follow-up, Home Care and Rehabilitation
(e.g., intense episodic dysphoria, irritability, or anxiety
usually lasting a few hours and only rarely more than a In general, prognosis of these patients is poor so lifelong care
few days). is needed. Family members have to be taught that the patient
7. Chronic feelings of emptiness. might self-mutilate or attempt suicide or injury to self/others.
8. Inappropriate, intense anger or difficulty controlling Limit setting has to be done with the patient in order to control
anger (e.g., frequent displays of temper, constant anger, the manipulative behavior. Patient can also verbalize the
recurrent physical fights). situation which provokes anger, instead of being aggressive.
9. Transient, stress-related paranoid ideation or severe Nurse should reinforce the realistic perceptions/appraisal
dissociative symptom. every time. Encourage the patient to perform simple decision
making. Nurse should identify the stressors and manage them
Treatment effectively. Drug adherence plays a vital role to control the
symptoms.
• Dialectical behavior therapy (DBT)
• Psychodynamic psychotherapy
EATING DISORDERS
• Transference-focused psychotherapy (TFP)
• Mentalization-based therapy (MTP) Eating disorders are characterized by severe form of
• Supportive psychotherapy disturbances in eating pattern/behavior leading to life
• Emotion regulation training threatening conditions.
• Drugs—Antidepressants, antipsychotics, carbamazepine
ETIOLOGY OF EATING DISORDER
and lithium.
• Electroconvulsive therapy (ECT)—Occasionally if needed. • Neurobiology: Decreased endogenous opioid, hypo-
thalamus dysregulation (alters gonad or corticoid
Nursing Interventions for Borderline Personality production leads to amenorrhea), biochemical tests
Disorder (increased cortisol level), Positron Emission Tomography
Nurse has to observe the patient frequently and not to be (PET) shows a decreased metabolism of caudate
suspicious of the patient. Nurse has to establish a no-suicidal nucleus, altered function of dopamine, serotonin and
contract with the patient to prevent self-mutilation. Nurse norepinephrine.
can assign one separate staff to observe the patient in case of • Psychoanalytical: According to Mahler, restriction of
emergency. Nurse has to encourage the patient to ventilate the separation-individuation and autonomy (independence)
stressful feelings and set limits with certain behavior which is stage in the theory of child development may lead to
unacceptable or out of boundaries. Nurse has to be conscious anorexia nervosa.
that patient should not develop dependence on staff nurse and • Social factors: Influence of mass media or individuals
so assigning the different nurse on shift basis is important. with certain occupation might give importance to their
Nurse can encourage the patient to explore the situation weight, e.g., dancers, beauty contestants.
causing fear and give positive reinforcement to the acceptable • Psychological factors: Low self-esteem, perfectionism
behavior. and family disputes.
CHAPTER 10 Nursing Management of Patients with Sexual, Personality... 299

ICD-11 and DSM-5 Classification of Eating Disorders

ICD-11 DSM-5 Classification of eating disorders
6B80 307.1 Anorexia nervosa
6B80.10 — Restricting type
6B80.11 Binge eating/Purging type
6B81 307.51 Bulimia nervosa
6B82 307.51 Binge eating disorder
6B83 307.59 Avoidant/Restrictive food intake disorder
6B84 307.52 Pica
6B85 307.53 Rumination disorder
6B8Y 307.59 Other specified feeding or eating disorder
6B8Z 307.50 Unspecified feeding or eating disorder

DSM-5 Diagnostic Criteria for Eating Disorders

Anorexia nervosa
• Restriction of energy intake relative to requirements, leads to the significantly low body weight in context of age, gender, development
and physical health.
• Intense fear of gaining weight, even though at a significantly low weight.
• Persistent lack of recognition of the seriousness of the current low body weight.
Bulimia nervosa
• Binge eating within short duration of time
• No control over eating
• Immediate compensatory behavior is present (e.g., inducted vomiting, use of diuretics, etc.)
• Self-evaluation of raised body weight or appearance.
• Disturbances do not occur during the episode of anorexia nervosa.
Binge eating
• Binge eating episodes are associated with three or more of the following features such as:
i. Eating much more rapidly than normal.
ii. Eating until feeling uncomfortably full.
iii. Eating large amounts of food when not feeling physically hungry.
iv. Eating alone because of feeling embarrassed by how much one is eating.
v. Feeling disgusted with oneself, depressed, or very guilty afterward.
vi. Increased food intake within short period of time.
• Unable to control the behavior.
• Marked distress in regard to the Binge eating.
• Binge eating happens at least once a week for 3 months.
• Will not use any compensatory behavior (purging/nonpurging).
• Does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.
Avoidant-restrictive food intake disorder
• Insufficient quantity of food intake to meet the required energy or nutritional requirements.
• Pattern of restricted eating has caused significant weight loss that leads to the dependence on oral nutritional supplements or tube
feeding causing the significant functional impairment.
• Pattern of eating behavior does not reflect concerns about body weight or shape.
Restricted food intake is not better accounted for lack of food availability, the effects of medication or substance or another health
condition.
Pica
• Regular consumption of non-nutritive non-food objects such as clay, soil, chalk, plaster, plastic, metal and paper or raw food ingredients
such as large quantities of salt or cornflour.
• Applicable to the individual who has reached a developmental age approximately 2 years (able to distinguish between edible and
non-edible substances).
• Behavior causes damage to health and impairment in functioning.
Contd…
300 Textbook of Psychiatric Nursing for BSc Nursing Students

Rumination-regurgitation disorder
• Intentional and repeated bringing up of previously swallowed food back to mouth (i.e., regurgitation), which may be re-chewed and
re-swallowed (i.e., rumination), or may be deliberately spat out (but not as in vomiting).
• Regurgitation behavior is frequent and sustained for several weeks.
• Regurgitation behavior is not fully accounted for by another medical conditions which cause regurgitation.
• Applicable to the individual who reached the developmental age of at least 2 years.

Common Comorbid conditions with eating disorder: Table 10.11: Complications of eating disorders
• Affective disorders: Depression and dysthymia.
Aspects Complications of eating disorders
• Personality disorder: Borderline personality disorder
and dependent personality disorder. Cardiovascular Bradycardia
Myocarditis
• Substance abuse: Alcohol, nicotine, cocaine and other Arrhythmias Abuse of Ipecac Syrup
substances. Heart failure
• Neurosis: Generalized anxiety disorder, panic disorder Hypotension
and obsessive-compulsive disorder. Endocrine Amenorrhea
Imbalance of:
COMPARISON OF ANOREXIA NERVOSA AND • Luteinizing hormone (LH)
BULIMIA NERVOSA • Follicle-Stimulating Hormone (FSH)
• Cortisol
Comparison of anorexia nervosa and bulimia nervosa is given • Estrogen/Testosterone
• Thyroxine and Tri-iodothyronine
in Table 10.10. Irregular menses
Table 10.10: Comparison of anorexia nervosa and bulimia nervosa Hypoglycemia

Aspects Anorexia nervosa Bulimia nervosa Fluids and Metabolic alkalosis (due to vomiting)
electrolytes Metabolic acidosis (due to diarrhea)
Age of onset 14–16 years 18–24 years
Hypokalemia
Lifetime 1–3% 0.5–1% Hypochloremia
Purging/vomiting
prevalence Hyponatremia
Gender Female Dehydration
Main symptoms Fear of being obese Gastrointestinal Enlargement of parotid gland
Weight loss 85% of expected Normal or decreased Severe abdominal pain Purging/
weight Esophagitis vomiting
Raised liver function test
Complications Starvation, Dental/Enamel
Hypotension, erosion, dehydration, Fungal infection of rectum
Irritable bowel syndrome Use of
Hypothermia and hypokalemia,
Constipation enema/
shock esophageal tear
Rectal prolapse/abscess/ laxatives
Post binge Absent Present bleeding
anguish
Hematology • Mild anemia
Awareness of Absent Present • Leukopenia
illness
Dental Dental and enamel erosion (due to vomiting)
Types • Restricted type • Purging type
(Not eating food) ▪ Direct—vomiting Renal Renal failure
• Binge eating/ ▪ Indirect—use Musculoskeletal • Muscle wasting
Purging type of laxatives or • Osteoporosis
enema
• Nonpurging type Psychological • Preoccupied with thoughts of food
(starvation and • Symptoms of depression
exercise) • Restricted emotional expression
• Fear of weight gain

COMPLICATIONS OF EATING DISORDERS Miscellaneous • Lethargy

• Lanugo
The complications of eating disorders have been given in • Body image disturbances
• Cold intolerance
Table 10.11.
CHAPTER 10 Nursing Management of Patients with Sexual, Personality... 301

CATEGORIES OF EATING DISORDERS • Anxiety related to impaired coping skills as evidenced by

anxious facial expression.
• Anorexia nervosa • Activity intolerance related to poor food intake.
„ Restricting type: Weight loss by excess starvation or • Low self-esteem related to distorted body image.
rigid exercise. • Diarrhea related to laxative use.
„ Binge eating/purging type: Weight loss by binge • Constipation related to reduced fluid intake.
eating and purging (use of laxatives, diuretics and • Fatigue related to poor intake of food.
self-vomiting) in this episode.
• Bulimia nervosa SIGNS AND SYMPTOMS OF EATING DISORDERS
REVEALED DURING PHYSICAL ASSESSMENT
„ Purging type: Induce vomiting by self or misuse of
enemas, diuretics or laxatives. Enlarged parotid gland, dental and enamel erosion (due to
„ Nonpurging type: Compensatory behaviors such as vomiting), muscle wasting, constipation, anemia, severe
starvation/fasting or excess exercise but do not induce abdominal pain, lethargy/fatigue and Russell’s sign (Callus
vomiting by self or misuse of enemas, diuretics or Knuckles due to self-induced vomiting are seen in eating
laxatives. disorders) (Figure 10.3).

ASSESSMENT OF EATING DISORDERS TREATMENT OF EATING DISORDERS

• Questionnaire Treatment of Bulimia Nervosa
„ Body Image Assessment (BIA)
• Psychoeducation: Focus on normal eating patterns:
„ Eating Attitude Test (EAT)
„ Self-monitoring technique: Maintaining food diary
„ Private Body Talk Questionnaire (PBTQ)
which accounts daily food intake/binging and self-
„ Eating Habits Questionnaire (EHQ)
vomiting or frequent usage of laxatives.
„ Body Exposure in Sexual Activity Questionnaire
„ Nutritional counseling: Balanced diet, no binge
(BESAQ)
eating, follow regular meal timing, etc.
„ Body Image Automatic Thoughts Questionnaire
„ Cognitive behavior therapy: Negative cognition
(BIATQ)
about the food needs to be changed into right thoughts
„ Situational Inventory of Body Image Dysphoria
and make the patient to perform correct action.
(SIBID)
• Medications: Antidepressants such as fluoxetine,
„ Bulimic Inventory Test, Edinburgh (BITE)
desipramine, Bupropion, imipramine, trazodone and
„ Appearance Schemas Inventory (ASI)
• Waist to hip ratio
• Body Mass index or Quetelet’s index = Weight (kg)/
Height (m2)
• Ratio of skin fold
„ Trunk compared with extremities
„ Upper arm compared with upper trunk
• To assess body fat and distribution—USG, MRI, CT
scan, body electrical conductivity and dual photon
absorptiometry can be used.

NURSING DIAGNOSIS

• Impaired nutrition less than body requirement related to

not eating food.
• Impaired nutrition more than body requirement related
to improper eating pattern.
• Fluid volume deficit related to compensatory behavior of
eating disorder. Figure 10.3: Signs and symptoms of eating disorders revealed
• Body image disturbances related to poor ego development. during physical assessment
302 Textbook of Psychiatric Nursing for BSc Nursing Students

Monoamine oxidase inhibitors (MAOIs) are used as • Urophagia—Eating urine

medicines. Other medications such as phenytoin (if EEG • Pagophagia—Eating ice
abnormalities present) and lithium are also useful.
• Nursing interventions: Maintain intake output chart. Epidemiology
Monitor the weight and ensure the normal weight. • Common in both genders, 15% chances in case of mental
Encourage the patient to say about the feelings of fear and retardation.
anxiety. Supervise the eating pattern, it should be at least • Comorbid illnesses: Schizophrenia, anorexia nervosa,
3000 calories per day. Obtain the goal to gain 0.5–1 kg bulimia nervosa and autism.
per week. Monitor serum electrolyte level and make the
restroom nonaccessible immediately after taking food to Differential Diagnosis
prevent vomiting. Zinc and iron deficiency.
• Miscellaneous: Relaxation therapy, skills training, stress
management and problem solving measures.
Treatment
Positive and negative reinforcement.
Treatment of Anorexia Nervosa
Rumination Disorder
• Psychological therapies: Self-monitoring, desensitization,
cognitive restructuring and relaxation therapy. Regurgitation of the eaten substances and chewing out without
• Medications: Antidepressants (tricyclic antidepressants, vomiting is called rumination disorder.
selective serotonin reuptake inhibitors (fluoxetine),
Etiology
atypical antipsychotics (pimozide, chlorpromazine) and
other medications (cyproheptadine, lithium). Link with gastrocolic reflex.
• Nursing interventions: Advise the patient to self-monitor
Differential Diagnosis
the food diary to supervise oneself regularly. Nurse can
teach the family members to promote trust on the patient. Pyloric stenosis (will have projectile vomiting).
Nurse can keep time limit for each meal. Maintain the
Treatment
eating contract with patient to ensure specific amount
of food will be taken on particular timings. Nurse can Child guidance clinics, antipsychotics, ranitidine (H2 receptor
encourage the patient to ventilate the fear/anxiety antagonist) pantoprazole (proton pump inhibitors) and
about the eating patterns. Nurse can assess the suicidal metoclopramide (to empty the stomach contents).
risk. Ryle’s tube feeding can be initiated if the patient
is persistently refusing to take food. Nurse has to teach OBESITY
assertiveness and engage the patient in role play and teach
Excessive accumulation of body fat is termed obesity. In
the patient about community help groups after discharge.
general, obesity is assessed by body mass index or Quetelet’s
index = Weight (kg)/Height (m2) (Table 10.12).
EATING DISORDERS OF INFANCY AND
CHILDHOOD
Etiology of Obesity
PICA • Neurotransmitters: Altered function of dopamine,
Pica is defined as eating the nonedible items. The onset serotonin and norepinephrine.
is beyond the milestone development, eating a nonedible • Hormonal imbalance: Thyroid stimulating hormone,
substance is considered disorder. Duration of symptoms might gonadotropin stimulating hormone and obestatin.
last for few months to years. • Miscellaneous: Strong stimulation of olfactory bulb by
food odors stimulates to eat more.
Types of Pica
• Geophagia—Eating sand, mud and soil Factors Contributing to Obesity
• Xylophagia—Eating wood Family history of obesity, developmental factors such as
• Hyalophagia—Eating glasses increased number of adipocytes with their size, abnormal
• Tricophagia—Eating hair fat distribution and decreased leptin, decreased physical
• Coprophagia—Eating feces exercise, ventromedial hypothalamus damage, mood
CHAPTER 10 Nursing Management of Patients with Sexual, Personality... 303

disorders (atypical depression, seasonal affective disorder), ▪ F65.2 Exhibitionism

disease such as Cushing disease, myxedema and psychotropic ▪ F65.3 Voyeurism
agents (antipsychotics, antidepressants, mood stabilizers and ▪ F65.4 Pedophilia
steroids). ▪ F65.5 Sadomasochism
▪ F65.6 Multiple disorders of sexual preference
Table 10.12: Categories of weight in body mass index ▪ F65.8 Other disorders of sexual preference
▪ F65.9 Disorder of sexual preference, unspecified
Categories of weight in body mass index kg/m2
• F66 Psychological and behavioral disorders associated with
Normal 18.5–25 sexual development and orientation
Overweight 25–30 ▪ F66.0 Sexual maturation disorder
▪ F66.1 Egodystonic sexual orientation
Obesity Class I (moderate) 30–35
▪ F66.2 Sexual relationship disorder
Obesity Class II (severe) 35–40 ▪ F66.8 Other psychosexual development disorders
Obesity Class III (very severe) 40–45 ▪ F66.9 Psychosexual development disorder, unspecified
Obesity Class IV (morbid) 45–50

Differential Diagnosis EXTRA EDGE

• Night eating syndrome: Overeating at night time with ICD-10 Classification of Personality Disorders
sleep problems. • F60-F69 Disorders of adult personality and behavior
• Pickwickian syndrome or obesity hypoventilation • F60 Specific personality disorders
syndrome: Individual with obesity fails to breathe deeply ▪ F60.0 Paranoid personality disorder
which results in decreased oxygen supply in blood. ▪ F60.1 Schizoid personality disorder
• Binge eating syndrome: Recurrent eating of large amount ▪ F60.2 Dissocial personality disorder
of food. ▪ F60.3 Emotionally unstable personality disorder
▪ F60.4 Histrionic personality disorder
• Dysmorphophobia: Excess dislike of one’s own body. ▪ F60.5 Anankastic personality disorder
▪ F60.6 Anxious personality disorder
Management of Obesity ▪ F60.7 Dependent personality disorder
▪ F60.8 Other specific personality disorders
• Lifestyle modification: Regular exercises, balanced and ▪ F60.9 Personality disorder, unspecified
nutritious diet, yoga, meditation, drink more water, quit
• F61 Mixed and other personality disorders
alcohol and smoking. ▪ F61.0 Mixed personality disorders
• Psychological: Diet counseling. ▪ F61.1 Troublesome personality changes
• Medical management: Lorcaserin, phentermine • F62 Enduring personality changes, not attributable to brain
(approved by Food and Drug Administration) and damage and disease
sibutramine (regulate the neurotransmitters thereby ▪ F62.0 Enduring personality change after catastrophic
regulate the appetite). experience
▪ F62.1 Enduring personality change after psychiatric
• Surgical management: Bariatric surgery (liposuction,
illness
gastric banding, duodenal-jejunal bypass surgery). ▪ F62.8 Other enduring personality changes
▪ F62.9 Enduring personality change, unspecified
• F68 Other disorders of adult personality and behavior
EXTRA EDGE • F69 Unspecified disorder of adult personality and behavior
ICD-10 Classification of Sexual Disorders
DSM-5 Classification of Personality Disorders
• F64 Gender identity disorders
▪ F64.0 Transsexualism • Cluster A (odd or eccentric disorders): Paranoid personality
▪ F64.1 Dual-role transvestism disorder, schizoid personality disorder and schizotypal
▪ F64.2 Gender identity disorder of childhood personality disorder
▪ F64.8 Other gender identity disorders • Cluster B (dramatic, emotional or erratic disorders): Antisocial
▪ F64.9 Gender identity disorder, unspecified personality disorder, borderline personality disorder, histrionic
personality disorder and narcissistic personality disorder
• F65 Disorders of sexual preference • Cluster C (anxious or fearful disorders): Avoidant personality
▪ F65.0 Fetishism disorder, dependent personality disorder and obsessive-
▪ F65.1 Fetishistic transvestism compulsive personality disorder.

Contd…
304 Textbook of Psychiatric Nursing for BSc Nursing Students

SUMMARY
• Gender identity disorders include transsexualism, dual role transvestism, intersexuality and gender identity disorders of childhood.
• Disorders of sexual preference include exhibitionism, frotteurism, sadism, masochism, sadomasochism, pedophilia, zoophilia (bestiality),
klismaphilia, urophilia, coprophilia, necrophilia, telephone or mail scotologia, fetishism and fetishistic transvestism.
• Disorders of sexual maturity include sex maturation disorder, egodystonic sexual orientation disorder/homosexuality, obligatory
homosexuality, preferred homosexuality, bisexuality, situational homosexuality, latent homosexuality and sex relationship disorder.
• Disorders of sexual dysfunction include sexual aversion disorder, hypoactive sexual desire disorder, excessive sexual desire disorder
(satyriasis in male, nymphomania in female), excitement/sexual arousal disorder (male penile erection disorder, female arousal disorder),
orgasmic disorder (anorgasmia in male, anorgasmia in female) and sexual pain disorder (non-organic vaginismus, dyspareunia), sexual
disorders related to general medical condition, substance-induced sexual dysfunction and sexual dysfunction not otherwise specified
(NOS).
• Personality is defined as enduring qualities of a person in different circumstances. These qualities develop into personality traits
(character). When these traits become abnormal, inflexible or maladaptive, they can cause significant personal distress and cause social/
occupational impairment which leads to personality disorder.
• Cluster A (odd or eccentric disorders) includes paranoid personality disorder, schizoid personality disorder and schizotypal personality
disorder.
• Cluster B (dramatic, emotional or erratic disorders) includes antisocial personality disorder, borderline personality disorder, histrionic
personality disorder and narcissistic personality disorder.
• Cluster C (anxious or fearful disorders) includes avoidant personality disorder, dependent personality disorder and obsessive-compulsive
personality disorder.
• Eating disorders are characterized by severe form of disturbances in eating pattern/behavior leading toward life threatening condition.
• Types of eating disorders include anorexia nervosa, bulimia nervosa, pica, rumination disorder and obesity.

ASSESS YOURSELF

Long Answer Questions Multiple Choice Questions

1. Define personality disorders and explain the etiology, 1. Regurgitation of the eaten substances and chewing
diagnostic criteria and management of antisocial out without vomiting is defined as:
personality disorders. a. Pica b. Rumination disorder
2. Define eating disorders and classify the types and explain c. Anorexia nervosa d. Bulimia nervosa
the etiology, diagnostic criteria and the management of
2. Normal Body Mass Index is ________ kg/m2.
patient with eating disorders.
a. 18.5–25 b. 25–30
Short Answer Questions c. 30–35 d. 35–40

1. Differentiate between anorexia nervosa and bulimia 3. Callus Knuckles due to self-induced vomiting seen in
nervosa. eating disorders is ________.
2. What are clinical manifestations of eating disorders? a. Omega sign b. Russell’s sign
3. Write about nursing management of patient with eating c. Kernig’s sign d. Cullen’s sign
disorders. 4. Post binge eating anguish is ________ in bulimia
nervosa.
Short Notes a. Present
Write short notes on: b. Absent
1. Sexual disorders c. Neither present nor absent
2. Etiology of eating disorders d. None of the above
3. Pica 5. Psychodynamic factor (defense mechanism)
4. Gender identity disorders contributing to paranoid personality disorder is
5. Clusters of personality disorders _________.
6. Borderline personality disorder a. Regression b. Projection
7. Obesity c. Fantasy d. Reaction formation
CHAPTER 10 Nursing Management of Patients with Sexual, Personality... 305

6. Sexual fantasies and desires of sexual activity occur 9. Presence of both anatomical and psychological aspect
in: of other sex is called _______.
a. Appetitive phase b. Excitement phase a. Transsexualism b. Intersexuality
c. Plateau phase d. Resolution phase c. Sadomasochism d. Pedophilia

7. Eating hair means _______. 10. Common comorbid conditions with eating disorder is
__________.
a. Tricophagia b. Urophagia
a. Substance abuse b. Personality disorder
c. Coprophagia d. Trichotillomania
c. Depression d. All of these
8. Wearing the dress of opposite gender for purpose of
sexual excitement means ______. Answer Key
a. Transvestism b. Transsexualism 1. b 2. a 3. b 4. a 5. b
c. Homosexuality d. Heterosexuality 6. a 7. a 8. a 9. b 10. d
Notes
 CHAPTER

Child Psychiatry 11
LEARNING OBJECTIVE

After studying this chapter, the student will be able to gain knowledge regarding the child psychiatry in order to render the nursing care
to children with psychiatric disorders.

CHAPTER OUTLINE
• Introduction • Tic Disorder
• Historical Perspectives/Development in Child Psychiatry • Sibling Rivalry
• Mental Retardation or Intellectual Disability or Intellectual • Enuresis
Developmental Disorder or Mentally Challenged Individuals • Encopresis
• School Refusal or School Phobia
Disorders of Psychological Development
• Sleep Disorders in Children
• Specific Developmental Disorders of Speech and Language
• Miscellaneous Adult Psychiatric Disorders Present in
• Disorders of Language or Specific Language Impairments
Children
• Specific Developmental Disorders of Scholastic Skills
• Feeding Disorder of Infancy and Childhood
• Autism Spectrum Disorder
• Pica
• Conduct Disorder
• Stereotyped Movement Disorders
• Juvenile Delinquency
• Child Abuse or Child Battered Syndrome
• Separation Anxiety Disorder
• Follow-up, Home Care and Rehabilitation for Childhood
• Treatment
Psychiatric Disorders
• Attention Deficit Hyperactivity Disorder

KEY TERMS
Mental retardation or Intellectual disability, Specific developmental disorders of speech/language, Scholastic skills, Motor function,
Mixed specific developmental disorders, Pervasive developmental disorders, Autism spectrum disorders, Hyperkinetic disorders,
Conduct disorders, Juvenile delinquency, Separation anxiety disorder, Phobic anxiety disorder, Social anxiety disorder, Sibling rivalry
disorder, Nonorganic enuresis, Nonorganic encopresis, Feeding disorder of infancy and childhood, Pica, Stereotyped movement
disorders.
308 Textbook of Psychiatric Nursing for BSc Nursing Students

INTRODUCTION ICD-11 DSM–5 Classification of mental disorders

6A00.4 — Provisional intellectual disability
Child psychiatry deals with the assessment and treatment of
children’s behavioral and emotional problems. — 315 Global developmental delay
The common child psychiatric disorders are listed here: 6A00.Z 319 Unspecified intellectual disability
• Mental retardation or intellectual disability (intellectual developmental disorder)
• Attention Deficit Hyperactivity Disorder (ADHD) Communication disorders
• Autism spectrum disorder (ASD) 6A01 315.39 Language disorder
• Tic disorder 6A01.0 315.39 Speech sound disorder
• Communication disorder — 315.35 Childhood-onset fluency disorder
• Conduct disorder (stuttering)
• Specific learning disorder — 307.0 Adult-onset fluency disorder
6A01.22 315.39 Social (pragmatic) communication
HISTORICAL PERSPECTIVES/DEVELOPMENT IN disorder
CHILD PSYCHIATRY 6A01.Z 307.9 Unspecified communication disorder

Persons with Disability Act, 1995 (PWD) emphasized on Autism spectrum disorder
education and employment provisions for children with 6A02 299.00 Autism spectrum disorder
disability. Constitution of India (1950), Article 41 emphasized — 293.89 Autism spectrum disorder with
the ‘compulsory education for all children up to 14 years of catatonia
age and so special schools were established. Milestones of Attention-deficit/hyperactivity disorder
development in child psychiatry are summarized in Table 11.1. 6A05.0 314.00 Predominantly inattentive presentation
Table 11.1: Historical perspectives/development in child 6A05.1 314.01 Predominantly hyperactive/impulsive
psychiatry presentation
6A05.2 314.01 Combined presentation
Year Description
6A05.Y 314.01 Other specified attention-deficit/
1935 Leo Kanner published a first book about child psychiatry hyperactivity disorder
1954 First graduate program in child psychiatry was introduced 6A05.Z 314.01 Unspecified attention-deficit/
1971 Professional organization for child psychiatric nursing was hyperactivity disorder
introduced Specific learning disorder
1979 American Nurses Association (ANA) certification of child 6A03.0 315.00 With impairment in reading
psychiatry commenced
6A03.1 315.2 With impairment in written expression
1895 ANA standards of child/adolescent psychiatric nursing
practice was established. 6A03.2 315.1 With impairment in mathematics
Motor disorders
— 315.4 Developmental coordination disorder
Classification of Child Psychiatry (ICD-11 and
DSM-5) 6A06 307.3 Stereotypic movement disorder
Tic disorders
Classification of child psychiatry (ICD-11 and DSM-5) are
8A05.00 307.23 Tourette’s disorder
given in Table 11.2.
— 307.22 Persistent (chronic) motor or vocal tic
Table 11.2: Classification of child psychiatry (ICD-11 and DSM-5) disorder
ICD-11 DSM–5 Classification of mental disorders — 307.21 Provisional tic disorder
Neurodevelopmental disorders — 307.20 Other specified tic disorder
Intellectual disability (intellectual developmental disorder) — 307.19 Unspecified tic disorder
6A00.0 — Mild intellectual disability Other neurodevelopmental disorders
6A00.1 — Moderate intellectual disability 6A0Y 315.8 Other specified neurodevelopmental
disorder
6A00.2 — Severe intellectual disability
6A0Z 315.9 Unspecified neurodevelopmental
6A00.3 — Profound intellectual disability
disorder
Contd…
CHAPTER 11 Child Psychiatry 309

MENTAL RETARDATION OR INTELLECTUAL Classification

DISABILITY OR INTELLECTUAL DEVELOPMENTAL
DISORDER OR MENTALLY CHALLENGED ICD-11 DSM–5 Classification of intellectual disability
INDIVIDUALS (intellectual developmental disorder)
6A00.0 — Mild intellectual disability
Introduction 6A00.1 — Moderate intellectual disability
Mental retardation is the most common psychiatric diagnosis 6A00.2 — Severe intellectual disability
among children. The older terms used for mental retardation 6A00.3 — Profound intellectual disability
are as follows: 6A00.4 — Provisional intellectual disability
• Mental subnormality: World Health Organization
— 315 Global developmental delay
(WHO) used this term which has two categories:
6A00.Z 319 Unspecified intellectual disability
i. Mental retardation: Subnormal functioning due to
(intellectual developmental
pathological cause. disorder)
ii. Mental deficiency: Used for legal purpose when IQ is
less than 70. The classification of intellectual disability has been given in
• Feeble-mindedness: It denotes mild mental retardation. Table 11.3.
• Oligophrenia: This term is used in Western Europe Table 11.3: Classification of mental retardation or intellectual
countries. disability as per ICD-11 and DSM-5
The term, ‘Intellectual disability’ is used in DSM-5 and the
Classification IQ level of intellectual Requirement of
equivalent term is ‘Mental Retardation’ as per ICD-10 and of intellectual disability support measures
intellectual development disorder by ICD-11. Categories of disability
intelligence (ICD-10 concept) are shown in Figure 11.1. ICD-11
Mild Two to three standard May require
Definition deviations below the appropriate support
Mental Retardation is defined as, “sub-average intellectual mean (approximately
0.1–2.3 percentile)
functioning which results in or is associated with concurrent
impairment in adaptive behavior and is manifested during the Moderate Three to four standard Require consistent
deviations below the support
development.”
mean (approximately
 —American Association for Mental Retardation, 1983 0.003–0.1 percentile)
Severe Four of more standard
Profound deviations below Daily support in
the mean (less than the supervised
approximately the environment
0.003rd percentile)
Provisional There is evidence of a disorder of intellectual
development but child under the age of four or
not possible to conduct a valid assessment of
intellectual functioning because of the sensory
or physical impairments such as blindness,
deafness, locomotor disability, severe behavior
problems or co-morbid mental and behavioral
disorders.
DSM-5
The term, ‘Intellectual disability’ or ‘Intellectual development
disorder’ is used in DSM-5. It is classified as mild, moderate,
severe and profound intellectual disabilities based on the
intellectual functions (reasoning, problem-solving, planning,
abstract thinking, judgment, academic learning, learning from
experience, etc.) and adaptive functioning (communication,
social participation, independent living, etc.)
Contd…
Figure 11.1: Categories of intelligence
310 Textbook of Psychiatric Nursing for BSc Nursing Students

Classification IQ level of intellectual Requirement of test to identify phenylketonuria is guthrie test and
of intellectual disability support measures ferric chloride test.
disability ◆ Lesch-Nyhan syndrome: It is also called juvenile
Miscellaneous gout which is caused due to the deficiency
Based on the level of intensity of care required for children with of hypoxanthine-guanine phosphoribosyl
intellectual disability, it is categorized as intermittent support (on transferase (HGPRT).
the need basis), Limited support (with a particular time span), ◆ Galactosemia: Infant is unable to metabolize
Extensive support (in the required life areas) and pervasive
galactose (It is simple sugar along with glucose it
support (constant support across the all-life areas and in all
environment). forms lactose), which accumulates in brain and
might lead to mental retardation.
◆ Tay-Sachs disease: A rare fatal inherited disorder
Incidence and Prevalence that occurs due to the absence of an important
Mental retardation is seen in 1% of population. It is more enzyme hexosaminidase-A (Hex-A) leads to the
common in males. Mild mental retardation is more common destruction of nerve cells in brain and spinal cord.
in low socioeconomic group. High incidence of mental „ Complications of pregnancy: Maternal malnutrition,
retardation is seen among school going children in the age toxemia of pregnancy, placenta previa, vaginal
group of 10–14 years. Percentage distribution of children with hemorrhage, cord prolapse, premature separation of
mental retardation is shown in Figure 11.2. placenta, iodine deficiency in pregnancy (restricts
the growth of brain) and teratogenic effects of drugs,
Causes of Intellectual Disability especially in first trimester lead to mental retardation
Biological Factors in children.
Maternal infections: Rubella (German Measles),
• Prenatal causes: These include:
„

„ Genetic syndromes toxoplasmosis, syphilis, cytomegalic inclusion body

◆ Down’s syndrome: Patients have 47 chromosomes disease, HIV infection, maternal hepatitis, influenza,
with an additional chromosome number 21. pneumonia.
◆ Fragile X syndrome: Fragile site in band q27–28 • Perinatal causes: Premature birth, intrauterine growth
on X chromosome. retardation, birth injuries, kernicterus, Rh incompatibility
◆ Prader-Willi syndrome: Disorder caused by between mother and fetus are responsible for mental
deletion in the part of chromosome 15. retardation.
„ Errors of inborn metabolism • Postnatal causes: Infections (meningitis, encephalitis),
◆ Phenylketonuria: Simple autosomal recessive malnutrition, toxins (lead, alcohol), hydrocephalus
trait which has deficiency of liver enzyme (abnormal collection of Cerebrospinal Fluid around
phenylalanine hydroxylase which leads to lack the brain), macrocephaly, microcephaly, cerebral palsy,
of ability to metabolize phenylalanine. Screening Heller’s disease, head injury, uncontrolled seizures are
some of the causes.

Sociocultural Factors
• Social adversity: Lack of social skills may cause mild
intellectual disability.
• Poverty and large family size: Mother is unable to take
care of the child due to low socioeconomic status and
increased family size may lead to mental retardation in
child.
• Lack of sensory impairment during infancy.

Features of Intellectual Disability in Children

Features of Intellectual disability in children are explained in
Figure 11.2: Percentage distribution of children with mental Table 11.4. 5D’s of mental retardation or intellectual disability
retardation are given in Flowchart 11.1.
CHAPTER 11 Child Psychiatry 311

Table 11.4: Features of intellectual disability in children or independent living) across multiple environments
(example—at home, school, work, community)]
Aspects Mild Moderate Severe
• Onset of intellectual and adaptive deficits during the
intellectual intellectual intellectual
disability disability disability developmental period.
Standard 2–3 3–4 >4
deviations NOTE
below mean
Diagnostic term ‘Intellectual disability’ is the equivalent term for
% of patients 85% 10% 5% the ICD-11 diagnosis of intellectual developmental disorders. As
Self-care ability Independent Need some help Limited per United States Law, the term ‘Mental Retardation’ is replaced
Read and write Acceptable Basic Minimum or with intellectual disability.
none
Specify if it is:
Language Reasonable Limited Minimum or
none Mild, moderate, severe or profound on the basis of the adaptive
functioning and not on the basis of Intelligence Quotient Level
Social skills Normal Moderate Little
because adaptive functioning is only determining the level of
Ability to work Semi-skill Unskilled Unskilled
supports required and Intelligence measurement are less valid
Physical Rare Sometimes Commonly in the lower end of the Intelligence Quotient range.
problems seen
Causes Sometimes Often Usual ICD-11 Diagnostic Criteria for Intellectual
identified
Disability (Intellectual Developmental Disorder)
Flowchart 11.1: 5D’s of mental retardation or intellectual disability • Disorders of intellectual development are a group of
etiologically diverse conditions originating during the
developmental period characterized by significantly
below average intellectual functioning and adaptive
behavior that are approximately two or more standard
deviations below the mean (approximately less than
the 2.3rd percentile), based on appropriately normed,
individually administered standardized tests.
• Where appropriately normed and standardized tests
are not available, diagnosis of disorders of intellectual
development requires greater reliance on clinical
judgment based on appropriate assessment of comparable
behavioral indicators.
DSM-5 Diagnostic Criteria for Intellectual Specify if it is:
Disability (Intellectual Developmental Disorder) • Mild intellectual disability: Two to three standard
deviations below the mean (approximately 0.1–2.3
Intellectual developmental disorder is a disorder in which the
percentile).
onset happens during the developmental period in both the • Moderate intellectual disability: Three to four standard
intellectual and adaptive functioning deficits of conceptual, deviations below the mean (approximately 0.003–0.1
social and practical domains. percentile).
Below given criteria should meet in this case: • Severe and profound intellectual disability: Four or
• Deficits in intellectual functions (problem-solving, more standard deviations below the mean (less than
reasoning, abstract thinking, planning, judgment, approximately the 0.003rd percentile).
learning from experience, academic learning, etc.) • Provisional intellectual disability: There is evidence
• Deficits in adaptive functioning that result in failure of a disorder of intellectual development but in child
to meet developmental or sociocultural standards under the age of four, it is not possible to conduct a
for personal independence and social responsibility. valid assessment of intellectual functioning because of
Without ongoing support, the adaptive deficit limits the sensory or physical impairments such as blindness,
functioning in one or more activities of daily life deafness, locomotor disability, severe behavior problems
[(For example, communication, social participation or comorbid mental and behavioral disorders.
312 Textbook of Psychiatric Nursing for BSc Nursing Students

Diagnosis Management of Children with

• History collection: Any consanguineous marriage in Intellectual Disability or Mental Retardation
family, faulty parenting style, infant reaction toward • Adequate support and special needs in schooling:
the stress, history of head injury/seizures/fever, feeding Special schools are available to improve the academic skill
habits, smiling unnecessarily at others, any cyanosis after for mild mentally retarded children.
birth; also collect history whether baby cried after birth • Behavior therapy: Positive and Negative Reinforcement
or not. (Flowchart 11.2) might change the maladaptive behavior
• Physical examination: in children. Aversive stimuli should be avoided. Modeling
„ Inspection: General behavior, appearance, facial is a technique used in mild mentally retarded children,
expression, coordination of movements, skin fold i.e., demonstrate the desired behavior to the children. For
thickness. example, demonstrate the children how-to put-on shirt
„ Palpation: Skin texture, muscle tone and pulse rate. button and ask the child to repeat the same.
„ Percussion: It is done when there is a swelling present • Group therapy: Parents of mentally retarded children
in head. share their burdens in group therapy which helps the
„ Auscultation: Cardiovascular sounds. parents to gain reassurance.
„ Measurements: Height, weight, chest/abdominal • Social skills training: ‘Trainable’ category of mentally
circumference and cephalic index (cranial vault). retarded children is capable of acquiring the social skills
• Blood and urine test: If metabolic disorders are suspected. and require the social skills training.
• Karyotyping, amniocentesis and chorionic villus • Vocational skills training: Supportive employment/job
sampling (CVS): If chromosomal anomaly is suspected. placement.
• Electroencephalogram (EEG): To monitor the sleep • Remedial education: Mentally retarded children
pattern, assess cognitive status and to detect seizures in especially those who come under category of ‘Educable’,
mentally retarded children. have capacity to grasp academic skills.
• Assessment of hearing and speech deficits • Parents’ training programs: Train the parents to take
• Psychological test: To detect brain damage, the tests care of the mentally retarded children. Length of training
applied are: Draw a person test, Stanford Binet test, program is 8 days–2 months. Targeted behavior such as
Bender-Gestalt test, Benton visual retention test, temper tantrum, lack of social interaction, inattention,
Weschler’s Adult Intelligence Scale (WAIS), Weschler’s aggressive act, sleep disturbances, etc. are discussed
Intelligence Scale for Children (WISC), vineland adaptive during the training session. It has two main principles:
behavior scale and American Association on Mental 1. Parents have to learn the mentally retarded children’s
Deficiency (AAMD) adaptive behavior scale (Scales used management through lectures and demonstration.
to assess social functioning). 2. Apply the learnt techniques in practice at home and
Mental age (MA) in return have a discussion to verbalize the results and
Intelligence quotient (IQ) = × 100 also to sort out the issues.
Chronological age (CA)

American Association on Mental Deficiency (AAMD) Flowchart 11.2: Behavior therapy for mentally
explained adaptive behavior skills based on individual’s age retarded children
(Table 11.5).
Table 11.5: American Association of Mental Deficiency (AAMD)–
adaptive behavior skills

Categories of age American Association of Mental

Deficiency (AAMD) adaptive behavior
skills
Infancy and early Sensorimotor and social skills
childhood
Childhood and Academic, judgment, reasoning and social
early adolescence skills
Late adolescence Performance of task, vocational and social
and adulthood responsibilities
CHAPTER 11 Child Psychiatry 313

• Parental counseling: It helps to promote the positive Differences between mental retardation and mental illness are
acceptance of children. It aids the parents to be aware explained in Table 11.6.
of the importance of social stimulation such as smiling, Table 11.6: Differences between intellectual disability and mental
talking, cuddling, or holding the child while crying. Nurse illness
has to create awareness regarding the special schools,
vocational rehabilitation centers and day care centers. Aspects Intellectual disability Mental illness
• Special institution: Residential care (to take care of Disease It is not a disease It is a disease
profound mentally retarded children) and day care center/ Curable No, it cannot be cured. However, It may or may
sheltered workshops (to take care of mild and moderate associated vision/hearing/ not be cured.
mentally retarded children). behavioral problems can be
treated
• If the child is aggressive/agitated: Mood stabilizers,
benzodiazepines and atypical antipsychotics are used.
Myths about Mental Retardation
Administer antipsychotics if these are highly essential, in
order to avoid the unwanted side effects. • It is always hereditary.
• Management of psychosocial deprivation: Nurse has to • It can be cured.
promote the verbal, emotional and sensory stimulations • It is not common.
through play therapy. Play should not be conducted as • All mentally retarded children are same/alike.
competition among these children because the failure • Mentally retarded children are impossible to train educate.
in the task might demotivate the children. Shared play
activities might improve social skills. Firm limits have Prevention of Mental Retardation or Intellectual
to be maintained consistently among children with poor Disability
impulse control. Mental retardation or intellectual disability is classified as
• Management of seizures: The most common comorbid primary, secondary and tertiary prevention as shown in
illness seen in mentally retarded children is seizure. Nurse Flowchart 11.3.
has to remove the sharp objects away from the children
during the seizure. If the seizure occurs in the bed, put Assessment of Children with Mental
the side rails. Remove the tight clothing or chains. Take Retardation or Intellectual Disability
measures to prevent the tongue fall back. If possible, turn
Common screening tools of mental retardation have been
the child’s head toward one side during the seizure. It
given in Table 11.7. Other screening tools used to assess Mental
might help to drain the secretions and these secretions
Retardation are Bharat Raj Developmental Screening Test
will not obstruct the respiratory path. Monitor the timing
(DST), Upanayan Early Intervention Programming System
and type of seizure. Administer benzodiazepines as the
(1987) and Functional Assessment Checklist for Programming
physician orders.
(FACP-1991).
• Medications:
„ To control stereotyped motor abnormalities: Table 11.7: Common screening instruments of mental retardation
Chlorpromazine and haloperidol can be used. Common screening instruments Age group
„ To control aggression: Antipsychotics, sodium
Denver development scale 0–6 years
valproate, lithium carbonate, naltrexone and
carbamazepine are used. Gesell’s development scale 4 weeks–6 years
„ If child is inattentive: Stimulants such as Mental and motor growth of Indian 1–2 years
amphetamine and methylphenidate can be used. babies (Pramila Pathak, 1976)
• Management of speech deficits: Lip reading/Speech Griffith mental development scale 2–8 years
therapy and assisting with hearing aids are helpful. Cattell’s infant IQ scale 2 months–2½ years
• Management of sexual problems: Masturbation is Stanford binet IQ scale 2½ years–18 years
common among mentally retarded so the children can be Bhatia battery of performance test 6–14 years
diverted with clay making, finger painting and sand play
Raven’s Progressive Matrices; Weschler’s 8½ years–16 years
activities. Intelligence Scale for Children (WISC)
• Miscellaneous: Supportive counseling to parents and
Minnesota Preschool scale 1½ years–6 years
caregivers, physiotherapy and occupational therapy.
Identify and treat the comorbid illness. Vineland social maturity scale 0–25 years
314 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 11.3: Classification of prevention of mental retardation

Nursing Management of Patient with Mental Retardation or Intellectual Disability

• Risk for injury related to aggression as evidenced by signs of impending violence

Nursing interventions Rationale

Provide safe environment to client To promote safety
Store things easily reachable which are used by the client often To prevent injury
Put side rails if seizure is suspected To prevent the patient fall
Recognize the signs of impending aggression in early stage To help the nurse to take precautions/measures
Keep the sharp items out of reach To prevent injury
Avoid other clients be on their bed To safeguard other patients
Administer antipsychotics as per the doctor’s order To calm the client

• Impaired social interaction or verbal communication related to speech deficit as evidenced by inability to communicate

Nursing interventions Rationale

Use simple language or words to explain Helps the client to understand the communication easily.
Use nonverbal gestures/signals appropriately Helps the client to understand the communication process
Ask the client to participate in group therapy session or with any Helps the patient to listen the interact with other patients.
other interactions.
Provide speech therapy Promotes speaking ability
Use hearing aids if needed Helps the client to listen the others’ speech
Provide social skills training Improves social skills
Promote play therapy as a group Gives a chance to talk with others

• Self-care deficit related to lack of maturity as evidenced by inability to take care of oneself

Nursing interventions Rationale

Identify the aspects of self-care which is deficit It provides the baseline data
Focus and train the self-care which is found to be deficit It helps to promote the self-care
Shift to the next self-care activity when one aspect was mastered well It helps to improve the self-care
Promote positive reinforcement if the client behavior is acceptable It motivates the desirable behavior
CHAPTER 11 Child Psychiatry 315

participation, or academic or occupational performance,

DISORDERS OF PSYCHOLOGICAL DEVELOPMENT
individually or in any combination.
• The onset of symptoms is in the early developmental
SPECIFIC DEVELOPMENTAL DISORDERS OF
period.
SPEECH AND LANGUAGE
• The disturbance is not attributable to a speech-motor or
Stuttering/Stammering/Childhood Onset sensory deficit, dysfluency associated with neurological
Fluency Disorder insult (e.g., stroke, tumor, trauma), or another medical
condition and is not better explained by another mental
Disorders of speech are characterized by disturbances in
disorder.
fluency or rhythm of speech, blocking of speech intermittently,
rapid repetition of words, sounds get prolonged and presence Management of Stuttering/Stammering/
of anxiety or distress. Children are usually aware of abnormal Childhood Onset Fluency Disorder
speech patterns. The term, ‘childhood onset fluency disorder’
Simplest measures to control stammering or stuttering is ‘Ask
is given by DSM-5.
the patient to talk more slowly’. Speech and language therapy
such as fluency shaping therapy, stuttering modification
DSM-5 Diagnostic Criteria for Childhood Onset
therapy and use of electronic fluency device are some of the
Fluency Disorder
treatment methods. Social skills or communication skill
• Disturbances in normal fluency and time patterning of training, assertiveness training, counseling and psychological
speech which is inappropriate for individual’s age and treatment can also be given.
language skills, persist over time and are characterized by
the frequent and marked occurrences of one (or more) of Cluttering
the following: Erratic and dysrhythmic speech pattern with fast jerky
„ Sound and syllable repetitions spurting of words. Children are usually not aware of abnormal
„ Sound prolongations of consonants as well as speech pattern. The comparison of cluttering with stuttering or
vowels. stammering has been presented in Table 11.8.
„ Broken words (e.g., pauses within a word).
„ Audible or silent blocking (filled or unfilled pauses in Selective Mutism
speech). Complete absence of speech in social situations. It will recover
„ Circumlocutions (word substitutions to avoid spontaneously, if not recovered then administer cognitive
problematic words). behavior therapy in the form of systematic desensitization
„ Words produced with an excess of physical tension. (gradual steps taken to ensure the child to talk in front of the
„ Monosyllabic whole-word repetitions (e.g., “I-I-I-I strangers). If stammering is the underlying issue, it has to be
see him”). sorted out by providing speech therapy. Selective serotonin
• The disturbance causes anxiety about speaking reuptake inhibitors (SSRI) can be given if the symptoms of
or limitations in effective communication, social social phobia are prominent.

Table 11.8: Stuttering/stammering versus cluttering

Aspects Stuttering/stammering Cluttering

Features of speech pattern Disorder of speech is characterized by: Disorder of speech characterized by:
• Disturbances in fluency and rhythm of speech • Erratic
• Blocking of speech intermittently • Dysrhythmic speech pattern
• Rapid repetition of syllable or sounds or monosyllabic words • Fast jerky spurting of words
(e.g., I…I…I.. want…want…to sleep)
• Circumlocutions: Substitution of problematic words with the
simple words.
• Sounds get prolonged
• Anxiety or distress present.
• Child takes extra effort such as fist clenching, eye blinking, etc.
while speaking.
Self-awareness of Present Absent
abnormal speech pattern
316 Textbook of Psychiatric Nursing for BSc Nursing Students

DISORDERS OF LANGUAGE OR SPECIFIC Prognosis

LANGUAGE IMPAIRMENTS
It depends on the type of language disorder and associated
Disorders of language such as dysphasia or developmental cognitive deficits.
language disorder, dyslalia or phonological disorder or
developmental articulation disorder, receptive language SPECIFIC DEVELOPMENTAL DISORDERS OF
disorder, expressive language disorder and other developmental SCHOLASTIC SKILLS
disorders of language come under these impairments.
Specific Learning Disorders (Dyslexia) or
• Causes: Hereditary/Genetics; FOXP2 gene mutation (but
Developmental Learning Disorder
it is not common cause); Environmental factors such as
Glue ear (Otitis media with effusion is present). Meaning: The term ’Dyslexia’ came from Greek word, prefix
‘dys’ means poor or inadequate and suffix ‘lexia’ means word
Types of Language Disorders or language.
• Phonologic-Syntactic: Problem with the articulation or Definitions: A disorder in which the child fails to attain the
syntax or both (Problem in formation of speech). language skills of reading, writing and spelling commensurate
• Pragmatic language impairment (previously termed with their intellectual abilities.
semantic-pragmatic disorder): Problem with the use  —World Federation of Neurologists, 1968
and content of speech and no problem with formation of A learning disability which hinders the person’s ability to read,
speech. spell, write and speak.
• Landau-Kleffner syndrome or acquired Kleffner  —United States National Institute of Health
syndrome: Loss of language skills after a normal It is characterized by slow reading speed, slow acquisition
development. It is a rare disorder which usually starts of reading skills, omission of words, distortions, reversal of
from 3–9 years of age. 50–70% of children will suffer letters and impaired comprehension. It is clearly differentiated
with seizure attacks. EEG shows paroxysmal discharges from general backwardness in academics resulting from
in both right and left hemisphere of brain which is more low intelligence. Flowchart 11.4 shows the sub-categories of
prominently seen during non-rapid eye movement (non- dyslexia.
REM) sleep.
Etiology
Differential Diagnosis Etiology is idiopathic in general.
Hearing loss, low intelligence, selective mutism and childhood • Genetic: Defects in chromosome 1, 2, 6 and 15 might
dementia. cause dyslexia.

Flowchart 11.4: Subcategories of dyslexia

CHAPTER 11 Child Psychiatry 317

• Neurological: Accidents in prenatal/postnatal period or • The learning difficulties begin during school-age years
any other birth injuries (particularly injuries of the left but may not become fully manifested until the demands
hemisphere of brain). for those affected academic skills exceed the individual’s
limited capacities.
ICD-11 and DSM-5 Classification of Specific Learning
Disorder • The learning difficulties are not well accounted by
intellectual disabilities, uncorrected visual or auditory
ICD-11 DSM-5 Developmental learning disorder (ICD-11)/ acuity, other mental or neurological disorders,
Specific learning disorder (DSM-5)
psychosocial adversity, lack of proficiency in the language
6A03.0 315.00 With impairment in reading of academic instruction, or inadequate educational
6A03.1 315.2 With impairment in written expression instruction.
6A03.2 315.1 With impairment in mathematics Specify if
• With impairment in reading
Types • With impairment in written expression
• Trauma dyslexia: An acquired rare type of mental • With impairment in mathematics
disorder caused by injury to brain or conductive hearing • Level of severity (mild/moderate/severe)
loss.
ICD-11 Diagnostic Criteria for Developmental
• Deep dyslexia or primary dyslexia: Usually due to
Learning Disorder
hereditary factors, chromosomal defects affect the left
hemisphere and corpus callosum and the child has to • Significant and persistent difficulties in learning academic
compensate this defect using the right brain. skills such as reading, writing, or arithmetic.
• Developmental dyslexia or secondary dyslexia: It • Individual’s performance in the affected academic
occurs in the developmental stages of fetus. The severity skill is markedly below which has been expected for
decreases as the child grows older. chronological age and general level of intellectual
functioning and results in the significant impairment in
Diagnosis the individual’s academic or occupational functioning.
It is actually difficult to diagnose. Although it can be • Developmental learning disorder first manifests when
diagnosed based on the observations made in the classroom, academic skills are taught during the early school years.
history collection in regard to the developmental milestones, • Developmental learning disorder is not due to a disorder
performance in academics, educational tests to explore the of intellectual development, sensory impairment,
level of functioning related to basic skills and doing special neurological or motor disorder, lack of availability of
tests to assess the language skills. education, lack of proficiency in the language of academic
instruction or psychosocial adversity.
DSM-5 Diagnostic Criteria for Specific Learning Specify if
Disorder • With impairment in reading
• Difficulties in learning and using academic skills, as • With impairment in written expression
indicated by the presence of at least one of the below listed • With impairment in mathematics
symptoms for at least 6 months, despite the provision of
interventions that target those difficulties: Treatment
i. Inaccurate or slow and effortful word reading • Educational techniques: Teach the children to recognize
ii. Difficulty understanding the meaning of what is read the smallest sounds that make the words (phonemes)
iii. Difficulties with spelling and understand the letters which represent these sounds
iv. Difficulties with written expression (phonics). Child has to read aloud which helps in the
v. Difficulties mastering number sense, number facts, or improvement to develop the reading fluency, accuracy and
calculation speed. Child has to be encouraged to comprehend what he/
vi. Difficulties with mathematical reasoning she is reading.
• Affected academic skills are substantially and quantifiably • VAKT technique: Visual, auditory, kinesthetic and tactile
below those expected for individual’s chronological techniques. It is a multisensory learning and includes four
age and cause significant interference with academic learning styles such as visual, auditory, kinesthetic and
or occupational performance, or with activities of daily tactile (Table 11.9), in which the child learns through one
living, as confirmed by comprehensive clinical assessment. or other channels of learning.
318 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 11.9: Modalities of VAKT technique and its usage to specific • Electrophysiological changes: Autistic children show
modality impairment of sensory modulation in brain stem when
observed with brain stem auditory evoked responses
Modalities of VAKT Usage of items in order to enhance
technique learning skills among children with (BAERs).
dyslexia • Perinatal factors: Maternal bleeding after first trimester,
Visual Using images, pictures and spatial presence of meconium in amniotic fluid and exposure
understanding to sodium valproate or thalidomide may also cause
Auditory Using music and sounds autism.
Kinesthetic or physical Using body and hand movements • Separation-individuation theory of child development
by Margaret Mahler: Fixation in presymbiotic phase of
Tactile Using the sense of touch
development according to Mahler might lead to autism.
• Theory of mind in autism: This theory denotes that child
Role of Parents and Teachers
can understand others’ minds what they are thinking,
• Do’s: Parents and teachers have to identify the problem feeling or intending. Children with autism will have
at an early stage. Encourage the children to read aloud. ‘mind-blind,’ i.e., lack of ability to put oneself in others’
Provide adequate additional time for reading. Usage of place and think.
bullet points, color, flowcharts, more space and white • Family disputes/conflicts: Stress among family members,
boards are more helpful for easy understanding of faulty parenting style (a term ‘Refrigerator parents’ which
auditory, kinesthetic and tactile ways of learning. denotes parents who lack warmth and affection toward
• Don’t: Teachers or parents should not give more the child, is used here), parental rejection, family break
instructions to the children and do not use small prints up, etc. are examples of it. (Note: Family dispute/conflict
and overcrowded text. has been considered an older concept to cause autism but
• Specific spelling disorder: There is significant speech not widely accepted as a causative factor now).
impairment in saying the spellings of a specific word/
words with absence of a specific reading disorder. ICD-11 and DSM-5 Classification of Autism
• Specific arithmetic disorder: There will be significant ICD-11 DSM-5 Classification of autism
impairment in computational skills of addition,
6A02 299.00 Autism spectrum disorder
subtraction, division and multiplication.
— 293.89 Autism spectrum disorder with catatonia

AUTISM SPECTRUM DISORDER

DSM-5 Diagnostic Criteria for Autism Spectrum
Leo Kanner first described this disorder as Infantile Autism Disorder
and so it is also called Kanner’s syndrome. Autism spectrum
•Persistent deficits in social communication and social
disorder is characterized by persistent deficits in the ability to
interaction across multiple contexts, as manifested by the
initiate and to sustain reciprocal social interaction and social
following, currently or by history.
communication, and by a range of restricted, repetitive, and
„ Deficits in social-emotional reciprocity, ranging to
inflexible patterns of behavior and interests.
reduced sharing of interests, emotions, or affect;
failure to initiate or respond to social interactions.
Causes of Autism
„ Deficits in nonverbal communicative behaviors
• Genetics/hereditary factors: Monozygotic twins have used for social interaction, ranging to abnormalities
higher concordance than dizygotic twins. Siblings of in eye contact and body language or deficits in
autistic child shows 2% of prevalence rate. 2–5% might understanding and use of gestures; to a total lack of
have fragile X syndrome. facial expressions and nonverbal communication.
• Neuroanatomical studies: Enlargement of cerebral „ Deficits in developing, maintaining, and
ventricles and degeneration of cerebellum is seen. understanding relationships, ranging to difficulties
• Biochemical factors: Increased serotonin level is seen in in sharing imaginative play or in making friends; to
one third of children with autism. absence of interest in peers.
• Inflammation of central nervous system: Meningitis Specify current severity: Severity is based on social

and encephalitis. communication impairments and restricted, repetitive
• Infection: Maternal Rubella/cytomegalovirus. patterns of behavior.
CHAPTER 11 Child Psychiatry 319

• Restricted, repetitive patterns of behavior, interests, or and by a range of restricted, repetitive, and inflexible
activities, as manifested by at least two of the following, patterns of behavior and interests.
currently or by history (examples are illustrative, not • Onset occurs during the developmental period, typically
exhaustive; see text): in early childhood, but symptoms may not become fully
„ Stereotyped or repetitive motor movements, use of manifest until later, when social demands exceed limited
objects, or speech. capacities.
„ Insistence on sameness, inflexible adherence to • Deficits are sufficiently severe to cause impairment in
routines, or ritualized patterns of verbal or nonverbal personal, family, social, educational, occupational or other
behavior. important areas of functioning and are usually a pervasive
„ Highly restricted, fixated interests that are abnormal feature of the individual’s functioning observable in all
in intensity or focus. settings, although they may vary according to social,
„ Hyper- or hyporeactivity to sensory input or unusual educational, or other context. Individuals along the
interest in sensory aspects of the environment. spectrum exhibit a full range of intellectual functioning
Specify current severity: Severity is based on social and language abilities.
communication impairments and restricted, repetitive
patterns of behavior.
NOTE
• Symptoms must be present in the early developmental
period. Above definitional requirements for autism spectrum disorder
are met, with or without disorder of intellectual development and
• Symptoms cause clinically significant impairment in
with mild or no or significant impairment of functional language
social, occupational, or other important areas of current (code has to be allotted accordingly).
functioning.
• These disturbances are not better explained by intellectual
developmental disorder or global developmental delay. Main Features of Autism
Intellectual disability and autism spectrum disorder • Abnormal social reciprocal relationship: Poor eye to
frequently co-occur; to make comorbid diagnoses of eye contact, not interested to play with other children,
autism spectrum disorder and intellectual disability, lack of facial expression, lack of ability to establish
social communication should be below that expected for friendship, live in their own world (lack of attention to
general developmental level. parents and sibling), lack of empathy, reciprocal social
interaction (prefer to be alone and dislike when cuddled,
NOTE kissed or picked up) are present. All consider them as
easier babies. Due to the lack of parental attention, such
Individuals who have marked deficits in social communication,
but whose symptoms do not otherwise meet criteria for autism children prefer solitary activities and do not participate
spectrum disorder, should be evaluated for social (pragmatic) in social play.
communication disorder. • Abnormalities in communication: Children with autism
are unable to speak generally, if they speak it might be
Specify if: difficult to understand. There may be an immediate
• With or without accompanying intellectual impairment echolalia (immediate repetition of words spoken by
• With or without accompanying language impairment others) or delayed echolalia (repetition of words spoken
• Associated with a known medical or genetic condition or by others will happen but it will be delayed), incoherence
environmental factor of speech, absence of mode of communication such
• Associated with another neurodevelopmental, mental, or as babbling, gestures and facial expressions. Delay in
behavioral disorder development and production of speech (rate, rhythm,
• With catatonia volume, pitch, etc.) is present. Speech is monotonous,
• Catatonia associated with autism spectrum disorder to wooden and of mechanical nature. Conversation is like
indicate the presence of the comorbid catatonia. a monologue and not as a dialogue. Pronunciation errors
of both syllables and words may be present. Both verbal
ICD-11 Diagnostic Criteria for Autism Spectrum and nonverbal communication are impaired. Pronominal
Disorder reversal is seen, e.g., reverse of pronoun, ‘I’ with ‘You,’ i.e.,
• Persistent deficits in the ability to initiate and to sustain instead of saying ‘I feel happy’ child might say ‘You feel
reciprocal social interaction and social communication, happy.’
320 Textbook of Psychiatric Nursing for BSc Nursing Students

• Repetitive and restrictive behavior: Child with autism special school for training, 60% of autistic children show an
insists on ‘sameness’ (prefers to wear same clothes, eat improvement but might not lead an independent life.
same food and play with same toy), lack of creativity,
stereotyped behavior such as clapping hands, rolling the Management of Autism Spectrum Disorder
head, body rocking and making out whirling rounds can Assessment/Diagnosis
be seen. Autistic child may show anger burst out when a
• History collection: Interview can be conducted with the
toy is moved from its place.
parents regarding the child’s development.
• Screening Tools: There is no definite diagnostic tool
Associated Features
whereas commonly used rating scales are childhood
• Cognitive impairment: Autistic children might also have autism rating scale (CARS), autism diagnostic interview
mental retardation, in which few may have average and (ADI), autism behavior checklist, Gilliam Asperger’s
above average intelligence. Disorder Scale (GADI) and Child’s Social Behavior/
• Abnormal response to sensory stimuli: Hyperacusis Language Scale. Identify the other comorbid illnesses
(hypersensitivity to the sound heard), hypersensitivity to such as mental retardation, hearing loss, speech defects
touch while the child has no response to stimuli of pain. and neurological disorders.
• Self–injurious behavior: Head banging and self- • Positive emission tomography (PET): Impairment in
mutilation are commonly seen. 10–25% of children with frontal or parietal lobes can be seen.
autism will have generalized tonic clonic seizure (GTCS)
Psychological Therapies
and only few children will have temporal lobe epilepsy
(TLE). • Psychoeducation: Educate the parents, child and teacher
about autism spectrum disorder.
Risk Factors of Autism Spectrum Disorder • Social skills training or communication skills training
or life skills training.
• Genetic factors: Duplication in the section of
• Counseling and supportive therapy: Counseling services
chromosome 7 (In William’s syndrome, same section of
have to be provided to the family members to cope up
chromosome 7 is found deleted which displays the excess
with the distress, which happened due to behavior of
sociability behavior).
autistic children.
• Low birth weight • Special schooling: Refer the autistic children to the
• Increased paternal age special schools for their improvement.
• Exposure to medications during first trimester of • Home care: Teach the caregivers how to manage the
pregnancy (e.g., Sodium valproate). behavior of autistic children at home.
• Extreme male brain theory: According to this theory, • Behavior therapy: Unrealistic behavior has to be
autism shows an extreme of the typical male profile. modified into realistic one.
Males are usually ‘systemizing’ than ‘empathizing’. Child
with autism might have extreme male pattern. Psychotropic Medications
Low dose of antipsychotics is used to treat undesirable
NOTE challenging behavior. Special care must be taken during the
time of transition (change of school/home setting/caregivers)
Individuals with autism spectrum disorders (ASD) lack in both because the symptoms might worsen during this transition
empathy and theory of mind (ability to assess the mental state
period.
of others, that usually starts developing from 3 to 4 years of age.
So, autistic individuals are vulnerable for exploitation by others).
CONDUCT DISORDER

Course and Prognosis Definition

Autism has a long course and guarded prognosis (outcome A repeated and pervasive pattern of inappropriate behavior in
is serious and uncertain). 10–20% of autistic children show children or adolescence that violates the basic rights of others
improvement by 4–6 years of age in an ordinary school, is known as conduct disorder. Comparison of conduct disorder
10–20% of autistic children will live at home but require as per ICD-11 and DSM-5 is given in Table 11.10.
CHAPTER 11 Child Psychiatry 321

Table 11.10: Comparison of conduct disorder as per ICD-11 and ICD-11 DSM-5 Classification of conduct disorder
DSM-5
6C91.10 — Conduct-dissocial disorder, adolescent
Aspects Conduct disorder as per Conduct disorder onset with limited prosocial emotions
ICD-11 as per DSM-5 6C91.11 — Conduct-dissocial disorder, adolescent
Age of onset Childhood onset type: Before 13 years onset with typical prosocial emotions
before 10 years of age 6C91.1Y — Other specified conduct-dissocial
Adolescent onset type: disorder, adolescent onset
after 10 years of age
6C91.Z 312.89 Conduct-dissocial disorder,
Duration of At least 12 months or unspecified
Symptoms more

DSM-5 Diagnostic Criteria for Conduct Disorder

Incidence and Prevalence • A repetitive and persistent pattern of behavior in which
Prevalence is 5%. It is three times more common in males the basic rights of others or major age-appropriate societal
than females. Severity is more common in males. Early onset norms or rules are violated, as manifested by the presence
in children with conduct disorders are more prone to develop of at least three of the following 15 criteria in the past
antisocial personality disorder in adulthood. 12 months from any of the categories below, with at least
one criterion present in the past 6 months:
Etiology
Aggression to people and animals:

• Genetic factors: Child with one particular variant of 1. Often bullies, threatens, or intimidates others.
monoamine oxidase-A (MAO-A) gene are at risk of 2. Often initiates physical fights.
developing antisocial behavior. Cytogenetics states that, 3. Has used a weapon that can cause serious physical
‘Individual with ‘XXY Karyotype’ are more prone to harm to others.
develop aggression. 4. Has been physically cruel to people.
• Biochemical factors: Increased plasma levels of 5. Has been physically cruel to animals.
testosterone might cause aggressive behavior. 6. Has stolen while confronting a victim.
• Organic factors: Brain damage and seizures may cause 7. Has forced someone into sexual activity.
conduct disorder.
• Psychosocial factors: Low socioeconomic status, large Destruction of property:

family size, lack of achievement in school, child abuse 8. Has deliberately engaged in fire setting with the
or neglect, parents involved in criminal activities or intention of causing serious damage.
substance abuse, parental separation or death of father, 9. Has deliberately destroyed others’ property (other
inappropriate communication patterns of family and than by fire setting).
parental conflicts. Deceitfulness or theft:
10. Has broken into someone else’s house, building, or
ICD-11 and DSM-5 Classification of Conduct car.
Disorder 11. Often lies to obtain goods or favors or to avoid
ICD-11 DSM-5 Classification of conduct disorder
obligations.
12. Has stolen items of nontrivial value without
6C91 — Conduct-dissocial disorder
confronting a victim.
6C91.0 312.81 Conduct-dissocial disorder, childhood
onset Serious violations of rules:
6C91.00 — Conduct-dissocial disorder, childhood 13. Often stays out at night despite parental prohibitions,
onset with limited prosocial emotions beginning before age 13 years.
6C91.01 — Conduct-dissocial disorder, childhood 14. Has run away from home overnight at least twice
onset with typical prosocial emotions while living in the parental or parental surrogate
6C91.0Z — Conduct-dissocial disorder, childhood home, or once without returning for a lengthy
onset, unspecified period.
6C91.1 312.82 Conduct-dissocial disorder, adolescent 15. Is often truant from school, beginning before age
onset 13 years.
Contd…
322 Textbook of Psychiatric Nursing for BSc Nursing Students

• The disturbance in behavior causes clinically significant Features

impairment in social, academic, or occupational
C : Cheating others
functioning.
O : Obnoxious (very unpleasant or rude) and others are
• If the individual is age 18 years or older, criteria are not
blamed for one’s committed mistake
met for antisocial personality disorder.
N : No guilt and empathy; nasty behavior/speech
Specify whether: D : Drug and alcohol abuse
• Childhood-onset type: At least one symptom of conduct U : Unpredictable behavior and usage of dangerous weapons
disorder present prior to age 10 years. such as gun or knife
• Adolescent-onset type: No symptom of conduct disorder C : Cruel to animals and human beings/Criminal activities
present prior to age 10 years. are performed
• Unspecified onset: Criteria for a diagnosis of conduct T : Truancy
disorder are met, but there is not enough information
D : Destroy other’s property or deliberately set the fire
available to determine whether the onset of the first
I : Intimidates (frighten others in order to make them to do)
symptom was before or after age 10 years.
S : Steal other things
• With limited prosocial emotions.
O : Others are forced for sexual act and onset of antisocial
• Lack of remorse or guilt.
personality disorder
• Callous—lack of empathy.
R : Repeatedly saying lies and rage
• Unconcerned about performance.
• Shallow or deficient affect. D : Disrespect to others
• Specify current severity: Mild or moderate or severe. E : Esteem is low
R : Risk taking behavior or recklessness
ICD-11 Diagnostic Criteria for Conduct Disorder
Nursing Management of Children with Conduct
• Repetitive and persistent pattern of behavior in which the
Disorder
basic rights of others or major age-appropriate societal
norms, rules, or laws are violated such as aggression Assessment
toward people or animals; destruction of property; 4D’s in family history of children with conduct disorder or
deceitfulness or theft; and serious violations of rules. disruptive behavior is shown in Flowchart 11.5. Assess the
• The behavior pattern is of sufficient severity to result symptoms using strength and difficulties questionnaire and
in significant impairment in personal, family, social, child behavior checklist. Assess the comorbid disorders such as
educational, occupational or other important areas of autism, attention deficit and hyperactivity disorder (ADHD),
functioning. mental retardation. Perform the risk assessment, if the child
• To be diagnosed, the behavior pattern must be enduring has exhibited more antisocial behavior. Assess the cognitive
over a significant period of time (e.g., 12 months or more). deficits, intellectual functioning and learning disabilities.
• Isolated dissocial or criminal acts are thus not in
Neurological examination has to be done if there is history of
themselves grounds for the diagnosis.
brain trauma or seizure in present.
Specify whether:
• Childhood-onset type: At least one symptom of conduct Flowchart 11.5: 4D’s in family history of children with
disorder present prior to age 10 years. conduct disorder
• Adolescent-onset type: No symptom of conduct disorder
present prior to age 10 years.
• With limited prosocial emotions.
• With typical prosocial emotions.
• Unspecified.

NOTE
In conduct disorder, aggression is due to low self-esteem and low
frustration tolerance in children.
CHAPTER 11 Child Psychiatry 323

Nursing Interventions • Family therapy: When there is a significant dysfunction

• Management of violence/aggression: Nurse should be in family, which may be expressed by child’s behavior has
aware that the child is at risk of being violent any time and to be treated.
so be caution with the children with conduct disorder. • Medications: Atypical antipsychotic (risperidone) is the
Provide physical/mechanical restraints to the children if drug of choice if psychotic symptoms are present. Lithium
the aggression is out of control. Chemical restraints or and carbamazepine for treatment of impulsivity and
tranquilizers can be administered as per the physician’s aggression are given. Anticonvulsants are a diverse group
order. of pharmacological agents that are used in the treatment of
• Skill training program for children with conduct epileptic seizures and to central hyperactivity.
disorders: Skill training program has to be conducted for
children with conduct disorder to promote the emotional JUVENILE DELINQUENCY
skill, problem solving skill and social skill as shown in
Juvenile is an individual who is below the age of 16 (18 years
Flowchart 11.6.
in case of females). Juvenile delinquency implies to the
• Control of manipulative behavior: Reinforce the positive
participation by a minor child, usually between the ages of
behavior/socially acceptable behavior and gradually
10–17 years in illegal activities or behavior.
reduce the negative behavior. Manipulative behavior
has to be controlled using a psychotherapeutic approach
Etiology
namely, ‘limit setting’.
• Self–monitoring technique: Encourage the children to • Psychological factors: Psychiatric illness, feelings of
maintain a diary or log book to enter one’s own behavior. insecurity, emotional instability and inability to cope up
A brief statement of anger or any unacceptable behavior with stressors.
has to be noted by oneself with appropriate explanation. • Social factors: Family disputes/conflicts, uncaring
It helps the child to identify the patterns of thinking attitude of parents, broken family, single parent and bad
and one’s own behavior or action in various situations. conduct of parents.
Review the diary or log book at the time of discharge • Factors related to schooling: Severe punishment by
and encourage the child to continue this self–monitoring teachers, ill-treating the child in front of others and
technique even after the discharge. following the negative role models.
• Special considerations: Aggression can also happen in • Environmental factors: Children who live in the area
the school/classroom. Special attention must be given where more criminal activities are present, friends/
by counselor in the school to sort out cause of aggressive parents who have bad conduct may influence the child to
behavior. Truancy has to be considered specifically. perform such activities.
Pressurize the child to get back into the school. Resolve • Economic factors: Poverty and low socioeconomic status
the educational and other issues in the school. Nurse may lead to get involved in stealing or criminal activities.
has to maintain a good interpersonal relationship with
parents and teachers. Management
Reformatory schools and remand homes can help the child to
Flowchart 11.6: Skill training program for children with
conduct disorder learn the right moral values. Psychological therapies such as
play therapy, art therapy and psychodrama seem to be helpful.
Governmental measures such as Children’s Act (1977) state
that reformatory school and remand homes are made available
to develop the child with value education. Vocational training
program is helpful to the child to learn the vocational skills
for the future employment. Yoga, meditation and relaxation
therapy is also needed to reduce the children’s level of stress.

Prevention Measures
Educate the parents regarding the proper parenting style.
Counsel them in regard with family disputes/conflicts and its
importance to avoid them since it promotes the future growth
324 Textbook of Psychiatric Nursing for BSc Nursing Students

of the children. Empower the teachers to provide positive • Symptoms persist for at least several months and are
reinforcement of the child behavior instead of using harsh sufficiently severe to result in significant distress or significant
punishment or hurting words. impairment in personal, family, social, educational,
occupational, or other important areas of functioning.
SEPARATION ANXIETY DISORDER
DSM-5 Diagnostic Criteria for Separation Anxiety
Meaning: Children feel excessive anxiety due to separation Disorder
from home or from the person to whom the child is emotionally • Developmentally inappropriate and excessive fear or
attached (mostly the mother, caregiver or siblings). anxiety concerning separation from those to whom the
Definition: An excessive display of fear and distress, when individual is attached, as evidenced by at least three of the
faced with situation of separation from home or any specific following:
emotionally attached figure. i. Recurrent excessive distress when anticipating or
 —American Psychiatric Association experiencing separation from home or from major
Epidemiology: It is common in infants and children in the age attachment figures.
group of 6 months to 3 years. 75% of children with separation ii. Persistent and excessive worry about losing major
anxiety disorder will have school refusal. Around 50% of attachment figures or about possible harm to them,
anxiety disorders in children suffer from separation anxiety such as illness, injury, disasters, or death.
disorder. iii. Persistent and excessive worry about experiencing an
untoward event (e.g., getting lost, being kidnapped,
Etiology having an accident, becoming ill) that causes
• Biological: High activity of amygdala and defects in separation from a major attachment figure.
ventrolateral and dorsomedial area of prefrontal cortex iv. Persistent reluctance or refusal to go out, away from
are linked with separation anxiety disorder. home, to school, to work, or elsewhere because of
• Environmental: High level of stressors, loss of loved fear of separation.
ones, natural disasters, parental separation and change of v. Persistent and excessive fear of or reluctance about
school or neighborhood. being alone or without major attachment figures at
• Genetic and physiological: Researchers have proved home or in other settings.
that genetic factors are also a cause of separation anxiety vi. Persistent reluctance or refusal to sleep away from
disorder in which most of them were girls. Child home or to go to sleep without being near a major
temperament (timid and shyness in behavior) also leads attachment figure.
to separation anxiety disorder. vii. Repeated nightmares involving the theme of separation.
viii. Repeated complaints of physical symptoms (e.g.,
ICD-11 and DSM-5 Code for Separation Anxiety headaches, stomachaches, nausea, vomiting) when
Disorder separation from major attachment figures occur or
are anticipated.
ICD-11 Code 6B05
• The fear, anxiety, or avoidance is persistent, lasting at
DSM-5 Code 309.21 least 4 weeks in children and adolescents and typically
6 months or more in adults.
ICD-11 Diagnostic Criteria for Separation Anxiety • The disturbance causes clinically significant distress or
Disorder impairment in social, academic, occupational, or other
• Marked and excessive fear or anxiety about separation important areas of functioning.
from specific attachment figures. • The disturbance is not better explained by another
• In children, separation anxiety typically focuses on mental disorder, such as refusing to leave home because
caregivers, parents or other family members; in adults it is of excessive resistance to change in autism spectrum
typically a romantic partner or children. disorder; delusions or hallucinations concerning
• Thoughts of harm or untoward events befalling the separation in psychotic disorders; refusal to go outside
attachment figure, reluctance to go to school or work, without a trusted companion in agoraphobia; worries
recurrent excessive distress upon separation, reluctance about ill health or other harm befalling significant others
or refusal to sleep away from the attachment figure, and in generalized anxiety disorder; or concerns about having
recurrent nightmares about separation is present. an illness in illness anxiety disorder.
CHAPTER 11 Child Psychiatry 325

Clinical Features Table 11.11: Types of scale used for assessing separation anxiety
disorder
• Recurrent and excess distress which is anticipated or
experienced by separation from the attachment figure. Types of scale used for Name of the tool used for
• Persistent and excess worry about losing the attachment assessing separation assessment
anxiety disorder
figure.
• Excess worry about experiencing an untoward event Interviews Diagnostic Interview Schedule
for Children, 4th version (DISC-
(kidnap, accident, become ill) that may happen due to IV), Anxiety Disorders Interview
separation from attachment figure. Schedule for the DSM-IV, Child
• Persistent reluctance to go out of home or school due to Parent 4th version (ADIS-IV) and
fear of separation. Schedule for Affective Disorder
(SADS)
• Repeated nightmares.
• Reluctance to be alone without the attachment figure. Self-report scales Separation Anxiety Assessment
Scale for Children (SAAS-C)
• Refusal to sleep alone without the attachment figure.
Observation Dyadic Parent-Child Interaction
• Repeated physical complaints such as headache,
Coding System II (DPICS II) and
abdominal pain, leg pain and vomiting occur when Separation Anxiety Daily Diaries
separation from the attachment figure takes place. (SADD)
Preschool children Fear survey schedule for infants and
Nursing Management of Children with preschoolers and Infant–preschool
Separation Anxiety Disorder scale for inhibited behaviors

Assessment: Nurse should know about the four different

attachment styles. • Behavior therapy: It includes contingency management
1. Secure (child relies on caregivers for the emotional (positive reinforcement with verbal/rewards), systematic
support and protection). desensitization, modelling and guided imagery.
2. Anxious-avoidance, insecure (it occurs when infant • Parental counseling: Give counseling to the parents, so
avoids their parents). that it is helpful for the child to promote more autonomy
3. Anxious-ambivalent, resistant, insecure (infant feels and not to be over-protective in nature.
separation anxiety when separated from caregiver and • Psychotropic medications: Tricyclic antidepressants,
does not feel reassured when the caregiver returns to the antianxiety drugs and selective serotonin reuptake
infant). inhibitors (SSRI).
4. Disorganized (It occurs when there is lack of attachment
behavior). ATTENTION DEFICIT HYPERACTIVITY DISORDER
The types of scales used for assessing separation anxiety
Attention deficit hyperactivity disorder (ADHD) is a diagnosis
disorders have been given in Table 11.11.
as per DSM-5 and ICD-11 as explained in Table 11.12.
The three main features are as follows:
TREATMENT 1. Inattention
2. Hyperactivity
• Cognitive behavior therapy: It has three phases such
3. Impulsivity
as education, application into practice, and relapse
Symptoms should persist for at least 6 months. Symptoms
prevention. Educate the child that anxiety will affect the
have to be present both at home and school. Symptoms have to
physical/mental health. This therapy will enable the child
affect their academic performance and social behavior.
to recognize the anxious reaction and thereby the child
will reduce the response. According to Kendall, four Table 11.12: Attention deficit hyperactivity disorder as per ICD-11
components have to be taught to the children undergoing and DSM-5
cognitive behavior therapy such as:
Aspects ICD-11 DSM-5
1. Recognize the anxious feeling.
2. Discuss the situation which provokes anxiety. Age of onset Early to Mid-childhood 12 years
3. Develop the coping plan. Term Attention deficit hyperactive
4. Evaluate the effectiveness of coping plan. disorder
326 Textbook of Psychiatric Nursing for BSc Nursing Students

Epidemiology Inattention in ADHD

Attention deficit hyperactivity disorder is three times more Inattention in ADHD is characterized by forgetfulness,
common in males than females. Inattention is more common inability to sustain attention in any task, easily distracted
in females. Impulsivity and hyperactivity are more common toward an external stimulus, difficulty in organizing the work,
in males. ADHD is more common in low socioeconomic doing careless mistakes, often misplacing the objects, unable
group and in children who have been brought up in special to follow instructions and avoiding tasks which require more
homes. mental effort, e.g., doing homework.

Etiology Hyperactivity in ADHD

Idiopathic: Exact cause is unknown. However, the contributing Hyperactivity in ADHD is characterized by excess motor
factors are listed below: activity that is inappropriate to a situation, frequent moving
• Genetic factors: Family history of ADHD is having from one place to another in a classroom, being restless
greater risk of developing this disease. Monozygotic twins (commonly seen in older children), noisier and tendency to
have higher risk. Monozygotic twins are at greater risk run inappropriately.
than the dizygotic twins. Siblings of hyperactive children
are twice at risk of developing ADHD. Impulsivity in ADHD
• Biological factors: Monoamine dysfunction, fronto- Impulsivity in ADHD is characterized by tendency to act
striatal dysfunction, delayed cortical maturation and without thinking, excessively talking, interrupting the
encephalitis. conversations, answering before the question gets completed
• Environmental Factors: Use of food additives/artificial and not waiting in a queue.
colors and lead intoxication.
• Factors related to pregnancy and childbirth: Prenatal Diagnostic Criteria
exposure to toxins, smoking in pregnancy, babies with low DSM-5 Criteria for ADHD
birth weight, drug exposure during pregnancy, postnatal
The persistent pattern of inattention and/or hyperactivity-
infections, birth injuries, fetal distress, prolonged labor,
impulsivity which interferes in the functioning or development,
birth asphyxia and low APGAR score.
as characterized by points discussed in (1) and/or (2):
1. Inattention: Six (or more) of the following symptoms
ICD-11 and DSM-5 Classification of ADHD
must be present for at least six months with significant
ICD-11 DSM-5 Classification of ADHD impairment in the social and academic/occupational
6A05.0 314.00 Predominantly inattentive presentation activities:
6A05.1 314.01 Predominantly hyperactive/impulsive i. Doing careless mistakes in school work, or at work,
presentation or during other activities.
6A05.2 314.01 Combined presentation ii. He/she may find it difficult to sustain attention in
tasks or play activities.
6A05.Y 314.01 Other specified attention-deficit/
hyperactivity disorder iii. The child seems like not to listen when spoken
6A05.Z 314.01 Unspecified attention-deficit/
directly.
hyperactivity disorder iv. The child doesn’t follow the instructions and fails to
finish school work or duties at the workplace.
v. He/she may often dislike or avoid or feel reluctant to
Types of ADHD do the tasks which require sustained mental efforts.
• Predominantly hyperactive-impulsive type: Features of vi. He/she often has a difficulty in organizing the tasks.
hyperactivity and impulsivity are more prominent. vii. The child will often be forgetful in the daily activities.
• Predominantly inattentive type: Features of inattention viii. He/she will easily get distracted by external stimuli
are more prominent. ix. The child often loses necessary things required for
• Combined hyperactive impulsive and inattentive type: the completion of tasks or activities.
Features of hyperactivity, impulsivity and inattention are 2. Hyperactivity and impulsivity: Six (or more) of the
seen in children with ADHD in combined hyperactive following symptoms must be present for at least six months
impulsive and inattentive type. to a degree which is inconsistent with the developmental
CHAPTER 11 Child Psychiatry 327

level and that negatively impacts on social and academic/ • Impulsivity is a tendency to act in response to immediate
occupational activities: stimuli, without deliberation or consideration of the risks
i. Fidgeting with or tap hands or feet or squirms in and consequences (predominantly hyperactive/impulsive
seat. presentation—impulsivity symptoms are predominant).
ii. Often leaving seat in the situations when to remain • Combined presentation: Combination of both
seated in the place was expected. hyperactive/impulsive and inattentive symptoms present.
iii. Often running around in situations where it was • Persistent pattern (at least 6 months) of inattention
inappropriate. and/or hyperactivity-impulsivity, with onset during
iv. The child is often unable to play or being involved in the developmental period, typically early to mid-
leisure activities quietly. childhood.
v. He/she is often “on the go”, acting as if “driven by a • Degree of inattention and hyperactivity-impulsivity is
motor”. outside the limits of normal variation expected for age
vi. The child is often talk excessively. and level of intellectual functioning and significantly
vii. He/she often blurts out an answer before a question interferes with academic, occupational, or social
has been completed. functioning.
viii. The child is often having difficulty in waiting his or • The relative balance and specific manifestations of
her turn. inattentive and hyperactive-impulsive characteristics
ix. He/she often interrupts or intrudes on others. vary across individuals, and may change over the course
3. Several inattentive or hyperactive-impulsive symptoms of development.
should be present prior to 12 years of age. • In order to diagnose this disorder, behavior pattern has to
4. Several inattentive or hyperactive-impulsive symptoms be observable in more than one setting.
should be present in two or more settings (example–at
home, school or work; with friends or relatives; in other Nursing Management of Children with ADHD
activities).
• Educate the teachers/caregivers/parents that the child is
5. There are clear evidences that the symptoms will interfere
not blamed for his/her behavior.
or decrease the quality of social, academic or occupational
• Develop a trusting interpersonal relationship with
functioning.
the child. Convey to the child whether the behavior is
6. The symptoms may not occur exclusively during the
acceptable or not.
course of schizophrenia or other psychotic disorders
• Keep the sharp items away from the children because the
but they may not be better explained by another mental
child may get injured during the hyperactive movements.
disorder (Example–anxiety disorder, mood disorder,
• Ask the child to repeat the instruction before the
personality disorder, dissociative disorder, substance
commencement of any tasks.
intoxication or withdrawal).
• Ensure that the child is attentive when called by name and
also ensure whether the eye contact has been maintained
NOTE before any instructions.
Conner’s rating scale: Used to assess the severity of ADHD (Parents • Determine the goals daily and provide positive
and Teachers version is available). reinforcement step by step for the acceptable completion
of tasks.
• Give assistance to the child for the task completion and
ICD-11 Criteria for ADHD also reduce the assistance gradually to promote the
• Inattention refers to significant difficulty in sustaining independent actions.
attention to tasks that do not provide a high level of • Admit the child in special schools with a self-contained
stimulation or frequent rewards, distractibility and classrooms and quiet environment so that the child is not
problems with organization. distracted.
• Hyperactivity refers to excessive motor activity and • Parents’ training program as group sessions need to be
difficulties with remaining still, most evident in arranged and instructional materials have to be provided
structured situations that require behavioral self-control. with step-by-step explanation.
(Predominantly inattentive presentation—inattentive • Balanced diet and regular physical exercises might be
symptoms are predominant). helpful.
328 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 11.7: Medications for ADHD

• Behavior therapy is helpful especially if ADHD has Incidence and Prevalence

comorbid illness of conduct disorder.
It is more common in boys than girls. 5% of school
• Social skills training (Because children with ADHD lack
children have transient tics. Around 1% of school children
in social skill with peers due to disruptive behavior).
have either motor tics or vocal tics. Prevalence of Tourette’s
• Medications for ADHD are shown in Flowchart 11.7.
syndrome is 4/10,000 population. Among tics, vocal tics are
more common than motor tics and are more frequent in boys
NOTE than girls.
Atomoxetine is a drug of choice if ADHD is comorbid with Tourette
syndrome. Atomoxetine and Methylphenidate (Ritalin) might Etiology
cause priapism in males, i.e., prolonged painful penile erection.
Methyphenidate (ritalin) also causes weight loss in children so
• Idiopathic
growth/development has to be monitored regularly. • May be inherited as autosomal dominant disorder.

ICD-11 and DSM-5 Classification of Tic Disorders

Course and Prognosis
ICD-11 DSM-5 Classification of Tic disorders
Severity gets reduced when the child becomes older. ADHD
8A05.00 307.23 Tourette’s disorder
children show good prognosis if the psychosocial interventions
and medications are given together. ADHD children have low — 307.22 Persistent (Chronic) Motor or Vocal
Tic disorder
educational achievements. ADHD comorbid with conduct
disorder has high risk of developing antisocial personality — 307.21 Provisional Tic disorder
disorder and substance abuse disorder. — 307.20 Other Specified Tic disorder
— 307.19 Unspecified Tic disorder
TIC DISORDER

Tics is defined as sudden, nonrhythmic, involuntary, jerky

Classification of Tics
motor or vocal activity. Classification of Tics are shown in Flowchart 11.8.
CHAPTER 11 Child Psychiatry 329

Flowchart 11.8: Classification of Tics

• Disturbance is not attributable to the physiological effects

NOTE of a substance (e.g., cocaine) or another medical condition
(e.g., Huntington’s disease, post viral encephalitis).
Some patients might experience only vocal tics or only motor
tics. Many patients might experience Transient tics which will Classical Tic disorder has been named after Gilles de la
disappear after few months. Few patients may exhibit echolalia Tourette, a French physician, who was first person to describe
and echopraxia. this disorder. Tourette disorder is chronic, with combined
motor and vocal tics. Usually, motor tics precede the vocal tics
in Tourette disorder.
Features of Tics
Usually occurs in episodes or bouts with an urge or sensation Persistent (Chronic) Motor or Vocal Tic Disorder
initially before tics and sense of relief after the tics as shown in • Single or multiple motor or vocal tics have been present
Figure 11.3. during the illness, but not both motor and vocal.
• The tics may wax and wane in frequency but have
DSM-5 Diagnostic Criteria of Tic Disorders persisted for more than 1 year since first tic onset.
Tourette’s Disorder • Onset is before age 18 years.
• Disturbance is not attributable to the physiological effects
• Both multiple motor and one or more vocal tics have
of a substance (e.g., cocaine) or another medical condition
been present at some time during the illness, although not
(e.g., Huntington’s disease, post viral encephalitis).
necessarily concurrently.
• Criteria have never been met for Tourette’s disorder.
• Tics may wax and wane in frequency but have persisted
for more than 1 year since first tic onset. Specify if
• Onset is before age 18 years. With motor tics only with vocal tics only.

Figure 11.3: Episodes of Tic disorder

330 Textbook of Psychiatric Nursing for BSc Nursing Students

Provisional Tic Disorder Flowchart 11.9: Concept of sibling rivalry versus happy family

• Single or multiple motor and/or vocal tics.

• Tics have been present for less than 1 year since first tic
onset.
• Onset is before age 18 years.
• Disturbance is not attributable to the physiological effects
of a substance (e.g., cocaine) or another medical condition
(e.g., Huntington’s disease, post viral encephalitis).
• Criteria have never been met for Tourette’s disorder or
persistent (chronic) motor or vocal tic disorder.

Management
• History collection: Age of onset, course (continuous/
intermittent) and family history.
• Assessment: Rating scale used is Yale Global Tic Severity
Scale (YGTS). Assess for comorbid illnesses such as
Attention Deficit and Hyperactivity Disorder (ADHD),
Obsessive Compulsive Disorder (OCD), Autism spectrum
disorder and depression. If children have atypical features,
rule out dystonia or myoclonus or other neurological • Intensity: Rivalry increases when the age of both siblings
symptoms. is closer and when they are of same gender. When the
• Reassurance: Transient tics can be managed with severity increases, the expression of hostility (feel of
reassurance and routine monitoring. enmity) will be present toward the siblings.
• Behavior therapy • Behavior of children with high intensity: This in turn
„ Habit reversal training: It is the multi-component enhances the oppositional behavior toward the parents,
behavior treatment which is administered to treat dysphoria and temper tantrums in the form of anxiety or
the repetitive behavior of tics. It includes awareness social withdrawal.
training, competing response training (action • Causes: Child might feel that parents have love and
performed to replace the tic or impulsive behavior. affection toward the other child but not to self. Unresolved
For example, purse the lips for one who sticks out conflicts might also lead to sibling rivalry as shown in
the tongue repeatedly), contingency management, Flowchart 11.9.
relaxation training and generalization of new skills • Preventive strategies of sibling rivalry: Parents are
(Encouraging to practice new skills might control the advised to perform fun activities with feel of togetherness.
impulsive behavior). Parents are advised to spend time specifically with each
• Medications: Antipsychotics—haloperidol, risperidone, child. Teach the children how to gain the positive attention
pimozide, aripiprazole and other drugs such as clonidine, from parents in a positive way instead of expressing
guanfacine and tetrabenazine can be used. aggressively. Additional teaching is required to improve
• Deep brain stimulation: In case of treatment resistant the problem-solving skills and emotional intelligence.
tics, deep brain stimulation can be administered. Encourage the children to focus on win-win solutions as
a teamwork.
SIBLING RIVALRY
ENURESIS
Sibling rivalry refers to significant competition or animosity
among the siblings for the love and affection from parents and Introduction
is associated with unusual negative feelings. For example, elder Enuresis means urinary incontinence (involuntary passing of
son will think that my parents are showing love and affection urine). Bladder incontinence usually remains till the age of
to the younger ones only. four years. If continence has not developed beyond four years,
• Onset: It occurs following the birth of younger sibling. it is called enuresis.
CHAPTER 11 Child Psychiatry 331

„ Side-effects of medications: Diuretics and

NOTE antipsychotics.
„ Urinary tract infection
Purely diurnal enuresis is very rare condition and the secondary
enuresis might be due to some underlying emotional disorder. • Psychological factors: Death of parents, child of a
divorced parent, family disputes/conflicts and sexual
abuse.
Incidence and Prevalence • Social factors: Low socioeconomic status, improper toilet
Around 10% of children have enuresis at 5 years of age, 5% of training, etc.
children have enuresis at 10 years of age, 1% of children have Types of enuresis: Shown in Flowchart 11.10.
enuresis at 15 years of age. In regard to gender, diurnal enuresis
is common in females, nocturnal enuresis is common in males ICD-11 and DSM-5 Classification of Enuresis
and secondary enuresis is common in older children as shown
ICD-11 DSM-5 Classification of Enuresis
in Figure 11.4.
6C00 307.6 Enuresis
Etiology of Enuresis 6C00.0 — Nocturnal enuresis

• Genetic factors: Family history of enuresis might be the 6C00.1 — Diurnal enuresis
risk factor for the child to suffer with enuresis. 6C00.2 — Nocturnal and diurnal enuresis
• Biological factors: 6C00.Z — Enuresis, unspecified
„ Neurological—delay in the brain development,
Epilepsy and other neurological problems.
DSM-5 Diagnostic Criteria of Enuresis
„ Endocrine—reduced antidiuretic hormone and
diabetes. • Repeated voiding of urine into bed or clothes, whether
„ Renal/urological anomalies—unstable bladder and involuntary or intentional.
overactive bladder. • The behavior is clinically significant as manifested by
either a frequency of at least twice a week for at least
three consecutive months or the presence of clinically
significant distress or impairment in social, academic
(occupational), or other important areas of functioning.
• Chronological age is at least 5 years (or equivalent
developmental level).
• The behavior is not attributable to the physiological
effects of a substance (e.g., a diuretic, an antipsychotic
Figure 11.4: Common types of enuresis in females, male and medication) or another medical condition (e.g., diabetes,
older children spina bifida, a seizure disorder).

Flowchart 11.10: Types of enuresis

332 Textbook of Psychiatric Nursing for BSc Nursing Students

Specify whether: The alarm rings when urine makes contact with a
• Nocturnal only: Passage of urine only during nighttime sensor placed in the alarm.
sleep. „ Star chart: Child will get a star in calendar for each
• Diurnal only: Passage of urine during waking hours. non-enuresis night.
• Nocturnal and diurnal: A combination of the two • Medications: Tricyclic antidepressants (For example,
subtypes above. imipramine) and intranasal desmopressin (synthetic
antidiuretic hormone).
ICD-11 Diagnostic Criteria of Enuresis
ENCOPRESIS
• Repeated voiding of urine into clothes or bed, which may
occur during the day or at night, in an individual who has Introduction
reached a developmental age when urinary continence is
ordinarily expected (5 years). Encopresis is defined as repeated passage of feces at
• Urinary incontinence may have been present from inappropriate places or times after the bowel control is
birth (i.e., an atypical extension of normal infantile physiologically possible. There is no organic cause for this.
It is also called fecal incontinence. Toilet training is achieved
incontinence), or may have arisen following a period of
in 2–3 years of age whereas encopresis is termed when toilet
acquired bladder control.
training has not been achieved even after 4 years of age.
• Behavior is involuntary but in some cases it appears
intentional.
Epidemiology
• Enuresis should not be diagnosed if unintentional voiding
of urine is due to a health condition that interferes Encopresis is more common in males. 1–1.5% of children
with continence (e.g., diseases of the nervous system or develop encopresis by the age of 5 years. 25% of patients with
musculoskeletal disorders) or by congenital or acquired encopresis might also have enuresis.
abnormalities of the urinary tract.
Etiology
Specify whether:
• Nonorganic cause: Mental retardation, autism, childhood
• Nocturnal only: Passage of urine only during nighttime
schizophrenia, attention deficit and hyperactive disorder
sleep.
(ADHD), sibling rivalry, inadequate/inconsistent toilet
• Diurnal only: Passage of urine during waking hours.
training.
• Nocturnal and diurnal: A combination of the two
• Organic cause: Overflow diarrhea with constipation,
subtypes above.
inflammatory bowel disease, Hirschsprung’s disease,
hypothyroidism and neurological lesions
Management of Enuresis
• History collection: It helps to explore the family history Types of Encopresis are shown in Flowchart 11.11.
of enuresis.
• Physical examination: It helps to rule out the underlying Flowchart 11.11: Types of encopresis
organic cause for enuresis. It also helps to assess the type
of enuresis as primary, secondary, nocturnal, diurnal and
purely diurnal.
• Reassurance: Reassure the parents and children that
enuresis is a common condition.
• Behavioral strategies
„ Positive reinforcement: Motivate the children with
appreciation and reward for the absence of bed wetting
rather than criticizing or punishing the children.
„ Bell and pad technique/enuresis alarm: Bell and
pad technique involves the activation of alarm which
is connected to pad placed underneath the bedsheet.
CHAPTER 11 Child Psychiatry 333

ICD-11 and DSM-5 Classification of Encopresis There is no evidence of constipation on physical

examination or by history.
ICD-11 DSM-5 Classification of encopresis
6C01 307.7 Encopresis Treatment
6C01.0 — Encopresis with constipation or
overflow incontinence
Provide a consistent and adequate toilet training to the children.
Family support has to be given with proper understanding
6C01.1 — Encopresis without constipation
or overflow incontinence and family members might have a direct communication.
Emotional disturbances of child have to be identified early and
6C01.Z — Encopresis, unspecified
treated on priority.
• Behavior therapy: Provide positive and negative
DSM-5 Diagnostic Criteria of Encopresis
reinforcement to correct the maladaptive behavior.
• Repeated passage of feces into inappropriate places • Antidepressants: Imipramine is the drug of choice.
(e.g., clothing, floor), whether involuntary or intentional. • Miscellaneous: Psychotherapy and biofeedback.
• At least one such event occurs each month for at least
3 months. SCHOOL REFUSAL OR SCHOOL PHOBIA
• Chronological age is at least 4 years (or equivalent
developmental level). Introduction
• The behavior is not attributable to the physiological Children with school phobia refuse to go to school because of
effects of a substance (e.g., laxatives) or another medical fear. If parents attempt to convince the child, then the child
condition except through a mechanism involving may start pleading, crying, etc. and prefer to stay at home.
constipation. Child may also verbalize the multiple somatic complaints
Specify whether: such as headache, backache, abdominal pain, etc. and tries to
• With constipation and overflow incontinence. give excuses so that the child is allowed to stay at home. These
• Without constipation and overflow incontinence. somatic symptoms only occur when the child is leaving the
home and starting to go to the school (Table 11.13).
ICD-11 Diagnostic Criteria of Encopresis Table 11.13: School refusal versus truancy
• Repeated passage of feces in inappropriate places.
• Encopresis should be diagnosed if inappropriate passage School refusal Truancy
of feces occurs repeatedly (e.g., at least once per month Children refuse to go to school Children leave the school and
because of fear. go somewhere else without
over a period of several months) in an individual who has
the knowledge of parents
reached the developmental age when fecal continence is
ordinarily expected (4 years).
• The fecal incontinence may have been present from Epidemiology
birth (i.e., an atypical extension of normal infantile Prevalence is about 1% among school going children.
incontinence), or may have arisen following a period of Prevalence is equal in boys and girls.
acquired bowel control.
• Encopresis should not be diagnosed if fecal soiling is fully Management
attributable to another health condition (e.g., aganglionic
Behavior therapy is helpful to a large extent. Involve the parents
megacolon, spina bifida, dementia), congenital or
and teachers in health teaching so that teacher might offer extra
acquired abnormalities of the bowel, gastrointestinal
time for special coaching to the child in order to compensate
infection, or excessive use of laxatives.
for the missed hours of classes. If school refusal is found
Specify whether: chronic, ‘Systematic Desensitization’ has to be done by gradual
• With constipation and overflow incontinence: There is increase in the duration of time spent at school. Changing the
evidence of constipation on physical examination or by school is generally not advisable until the teachers are unable
history. to tackle this problem. Administer antidepressants if the
• Without constipation and overflow incontinence: depressive symptoms are identified.
334 Textbook of Psychiatric Nursing for BSc Nursing Students

SLEEP DISORDERS IN CHILDREN FEEDING DISORDER OF INFANCY AND

CHILDHOOD
Nightmares
Refusal of food and more food fads (highly adhere to one food
Children may wake up after the frightening dreams. The
item) in the presence of variety of available foods. There is no
themes of dreams are threat to survival or self-esteem. Dreams
organic disease. This may or may not be associated along with
are recalled but they are vivid in nature and also cause marked
rumination disorder (regurgitation and chewing of food items
distress. It occurs in second half of night time sleep (REM
without nausea or gastric problems).
Sleep). It is more common in females and usually starts at the
age of 3–6 years.
PICA
Management: Identify the root cause because in some
individuals, nightmares may be due to sudden stoppage of Pica is characterized by eating the nonedible substances.
psychotropics (REM rebound) or as a symptom of Post- It has already been explained in detail in Chapter 10 (eating
Traumatic Stress Disorder (PTSD). disorder).

Night Terrors or Sleep Terrors STEREOTYPED MOVEMENT DISORDERS

Child gets up from the sleep with panic, screaming and high
These are characterized by repetitive, voluntary, rhythmic and
level of anxiety. It occurs in third stage of night time sleep
nonfunctional movements which are not considered peculiar
(NREM Sleep). An episode of amnesia after awakening from
psychiatric or neurological issues.
the bed with a short duration of confusion is present.
Signs of stereotyped movement disorders are movements
such as body rocking, finger flicking, hair plucking, hand
Somnambulism
twisting, head banging and hand flapping.
Somnambulism refers to walking during the sleep. Child rises Treatment focuses on steps taken to modify this
from the bed and walks during night time. Blank staring face unacceptable behavior using scheduled behavior strategies
and unresponsiveness are present during Somnambulism. and individual/family psychotherapy.
Child can be woken up during walking in sleep with a
considerable effort. It occurs in first third stage of night time CHILD ABUSE OR CHILD BATTERED SYNDROME
sleep (NREM Sleep).
Child abuse is defined as physical, psychological or sexual
Management of Night Terrors and maltreatment of child or neglecting the child by caregivers.
Somnambulism
Classification as per World Health Organization
‘Scheduled Awakenings’—Awake the child prior to the
expected time of episode and allow the child to get back to the • Physical abuse: For example, beating, biting, burning,
sleep again. poisoning and suffocating the child.
Drugs: Benzodiazepine is advisable. • Sexual abuse: For example, stimulating a child for sex,
Other sleep disorders such as Obstructive Sleep apnea, action toward physical gratification, etc.
Insomnia, Narcolepsy, REM sleep disorder, etc. are also • Emotional or psychological abuse: For example,
commonly seen in adults. scolding, exploiting and isolating the child.
• Child neglect: For example, mother not taking care the
MISCELLANEOUS ADULT PSYCHIATRIC child. It involves two acts:
DISORDERS PRESENT IN CHILDREN i. Act of omission or neglect: Not taking care of child
(For example, not giving feed or clothing or education,
• Childhood onset schizophrenia etc.).
• Anxiety disorders Sub-Categories of Neglectful Act are as follows:
• Mood disorders ◆ Supervisory neglect: Absence of parent’s
• Eating disorders supervision leads to harm/abuse or any
• Dissociative disorders involvement in criminal activities.
CHAPTER 11 Child Psychiatry 335

◆ Physical neglect: Fails to provide basic physical FOLLOW-UP, HOME CARE AND REHABILITATION
things such as safe home, clothing, etc. FOR CHILDHOOD PSYCHIATRIC DISORDERS
◆ Medical neglect: Fails to provide the medical care
◆ Emotional neglect: Lack of encouragement and • Teach the parents regarding the milestone development,
disorders of childhood with their symptoms, behavior,
psychological support from caregivers.
treatment strategies and age-appropriate development
◆ Educational neglect: Fails to provide education.
tasks.
◆ Abandonment: Caregivers leave the child alone
• Educate the family members regarding the importance of
for long period of time.
reinforcing the acceptable behavior to the child in order
ii. Act of commission or performing abuse: When a
to promote the positive qualities in children.
parent/caregiver severely/violently abuses the child
• Teach the family members to identify the possible
either physically or sexually, it leads to subdural stressors that affect the children to behave in aggressive
hemorrhage, cerebral edema and cerebral hemorrhage. or disruptive way.
This problem is termed shaken baby syndrome. • Adequate information needs to be given to the parents in
regard to the special schools and local self-help groups
Nursing Management which are available for mentally challenged children and
Nurse has to involve the child in activities like playing and also create awareness about government policies which
drawing in order to ventilate the feelings related to abuse. are available to uplift those children in the society.
Communicate the children honestly as per age. Do not
blame the children for the abuse happened to them. Provide EXTRA EDGE
psychological support and ensure safe environment. Identify
limits and boundaries. Explain the appropriate behavior Classification of Child Psychiatry (ICD-10)
to children. Give counseling. Blood test has to be done to • F70-F79 Mental retardation
▪ F70 Mild mental retardation
identify the toxicity. Drugs have to be administered to combat ▪ F71 Moderate mental retardation
Hepatitis B and HIV/AIDS. Antidepressants, antianxiety and ▪ F72 Severe mental retardation
antibacterial drugs have to be administered based on the needs. ▪ F73 Profound mental retardation
• F80-F89 Disorders of psychological development
Legal Support to Prevent Child Abuse ▪ F80 Specific developmental disorders of speech and
language
Protection of Children Against Sexual Offences Act (POCSO ▪ F81 Specific developmental disorders of scholastic skills
–2012) and Immoral Traffic Prevention Act, 1956 are aimed to ▪ F82 Specific developmental disorders of motor function
fight for child rights to prevent the child abuse ▪ F83 Mixed specific developmental disorders
▪ F84 Pervasive developmental disorders
Parents and Nurse’s Role to Prevent Sexual • F90-F98 Behavioral and emotional disorders with onset
usually occurring in childhood and adolescence
Abuse in Children ▪ F90 Hyperkinetic disorders
Teach the children, differences between Good Touch and ▪ F91 Conduct disorders
▪ F93 Emotional disorders with onset in childhood
Bad Touch when strangers or any family members are
▪ F94 Disorders of social functioning specific to
allowed to touch the body parts such as hands, legs and adolescence and childhood
forehead. For example, Strangers are not allowed to touch the ▪ F95 Tic disorders
private parts. If so happened, the child has to say ‘STOP’ and ▪ F98 Other behavioral and emotional disorders with onset
in childhood and adolescence
also say ‘You are not allowed to touch me here’ as such.
336 Textbook of Psychiatric Nursing for BSc Nursing Students

SUMMARY
• Child psychiatry deals with the assessment and treatment of children’s behavioral and emotional problems.
• Mental retardation is defined as, ‘sub-average intellectual functioning that results in or is associated with concurrent impairment in
adaptive behavior and manifested during the development.’
• Stuttering/stammering/childhood onset fluency disorder is a disorder of speech characterized by disturbances in fluency or rhythm of
speech, blocking of speech intermittently, rapid repetition of words, sounds get prolonged and anxiety or distress is present.
• Disorders of language include dysphasia or developmental language disorder, dyslalia or phonological disorder or developmental
articulation disorder, receptive language disorder, expressive language disorder and other developmental disorders of language.
• Pervasive developmental disorder is characterized by abnormalities in social interaction and communication skills. It includes autism,
Asperger’s syndrome, Rett’s syndrome and childhood disintegrative disorder.
• ADHD is a persistent pattern of inattention and/or hyperactivity seen in children.
• Conduct disorder is defined as a repeated and pervasive pattern of age-inappropriate behavior that violates the basic rights.
• Juvenile delinquency refers to an act committed by an individual who is below the age of 16 (18 years in case of females) but is involved
in antisocial activities.
• Separation anxiety disorder occurs in children when separation takes place from the attachment figure.
• Tics is an abnormal involuntary movement which is sudden, repetitive, rapid and purposeless. It is classified into verbal and motor tics.
When tics are chronic, it is termed Tourette’s syndrome.
• Involuntary voiding of urine is enuresis and involuntary defecation is encopresis.
• School refusal means the children refuse to go to school because of fear. Truancy means the child will leave the school and go elsewhere.
• Pica is characterized by eating the nonedible substances.
• Stereotyped movement disorder is characterized by repetitive, voluntary, rhythmic and nonfunctional movements which is not
considered a peculiar psychiatric or neurological issue.
• Sleep disorders in children include Night terrors or Sleep Terrors, Somnambulism and Nightmares.

ASSESS YOURSELF

Long Answer Questions Multiple Choice Questions

1. Define intellectual disability. Write the etiology, classifi- 1. Drug of choice for children with ADHD is
cation, manifestations, prevention and management of ____________.
children with mild intellectual disability. a. Methylphenidate b. Haloperidol
2. Define pervasive developmental disorders. Describe the c. Lorazepam d. Chlorpromazine
etiology, classification, manifestations, prevention and
2. Craving and eating of nonedible items are:
management of children with autism.
a. Polyphagia b. Pica
3. Define ADHD. Write the etiology, classification,
c. Enuresis d. Anorexia nervosa
manifestations, prevention and management of children
with ADHD. 3. IQ level with two to three standard deviations below
the mean (approximately 0.1 – 2.3 percentile) denotes
Short Answer Questions ____________.
1. Write about nursing management of patient with mental a. Mild MR b. Moderate MR
retardation. c. Severe MR d. Profound MR
2. Define school phobia and school refusal. 4. ___________ is defined as a repeated and pervasive
3. What is separation anxiety disorder? pattern of age-inappropriate behavior that violates
the basic rights.
Short Notes a. Conduct disorder b. Mental retardation
Write short notes on: c. Autism d. ADHD
1. Tics disorder 5. An abnormal involuntary movement which is
2. Enuresis and encopresis sudden, repetitive, rapid and purposeless is termed
3. Sibling rivalry disorder ____________.
4. Conduct disorder a. Tics
5. Juvenile delinquency b. Conduct disorder
6. Child abuse c. Juvenile delinquency
7. Dyslexia d. Neurological disorder
CHAPTER 11 Child Psychiatry 337

6. Drug of choice to treat enuresis is ____________. 9. Bell pad technique is a behavioral strategy used to
a. Antianxiety drugs b. Antidepressants prevent ____________.
c. Sedatives d. Antipsychotics a. Nail biting b. Enuresis
7. Pervasive developmental disorder includes ________. c. Insomnia d. nightmares
a. Autism 10. Prioritized nursing management for children who
b. Asperger’s syndrome involve in head banging ____________.
c. Rett’s syndrome a. Safety measures b. Psychotropic drugs
d. All of the above c. Counseling d. Psychotherapy
8. A child is educated about the good touch and bad
Answer Key
touch in order to prevent ____________.
1. a 2. b 3. a 4. a 5. a
a. Child abuse b. Suicide
c. Sibling rivalry d. Conduct disorder 6. b 7. d 8. a 9. b 10. a
Notes
Nursing Management of CHAPTER
Patients with Organic
Brain Disorders or
Neurocognitive Disorders
12
LEARNING OBJECTIVE

After studying this chapter, the student will be able to understand the concepts of organic brain disorders and render the quality nursing
care to patients with organic brain disorders.

CHAPTER OUTLINE
• Organic Brain Disorders or Neurocognitive Disorders • Dementia (ICD-11) or Mild and Major Neurocognitive
• Delirium Disorders (DSM-5)
• Proper Communication Strategies for Patients with Organic • Nursing Management of Patients with Organic Brain
Brain Disorders Disorders
• Nursing Management • Geriatric Considerations
• Amnesia

KEY TERMS
Delirium, Dementia, Amnesia, Alzheimer’s disease, Lewy body dementia, Vascular dementia, Pick’s disease, Huntington’s chorea,
Parkinson’s disease, Tryptophan regulation Concept, Hypoactive delirium, Hyperactive delirium, Mixed delirium, Sundown syndrome,
Dyssomnia, Dysarthria, Prosopagnosia, Bradyphrenia, Klüver-Bucy syndrome, Catastrophic reaction, Bradyphrenia, Binswanger’s
disease.

ORGANIC BRAIN DISORDERS OR Organic brain disorders are neuropsychiatric disorders

NEUROCOGNITIVE DISORDERS that have a strong biological basis or a significant brain
dysfunction.
Definition
Classification of Organic Brain Disorders
Organic brain disorders are disorders of mental function in
Organic brain disorders are classified into delirium, dementia,
which the causative factor might be physiological rather than
amnesia and others as shown in Flowchart 12.1.
purely related to mind. The psychological dysfunction happens • Based on the etiology, it is classified into primary
due to the damage which had occurred in brain. Two main (intracranial causes) and secondary causes such as
causes of organic brain disorders are brain injury and diseases systemic infections, metabolic causes, endocrine causes,
that affect brain. nutritional factors and medications.
340 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 12.1: Classification of organic brain disorder

• Based on motor dysfunctions, it is classified into • Older age of onset

hyperactive, hypoactive and mixed. • History of alcohol or substance abuse
• Classification of amnesia and dementia have been • Neurological signs and symptoms
displayed through figures later in this chapter. Other • Memory impairment
types of organic brain disorders are classified into • Prominent visual or nonauditory hallucination
organic hallucinosis, organic delusional disorder, organic
mood disorder, organic personality disorder, organic Predisposing Factors
dissociative disorder, organic emotionally labile disorder. • Demographic status: Presence of age extremes (very old
or young) and being a male person.
ICD-11 Classification of Neurocognitive
• Functional status: Immobility, history of falls, functional
Disorders or Organic Brain Disorders
dependent and low performance in activity.
(Block L1-6D7)
• Cognitive status: History of delirium, dementia and
• 6D70 Delirium memory impairment.
• 6D71 Mild neurocognitive disorder • Sensory problems: Visual disturbances and hard of
• 6D72 Amnestic disorder hearing.
• 6D80 Dementia • Surgery: Orthopedic surgery and cardiac surgery
(cardiopulmonary bypass).
DSM–5 Classification of Neurocognitive • Environmental factors: Admission in intensive care
Disorders or Organic Brain Disorders unit, stress, use of physical restraints, patients on
• Delirium urinary catheterization and having disturbances in sleep
• Major and mild neurocognitive disorder pattern.
• Neurological, endocrine and metabolic disorders
Features of Organic Brain Disorders • Miscellaneous: Fever, hypothermia, infections, hypoxia,
shock, anemia, dehydration, poor nutritional status and
The classical features of organic brain disorders are listed
decreased serum albumin level.
below:
• First episode Synonymous terms for delirium and dementia have been given
• Acute onset in Table 12.1.
CHAPTER 12 Nursing Management of Patients with Organic Brain Disorders... 341

Table 12.1: Synonymous terms for delirium and dementia Etiology

Delirium Dementia Mnemonic
• Acute confusion state • Chronic brain syndrome I WATCH DEATH
• Organic brain syndrome • Chronic brain failure I : Infections (Urinary tract infections, pneumonia,
• Acute organic reaction septicemia, endocarditis)
• Toxic psychosis
W : Withdrawal (Opioids, alcohol)
• Metabolic encephalitis
A : Acute metabolic (Acidosis/alkalosis, renal failure)
T : Trauma
C : CNS pathology (Epilepsy, cerebral hemorrhage, head
Etiology of Organic Brain Disorders
injury, encephalitis, Subarachnoid
The causes of organic brain disorders have been described hemorrhage, migraine, stroke, focal
in Flowchart 12.2. In general, the causes are classified into lesions)
primary (intracranial) and secondary (other than brain H : Hypoxia
related causes). The secondary causes are metabolic causes, D : Deficiencies (Cyanocobalamin, thiamine, folic acid,
endocrine causes, nutritional deficiency, systemic infections, niacin, pyridoxine)
medications, etc. E : Endocrine (Thyroid, parathyroid, pituitary, adrenal)
A : Acute vascular (Stroke, myocardial infarction,
DELIRIUM pulmonary embolism, heart failure)
T : Toxins/drugs (Tramadol, digoxin toxicity, antianxiety
Definition agents, sedatives, hypnotics, anticholin-
• An acute confusional state with disturbances in level of ergics, corticosteroids, antihypertensives,
consciousness and reduced ability to focus, sustain, or anticonvulsants, barbiturates, furose-
shift attention. mide, theophylline, cimetidine, predniso-
• A change in the level of cognition, perceptual disturbances lone, captopril, tricyclic antidepressants)
which are not due to preexisting dementia. H : Heavy metals

Flowchart 12.2: Etiology of organic brain disorder

342 Textbook of Psychiatric Nursing for BSc Nursing Students

Mnemonic • 6D70.3 Delirium due to unknown or unspecified

DELIRIUM etiological factors.
D : Drugs
DSM-5 Classification of Delirium
E : Eyes/ears
L : Low oxygen Table 12.2 shows the classification of neurocognitive disorders.
I : Infection Table 12.2: Neurocognitive disorders
R : Retention of urine/stool
I : Ictal Neurocognitive disorders
U : Under-hydration and Under-nourishment 292.81 Medication-induced delirium
M : Metabolic 293.0 Delirium due to another medical condition or
delirium due to multiple etiologies
780.09 Other specified delirium or unspecified delirium
CLINICAL IMPLICATION
Tryptophan Regulation Concept
Stimulation of serotonin will increase melatonin. The melatonin Types of Delirium According to DSM-5 on the
will enhance sleep (hypersomnia) and further it will lead to Basis of Activity Level
hypoactive delirium. Increased N-dimethyltryptamine might lead Hypoactive Delirium
to agitation which is seen in hyperactive delirium. A combination
of both hypoactive delirium and hyperactive delirium is termed Patient will have intermittent sleep on and off for entire day.
mixed delirium. Symptoms of hypoactive and hyperactive delirium Patient will also have inattention while awake and fall into sleep
have been described in Flowchart 12.3. very soon. Patient might miss medications/appointments/
Flowchart 12.3: Tryptophan regulation concept meals.

Hyperactive Delirium
Patient will be highly active due to response of increased
internal stimuli.

Mixed Delirium
It is a combination of both hypoactive and hyperactive forms.
Majority of elders with delirium (80%) belong to mixed and
hypoactive type (Fig. 12.1).

Pathophysiology
In general, pathophysiology of delirium is idiopathic. The
neurotransmitters such as dopamine and serotonin might
increase in delirium. Inflammatory mechanism such as
cytokines, e.g., release of interleukin-1 from cells might occur
in delirium. Cerebral oxidative metabolism decreases. Elders
with impaired cholinergic transmission are prone to develop
delirium. Increased action of the hypothalamic-pituitary
adrenal (HPA) axis and other factors such as stress, sleep
disturbances and disturbed blood-brain barrier (BBB) also
contribute to the development of delirium.

ICD-11 Classification of Delirium Clinical Manifestations of Delirium

6D70 Delirium • Acute onset (less than 6 months).
• 6D70.0 Delirium due to disease classified elsewhere. • Clouding of consciousness (decreased awareness to the
• 6D70.1 Delirium due to psychoactive substances surrounding or external stimuli).
including medications. • Disorientation to time and place is common; and
• 6D70.2 Delirium due to multiple etiological factors. disorientation to person is rare.
CHAPTER 12 Nursing Management of Patients with Organic Brain Disorders... 343

Figure 12.1: Types of delirium

• Perceptional disturbances: Illusion and visual • Occupational delirium: It refers to the repetitive behavior
hallucination. seen in patients who act as if they are continuing their
• Sleep wake cycle disturbances: Insomnia during night usual occupation.
time and drowsiness in day time. • Motor/verbal perseveration
• Sundown syndrome or sundowning: Worsening of • Dyssomnia: Primary sleep disorder, difficulty in initiation
symptoms in evening (diurnal variation). Symptoms of or maintenance of sleep.
sundown syndrome such as wandering, mood swings, • Agraphia: Inability to write (language disorder due to
disorientation, insomnia, resistance, confusion and brain damage).
hallucination are present as shown in Figure 12.2. • Impairment in comprehension
• Memory disturbances: Impairment in registration and • Mood alteration (dysphoria/euphoria)
retention.
DSM-IV and 5 criteria of delirium have been given in
• Speech disturbances: Slurring of speech, Incoherence
Table 12.3.
in speech, dysarthria (motor speech disorder/difficult in
articulation of speech) and fleeting delusion (short lasting Table 12.3: DSM-IV and 5 criteria of delirium
delusion). DSM-IV criteria of delirium DSM-5 criteria of delirium
• Motor disturbances: Asterixis, multifocal myoclonus and
• Disturbances in • Disturbance in attention or
flocculation/carphologia. consciousness with cognition
• Labile affect decreased ability to focus, • Acute abrupt onset
sustain or shift attention • Changes from the baseline
• Change in cognition or • Fluctuating in nature
development of perceptual • Unable to explain
disturbance that is not completely by chronic
accounted well for a pre- psychiatric disorder
existing, existing or evolving • Impairment levels do not
dementia • occur in context of coma
• Rapid onset and fluctuation
in the course of illness

DSM-5 Diagnostic Criteria for Delirium

• A disturbance in attention (decreased ability to focus,
direct, sustain, and shift attention) and awareness
(decreased orientation to environment).
• Disturbances present over a short duration of time (hours
to a few days), represent a change from the baseline
attention and awareness, may tend to fluctuate in severity
during the course of a day.
• Presence of additional disturbance in cognition such as
memory deficit, language, disorientation, visuospatial
Figure 12.2: Symptoms of sundown syndrome ability and perception.
344 Textbook of Psychiatric Nursing for BSc Nursing Students

• The disturbances in attention and cognition are not better Confusion Assessment Method (CAM)
explained by another neurocognitive disorder and will 1. Acute onset and fluctuating course
not occur in context of severely decreased level of arousal 2. Inattention
such as coma. 3. Disorganized thinking
• Evidence obtained from history, physical assessment, 4. Impaired level of consciousness
lab findings that this disturbance is said to be a direct
Along with 1 and 2 criteria, 3 or 4 has to be present to diagnose
physiological consequence of substance intoxication or
withdrawal, another medical condition or due to multiple delirium.
etiologies. Mini mental status examination (MMSE) is used to assess
cognition.
Specify if:
• Delirium due to substance intoxication CT Scan/MRI
• Delirium due to substance withdrawal Dysfunction in prefrontal cortex, frontal/temporoparietal
• Delirium due to another medical condition cortex, fusiform cortex, subcortical region, basal ganglion,
• Medication-induced delirium thalamus and lingual gyri (particular with nondominant part
• Delirium due to multiple etiologies of brain).
• Acute (lasting for a few hours or days) or persistent
(lasting for weeks or months) Miscellaneous
• Hypoactive or hyperactive or mixed level of activity. Complete blood count (CBC), urine analysis,
electrocardiogram (ECG) and electroencephalogram (EEG)
ICD-11 Diagnostic Criteria for Delirium show slowing of brain activity and sometimes focal areas of
• Delirium is characterized by disturbed attention hyperactivity.
(decreased ability to focus, direct, sustain and shift
attention) and awareness (reduced orientation to Differential Diagnosis
environment) which develops over a short period of time Delirium versus Schizophrenia
and tends to fluctuate during the course of a day.
Onset of schizophrenia is rare after 50 years of age. Auditory
• Disturbed attention and awareness are accompanied
hallucinations are common in schizophrenia, whereas
by other cognitive impairment such as disorientation,
visual hallucinations are common in delirium. Memory is
memory deficit, language impairment, visuospatial ability
found to be grossly intact in schizophrenia. Disorientation
or perception.
occurs rarely in schizophrenia. Dysarthria (difficult in
• Disturbance in the sleep-wake cycle (decreased arousal of
articulation of speech) is not present in schizophrenia. No
the acute onset or the total sleep loss with the reversal of
significant fluctuations are seen over the course of the day in
sleep-wake cycle) may be present.
schizophrenia.
• Symptoms attributable to disease are not classified under
the mental and behavioral disorders or due to substance Delirium versus Mania
intoxication or withdrawal or due to a medication.
• In mania, client may be very agitated; however, cognition
usually does not decline.
Diagnosis
• Flight of ideas in mania usually has little coherence and
History Collection is not as distractible in nature. Disorientation is not
Collateral history from family members or friends with regard common in mania.
to baseline functions, pre-morbid personality and psychiatry
history must be collected from the patient. Delirium versus Dissociative Disorder
Spotty amnesia due to cognitive impairment.
Interview
Structured interview focuses on concentration, somnolence Delirium versus Depression
deficit, mood lability, ability of execution, short-term memory Table 12.4 shows the differences between dementia and
deficits and mobility. pseudodementia (depression).
CHAPTER 12 Nursing Management of Patients with Organic Brain Disorders... 345

Table 12.4: Differences between dementia and pseudodementia (depression)

Aspects Dementia Pseudodementia (Depression)

Complaints of cognitive impairment Rarely Mostly
Emphasis achievements • Patient emphasizes achievements • Patient emphasizes disability
• Patient is unconcerned about symptoms • Patient communicates distress
Mood Labile affect Depressed
Mental status exam • Makes mistakes Patient says, ‘Don’t know’ as answer to
• Impairment of recent memory most of the questions
• Confabulation
• Poor performance test
History No such history of dementia History of depression
Age group (More common) Elders Nonspecific
Organic symptoms Yes No
CT and EEG Abnormal Normal
Cooperation of the patient Cooperative Uncooperative
Cognitive impairment Present Absent
Benzodiazepines and barbiturates Worsen the disease May improve sleep only

Delirium versus Dementia

Table 12.5 shows the differences between delirium and dementia.
Table 12.5: Delirium versus dementia

Aspects Delirium Dementia

Onset Acute Gradual/insidious
Nature Reversible Irreversible
Duration Days to weeks Months to year
Course Fluctuating Progressive
Attention Impaired Normal until severe
Consciousness Fluctuating/altered Rarely alters/clear
Decreased awareness of self Present Present
Perception Illusions and hallucinations are common Hallucinations not common
Speech Slow and incoherent Repetitive difficulty in finding words
Disorientation Disorientation to time is common Disorientation to time, person and place occurs
Illness, medicine toxicity Often Rarely
Outcome Excellent, if corrected early Poor
Diurnal disruptions Present Present
Psychomotor changes Increased/decreased Often normal

PROPER COMMUNICATION STRATEGIES FOR • Use of language: Use short phrases and simple language.
PATIENTS WITH ORGANIC BRAIN DISORDERS • Repeat, rephrase and repair
„ Repeat: Help to fill speech. For example, I would like
• Getting patient’s attention: Stand in front of patient, to eat ____. If nurse repeats this, elders might add
maintain eye to eye contact and turn off noise in rice, dosa, etc.
environment. „ Rephrase: Help the elders to get correct response.
• Use closed-ended questions: For example, are you having E.g., if elder says juice, nurse might point out the
pain? are you feeling hungry? juice and say that, do you like to have a glass of
• Tone of voice: Do not shout and speak slowly. juice?
346 Textbook of Psychiatric Nursing for BSc Nursing Students

„ Repair: Use tactics to fill the missing information. For Music therapy, light therapy, use of hearing or visual aids
example, if elders point out canteen, nurse can ask the and involvement of family members in rendering nursing care
elder, are you feeling hungry? are found helpful. Steps have to be taken to normalize sleep-
• Orient and reorient frequently: Use of visual and hearing wake cycle.
aids, orientation is needed toward place, person and time
using calendar/clock. AMNESIA
• Use therapeutic touch
• Be a good listener Definition
• Do not argue with elders Amnesia refers to complete or partial loss of memory.
Cognitive functions of brain have been given in Table 12.6.
NURSING MANAGEMENT Table 12.6: Cognitive functions of brain
Identify the underlying cause and treat it. Complete lab Parts of brain Cognitive functions
investigation is required to identify the comorbid illness. Frontal Understanding behavior of others, problem
Medications are not first line treatment because psychotropics solving, plan ahead
may increase delirium. Nursing care of agitated/violent/ Parietal Control hearing, speech, language
noncooperative patients is included.
Amygdala Emotional responses are directed
Reorient training with the use of: Corpus callosum Passing information from one part to other
• Calendar: Orientation of date/day
• Clock: Orientation of time Functions and malfunctions of memory systems along with
• Family photos: Orientation of person parts of brain involved have been given in Table 12.7.
• Windows/clouds: Orientation of place/season (Fig. 12.3) Table 12.7: Memory systems—its functions, parts involved and its
malfunctions
Antipsychotics
Memory Functions Parts of brain Malfunctions
• Haloperidol 0.5–1 mg (must be avoided in patients with systems involved
hypotension, tachycardia and arrhythmias). Working Execution Prefrontal cortex Anterograde
• Risperidone (risperdal 0.5–2 mg) used in elders with memory and retrograde
dementia and it increases risk of stroke by three times. Episodic Recall Diencephalon, amnesia
i. Quetiapine 12.5–50 mg memory medial and
ii. Olanzapine 2.5–10 mg temporal lobe
iii. Benzodiazepines—For example, lorazepam 0.5–1 mg Semantic Funds of Temporoparietal Impairment in
orally. Physostigmine (antidote for anticholinergics) memory knowledge intelligence
will help to reverse the delirium that occurs due to Procedural Learning the Basal ganglion Impairment in
anticholinergics. memory skills skill learning

Figure 12.3: Reorientation training for patients with organic brain disorders
CHAPTER 12 Nursing Management of Patients with Organic Brain Disorders... 347

Types of Amnesia • 6D72.1 Amnestic disorder due to psychoactive

substances including medications.
Amnesia is classified into acute and chronic based on the
• 6D72.10 Amnestic disorder due to use of alcohol.
duration. On the basis of causative factors, amnesia could be
classified into amnesia due to general medical condition, due to • 6D72.11 Amnestic disorder due to use of sedatives,
effect of chemicals, thiamine deficiency and others. In general, hypnotics or anxiolytics.
amnesia is classified into transient global amnesia, transient • 6D72.12 Amnestic disorder due to other specified
epileptic amnesia, anterograde amnesia, retrograde amnesia, psychoactive substances including medications.
lacunar amnesia and dissociative amnesia as described in • 6D72.13 Amnestic disorder due to use of volatile
Flowchart 12.4. inhalants.
• Transient global amnesia: Sudden temporary episode of • 6D72.2 Amnestic disorder due to unknown or
memory loss. unspecified etiological factors.
• Transient epileptic amnesia: Memory loss due to • 6D72.Y Other specified amnestic disorder.
epilepsy either in ictal or postictal period. • 6D72.Z Amnestic disorder, unspecified.
• Anterograde amnesia: Inability to create new memories
due to brain damage. ICD-11 Diagnostic Criteria
• Retrograde amnesia: Inability to recall before the onset • Amnestic disorder is characterized by severe memory
of amnesia. impairment relative to individual’s age and general level
• Lacunar amnesia: Partial loss of memory or memory loss of intellectual functioning which is disproportionate to
of specific events. the impairment in other cognitive domain.
• Dissociative amnesia: Amnesia is purely psychogenic • It is manifested by severe deficit in memories or learning
due to intrapsychic conflicts. new concepts or inability to recall the previously learned
• Prosopagnosia or face blindness or facial agnosia: A one, without disturbance of consciousness or cognitive
neurological disorder characterized by the inability to impairment.
recognize faces.
• Recent memory is more disturbed than the remote
memory; and immediate recall is usually preserved.
ICD-11 Classification of Amnestic disorder
• Memory impairment may be due to underlying
6D72 Amnestic disorder neurological condition, injury, infection, tumor or other
• 6D72.0 Amnestic disorder due to diseases classified disease which affect the specific areas of brain or due to
elsewhere. chronic use of specific substances or medications.

Flowchart 12.4: Types of amnesia

348 Textbook of Psychiatric Nursing for BSc Nursing Students

Treatment „ 6D80.2 Alzheimer’s disease dementia, mixed type,

with cerebrovascular disease.
• Cognitive training is helpful to certain extent to improve
„ 6D80.3 Alzheimer’s disease dementia, mixed type,
memory. If transient global amnesia is present, the
with other nonvascular etiologies.
patient recovers after a short period.
„ 6D80.Z Dementia due to Alzheimer’s disease, onset
• For alcohol-induced amnesia, administer Inj. thiamine.
unknown or unspecified.
• 6D81 Vascular dementia
DEMENTIA (ICD-11) OR MILD AND MAJOR
NEUROCOGNITIVE DISORDERS (DSM-5) • 6D82 Dementia due to Lewy body disease.
• 6D83 Frontotemporal dementia.
Definition • 6D84 Dementia due to psychoactive substances including
Dementia is a group of heterogeneous and neurodegenerative medications.
disorders with presence of significant decline in memory, „ 6D84.0 Dementia due to use of alcohol.
cognitive abilities (planning, organizing, executing, thinking, „ 6D84.1 Dementia due to use of sedatives, hypnotics
judgment, etc.), emotional control (lability, apathy, irritability) or anxiolytics.
and social behavior. It is a chronic memory impairment „ 6D84.2 Dementia due to use of volatile inhalants.
with clear consciousness. It is progressive deterioration of „ 6D84.Y Dementia due to other specified psychoactive
intelligence, behavior and personality due to consequences substance.
of impairment in the brain hemispheres, particularly cerebral • 6D85 Dementia due to diseases classified elsewhere.
cortex and hippocampus to a large extent. „ 6D85.0 Dementia due to Parkinson’s disease.
„ 6D85.1 Dementia due to Huntington’s disease.
Incidence of Dementia „ 6D85.2 Dementia due to exposure to heavy metals
Alzheimer’s disease is the most common type of dementia and other toxins.
(60%). Vascular dementia is the second most common type „ 6D85.3 Dementia due to human immunodeficiency
of dementia (20%). Lewy body dementia is the third most virus.
common type of dementia (15%) Figure 12.4 shows the „ 6D85.4 Dementia due to multiple sclerosis.
incidence of dementia. „ 6D85.5 Dementia due to prion disease.
„ 6D85.6 Dementia due to normal pressure
ICD-11 Classification of Dementia hydrocephalus.
„ 6D85.7 Dementia due to injury to the head.
6D80 Dementia
„ 6D85.8 Dementia due to pellagra.
• 6D80 Dementia due to Alzheimer’s disease. „ 6D85.9 Dementia due to Down syndrome.
„ 6D80.0 Dementia due to Alzheimer’s disease with „ 6D85.Y Dementia due to other specified diseases
early onset. classified elsewhere.
„ 6D80.1 Dementia due to Alzheimer’s disease with late • 6D86 Behavioral or psychological disturbances in
onset. dementia.
„ 6D86.0 Psychotic symptoms in dementia.
„ 6D86.1 Mood symptoms in dementia.
„ 6D86.2 Anxiety symptoms in dementia.
„ 6D86.3 Apathy in dementia.
„ 6D86.4 Agitation or aggression in dementia.
„ 6D86.5 Disinhibition in dementia.
„ 6D86.6 Wandering in dementia.
„ 6D86.Y Other specified behavioral or psychological
disturbances in dementia.
„ 6D86.Z Behavioral or psychological disturbances in
dementia, unspecified.
• 6D8Z Dementia, unknown or unspecified cause.
• 6E0Y Other specified neurocognitive disorders.
Figure 12.4: Incidence of dementia • 6E0Z Neurocognitive disorders, unspecified.
CHAPTER 12 Nursing Management of Patients with Organic Brain Disorders... 349

DSM-5 Classification of Major and Mild Neurocognitive Disorders (Dementia)

Table 12.8 shows the classification of major and mild neurocognitive disorders.
Table 12.8: Classification of major and mild neurocognitive disorders

Major and mild neurocognitive disorders

294.11 Probable major neurocognitive disorder due to Alzheimer’s disease with behavioral disturbance
294.10 Probable major neurocognitive disorder due to Alzheimer’s disease without behavioral disturbance
331.9 Possible major neurocognitive disorder due to Alzheimer’s disease
331.83 Mild neurocognitive disorder due to Alzheimer’s disease
294.11 Major or mild frontotemporal neurocognitive disorder with behavioral disturbance
294.10 Major or mild frontotemporal neurocognitive disorder without behavioral disturbance
331.9 Possible major neurocognitive disorder due to frontotemporal lobar degeneration
331.83 Mild neurocognitive disorder due to frontotemporal lobar degeneration
294.11 Major or mild neurocognitive disorder with Lewy Bodies with behavioral disturbance
294.10 Major or mild neurocognitive disorder with Lewy Bodies without behavioral disturbance
331.9 Possible major neurocognitive disorder with Lewy Bodies
331.83 Mild neurocognitive disorder with Lewy Bodies
290.40 Probable major vascular neurocognitive disorder with behavioral disturbance
290.40 Probable major vascular neurocognitive disorder without behavioral disturbance
331.9 Possible major vascular neurocognitive disorder
331.83 Mild vascular neurocognitive disorder
294.11 Major neurocognitive disorder due to traumatic brain injury with behavioral disturbance
294.10 Major neurocognitive disorder due to traumatic brain injury without behavioral disturbance
331.83 Mild neurocognitive disorder due to traumatic brain injury
294.11 Major neurocognitive disorder due to HIV infection with behavioral disturbance
294.10 Major neurocognitive disorder due to HIV infection without behavioral disturbance
331.83 Mild neurocognitive disorder due to HIV infection
294.11 Major neurocognitive disorder due to prion disease with behavioral disturbance
294.10 Major neurocognitive disorder due to prion disease without behavioral disturbance
331.83 Major neurocognitive disorder due to prion disease
294.11 Major neurocognitive disorder probably due to Parkinson’s disease with behavioral disturbance
294.10 Major neurocognitive disorder probably due to Parkinson’s disease without behavioral disturbance
331.9 Major neurocognitive disorder probably due to Parkinson’s disease
331.83 Mild neurocognitive disorder probably due to Parkinson’s disease
294.11 Major neurocognitive disorder due to Huntington’s disease with behavioral disturbance
294.10 Major neurocognitive disorder due to Huntington’s disease without behavioral disturbance
331.83 Mild neurocognitive disorder due to Huntington’s disease
294.11 Major neurocognitive disorder due to another medical condition with behavioral disturbance
294.10 Major neurocognitive disorder due to another medical condition without behavioral disturbance
331.83 Mild neurocognitive disorder due to another medical condition
294.11 Major neurocognitive disorder due to multiple etiologies with behavioral disturbance
294.10 Major neurocognitive disorder due to multiple etiologies without behavioral disturbance
331.83 Mild neurocognitive disorder due to multiple etiologies
350 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 12.5: Basic forms of dementia Blood Tests

Complete blood count, thyroid hormones, urea, creatinine,
electrolytes, liver function test, lipid profile, glucose, vitamin
B12/thiamine/folate levels and HIV confirmation tests are
performed.

Neuroimaging
Magnetic Resonance Imaging (MRI) shows bilateral
temporal lobe atrophy in Alzheimer’s disease and checks
out sub-cortical vascular changes. Single-Photon Emission
Computerized Tomography (SPECT) shows temporoparietal
hypoperfusion in Alzheimer’s disease. DAT scan is a dopamine
transporter scan to assess function of dopamine transportation
and Nigrostriatal pathway. It is an accurate way to diagnose
Parkinson’s disease. Positron Emission Tomography (PET)
scan and Pittsburgh compound B (PiB) are used to identify
the amyloid deposition in Alzheimer’s disease. Computerized
Basic Forms of Dementia Tomography (CT) scan shows cortical atrophy and ventricular
enlargement. It also helps to check out treatable causes
Based on onset, dementia is classified into presenile and senile
such as tumors, subdural hematoma and normal pressure
type. The onset of presenile dementia is below 65 years of age;
hydrocephalus.
and the onset of senile dementia is above 65 years of age. The
structural classification of dementia is cortical and subcortical Electroencephalogram
type. Pick’s disease and Alzheimer’s disease are subtypes
Electroencephalogram (EEG) shows slow activity waves in
of cortical dementia. Parkinson’s disease, prion disease
Alzheimer’s disease and multi-infarct dementia. EEG waves
(Creutzfeldt-Jakob disease), Wilson’s disease, supranuclear are normal in pseudodementia; and periodic complexes are
palsy are subtypes of subcortical dementia (Flowchart 12.5). seen in Creutzfeldt-Jakob disease).

Diagnosis of Dementia Genetic Testing

Diagnosis of dementia is only done when there is presence of Apolipoprotein E4 mutation in Alzheimer’s disease; the
consistent symptoms for at least 6 months; and it should not be mutation seen in Huntington’s chorea. Mutant gene defects
done when patient is delirious or in confused state. Collateral result in malformed huntingtin protein which is prone to
history collection has to be done from care givers/relatives/ clumping in the brain and cause nearby cell death.
friends. Decline from previous level of functioning has to be
Miscellaneous
established.
Midstream urine (MSU) for culture and sensitivity, syphilis
Assessment of Cognition serology, HIV test, brain biopsy and CSF analysis (β amyloid
Categories of Mini Mental Status Examination (MMSE) have and tau protein) can be done, if required.
been explained in Table 12.9. Montreal Cognitive Assessment
(MoCA) and Clinical Dementia Rating Scale (CDRS) can also Decline of Memory and Cognition in Dementia
be used. Learning capacity to group new information declines in initial
Table 12.9: Categories of mini mental status examination
stage of dementia. The patient is unable to recall the events in
middle stage of dementia. Unable to recognize close relatives
Categories Score or even self is the advanced stages of dementia (Fig. 12.5).
Normal 26–30 The patient is unable to do complicated tasks which he/she
Mild dementia 21–25 could do earlier in initial stage of dementia. He/she seeks
assistance for simple tasks in middle stage of dementia. He/she
Moderate dementia 15–20
is unable to do any activity which requires cognitive function
Severe dementia 11–15
even with help, in advanced stages of dementia as shown in
Profound dementia £10 Figure 12.6.
CHAPTER 12 Nursing Management of Patients with Organic Brain Disorders... 351

Figure 12.5: Decline of memory in dementia Figure 12.6: Decline of cognition in dementia

Differences between cortical and subcortical dementia have DSM-5 Diagnostic Criteria for Major
been given in Table 12.10. Neurocognitive Disorder (Dementia)
Table 12.10: Differences between cortical and subcortical • Significant cognitive decline from a previous level in one
dementia or more cognitive domains, such as complex attention,
learning, memory, executive function, perceptual-motor
Aspects Cortical Subcortical dementia or social cognition, language) based on:
dementia
„ Concern of the individual or treating doctor or
Presence of • Frontal • Thalamus
reliable informant that there is a significant decline in
lesion in • Parietal • Basal ganglion
• Temporal • Brain stem cognitive function.
• Occipital „ A clear impairment in cognitive performance,
• Hippocampus documented by standardized neuropsychological
Severity Severe Mild to moderate testing.
Motor Normal • Tremors • Cognitive deficits interfere with everyday activities.
activities • Dystonia • Cognitive deficits do not occur exclusively in the context
• Dysarthria of a delirium.
• Flexed or extended • Cognitive deficits are not better explained by another
Posture
mental disorder (e.g., major depressive disorder,
• Chorea
• Ataxia schizophrenia).
• Rigidity • Specify whether due to:
Decline in Bradyphrenia Recall by cues done in „ Alzheimer’s disease
short-term (Decreased partial way „ Frontotemporal lobar degeneration
memory/ cognitive speed) „ Lewy body disease
cognition/ and recall by cues „ Vascular disease
recall can be done to
very little extent „ Traumatic brain injury
„ Substance/medication use
Depressive Not common Common
symptoms „ HIV infection
„ Prion disease
Delusions Simple Complex
„ Parkinson’s disease
Miscellaneous • Aphasia Nil
„ Huntington’s disease
(5 As) • Amnesia
• Agnosia „ Another medical condition
• Apraxia „ Multiple etiologies
• Acalculia „ Unspecified
352 Textbook of Psychiatric Nursing for BSc Nursing Students

ICD-11 Diagnostic Criteria for Dementia Management of Dementia

• Decline from a previous level of cognitive functioning General Considerations
with impairment in two or more cognitive domains
Provide the patient a safe and comfortable environment.
such as memory, attention, executive functions,
Regular social interactions with family members have to be
language, judgment, social cognition, visuoperceptual or
made. Promote adequate sleep. Advise the patient to eat healthy
visuospatial ability and psychomotor speed.
foods with high nutrients and antioxidants. Mental exercises,
• Cognitive impairment is not entirely attributable to normal
such as puzzles, aptitude, finding solutions to problems, are
aging and it significantly interferes with independence in
found to be helpful. It is important for the patient to relax well
person’s performance with activities of daily living.
either by hearing music or by involving in other recreational
Cognitive impairment is attributed or assumed to be activities. Patient can be advised to perform yoga and physical
attributable to the neurological or medical conditions exercises.
which affect the brain.
Psychological Treatment Modalities
Differential Diagnosis of Dementia
Cognitive Stimulation
Hypothyroidism, normal pressure hydrocephalus, vitamin B12
Cognitive stimulation is found useful in mild to moderate
deficiency and folic acid deficiency, depression and chronic
dementia. The objective of this therapy is to stimulate cognitive
subdural hematoma.
function. It can be administered twice a week as group activity.
Behavioral and Psychological Symptoms of For example, group discussion, games by identification of
Dementia words, letter cancellation test, etc.

About 90% of behavioral psychological symptoms in dementia Reality Orientation

(BPSD) occur in one or other stages of dementia. They cause Orient the patients with time, place and person. Discuss
significant distress to patients. In Lewy body dementia, visual current events with patients. For example, use of calendars,
hallucination is most common. In vascular dementia, emotional clock, newspaper reading, watching TV, consistent daily
instability is most common. Kurt Goldstein coined the term schedules, labeling the rooms, etc.
“catastrophic reaction” to explain this overreaction to minor
stressors which happens in a cognitive impaired individual. Validation Therapy
These outbursts are precipitated by misinterpretation of a Naomi Feil, a social worker from Germany, explored validation
request, misinterpretation of sensory stimuli, inability to therapy, which is a method of therapeutic communication
perform a task, overstimulation and fatigue. used in patients with moderate to late-stage dementia.
• Common behavior symptoms are as follows: It emphasizes emotional aspects of conversation rather
„ Aggression than the factual content. Therefore, it imparts respect to the
„ Agitation patient’s feelings and beliefs. Techniques of validation therapy
„ Restlessness include listening to the patients in an empathetic manner,
„ Wandering reminisce with elders, use therapeutic touch, maintain
„ Hostile behavior eye contact, use clear or low or loving tone of speech and
„ Cursing avoid arguing with them. Feeling validated, respected and
„ Hoarding understood will prevent argumentative or agitative behavior in
„ Screaming patients with dementia.
• Common psychological symptoms are as follows:
Alzheimer’s Dementia
„ Mood changes
„ Apathy Neuropathological changes in Alzheimer’s dementia were
„ Anxious explained by Alois Alzheimer (Fig. 12.7). Alzheimer’s
„ Hallucination dementia is the most common type of dementia. Females are
„ Delusion more commonly affected with Alzheimer’s disease than males.
„ Sleep disturbances Risk is high if family history of dementia is present. Incidence
„ Problems with appetite of Alzheimer’s disease increases as the age increases.
CHAPTER 12 Nursing Management of Patients with Organic Brain Disorders... 353

• Decreased corticotrophin and somatostatin

• Aluminum toxicity
• Cell membrane phospholipids metabolism
• Abnormal glutamate metabolism
• Apo E4 (Apolipoprotein E4) allele
„ Single Apo E4 (Apolipoprotein E4) allele,
heterogeneous with double risk of Alzheimer’s disease
„ Two Apo E4 (Apolipoprotein E4) allele, homogeneous
increase in the risk of Alzheimer’s disease (five folds).

Protective Factors against Alzheimer’s Dementia

Figure 12.7: Peculiar changes in brain seen in Alzheimer’s dementia • Physical exercises
• Intellectual stimulation: Puzzles, mind games, aptitude
Types of Alzheimer’s Dementia testing, etc.
Early Onset • Foods rich in antioxidants and polyunsaturated fatty acid
(PUFA)
Onset is usually <65 years of age (mostly in late 40s and early
„ Fruits
50s). Nearly 5% of patients have early onset of Alzheimer’s
„ Vegetables
disease. It is very severe with rapid progression in nature. Three
„ Sea foods (fish)
genes commonly implicated in early onset of dementia are
„ Curcumin (ingredient of turmeric)
Presenilin 1 Gene, Presenilin 2 Gene and Amyloid Precursor
Protein (APP) gene. Diagnosis
Late Onset • Macroscopic view: Cerebral ventricles are enlarged,
Onset is usually >65 years of age. It is gradually progressive cerebral cortex shrinks; and shrinkage of hippocampus
in nature. Commonly, 95% of patients suffer with late onset and widening of cerebral sulci are seen.
of Alzheimer’s disease. Apo E4 (Apolipoprotein E4) gene has • Microscopic view: Senile plaques, granulovacuolar
been implicated in this type. degeneration, neurofibrillary tangles and cell loss in
Types of Alzheimer’s dementia can also be classified cortical nerves are seen.
based on: with behavioral symptoms and without behavioral • Neurochemical changes include a decrease in choline
symptoms. Behavioral symptoms include anger, aggression, acetyltransferase or acetylcholinesterase (Ach).
emotional distress, verbal or physical outburst, restlessness, • CT/MRI
hallucinations, delusions, sleep problems, irritability and „ Enlargement in ventricles.
anxiety.
Neuropathological changes in Alzheimer’s Dementia
Risk Factors and Etiology Deposits of β-amyloid lead to plaque formation outside
• Pathological stress the neuron. Hyperphosphorylation of tau protein causes
• Cardiovascular diseases neurofibrillary tangles (NFT) inside the neuron. There may be
• Hypertension nonspecific changes such as oxidative stress and inflammation
• Obesity that happen in Alzheimer’s disease (Fig. 12.8).
• Depression
Treatment
• Traumatic brain injury
• Presence of family history Acetylcholinesterase Inhibitors
• Smoking Drugs inhibit acetylcholinesterase, which will break
• Monozygotic twins acetylcholine (Ach). Acetylcholine decreases in Alzheimer’s
• Down syndrome disease. Acetylcholine is important for learning and memory.
• Amyloid (Precursor of chromosome 21) • Rivastigmine (Exelon) 5–6 mg
• Hypoactive neurotransmitters such as acetylcholine and • Donepezil (Aricept) 5–10 mg/day
norepinephrine • Galantamine (Reminyl) 8 mg
• Cholinergic hypothesis • Tacrine
354 Textbook of Psychiatric Nursing for BSc Nursing Students

Figure 12.9: Main diagnostic criteria for AIDS dementia complex

AIDS Dementia Complex

Acquired immunodeficiency syndrome (AIDS) is caused by
human immunodeficiency virus (HIV) which is a retrovirus
that crosses the blood-brain barrier (BBB). HIV infected
macrophages and lymphocytes lead to decreased cognition,
motor, behavioral and neurological functions. Approximately
Figure 12.8: Neurons in Alzheimer’s disease
two-third of patients with AIDS will develop dementia. Main
diagnostic criteria for AIDS dementia complex are deficits of
N-methyl-D-aspartate receptor (NMDA) Receptor behavior, motor and cognition as shown in Figure 12.9. HIV
Antagonist proteins or virotoxins have direct toxic effects toward nerve
Glutamate is the excitatory neurotransmitter released by nerve cells by initiating astrocytes, macrophages and microglia to
cells in the brain. NMDA (N-methyl-D-aspartate) receptor release chemokines, cytokines and neurotoxic substances.
allows the glutamate to connect with the nerve cell and Prognosis is generally variable. Poor prognosis is seen in low
therefore, calcium enters the cell which carries the electrical or decreased CD4 count, platelet count, hemoglobin level and
or chemical signals. In Alzheimer’s disease, nerve cells make body mass index (BMI). CT scan reveals cortical atrophy in
increased quantities of glutamate. So, increased amount of the initial period of onset (1–4 months). Treatment includes
calcium that enters the nerve cells damages the neurons. zidovudine, which partially helps to reduce neuropsychological
Hence, NMDA receptor antagonists block the connection of deficit.
the glutamate with the nerve cell and they maintain healthy
neurons. Memantine (Ebixa, Axura, Namenda) is the drug of Lewy Body Dementia
choice for patients with Alzheimer’s disease. In Lewy body dementia, decline in cognition comes with three
Miscellaneous more features:
• Antidepressants 1. Fluctuations in alertness.
• Antipsychotics (used with caution because of higher risk 2. Recurrent and vivid visual hallucinations in early stages
of stroke when they are used in dementia patients) of disease.
• Benzodiazepines 3. Features of Parkinson’s disease: Muscle rigidity, loss
• Mood stabilizers of spontaneous movement, mask-like face, bradykinesia,
• Avoid anticholinergics or drugs with similar effects of etc.
anticholinergics, such as tricyclic antidepressants, because Other features include syncope, autonomic symptoms, rapid
they can worsen the cognitive impairment leading to eye movement (REM) sleep behavior disorder and severe
confusion. neuroleptic sensitivity.
Medial temporal atrophy is not a vital feature in this type
Prognosis of dementia since memory impairment is not a prominent
Prognosis is progressive and irreversible. Deterioration rate one. Family history is also not an essential part in this type of
varies among individuals. Early onset Alzheimer’s disease will dementia. Lewy bodies are also seen in Parkinson’s disease.
progress faster. Death usually occurs within 20 years of onset; Single-photon emission computed tomography (SPECT) scan
and the cause of death is usually bronchopneumonia. shows occipital hypoperfusion or hypometabolism.
CHAPTER 12 Nursing Management of Patients with Organic Brain Disorders... 355

Pathophysiology Characteristic Features

Accumulated components of alpha-synuclein protein within • Abrupt onset and usual age of onset is between 60 and
nucleus of neurons in the brain control various aspects of 75 years.
memory and motor control, so that the particular functions of • Acute exacerbations (because of repeated infarctions)
brain get affected. • Deterioration is step wise (Pattern as step-ladder)
• Course is fluctuating
Treatment • History of stroke or transient ischemia
Acetylcholinesterase inhibitors (rivastigmine, donepezil, • Focal neurological signs
galantamine) and N-methyl-D-aspartate (NMDA) receptor • Presence of insight
antagonist (memantine) are used. Avoid antipsychotics • Emotionally labile
because of neuroleptic sensitivity. Levodopa will not help
in improving the motor symptoms in this type of dementia, Diagnosis
though it works well in Parkinson’s disease. Carotid bruit, fundoscopic abnormalities, EEG shows focal
slowing and CT scan shows multiple infarcts in brain and
Vascular Dementia or Multi-infarct Dementia enlarged cerebral ventricles.
(MID)
Treatment
Vascular dementia is considered the second most common
type of dementia. It is more common in men. It can be Treatment modalities include prevention of primary and
prevented by managing the risk factors well. Primary risk secondary risk factors, control of high blood pressure.
factors are stroke and transient ischemic attack. Secondary risk Medications, such as antiplatelet (aspirin), antipsychotics,
factors are diabetes, hypertension, smoking, coronary artery antidepressants, psychostimulants and benzodiazepines, can
diseases and dyslipidemia (Fig. 12.10). be used.

Mechanism Pick’s Disease or Frontotemporal Dementia

There is presence of occlusive plaque or thromboembolism or Frontal lobe is prominently involved (frontal signs are
hemorrhage in blood vessels. Multiple small cortical infarcts are inhibited). Atrophy, neuronal loss, gliosis and intraneural
present in vascular dementia. Small vessel vascular dementia bodies (pick bodies) can be seen in frontal temporal lobe.
due to damage of white matter is termed Binswanger’s disease Klüver-Bucy syndrome is represented by lesions in medial
(Subcortical leukoencephalopathy). Lacunar state/Lacunar temporal lobe and it is common in Pick’s disease in which
syndrome/status lacunaris is defined as more minute infarcts insertion of inappropriate things in mouth (hyperorality), high
called lacunae which are seen in vascular dementia and in sexual desire (hypersexuality) and poor response to emotional
severe hypertension. stimuli (placidity) can be seen (Fig. 12.11).

Figure 12.10: Healthy blood vessel and blood vessel with multiple Figure 12.11: Kluver-Bucy syndrome
infarction in vascular dementia
356 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 12.11: Differences between Alzheimer’s disease and Pick’s

disease

Aspects Alzheimer’s Pick’s disease or

disease frontotemporal
dementia
Age of onset Commonly above 50–60
65 years
Speech problems Most common Less
Memory impairment Early Late
Behavior changes Late Early

Prion Disease
Replicative protein mutates and causes a variety of spongiform
Figure 12.12: Subdivision of Pick’s disease
based on presentation diseases. It can transmit through use of contaminated dura
mater, corneal graft and ingesting meat from cattle (Bovine
spongiform encephalopathy).
Subdivision of Pick’s disease on presentation basis
shows that 60% are behavioral variants, 20% have semantic
Huntington’s Chorea or Huntington’s disease
dementia and 20% show progressive nonfluent aphasia
(Fig. 12.12). A genetically dominant disease due to chromosome four
• Behavioral variant: Frontal lobe is mainly involved; so, defect. Onset is around 30–40 years of age.
executive function, personality and emotional control are
Epidemiology
affected.
• Semantic dementia: Temporal lobe is mainly involved. Male and female are equally affected. 6 members in 1 lakh
Language comprehension is said to be poor but the population are affected with Huntington’s chorea.
expression is fluent.
Signs
Progressive Nonfluent Aphasia Choreoathetoid movements are an early sign of Huntington’s
Progressive nonfluent aphasia (PNFA) is a clinical syndrome chorea and dementia is a late sign.
associated with frontotemporal lobar degeneration. It is
insidious in onset. The specific degeneration of frontal and Pathophysiology
temporal lobe might create peculiar language deficit. This • Brain atrophy is seen in basal ganglia and caudate
disorder commonly has a primary effect on the left hemisphere, nucleus.
which causes the symptomatic display of expressive language • Associated psychiatric symptoms are mood disorders
deficit and sometimes may disrupt the receptive abilities while (50%), personality disorders (25%) and schizophrenia
comprehending complex language. The main clinical features (25%).
are progressive difficulties with speech production. There
may be problems with different parts of speech production. Differential Diagnosis
Hence, the patients may present with articulation breakdown, Psychosis, depression.
phonemic breakdown (difficulties with sounds) and other
features such as hesitant or effortful speech, stuttering, apraxia Course and Prognosis
of speech, phonemic paraphasia (sound errors in speech, for Progressive.
example ‘cat’ was pronounced as ‘gat’), apraxia of speech and
agrammatism (usage of wrong grammar or tense). Treatment
Differences between Alzheimer’s disease and pick’s disease Antipsychotics, antidepressants, benzodiazepines and genetic
have been depicted in Table 12.11. counseling.
CHAPTER 12 Nursing Management of Patients with Organic Brain Disorders... 357

Parkinson’s Disease Surgical treatment includes

• Deep brain stimulation—implanting a pacemaker-
Parkinson’s disease is a neurodegenerative disease caused by
like unit, transmit the impulses to electrodes placed in
degeneration of neurons in brain particularly in nigrostriatal
subthalamic nucleus.
pathway of the basal ganglia. The cells in substantia nigra will
release dopamine. Points to Remember
Basal ganglia pathway is responsible for regulation • Do not use benzodiazepine for delirium unless the delirium is
of movement. Cells of substantia nigra degenerate; and due to alcohol or benzodiazepine withdrawal.
• Black box warning: Atypical and typical antipsychotics
movement disturbances are present in Parkinson’s disease.
are not considered approved drugs for dementia-related
Motor symptoms are as follows: psychosis because they have higher risk of death. Avoid using
• Tremors haloperidol via IV since it increases the risk of cardiac arrest.
• Bradykinesia
• Muscle rigidity Stages of Dementia
• Lack of facial expression • Early stage of dementia occurs usually at 2–4 years
• Unstable posture after the onset of dementia. The common symptoms
• Stooped and shuffling gait are forgetfulness, poor performance in work, decreased
Other symptoms include: interest in environment and reluctance to initiate
• Decreased sense of smell action.
• Low voice tone • Middle stage of dementia occurs usually at 2–12 years
• Foot cramps after the onset of dementia. The common symptoms
• Sleep disturbances are anxiousness, irritability, progressive memory loss,
• Depression wandering, difficulty in following simple instructions,
• Constipation social isolation and neglect of personal hygiene.
• Drooling of saliva • Late stage of dementia occurs usually more than
12 years after the onset of dementia. The common
Differences between lewy body dementia and Parkinson’s
symptoms are significant weight loss, unable to recognize
disease have been given in Table 12.12.
the family members, inability to communicate, inability
Table 12.12: Differences between Lewy body dementia and to stand or walk. Death may occur due to aspiration
Parkinson’s disease
pneumonia. Stages of dementia have been presented in
Aspects Lewy body dementia Parkinson’s Flowchat 12.6.
disease
Onset of dementia Mostly precedes motor Mostly Flowchart 12.6: Stages of dementia
symptoms or at the onset follow motor
of motor symptoms symptoms
Type of dementia Cortical Sub-cortical
Motor symptoms 50% 100%
at diagnosis
Cognitive Present Absent
fluctuation
Visual hallucination Present Absent
Resting tremors Not prominent Prominent

Medical treatment includes:

• Levodopa
• Carbidopa
• Monoamine oxidase inhibitors, e.g., selegiline
• Catechol-O-Methyl Transferase (COMT) inhibitors, e.g.,
entacapone, tolcapone.
• Anticholinergics
358 Textbook of Psychiatric Nursing for BSc Nursing Students

Mild Cognitive Impairment • Risk of infection

• Risk of aspiration
Mild cognitive impairment (MCI) is an intermediate
• Risk of injury
state between normal aging and dementia. Mild cognitive
impairment will develop into dementia usually within three Psychological Perspective
years. Types of mild cognitive impairment have been listed
• Disturbed thought process
below:
• Memory impairment
1. Amnestic mild cognitive impairment: Affects memory • Anxiety
function. It is a risk factor for Alzheimer’s disease. • Disturbed identity of self
2. Nonamnestic mild cognitive impairment: Does not • Powerlessness
affect memory function. It is a risk factor for frontal
temporal dementia and Lewy body dementia. Social Perspective
3. Mixed mild cognitive impairment: It is a combination of • Poor social interaction
both amnestic and nonamnestic type. It is a risk factor for • Interrupted family process
vascular dementia. • Impaired verbal communication

Continuum from Normal Aging to Dementia

NURSING INTERVENTIONS
Normal aging process takes place among all elders, whereas
patients with dementia will undergo the intermediate state Memory impairment related to declined cognitive functions as
evidenced by impairment of recent memory revealed by mental
which includes mild cognitive impairment and it slowly status examination.
develops into dementia within three years as shown in
Figure 12.13.
Nursing interventions Rationale

NURSING MANAGEMENT OF PATIENTS WITH Orient the patients to time, To help the patient become
place and person aware of time, place and
ORGANIC BRAIN DISORDERS
person
Nursing Assessment Use calendars to remind the Help to know the daily routines
daily routines
Nurse has to assess the cognitive functions, safety needs of Use reminders in phone to It helps the patient to be
patients, social interaction with others, activities of daily living, remember the work schedules reminded of the work
nutritional needs, hygienic needs and need for sleep and rest. on time schedules
Do Mini-Mental State To review the client’s cognitive
Nursing Diagnosis Examination (MMSE) or functions
Folstein test periodically
Biological Perspective
Check lab reports to rule out It helps to identify the factors
• Self-care deficit contributing factors which affect cognition
• Impaired physical mobility
• Sleep pattern disturbances • High risk of injuries to elderly patients who lack
coordination and balance evidenced by Romberg test
in neurological assessment.

Nursing interventions Rationale

Stick the safety stickers on case To make all the health team
files workers aware of high-risk
patients who need safety
measures
Provide non-slippery shoes To prevent the patient from
falling
Ensure the holders are It gives the grip to hold while
attached in bathrooms/toilet the patient is walking in the
bathroom. Therefore, it will
Figure 12.13: Continuum from normal aging to dementia prevent the patient’s fall
Contd…
CHAPTER 12 Nursing Management of Patients with Organic Brain Disorders... 359

Nursing interventions Rationale Administer IV fluids to the patient in order to promote

hydration, apply physical restraints, if the patient is
Provide ‘low bed’ to the It will help the patient claim
patient the bed easily uncontrollable or exhibiting violent behavior. Administer
Store the things near patients It provides easy access to
oxygen to the patient, if required.
which are repeatedly used by patient
them GERIATRIC CONSIDERATIONS
Provide call bell near the Bell helps to call the nurse
patient in order to seek help immediately in case of Assess the cognitive status of elders in order to identify
from nurse, if needed emergency the cognitive dysfunction in early stage itself. Identify the
Put on side rails when client is To prevent the patient’s fall suicidal thoughts verbalized to friends or relatives. Assess
sleeping from the bed the capacity to perform the task independently. Feelings of
loneliness, worthlessness, hopelessness and helplessness need
• Self-care deficit related to lack of ability for brushing, to be identified at an early stage because these are symptoms of
bathing, grooming, putting dress as evidenced by depression that may lead to suicide. Disorders of language or
patient verbalization. aphasia are due to organic lesions in brain. Consider sensory
deprivation such as loss of vision, hearing, touch, smell and
Nursing interventions Rationale taste in elders. Elderly abuse (granny bashing) needs to be
Identify the areas of To get the baseline data assessed and prevented (psychological abuse, sexual abuse
dysfunction in self-care and physical abuse must be assessed). Special care is needed
Motivate the patient to To improve the skills and abilities of for elders residing in nursing homes. Teach true coping
perform daily activities the patient
mechanism to the elders so that they can handle the stressors.
Assist the patient in all It will help the patient perform the
activities, if necessary activities Follow-up, Home Care and Rehabilitation
Be consistent in Remaining consistent in assignment
assignment of daily care will avoid confusion in patients • Reminiscence therapy helps the elders to hold up good
givers memories.
Involve family members It promotes a feeling of well-being • Social skills training is helpful to enhance social skills.
in patient care among family members • Psychological support from caregivers and family
Provide structural Guide the patient in a structured way members is essential.
schedule of activities without any confusion • Recreational and relaxation therapies help the elders
enhance coping skills and deal with stressors.
• Poor social interactions related to lack of socialization • Promotion of self-esteem is a vital part and can be
with others as evidenced by poor social judgment in improved by promoting the activities of daily living.
mental status examination. • Memory training is helpful to improve the cognition.
• Orientation to time, place and person is essential.
Nursing interventions Rationale • Take steps to promote individuality and make them to feel
Observe the patient and perform To get the baseline data that elders are a part of society. Promotion of physical,
mental status examination psychological and social wellness will promote them in
Provide social skills therapy To improve social skills holistic way.
Involve the patient and family It gives an opportunity to the • Treat depression at early stages to prevent suicidal
members to participate in patient to talk with others thoughts.
psychodrama
• Psychotropic drugs have to be followed if prescribed by a
Promote group therapy It enhances the social skills physician; and drug adherence has to be monitored.
Organize games involving all It gives an opportunity to the • Positively expressed emotions of care givers will promote
patients patient to mingle with others psychological well-being of elders.
360 Textbook of Psychiatric Nursing for BSc Nursing Students

EXTRA EDGE
ICD-10 Classification of Organic Brain Disorders ▪ x2 Other symptoms, predominantly hallucinatory
F00-F09 Organic, including symptomatic, mental disorders ▪ x3 Other symptoms, predominantly depressive
• F00 Dementia in Alzheimer’s disease ▪ x4 Other mixed symptoms
▪ F00.0 Dementia in Alzheimer’s disease with early • F04 Organic amnestic syndrome, not induced by alcohol and
onset other substances
▪ F00.1 Dementia in Alzheimer’s disease with late onset
▪ F00.2 Dementia in Alzheimer’s disease, atypical or mixed • F05 Delirium, not induced by alcohol and other psychoactive
type substances
▪ F00.9 Dementia in Alzheimer’s disease, unspecified ▪ F05.0 Delirium, not superimposed on dementia
▪ F05.1 Delirium, superimposed on dementia
• F01 Vascular dementia ▪ F05.8 Other types of delirium
▪ F01.0 Vascular dementia of acute onset
▪ F05.9 Delirium, unspecified
▪ F01.1 Multi-infarct dementia
▪ F01.2 Subcortical vascular dementia • F06 Other mental disorders due to brain damage or
▪ F01.3 Mixed cortical and subcortical vascular dementia dysfunction and due to physical disease
▪ F01.8 Other vascular dementia ▪ F06.0 Organic hallucinosis
▪ F01.9 Vascular dementia, unspecified ▪ F06.1 Organic catatonic disorder
▪ F06.2 Organic delusional [schizophrenia-like] disorder
• F02 Dementia in other diseases classified elsewhere
▪ F06.3 Organic mood [affective] disorders
▪ F02.0 Dementia in Pick’s disease
◆ .30 Organic manic disorders
▪ F02.1 Dementia in Creutzfeldt-Jakob disease
◆ .31 Organic bipolar affective disorders
▪ F02.2 Dementia in Huntington’s disease
◆ .32 Organic depressive disorders
▪ F02.3 Dementia in Parkinson’s disease
▪ F02.4 Dementia in Human Immunodeficiency Virus [HIV] ◆ .33 Organic mixed affective disorder
disease ▪ F06.4 Organic anxiety disorder
▪ F02.8 Dementia in other specified diseases classified ▪ F06.5 Organic dissociative disorder
elsewhere ▪ F06.6 Organic emotionally labile [asthenic] disorder
▪ F06.7 Mild cognitive disorder
• F03 Unspecified dementia-A fifth character may be added to ▪ F06.8 Other specified mental disorders due to brain
specify dementia in F00-F03, as follows: damage or dysfunction and due to physical disease
▪ x0 Without additional symptoms ▪ F06.9 Unspecified mental disorder due to brain damage
▪ x1 Other symptoms, predominantly delusional and dysfunction and due to physical disease

SUMMARY
• Organic brain disorders are neurological and psychiatric disorders with strong biological basis.
• Organic brain disorders are classified into delirium, dementia, amnesia and others (organic hallucinosis, organic delusional disorder,
organic mood disorder, organic personality disorder, organic dissociative disorder, organic emotionally labile disorder).
• Delirium is an acute confusion state, whereas dementia is chronic.
• Predisposing factors of delirium are extreme ends of age (very old or young), male gender, immobility, history of falls, functional
dependent, low performance in activity, history of delirium or dementia, memory impairment, visual disturbances, hard of hearing,
orthopedic surgery, cardiac surgery or cardiopulmonary bypass, intensive care unit (ICU) admission, stress, use of physical restraints,
patient’s urinary catheterization, sleep disturbances, neurological or endocrine or metabolic disorders, fever, hypothermia, infections,
hypoxia, shock, anemia, dehydration, poor nutrition and decreased serum albumin level.
• Delirium can be classified into hyperactive, hypoactive and mixed.
• Melatonin is increased in hypoactive delirium; and N-Dimethyltryptamine is increased in hyperactive delirium.
• Increased dopamine and serotonin, release of interleukin-1 from cells, decreased cerebral oxidative metabolism, elders with impaired
cholinergic transmission, stress, sleep disturbances, increased action of the hypothalamic-pituitary adrenal (HPA) axis might lead to
delirium.
• Acute onset, clouding of consciousness, perceptional disturbances, sleep wake cycle disturbances, sundown syndrome, memory
disturbances, speech disturbances, motor disturbances, labile affect, occupation delirium, motor/verbal perseveration, dyssomnia,
agraphia, impairment in comprehension, mood alteration and disorientation (disorientation to time and place is common, whereas
disorientation to person is rare) are clinical manifestations of delirium.
• Confusion assessment method, mini mental status examination, CT scan, MRI, CBC, urine analysis, EKG, EEG are helpful to diagnose
delirium.
• Dementia, schizophrenia, depression, mania, dissociative disorders are differential diagnosis of delirium.

Contd…
CHAPTER 12 Nursing Management of Patients with Organic Brain Disorders... 361

• Repeat, rephrase, repair, speaking slowly, using therapeutic touch, be a good listener, do not argue with elders, using closed-ended
questions, using small sentences are the proper communication strategies used in patients with organic brain disorder.
• Management of patients with delirium includes: Identify the underlying cause, complete lab investigation, nursing care of agitated/
violent/noncooperative patients, reorientation training with the use of drugs such as benzodiazepine, antipsychotics, physostigmine
etc., music therapy, light therapy, normalize sleep-wake cycle, use of hearing and visual aids, involvement of family in nursing care.
• Complications of delirium are falls, aspiration pneumonia, pressure ulcer, malnourishment, fatigue and decreased ability or functioning.
• Complete or partial loss of memory is called amnesia.
• Types of amnesia include transient global amnesia, transient epileptic amnesia, anterograde amnesia, retrograde amnesia, lacunar
amnesia dissociative amnesia and prosopagnosia or face blindness or facial agnosia.
• If alcohol-induced delirium occurs, then administer Inj. thiamine.
• Alzheimer’s disease is the most common type of dementia.
• Neuropathological changes in Alzheimer’s disease: Deposits of β amyloid lead to plaque formation outside the neuron; and
hyperphosphorylation of tau protein causes neurofibrillary tangles (NFT) inside the neuron.
• Acetylcholinesterase inhibitors are used to treat Alzheimer’s disease.
• Cognitive deficit, behavior deficit and motor deficit are the main diagnostic criteria for AIDS dementia complex.
• Decline in cognition with fluctuations in alertness, recurrent and vivid visual hallucinations in early stages of disease and features of
Parkinson’s disease are seen in Lewy body dementia.
• Nursing management of organic mental disorders includes enhancement of cognitive functions, prevent the patient’s fall, promote
self-esteem, orientation training, improve the patient’s self-care, social skills, etc.

ASSESS YOURSELF

Long Answer Questions 5. Types of dementia

1. Define delirium. Explain the classification, etiology, 6. Etiology of delirium
psychopathology, diagnosis, clinical manifestations and 7. Nursing management of patients with dementia
management of patients with delirium. 8. Complications of delirium
2. Define dementia. Explain the classification, etiology, 9. ICD-11 classification of organic mental disorders
psychopathology, diagnosis, clinical manifestations and 10. Clinical manifestations of delirium
management of patients with dementia. 11. Assessment of cognitive functions
12. Psychopathology of organic mental disorders
Short Answer Questions 13. Differences between cortical and subcortical dementia
1. What are the different types/forms of dementia based on 14. Pick’s disease
onset and structural classification? 15. Lewy body dementia
2. What are the features of organic brain disorders?
3. What are the different types of delirium according to Multiple Choice Questions
DSM-5 on the basis of activity level? 1. _________ is an acute confusional state in organic
4. What are the proper communication strategies for brain disorder.
patients with organic brain disorders? a. Delirium b. Dementia
5. What are the different types of neuroimaging for c. Amnesia d. None of these
diagnosing dementia?
2. Which type of hallucination is predominant in
6. What are the behavioral and psychological symptoms of
organic brain disorders?
dementia?
7. What are the characteristic features of vascular dementia a. Visual b. Auditory
or multi-infarct dementia (MID)? c. Gustatory d. Tactile
3. Increased N-dimethyltryptamine will lead to _______
Short Notes delirium.
Write short notes on: a. Hypoactive b. Hyperactive
1. Alzheimer’s disease c. Mixed d. None of these
2. Differences between delirium and dementia 4. Toxic psychosis is also called:
3. Differences between dementia and pseudodementia a. Delirium b. Dementia
4. Types of amnesia c. Amnesia d. None of these
362 Textbook of Psychiatric Nursing for BSc Nursing Students

5. Which is the proper communication technique used 13. Kluver-Bucy Syndrome is common in __________
in patients with organic brain disorders? a. Alzheimer’s disease b. Vascular dementia
a. Use of open-ended questions c. Lewy body dementia d. Pick’s disease
b. Use of closed-ended question 14. _________ lobe in brain is predominantly involved in
c. Use of small sentences Pick’s disease.
d. Both b and c
a. Frontal b. Temporal
e. Option a, b and c c. Parietal d. Occiput
6. Sundown syndrome means: 15. Amnesia which is purely psychogenic due to
a. Worsening of symptoms in evening intrapsychic conflicts is called _________
b. Improvement of symptoms in evening a. Anterograde amnesia b. Retrograde amnesia
c. Worsening of symptoms in morning c. Lacunar amnesia d. Dissociative amnesia
d. Improvement of symptoms in morning
e. Both a and d 16. Wandering behavior is seen in _________ stage of
dementia.
7. _________ is an antidote for anticholinergic that will a. Early b. Middle
help to reverse the delirium due to anticholinergics. c. Final d. None of these
a. Neostigmine b. Physostigmine
c. Atropine d. Pilocarpine 17. Which is the second most common type of dementia?
a. Alzheimer’s disease b. Vascular dementia
8. ___________________ is the most common type of c. Lewy body dementia d. Pick’s disease
dementia.
a. Alzheimer’s disease b. Vascular dementia 18. Replicative protein that mutates and causes a variety
c. Lewy body dementia d. Pick’s disease of spongiform diseases is seen in ________
a. Prion disease b. Huntington’s chorea
9. Hyperphosphorylation of tau protein in intracellular c. Vascular dementia d. Lewy body dementia
areas is seen in _______
19. Which of the following is cortical dementia?
a. Alzheimer’s disease b. Vascular dementia
c. Lewy body dementia d. Pick’s disease a. Parkinson’s disease
b. Creutzfeldt-Jakob disease
10. Which of the following is NOT TRUE about Lewy c. Wilson’s disease
body dementia? d. Pick’s disease
a. Fluctuation of cognition is present
20. The course of disease is ______________ in delirium.
b. Visual hallucination is prominent
a. Fluctuating
c. It is mostly a subcortical type
b. Progressive
d. Motor symptoms are seen
c. Intermittently fluctuating and progressive
11. _________ used in elders with dementia will increase d. None of the above
risk of stroke by three times.
a. Antidepressants b. Antipsychotics Answer Key
c. Anxiolytics d. Mood stabilizers 1. a 2. a 3. b 4. a 5. d
6. a 7. b 8. a 9. a 10. c
12. Usual age of onset in Pick’s disease is _________
11. b 12. b 13. d 14. a 15. d
a. >60 years b. 50–60 years
c. 40–50 years d. 30–40 years 16. b 17. b 18. a 19. d 20. a
 CHAPTER

Psychiatric Emergencies
and Crisis Intervention 13
LEARNING OBJECTIVE

After studying this chapter, the student will be able to gain knowledge regarding the psychiatric emergencies in order to render the
nursing care to the patients with psychiatric emergencies.

CHAPTER OUTLINE
• Introduction • Delirium
• Common Psychiatric Emergencies • Epileptic Furor
• Aggression/Violence
Maladaptive Behaviors of Individuals and Groups: Crisis, Stress
• Transient Situational Disturbances
and Disasters
• Victims of Disaster
• Adaptive Behavior
• Catatonic Stupor
• Maladaptive Behavior
• Victim of Rape
• Crisis
Medical Emergency in Psychiatry • Grief and Bereavement
• Neuroleptic Malignant Syndrome • Counseling
• Overdose of Psychotropic Agents • Stress
• Substance Intoxication and Withdrawal • Coping Mechanism
• Serotonin Syndrome • Geriatric Considerations

KEY TERMS
Suicide, Aggression/Violence, Catatonic stupor, Hysterical attacks, Delirium tremens, Transient situational disturbances, Epileptic furor,
Neuroleptic malignant syndrome, Drug toxicity, Victims of disaster, Rape victim, Stress adaptation model, Crisis and grief.

INTRODUCTION a patient that negatively impacts a patient’s ability to

function in his/her environment. It must be treated
• Emergency: It is a serious, unexpected and often properly otherwise individual may harm himself or
dangerous situation, which requires an immediate action. herself or to the others.
• Psychiatric emergency: A psychiatric emergency is • Crisis: An emerging situation which causes significant
an acute disturbance of behavior, thought or mood of distress either to the individual group or society
364 Textbook of Psychiatric Nursing for BSc Nursing Students

that leads to sudden disability and needs immediate Objectives to Treat Psychiatric Emergencies
management is called crisis. When this crisis situation
The following are the objectives to treat psychiatric emergencies:
causes psychological distress to an individual, it is called
• To develop the emotional security of an individual and
psychiatric emergency.
others
• To reduce the anxiety of family members
Characteristics of Psychiatric Emergencies
• To safeguard the life of individual
• Psychiatric emergency is a situation that causes significant • To enhance the coping ability
psychological distress.
• Presence of disharmony within an individual and toward Types of Psychiatric Emergencies
environment (danger toward the self or others or society
Types of psychiatric emergencies have been given in
or property).
• Condition of the individual that needs immediate crisis Figure 13.1.
intervention.
Classification of Psychiatric Emergency
• Abrupt or sudden disorganization within the individual
might lead to lack of coping skills in day-to-day The classification of psychiatric emergency has been given in
situations. Flowchart 13.1.

Figure 13.1: Types of psychiatric emergencies

CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 365

Flowchart 13.1: Classification of psychiatric emergency causing one’s own death intentionally, whereas the attempted
suicide is the deliberate infliction of injury on oneself or an
attempt to commit suicide but the individual survives.

Epidemiology
In India, suicide is one of the top ten leading causes of death.
Incidence of suicide is 10.8/1,00,000 population. Suicide is
more common in males than in females. It is common in the
age group of 18–30 years.

Etiology (Fig. 13.2)

Psychiatric Disorders
• Major depression
• Schizophrenia
• Bipolar mood disorder
• Substance or alcohol abuse
COMMON PSYCHIATRIC EMERGENCIES • Delirium
• Dementia
Suicide • Personality disorders
The term ‘suicide’ has been derived from the Latin word
Physical Disorders
‘Suicidium’, which means killing of oneself.
• Prefix ‘Sui’ denotes oneself. • Patients with chronic diseases like acquired immuno-
• Suffix ‘Cidium’ denotes killing. deficiency syndrome (AIDS), cancer, etc.
• Unbearable pain, epilepsy, multiple sclerosis, etc.
Definition Biological Factors
Suicide is defined as “intention to kill oneself ” or “self-inflicted Imbalance in release of neurotransmitter, namely serotonin
cessation of life” which ends in a fatal outcome. might provoke suicidal ideation.
Attempted Suicide Psychosocial Factors
Attempt for suicide is widely seen among patients suffering • Long-term difficulties in relationships toward friend and
from different types of psychiatric issues. Suicide is the act of family.

Figure 13.2: Etiology of suicide

366 Textbook of Psychiatric Nursing for BSc Nursing Students

• Losing hope or the will to live. Flowchart 13.2: Methods of committing suicide
• Significant losses in a person’s life, such as death of loved
ones.
• Loss of important relationship, loss of employment, etc.
• Failure in exams.
• Financial losses.
• Poor anger management (unable to control anger).
• Frustrations.
• Aiming to threaten others.

Methods of Committing Suicide

Methods of committing suicide have been given in
Flowchart 13.2.
Types of suicide have been tabulated in Table 13.1.

Suicide Intention Model

World Health Organization (WHO) and Institute of Health
Metrics and Evaluation (IHME) used the model given by
Center for Suicide Prevention, Canadian Mental Health
Association to get a clarity in regard to the interchange of terms

Table 13.1: Types of suicide

Types of suicide Description Examples

Based on social categories as per Emile Durkheim (1951)
Egoistic suicide Suicide due to lack of social integration. Divorce
Altruistic suicide Sacrifice of one’s life for the benefit of others Mr Raj is recently diagnosed with end stage
or to preserve the traditions and honor of cancer, committed suicide because he never
society. wanted to become an economic burden for his
family.
Anomic suicide Suicide due to occurrence of sudden changes Loss of job
in individual’s life
Samsonic suicide or suicide of Suicide due to sudden unfriendly experiences Wife is not faithful to husband and husband
revenge attempted suicide to take revenge.
Miscellaneous types
Parasuicide Injure himself/herself due to self-motivation Ms Raji attempted suicide to threaten her parents
but does not wish to die in order to accept her love affair; does not wish
to die.
Cyber-suicide Suicide happens due to internet-related Blue whale game
issues
Copycat suicide Suicide attempt was made by copying a Ms Sumathi attempted suicide by adopting the
peer group or friend or family member who same method as her mother had attempted.
attempted suicide previously.
Anniversary suicide Suicide has taken place on the same Ms Sushma attempted suicide on the anniversary
anniversary date of family member or friend date of her husband’s death.
who was dead.
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 367

Flowchart 13.3: Suicide intention model by Canadian Mental

Health Association, Center for Suicide Prevention (2016)

Figure 13.3: Suicidal barometer model

‘self-harm and suicide’. Self-harm is not done with high intent
to die, whereas suicidal attempts are done with high intent The features of suicidal levels as per suicidal barometer
to die. The term ‘unintentional suicide’ denotes the lifestyle model have been given in Table 13.3.
changes or ill-health habits, such as smoking, alcoholism, lack
of exercises, eating junk foods, riding a bike without helmet, Risk Factors and Warning Signs of Suicide
that might cause injury or death (Flowchart 13.3). Risk factors denote the probability to increase the risk of
The differences between self-harm and suicide have been suicidal crisis.
given in Table 13.2. The following are signs of clinical depression:
Table 13.2: Differences between self-harm and suicide • Withdrawal or isolation from friends and family
• Sadness and hopelessness
Aspects Self-harm Suicide • Feeling trapped with unbearable pain
Purpose Performed to Performed with the • Talking in such a way as being burden to others
avoid suicide intention to die • Lack of interest in previous activities or in what is going
impulses
on around them
Methods Cutting, self- Poisoning by self • Physical changes such as lack of energy, different sleep
commonly hitting, burning
patterns, change in weight or appetite
used
• Loss of self-esteem
Frequency of More frequent Less frequent
incident • Increased use of alcohol or drugs
• Presence of mood swings
Severity Less High
• Being anxious, agitated or reckless
• Exhibiting rage or talking about revenge
Suicidal Barometer Model • Negative comment about self-worth
Suicidal barometer model describes various suicidal levels • Speaking or writing about death or suicide
such as nonsuicidal, low suicidal, moderate suicidal and high • Giving their valuable possessions to somebody
suicidal (Fig. 13.3). • More interest in personal wills or life insurances

Table 13.3: Features of suicidal levels

Features High suicidal Moderate suicidal Low suicidal Nonsuicidal

Wish to live Very low Low Moderately high Very high
Wish to die Very high Moderately high Low Very low
Prediction of future suicidal attempts High High Low Absent
Attempts with intent to die High Present low Absent
Life/death debate Frequent Frequent Infrequent Absent
368 Textbook of Psychiatric Nursing for BSc Nursing Students

American Foundation for Suicide Prevention emphasizes Aspects Description

that the suicide determination is to be done with the help of
Psychiatric • Borderline personality disorder
three factors such as health factors, environmental factors and dimension • Psychotic illness
history-related factors. • Reactive depression
Factors that determine suicidal risk have been given in Physical • Functional impairment
Table 13.4. Illness • Pain syndromes
• HIV/AIDS
Table 13.4: Factors that determine the suicidal risk as per American
• Malignant neoplasm
Foundation for Suicide Prevention
• Any terminal illness
Health-related Environmental History-related Genetic and • Family history of suicide
factors factors factors Familial • Previous suicidal attempts
• Family history of psychiatric illness or abuse
• Mental • Financial loss • Previous suicide
illness • Exposure to suicidal attempts
• Substance attempts among • Family history of Suicidal Risks in Ward
abuse family members or suicide
• Chronic pain media • Cultural beliefs • Attempted suicides are the most common among
• Sleep • Stressful life events that support psychiatric patients, who suffer from major depressions
pattern such as loss of loved suicide due to their delusions, feeling of worthlessness and
difficulties ones, loss of job, • History of hopelessness.
• Serious divorce, etc. deliberate self-
health • Access to lethal harm
• Schizophrenic patients are highly prone especially when
problems means such as • Recent they develop postschizophrenic depression; they may also
drugs etc. hospitalization attempt suicide due to delusions and hallucinations.
• Prolonged stressors • Manic patients may also attempt/commit suicide due to
such as harassment, their grandiose delusions, i.e., to prove their supernatural
relationship
problems, etc.
powers.
• Drugs or alcohol: Alcoholic adult patients commit
Aspects of suicidal risk have been given in Table 13.5. suicide due to development of depression during
withdrawal phase. Few other drugs or substances may
Table 13.5: Aspects of suicidal risk
provoke suicidal ideation among addicts.
Aspects Description
Warning Clues of Suicide
Demographic • Gender: Male
profile • Marital Status: Single, widow, divorced, There are certain warning clues of suicide that are helpful in
Separated predicting the suicidal attempts (Table 13.6).
• Age: Adolescence and old age
Table 13.6: Aspects of warning clues of suicide
Psychological • Hopelessness, helplessness and
dimension worthlessness (depressed) Warning clues Description
• Agitation of suicide
• Psychic pain or turmoil
Behavioral • Writing suicidal notes
• Low self-esteem
clues • Abrupt changes of mood
• Fragile narcissism and perfectionism
• Making the will
Psychosocial • Socioeconomic status: High • Giving out the valuable possessions
dimension • Job: Unemployment • Buying some lethal drugs
• Social support: Absent
Verbal clues Passing negative comment directly or indirectly
Behavioral • Aggression • Use of overt statement (Passing direct
dimension • Panic attacks comments)
• Severe anxiety • For example: I wish, I want to die. This is
• Intoxication the last time you are seeing me.
• Impulsivity • Use of covert statement (Passing indirect
• Prior suicidal attempts comments)
Cognitive • Thought constriction For example: Everything will be fine very
dimension • Polarized thinking soon. I won’t be a problem to anyone.

Contd… Contd…
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 369

Warning clues Description Table 13.8: Guidelines for clinical action based on the score
of suicide obtained in SAD PERSONS rating scale

Situational Certain life experiences associated with major Score Guidelines for clinical action
clues stress denote the situational clues, e.g., diagnosis
0–2 Can send to home with follow-up
of fatal diseases, loss of job, sudden death of
beloved ones, heavy financial losses, etc. 3–4 Follow-up closely and consider hospitalization
Syndromic Psychological disturbances associated with 5–6 Strongly consider hospitalization
clues suicide, psychotic illness, acute delirium, 7–10 Hospitalize immediately
depression, etc.
Nonverbal • Sleeping excessively or sleeping too less
clues • Depressive mood • Strong family and social support
• Lack of attention and concentration • Easy access to clinical interventions
• Addictive behavior • Skills in problem solving and conflict resolution
• Lack of interest in all activities • Restricted access to lethal means of suicide
• Poor performance in school or job
• Strong support from the health care professional
• Boredom
• Restlessness • Cultural and religious beliefs that discourage suicide.
Emotional and • Hopelessness, helplessness and Three levels of prevention of suicide are shown in
behavioral worthlessness Flowchart 13.4.
changes • Feeling of shame and guilt
Suicide prevention and stress helpline numbers of
associated with • Self-neglect
suicide • Withdrawal from friends and family different regions are given in Table 13.9.
members
• Being preoccupied with dying Flowchart 13.4: The levels of prevention of suicide
SAD PERSONS rating scale can be used to determine the
suicidal risk (Table 13.7).
Table 13.7: SAD PERSONS rating scale

Letter Characteristics Score

S Sex (male) 1
A Age (25–44 years or 65 years) 1
D Depression 1
P Previous suicidal attempts 1
E Ethanol usage 1
R Rationale thinking loss 1
S Lacking social support 1
O Organized plan 1
N No spouse 1
S Sickness is present 1

Based on the SAD PERSONS rating score, the guidelines for

clinical action have been given in Table 13.8.

Protective Factors for Suicidal Attempts

Protective factors are responsible for decreasing the risk of
suicidal crisis. The following are the factors which help to
prevent an individual from attempting suicide.
370 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 13.9: Suicide prevention and stress helpline numbers Do’s Don’ts
(Updated till September 2019)
Sedate the patient, if Do not scold patient in front
Region* Name of the suicide Helpline numbers uncontrollable of others for his/her behavior
prevention phone center* Teach the family members or Do not allow the patient to
Sumaitri 011-23389090 care givers that patient needs to take medicine by self
be monitored continuously due
Sanjivini Society for Mental 011-24311918,
Delhi to the increased suicidal risk
Health 243118883
Encourage the patient to Never keep syringes and
Fortis National Helpline 91-8376804102
verbalize his/her thoughts needles in patient’s room
Gangtok Sikkim Helpline Number 1800-3453225, related to suicide
03592-202111
Apply restraints, if necessary Do not keep drug cupboards
Serve 9830785060 within the reach of patients
Clippings 98300 27976
Kolkata Defeat depression 9830027975
Medicolegal issues related to Suicide
AASRA 91-22-27546669 Section 309 of Indian Penal Code (IPC) states that whoever
Singing Soulz 9892003868 attempts to commit suicide and does any act toward the
commission of such offence shall be punished with simple
Mumbai Samaritans 8422984528/ imprisonment for a term which may extend to 1 year or fine or
8422984529/ both.
8422984530
Sneha Suicide Prevention 044 2464 0050
Helpline Nursing Management
Chennai
Jeevan Suicide Prevention 044 2656 4444 Management of Attempted Suicide
Hotline
Attempted suicide is not only psychiatric emergency, but also
Bangalore Sahai 080-25497777 a medical emergency. Firstly, do not panic and also do not
Hyderabad One Life 78930 78930 make other panicky. Inform the psychiatrist immediately.
Kochi Maithri 91-484-2540530 Monitor the vital signs. Nurse should act fast depending on
Nagpur Nagpur Suicide Prevention 8888817666 the method of suicidal attempt done by the patient. Nurse
Helpline should change the rooms of other patients, if necessary.
All-India Vandrevala Foundation 1860-266-2345/ Treat the underlying psychiatric conditions, e.g., depression
1800-233-3330/ or schizophrenia. If necessary, give antidepressants,
0261-2662700
antipsychotics and electroconvulsive therapy (ECT) as per the
(*Suicide prevention helplines [online] available from order of psychiatrist.
http:// www.healthcollective.in/suicide-prevention-helplines)
Nurse plays an important role in management of
[Access Sep. 2019]
attempted suicide. Nurse should maintain good rapport with
Nurse’s Responsibilities the patient. Ward should have sufficient number of staff to
The responsibilities of a nurse in prevention of suicide have monitor a patient with suicidal risk. Nurse should encourage
been given in Table 13.10. the patient to express his/her plans of suicide and also
encourage the patient to develop socialization. Nurse needs to
Table 13.10: Responsibilities of a nurse in prevention of suicide
record the behaviors or the behavior changes seen in patient.
Do’s Don’ts Nurse can involve the patient in group games in order to relax
Closely monitor the patient Do not leave the patient and divert from the suicidal ideation. Nurse can also encourage
alone the patient to get involved in spirituality, relaxation exercises,
Accompany the patient wherever Do not allow patient to lock watching TV, etc. Nurse needs to give appropriate counseling
he/she goes inside the bathroom to the patient. If the patient has attempted suicide, inform the
Avoid keeping dangerous objects Don’t keep ties, belt, sharp psychiatrist immediately and then start life-saving procedures
near the patient instruments, shoe laces, long to preserve patient’s life. If the patient is dead, inform the
towels near the patient, etc. police and proceed with further legal or clinical actions.
Contd…
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 371

Nursing Diagnosis • Socioenvironmental factors: Friends/relatives who have

• High-risk of suicide or self-directed violence related to association with antisocial elements, access to lethal
feelings of desperation. weapons and living in a community where violence is
• Hopelessness or lack of self-esteem related to lack of predominant.
social support system. • Sociocultural factors: Unemployment, poverty,
• Ineffective coping skills related to lack of coping ability disruption in marital life and single parent in a family.
with stressors as evidenced by suicidal attempts. • Cognitive factors: Negative perception/attitude that
• Masked depression related to guilt. induces aggression/hostile behavior.
• Psychological factors: Low self-esteem, severe emotional
Nursing interventions with rationales are given in Table 13.11. deprivation, overt rejection in childhood and low
Table 13.11: Nursing interventions with rationales frustration tolerance.
• Behavioral factors: Agitation, poor impulse control,
Nursing interventions Rationales shouting at others and damaging the nearby things.
Encourage the patient To reduce isolation and to divert
to stay with friends and him/her from the suicidal thoughts Etiology of Violence
family members
Organic Psychiatric Disorders
Advise the patient not to In case of crisis situation, individual
take any decision in crisis is unable to think and take decision • Acute organic brain syndrome or delirium, e.g., delirium
situation correctly. tremens.
Encourage the patient Mental ventilation helps to ventilate • Chronic organic brain syndrome or dementia, e.g.,
to talk and verbalize the the inbuilt suicidal ideas and catastrophic reaction.
feelings therefore, minimizes the occurrence • Wernicke-Korsakoff ’s psychosis.
of suicide. It further helps to
minimize the suicidal tendencies.
Nonorganic Psychiatric Disorders
Maintain accurate and It acts as evidence for the rendered
timely records nursing care or treatment.
• Psychotic disorder (schizophreniform disorder, schizo­
phrenia-paranoid and catatonic type).
• Mania
AGGRESSION/VIOLENCE • Depression
• Substance abuse (intoxication and withdrawal syndrome)
Anger: “Anger is a normal human emotion that may be • Epilepsy (epileptic furor, complex partial seizure and
handled or expressed assertively to solve the problem and postictal confusion).
show a productive change.” —Horton-Deutsch, 2003 • Neurotic disorder (panic disorder, posttraumatic stress
Aggression: Aggression is an expression of anger by physical disorder).
or psychological or verbal means in a socially inappropriate • Impulsive violent behavior (Borderline personality
manner, which may or may not cause significant harm to self disorder and intermittent explosive disorder).
or others. • Reactive psychosis.

Risk Factors for Violence Medical Disorders Associated with Violent Behavior
• Demographic factors: Male gender, young age, • Neurologic illnesses
unemployment and illiteracy. „ Head injury with intracerebral, subarachnoid or
• Family history: Involvement in criminal activity, subdural hematoma.
antisocial behavior, cruelty to other human beings/ „ Cerebral infarction.
animals and violence among family members. „ Brain infections such as encephalitis, meningo-
• Biological factors: Central nervous system dysfunction/ encephalitis.
infections, abnormalities in neurotransmitters, frontal or „ Seizure disorders (interictal, postictal or temporal
temporal lobe dysfunction, limbic system dysfunction lobe epilepsy).
and traumatic brain injury. „ Huntington’s disease.
• Biochemical factors: Decreased serotonin level. „ Hepatic encephalopathy.
372 Textbook of Psychiatric Nursing for BSc Nursing Students

„ Wilson’s disease
„ Parkinson’s disease due to levodopa toxicity.
• Endocrine disorders: Hypothyroidism, thyrotoxicosis,
hyperparathyroidism and Cushing’s syndrome.
• Metabolic disorders: Hypoglycemia, electrolyte
imbalance, hypoxia and hypocholesterolemia.
• Vitamin deficiencies: Folic acid, niacin, pyridoxine and
vitamin B12.
• Infections: Acquired Immunodeficiency Syndrome
(HIV/AIDS), syphilis and tuberculosis.
• Temperature disturbances: Hyperthermia and
hypothermia.
Figure 13.4: Assault cycle
Sources and Expressions of Anger
The signs of anger are categorized into subjective and • Level of consciousness: Confusion, disorientation,
objective (Table 13.12). memory impairment and changes in mental status.
• Affect: Hostile behavior, anger, irritability, extreme anxiety,
Behavior Associated with Aggression labile affect and inappropriate or excessive euphoria.
• Verbal behavior signs: Pressure of speech, verbal threat
Assault Cycle
to real or imagined object, demand of attention and
thought content with a paranoid ideation. Smith’s stress model (1981) explained the assault cycle which
• Motor agitation: Clenching fists, inability to sit still for a has five stages of aggressive response to physical or emotional
long time, increased respiratory rate, pacing and sudden stress (Figure 13.4).
cessation of motor activity. Different phases of assault cycle are given in Table 13.13.

Table 13.12: Category-wise signs of anger

Anger turned outward Anger turned inward

Subjective signs Objective signs Subjective signs Objective signs
• Impatience • Irritation • Guilt • Substance abuse
• Annoyance • Hostile behavior • Tensed • Crying often
• Negative attitude • Tensed facial expression • Disappointment • Suicidal attempts
• Feeling Jealous • Verbal abuse • Feeling inferior • Self-mutilation
• Feeling of harming others • Verbalization of anger • Lack of self-confidence • Apathy
• Want to scold others • Temper tantrums • Low self-esteem
• Domination • Rage • Depression
• Screaming • Powerlessness
• Assault • Helplessness
• Damage to property • Somatic symptoms
• Beating others • Feeling hurt
• Argumentativeness
• Use of weapons as threat

Table 13.13: Phases of assault cycle

Phases of assault cycle Description Level of anxiety Behavioral response Nursing interventions
Triggering phase Stressors trigger the Mild Irritable, perspiration, • Encourage the client to
individual suspiciousness, change in ventilate the feelings
voice/breathing pattern, • Give support empathically
restlessness • Use small, clear and simple
sentences
• Encourage the client to
maintain control
Contd…
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 373

Phases of assault cycle Description Level of anxiety Behavioral response Nursing interventions
Escalation phase Escalating behaviors Moderate Agitation, screaming, • Direct the client toward a
such as movement demanding, clenched fists, quiet room
toward the loss of flushed face • Administer the oral
control medications as ordered
• Ask the staff nurse to stand at
a distance and motivate the
client to have a control over
his/her behavior
Crisis phase Physical and Severe Fighting or kicking others, Physical or chemical restraints
emotional crisis throwing things, rage
causes the complete
loss of control

Recovery phase Cooling down Moderate or Lowering voice, reduced Evaluate the client’s progress
period in which the Mild body tension, feeling toward the loss of control
individual moves relaxed
toward calming
effect
Post-crisis depression Individual attempts Mild Crying, asking sorry, • Decrease the degree of
phase reconciliation with realizing the mistakes seclusion and restraints
others committed • Discuss alternative solutions
to problems

Management of Violence The do’s and don’ts in violence management have been given
in Table 13.14.
• Assessment: Assess the signs of impending violence such
as shouting at others, throwing things, running or chasing Table 13.14: Do’s and don’ts in violence management
others, etc. in early stage itself so that the nurse can be
Do’s in management of violence
alert to manage the violent behavior effectively.
• Assess the signs of impending violence at the earliest.
• Reassurance: Approach the patient in firm and kind way. • Protect yourself first
Always talk to the patient in a soft manner. Nurse should • Secure the nearby patients (Instructing them not to stand
ask direct and concise questions in patient’s language, near the violent patient)
which helps the patient to understand easily. Ask open- • Keep the nearby doors open
• Show the concern and establish adequate rapport
ended questions to the patient. Try to reassure the patient
• Apply restraints, if necessary
in calm and soft manner. • Call for help, if required
• Medications Don’ts in management of violence
„ Inj. haloperidol 4–10 mg IM/IV
• Don’t keep any sharp objects near the patient
„ Tab. chlorpromazine 50–100 mg/oral • Don’t sit when the patient is at your back (Keep the patient
„ Inj. diazepam 5–10 mg/Slow IV always in front of you)
• Psychological well-being: Advise the client to ‘talk out’ • Don’t stand/sit very near to the patient
the feelings which cause aggression rather than acting • Don’t wear any neck chain/tie/jewelry
• Don’t keep any family members who provoke violence in
them out. Stay with the patient which decreases the level patient’s room
of anxiety. • Don’t tie the physical restraints in bed side rails (instead tie
securely in bed cradle)

NURSES RESPONSIBILITY Restraints

Collect the history and perform the physical examination. Restraints are used during certain medical procedures to
Administer IV fluids to assess the level of dehydration. Keep the restrain the patients with minimum discomfort and pain.
decreased environmental stimuli and keep less furniture in the
There are two types of restraints: physical and chemical
patient’s room. Remove all sharp instruments from the room.
(Flowchart 13.5).
374 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 13.5: Types of restraints Table 13.15: Time frame to monitor physical restraints

Time frame to monitor the Observations made

physical restraints
5 minutes once for 1st half hour • Check the peripheral
10 minutes once for 2nd half hour pulse
• Assess the color/
15 minutes once from one hour temperature of all
onward extremities
Physical Restraints
• Guidelines to apply physical restraints: Obtain the Chemical restraints: Chemical restraints are defined as the
written order from the treating physician to apply physical medications/drugs which are helpful to control the violent
restraint. Get the written consent from the patient’s care behavior of patient. For example, injection Haloperidol
givers to perform the same. Apply the physical restraints 4–10 mg IM/IV, injection Chlorpromazine 50–100 mg/IM and
one by one tying the joints of upper and lower extremities injection Diazepam 5–10 mg/slow IV can be administered.
with the bed cradle (don’t tie the restraints in side rails).
Restraints should not be too tight or too loose. Restraints Strategies to Manage and Prevent Violence
that are too tight might obstruct the blood flow leading to
Communication strategies used to prevent aggressive
necrosis. Restraints that are too loose might have chance
behavior are as follows:
of removal.
• Listen to the patient
• Guidelines to monitor physical restraints: Check
• Show respect to the patient
the peripheral pulse and the color/warmth of all the
• Speak softly to the patient
extremities every 5 minutes once for first half an hour,
• Be calm
10 minutes once for second half an hour and 15 minutes
• Have an adequate space between yourself and patient.
once for the next one hour (Table 13.15).
• Have an intermittent eye-to-eye contact with patient.
• Guidelines to remove physical restraints: Remove
• Encourage the patient to talk.
physical restraints one by one from all the extremities
• Don’t make any unnecessary promises, which are unable
after making adequate observations. For example, in
to be kept.
case of four-point restraint, first remove the restraint
• Talk in a nonjudgmental and nonprovocative manner.
in right foot, secondly the left foot, then right wrist and
lastly the left wrist after making adequate intermittent Strategies to manage violence/aggression have been tabulated
observations. in Table 13.16.

Table 13.16: Strategies to manage violence

Preventive strategies Anticipatory measures Containment

• Create self-awareness: • Communication • Crisis management
Awareness about oneself will • Environment change (As a team response)
help to identify one’s strengths • Seclusion
and weaknesses • Restraints
• Patient education: Educate the
patient regarding the measures
to control violence by self.
• Assertiveness training:
Communicate assertively
▪ Express the appreciation as
appropriate
▪ Say ‘No’ to unreasonable
request
▪ Communicate directly to
other person
▪ State the complaints, if
necessary
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 375

Strategies to prevent assault have been given in Table 13.17. Clinical Manifestations
Table 13.17: Strategies to prevent assault Guilt, anger or aggression, irritable, frustration, confusion and
numbness.
Strategies to prevent Strategies to prevent physical
verbal assault assault
First Aid Management
• Answer in a soft, simple • Call for help, if required
and honest way to all • Nurse has to keep his/her • First treat the life-threatening physical problem and then
the questions asked by hands visible refer to the mental health service.
the patient • Always keep the door open
• Provide counseling.
• Be calm and empathic in • Stay at least an arm’s length
nature away from the patient • Teach coping patterns to prevent crisis. (Teach the
• Use nonthreatening • Escape from the place, if strategies to the survivors on how to get help, request
body language required information, access resources and get required support).
• Use reflective • Face the person in the sideways
statements rather than • If patient is choked, use head Medications
the judgmental ones tilt and chin lift maneuver to
the chest and maintain the Administer benzodiazepines to reduce anxiety.
airway
Critical Incident Debriefing
TRANSIENT SITUATIONAL DISTURBANCES Critical incident debriefing is a special technique used to
decrease the discomfort of disaster victims. It has the following
Transient situational disturbances are characterized by five phases:
disturbed behavior and feelings due to repeated external 1. Fact phase: Participants are asked to share their perception
stimuli. The term ‘transient’ denotes short term. about the incident. When they share, new information is
noted and integrated for a common understanding.
Management 2. Thought phase: Participants are asked to reflect on the
• Reassure and allow the patient to ventilate his/her feelings. incident and tell how they felt personally at different
• Provide counseling. stages of crisis.
• Administer mild sedation, if required. 3. Reaction phase: Participants are asked to identify the
emotional aspect of incident. (For example, asking
Panic Attacks the participant which is worst part of incident).
Panic attacks refer to episodes of acute anxiety as a part of When participants come to know that ‘others are also
psychotic or neurotic disorders. experiencing the same’, it might make them realize that
these kinds of feelings are normal behavioral responses to
Symptoms abnormal situations/circumstances.
• Palpitations 4. Teaching phase: Emotional, cognitive and spiritual
• Tremors strategies are used to decrease stress.
• Sweating 5. Re-entry phase: Facilitator summarizes the process and
• Feel of choking, abdominal distress, fear of dying clarifies the doubts of participants. Referral for further
• Nausea, paresthesia and hot or chill flushes. counseling sessions can be done, if required.

Management CATATONIC STUPOR

Reassure the patient and administer Inj. diazepam 10 mg or
Catatonic stupor is a clinical syndrome with a combination
lorazepam 2 mg.
of akinesis (absence of movements) and mutism (absence of
speech).
VICTIMS OF DISASTER

Victims of disaster are the persons who survived disasters such

Signs and Symptoms
as earthquakes, riots, flood, drought, cyclone, terrorism, etc. • Mutism: Absence of speech completely.
They usually undergo a severe form of sudden and unexpected • Rigidity: Rigid posture maintained against the force tried
stress. for movement.
376 Textbook of Psychiatric Nursing for BSc Nursing Students

• Negativism: High resistance to commands • Payback rape or punishment rape or revenge rape: Rape
• Posturing: Having bizarre posture for a long duration done by the rapist with intent to give punishment.
• Waxy flexibility: Body parts placed in a position will • Custodial rape: Rape done to an individual who is in
be kept for a longer duration even if they are found custody (e.g., in police station, hospital, etc.)
uncomfortable to patient.
Nicholas Groth classified rape based on the goal of the rapist
• Echopraxia: Mimicking of actions
(types of perpetrators) as follows:
• Echolalia: Mimicking of words heard
• Anger rapist: Rape is done in order to show the anger
• Ambitendency: Tentative actions are made due to
toward victim.
conflicting impulses. No goal-directed behavior is
• Power rapist: Rape is done in order to show the power
observed, for example, a patient is asked to close eyes
toward victim.
by the nurse; the patient closes partially and opens
• Sadistic rapist: Rape is done in order to enjoy or to get
completely.
pleasure by harming the victim.
• Automatic obedience: Commands followed automatically
irrespective of their consequences.
Signs and Symptoms
• Verbigeration: Incomprehensive speech.
• Psychological pillow: Patient holds his/her head a few Low self-esteem, self-blame, fear of being killed, social
centimeters above the bed for many hours. isolation, feeling of depersonalization or derealization, fear of
• Mannerisms degradation, recurrent intrusive thoughts, sleep disturbances,
• Stereotypical speech: Meaningless repetitive speech. loss of appetite, depression and anxiety. It might lead to post-
traumatic stress disorder (PTSD) if persists for long term.
Nursing Management
Nursing Management
• Collect the history from the patient’s family members.
• Perform physical examination and send the blood samples • Provide reassurance and give adequate psychological
to identify the patient’s health problems. support.
• Nurse has to ensure the patent airway in order to prevent • Perform physical assessment to identify any injury.
the tongue from falling back as it might cause respiratory • Send blood samples to rule out any sexually transmitted
arrest. diseases (STDs), especially HIV infection and initiate the
• Administer intravenous fluids in order to meet the fluid appropriate medications as per the order, if the infection
balance. is present.
• Other nursing care is similar as that for an unconscious • Give contraceptive pills to prevent pregnancy.
patient. • Encourage the patient to ventilate the feelings related to
the rape trauma.
VICTIM OF RAPE • Provide counseling services to enhance the psychological
well-being of victim.
Rape is a traumatic experience for victim in which the
perpetrator coerces or physically forces a female for sexual
MEDICAL EMERGENCY IN PSYCHIATRY
intercourse against her consent.
NEUROLEPTIC MALIGNANT SYNDROME
Types of Rape
• Date rape: Rape done by a person whom the victim Neuroleptic malignant syndrome is an extrapyramidal
knows already. syndrome/hypermetabolic reaction to the dopamine
• Marital rape or spousal rape: Rape done by husband antagonists, especially antipsychotics. It usually occurs in the
toward his wife. early phase of treatment and rarely occurs in the maintenance
• Gang rape: Rape done by a group of individuals. phase. It occurs in around 3% of patients who are under
• Statutory rape: Rape done to an individual who is unable treatment with antipsychotics. Risk of developing neuroleptic
to give consent as per the law (minors below the age of 18). malignant syndrome increases in agitated patients who get
Here, there will not be any physical force by perpetrator. increased dosage of drugs.
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 377

Signs and Symptoms oculogyric crisis can be provided with administration of

parenteral antihistaminic agents (e.g., promethazine 25 mg
Hyperpyrexia, hypertension, muscle rigidity, tachycardia,
IM). Administer oxygen in case of breathing difficulty. Start
tachypnea, autonomic dysfunction and changes in the mental
the intravenous line, administer anticonvulsants and proceed
status.
with hemodialysis, if required.
Diagnosis
SUBSTANCE INTOXICATION AND WITHDRAWAL
Laboratory findings include respiratory and metabolic
acidosis, increased creatine kinase (CK), myoglobinuria and Substance intoxication may happen as a primary presenting
leukocytosis. complaint or it may happen along with any psychiatric
disorder. Withdrawal from barbiturates, sedatives, hypnotics,
Treatment benzodiazepines and alcohol is clinically similar.
Stop the antipsychotic drugs. Treat the myoglobinuria/
Alcohol Withdrawal Effects
fever/acidosis, by providing supportive care. The dopamine
agonist—Tab. bromocriptine 2.5–2.0 mg tds or Inj. dantrolene Withdrawal of alcohol may be life-threatening, if the patient
up to 10 mg/kg IV/4th hourly is used as a muscle relaxant. has seizures. Delirium tremens is a withdrawal symptom that
Patient needs to be treated in intensive care unit. starts within 7 days of alcohol withdrawal (usually within
24–72 hours). It is a medical emergency and needs to be treated
Miscellaneous in critical care unit. Management of alcohol withdrawal is
usually with high dose of benzodiazepines, maintenance of
Reintroduction of antipsychotics after recovery may retrigger
fluid/electrolyte balance and administration of parenteral
the syndrome in one-third of patients. Mortality rates are
thiamine.
around 10–20%.
Management of Violent Behavior During
OVERDOSE OF PSYCHOTROPIC AGENTS Substance Withdrawal
History Alcohol, phencyclidine and cocaine are the substances that
commonly lead to aggression or violent behavior. Patients
Collect history from the patient regarding the intention of
should be kept under observation in a separate room, away
taking over-dosage of drug whether it is suicidal or accidental.
from stimulation. Physical restraints or chemical restraints
Identify the amount of the drug consumed.
(sedation) may be needed for patients who are aggressive. Inj.
Lorazepam 2–4 mg or diazepam 10–20 mg is recommended to
First Aid Management
be administered at once to treat agitation.
If a patient has taken toxic dosage of psychotropics and is
awake, then induce vomiting followed by administering the Treatment Modalities
activated charcoal. Treatment in a hospital is safe and mandatory if the patient is
febrile (>101°F), not taking oral fluids and is having a severe
Monitoring and Treatment underlying physical disorder.
Overdose with carbamazepine or tricyclic antidepressants
needs a regular cardiac monitoring. Overdose with SEROTONIN SYNDROME
benzodiazepines or barbiturates and alcohol may cause
Definition
respiratory arrest. Therapeutic as well as toxic dosage of
antipsychotics may cause acute extrapyramidal symptoms such Serotonin syndrome is defined as over activation of
as akinesia, oculogyric crisis, dystonia and torticollis. Akathisia serotonergic receptors which leads to increased secretion of
is the most adverse effect of high-potency antipsychotic and serotonin.
it might be accompanied by extreme anxiety or terror, if it
gets severe. Acute onset of orofacial dystonia or oculogyric Etiology
crisis might suggest purposeful or inadvertent ingestion of Serotonin syndrome happens due to use of two or more
antipsychotics. Immediate relief from orofacial dystonia or serotonergic medications.
378 Textbook of Psychiatric Nursing for BSc Nursing Students

Drugs that induce serotonin syndrome have been given in Flowchart 13.6: Clinical triad of abnormalities in
Table 13.18. serotonin syndrome

Table 13.18: Drugs inducing serotonin syndrome

Class Drugs that induce Serotonin syndrome

Antidepressants • Monoamine oxidase inhibitors (MAOIs)
• Tricyclic antidepressants (TCAs)
• Selective serotonin reuptake inhibitors
(SSRIs)
• Serotonin and norepinephrine reuptake
inhibitors (SNRIs)
• Atypical antidepressant—nefazodone
• Miscellaneous—trazodone and
mirtazapine
CNS Stimulants • Methyl​enedioxy​
methamphetamine (MDMA)
• Amphetamine
• Methylphenidate
• Phentermine
• Methamphetamine
• Lisdexamfetamine
• Cocaine
Opioids • Tramadol or increased motor activity, tachycardia, altered mental
• Pethidine state (delirium), mood changes, myoclonus, dilated pupils,
• Fentanyl
abdominal pain, diarrhea, diaphoresis, hyperreflexia, tremors
• Dextropropoxyphene
• Pentazocine and hypertension.
• Oxycodone The clinical triad of abnormalities in serotonin syndrome
• Hydrocodone is shown in Flowchart 13.6.
• Buprenorphine
Serotonin Triptans (tryptamine based drug used to treat Complications
agonists migraine and cluster headache)
Serotonin syndrome may lead to cardiovascular collapse,
Psychedelics • Lysergic acid diethylamide (LSD) disseminated intravascular coagulation (DIC) and
• 5-Methoxy-diisopropyltryptamine
rhabdomyolysis (damaged muscles will release myoglobin into
Antihistamine Chlorpheniramine bloodstream which causes damage to kidney).
Antipsychotics Risperidone and olanzapine
Mood stabilizers Sodium valproate and lithium Prevention
Antiretroviral Ritonavir Use the drugs with caution that might induce serotonin
drugs syndrome. Give adequate washout period while changing
Muscle relaxants Metaxalone one group of antidepressants to another group. For example,
Antiemetics Granisetron and ondansetron if the drug from tricyclic antidepressants (TCAs) group to
Miscellaneous Tryptophan, 5-hydroxytryptophan, Buspirone monoamine oxidase inhibitors (MAOIs) group needs to be
and linezolid changed in order to enhance the prognosis of patient, then
Herbs • St John’s Wort give washout period (waiting period) for 2 weeks in order to
• Nutmeg prevent serotonin syndrome. Similarly, change of medicine
• Panax ginseng from MAOIs to SSRI requires 14 days of washout period and
• Yohimbe
change of medicine from SSRI to MAOIs requires 5 weeks of
• Syrian rue
washout period.

Clinical Manifestations Treatment

A sudden increase in serotonin might lead to a life-threatening Medications such as dantrolene (a potent muscle relaxant) and
condition, which manifests as hyperthermia, excitement periactin (serotonin antagonist) can be administered.
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 379

DELIRIUM There are several types of maladaptive behaviors, ranging

from relatively minor impairments (such as nail-biting and
Nursing Management separation difficulties) to more severe impairments (such as
Environmental manipulation, frequent orientation (time, self-harm) in response to crisis. The following are the common
person and place) and medications might be helpful to reduce maladaptive behaviors in general.
severity of delirium. • Avoidance coping: It is a type of behavior in which
someone avoids stressful thoughts or feelings in order
Medications to protect himself/herself from psychological damage.
It involves seeking situations which have less stressors, and
Low dose of haloperidol (0.5–2 mg) is the drug of choice. avoiding situations which have more stressors. A common
When delirium is due to substance withdrawal, Tab. lorazepam disease condition of avoidance coping is panic disorder,
(0.5–2 mg) is the drug of choice to control agitation. which can itself lead to agoraphobia, a condition in which
sufferers become anxious in unfamiliar environments.
Used with Caution • Self-harm (SH): Self-harm is the deliberate, direct, self-
Anticholinergic drugs (e.g., benztropine) must be used with inflicted destruction of body tissue without suicidal intent
caution in patients with delirium, especially among elders, and for the purposes which are not socially sanctioned
because the drug may cause anticholinergic toxicity (atropine (Gratz, 2001). It used to be known as ‘deliberate
psychosis). self- harm’ or DSH. The most common forms of self-
harm are skin-cutting, burning oneself, causing physical
EPILEPTIC FUROR trauma to oneself, scratching oneself, pulling one’s own
hair, interfering with healing wounds, and so on. It
Patient has sudden unprovoked attacks of anger and gets can be spontaneous or planned, and it can be a regular
violent or agitated with psychomotor epilepsy. Treatment occurrence or a one-off event.
includes administration of sedatives (Inj. diazepam 10 mg • Disordered eating: Disordered eating refers to a range
IV), oral anticonvulsants to treat epilepsy and Inj. haloperidol of abnormal eating behaviors, including binge-eating,
10 mg IV to control psychotic symptoms. excessive dieting, bulimia, and attachment of well-being
to body image. The most common form of disordered
MALADAPTIVE BEHAVIORS OF INDIVIDUALS eating is dieting, i.e., severely restricting the amount
AND GROUPS: CRISIS, STRESS AND DISASTERS of food you eat. Disordered eating can have profound
destructive consequences on someone’s life; and research
Behavioral problems or maladaptive behaviors can occur from
has shown a relationship between disordered eating and
childhood to adulthood. If not treated or managed, they can
the ability to deal with stress or conflict. There is also a
be harmful not only to the society and people but also to the
relationship between suicidal thoughts or behaviors and
person manifesting maladaptive behaviors. It is important
disordered eating in adolescents.
for the person to be given help and support by professionals,
• Substance misuse: Substance misuse can be the use
society and family members.
of illicit drugs, or the use of prescribed medications in
ways other than the intended purpose, or problematic
ADAPTIVE BEHAVIOR
use of alcohol. Generally, it is defined as, ‘taking of any
Adaptive behavior is a collection of skills that the people learn substance (including alcohol) in such a way that it leads
and employ to function in everyday life. They allow us to adapt to harm’. Substance misuse has been found in some cases
to correlate with anti-social behavior, criminal behavior
to the demands of life and fulfil our needs.
and changes in one’s personality. Addiction, death, injury,
violence, accidents, homicide and suicide are linked (to
MALADAPTIVE BEHAVIOR
varying degrees) to the misuse of substances. For example,
Maladaptive behavior refers to the type of behavior that the rate of suicide frequently increases with alcoholism.
inhibits a person’s ability to adjust with certain situations. We
must adapt our behavior to face challenges and conflicts in Maladaptive Behaviors in Response to Stress
daily life. However, people can develop a tendency to escape Stress is a nonspecific response of the body to any demand
from these challenges rather than dealing with them. made upon it, either caused by the results of pleasant or
380 Textbook of Psychiatric Nursing for BSc Nursing Students

unpleasant situations. Initially, people attempt to cope with to health and can cause pain and injury is a maladaptive
stressful situations by using a number of adaptive coping behavior.
strategies. However, when the impact of stress exceeds their
coping ability, they resort to maladaptive behavior. At first, Workaholism
these strategies might seem useful, but in the end, the situation Spending too much time at work can be a maladaptive behavior
gets worse. Here are some maladaptive behaviors exhibited by when it becomes an addiction. At first, it can be an unconscious
individuals in response to stress. way to cope with psychological issues, but it progresses and
eventually impairs the functions of the individual when he/she
Maladaptive • Substance abuse
behaviors in • Attention-seeking behavior comes to non-working environment. Over a period of time, a
response to • Sex addiction workaholic individual will be in conflict with family members,
stress • Anger conversion burned-out at work and will have impaired health.
• Addiction to exercise
• Workaholism Internet Addiction
• Internet addiction
Compulsive use of the internet is a maladaptive behavior.
These individuals manifest reactions such as depression
Substance Abuse
when not using the internet, anger, forgetting to eat, denying
People use drugs or medications excessively often to reduce excessive spending of time on internet and preferring to be
pain, to decrease the level of anxiety and get temporary relief online instead of being with family and friends.
from problems or bad experiences. However, this can lead to
changes in the brain functions and increase the chances of Patterns of Maladaptive Coping Among Children
dependency.
• It has been recognized that maladaptive coping apparently
Attention-Seeking Behavior stems from adverse childhood experiences and predicts
the psychopathology across lifespan. However, same
Attention-seeking behavior is a type of maladaptive behavior
in which an individual seeks attention or wants to be the research has addressed how maladaptive styles of coping
center of attention by making excessive actions that can draw develop (Fig. 13.5).
attention of others toward him/her. Manipulation, admitting • Zimmer-Gembeck and Skinner’s integrative review
to crimes or doing the wrong things he/she is not intended to showed that older children and adolescents may continue
commit but to seek the attention of others toward oneself are to use less mature or primitive forms of coping (e.g.,
considered maladaptive behaviors. escaping from the situation and seeking contact with a
caregiver) when they face extremely stressful events.
Sex Addiction • Children develop problematic coping to protect
Some people have an excessive desire to have sexual relations, themselves from overwhelming stress or maltreatment.
which is also an example of maladaptive behavior. Such people • Children develop negative coping and thinking patterns
rely on sex to escape, relieve pain and even manage stress. from invalidating interactions with caregivers.
These actions may lead to harming other people and oneself
to the point of losing jobs, missing school and engaging in
unprotected sex with numerous individuals.

Anger Conversion
When a person converts his/her anger to violence such as
hurting someone else, committing crimes and inflicting
physical harm to oneself or other people, this becomes an
inappropriate and maladaptive behavior.

Addiction to Exercise
Excessive exercise can be considered a compulsive maladaptive
behavior, especially if a person manifests certain signs like
being restless or anxious if the person quits exercise. Engaging
in strenuous physical activities that can be detrimental Figure 13.5: Maladaptive coping among children
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 381

generate new appropriate behaviors. Stunned behavior has

been reported in many disaster situations from fires to flood.

Stereotypical Behaviors
Sometimes people can avoid freezing by engaging in a pre-
existing schema during the disaster. For example, while
evacuating a building during a disaster, people may pass by
the emergency exits as they use their normal preplanned exit
route.
For example, during the September 11, 2001 attacks on
the World Trade Center, people took time to shut down their
computers before exiting. Since the victims did not have a
preplanned schema for leaving under emergency conditions,
they implemented their normal ‘leaving’ behavioral schema,
which included the switching off of their computers.
Figure 13.6: Maladaptive behaviors in response to
crisis or disasters Inappropriate Behaviors
People in threat situations can also make poor decisions which
• Thus, repeated use of developmentally primitive leads to inappropriate action. Due to time pressure, victims can
coping, lack of exposure to healthy alternatives, or be faced with a large amount of ambiguous, incomplete and
repeated exposure to overwhelming stress may solidify a novel information. Under these types of conditions, people
maladaptive style of coping—one that relies too much on are more likely to make errors in judgment. Obviously, poor
primitive strategies such as avoidance and denial. decision making in a life-threatening situation can increase the
risk of injury or death.
Maladaptive Behaviors in Response to Crisis or For example, during the Japanese earthquake in March
Disasters 2011, people in a supermarket were running to save bottles
People can behave in an appropriate manner during an of alcohol from smashing rather than carrying out the correct
emergency. They become indecisive and act in a stunned earthquake drill.
and bewildered manner. Some victims will display serious
Memory Failures
maladaptive behavior, including confusion, crying, paralyzing
anxiety and hysteria. People may be passively standing by or Disaster victims often report failures in memory under threat.
running aimlessly here and there (Fig. 13.6). One theory states that the victims of disasters have memory
problems since the body releases high levels of the stress
Denial hormone cortisol that might affect the parts of the brain which
Denial is one of the main maladaptive behaviors for the people are responsible for memory processing. Another theory is that
who fail to respond toward the danger because they enter a the worry and anxiety caused by the disaster occupies the area
state of denial. Denial can result if people do not trust the of the brain which is responsible for processing memories.
source of the disaster warning signal. Generally, people do not For example, failing to remember where you left your front
respond to disaster signs because they don’t want to deviate door keys during a fire will have more serious implications.
from what others are doing. Whatever the reason, it is clear that memory failures during
For example, during Chennai flood, many persons were disasters can cause people to forget how to use emergency
reluctant to vacate to safer places because people from their equipment or how to follow emergency procedures.
own locality were not vacating. One more reason people do
not respond to threat is because it becomes very difficult to Holding it Together Until Rescue
create new behaviors under threat. One interesting observation of disaster victims is that some are
able to take prompt and effective actions under threat but at
Freezing the point of rescue, they become dazed. For example, Chilean
During disasters, freezing (also known as cognitive paralysis) mine survivors who acted in a rational manner while trapped
is commonly seen as a struggling behavior of people to underground but became stunned and dazed upon rescue.
382 Textbook of Psychiatric Nursing for BSc Nursing Students

CRISIS treated with antidepressants, so that the psychological

problem can be resolved; if not done, it might lead to
Crisis Intervention crisis situation.
Meaning of Crisis • Chronic and repeated stressor: Continuous and repeated
stressor in all action might influence the crisis. For
The term, ‘crisis’ came from the Chinese word, ‘weiji’, which
example, unemployment for a longer period after trying
means ‘danger at a point of juncture’. Crisis came from the
repeatedly can cause crisis.
Greek word, ‘Krisis’, which means ‘decision’ or ‘judgment’ or
• Physical factor: Health-related issues might cause
‘dispute’.
continuous stressor and therefore, lead to crisis. For
Definitions of Crisis example, amputation after a road traffic accident is a
physical factor influencing crisis.
• Crisis is an immediate compulsive act, which alters the
• Concurrent factors: Stressors are the ones which
homeostasis of an individual and it remains unresolved
influence the stress on an individual. Along with one
act at a moment due to loss of control.
stressor, another stressor might influence the stress on
• Crisis is a sudden event in one’s life which disturbs
the individual which is termed concurrent factor. For
homeostasis during which the usual coping mechanism
example, an individual might meet with an accident
can’t resolve the problem. —Lagerquist, 2001
suddenly (stressor), additionally, the individual’s wife dies
Characteristics of Crisis suddenly (additional stressor). This puts the individual in
crisis (Flowchart 13.7).
• Crisis is personal in nature.
• It is precipitated by a specific event. Types of Crises
• It contains the potential factor for growth and
Different types of crises along with their description and
deterioration.
examples have been given in Table 13.19.
• Crisis is a disturbance caused by a stressful event or a
perceived thought.
Phases of Crisis
• Crisis also depends on the perception of event and the
perceived event can be identified. Caplen Phases of Crisis
• Crisis can be equated with psychopathology. Caplen (1964) classified crisis into four phases as described
• Crisis can be a challenge or a positive outcome. below (Figure 13.7):
1. Phase I takes place when an event is perceived as a threat,
Factors Influencing Crisis then the normal coping mechanism gets activated. If the
• Psychological factor: Psychological causes might induce coping mechanism works well, then there will not be any
stress, thereby leading to crisis, if not resolved at a time. crisis. If it fails, then entry to the second phase of crisis
For example, severely depressed individual has to be takes place.

Flowchart 13.7: Factors influencing crisis

CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 383

Table 13.19: Types of crises along with their description and examples

Types of crises Description Examples

Maturational crisis Transitional point, when an individual needs to adjust Mr X got newly married, unable to adopt the pattern of
or developmental and adapt to the new life responsibilities but fails to do lifestyle, adjust with wife, sudden unexpected expenses,
crisis so resulting in maturational crisis. Common transitional etc. leading to maturational crisis
periods having high chances of crisis potential are
new job, early adolescence, marriage, parenthood and
retirement. Changes in
relationship, emotional growth and adjustment are
required to prevent this type of crisis.
Situational crisis It is precipitated by a stressful event which is • Sudden economical loss
unanticipated or suddenly creates a disequilibrium, • Abrupt role changes
which acts as a threat to biological, physical, • Death of loved ones
psychosocial integrity • Premature death of baby
• Psychological or physical illness
• Poor academic performance
• Loss of ability to work
• Transfer to another work environment
Social crisis An accidental and unanticipated loss causes drastic Natural disasters such as:
negative changes in the environment • Earthquake
• Flooding
• Tsunami
• Drought
• Cyclone
Man-made disasters such as:
• Nuclear accidents or bomb blast
• Violence/war
• Mass attack/Terrorism
• Contamination using toxic waste in huge areas
Crisis reflecting Psychological illness of family members might affect Mother might have high risk of depression who is taking
psychopathology other individuals in the family care of her son with mental illness
Post-traumatic Crisis that happens after a physical or psychological Individual is suffering with depression after a road traffic
crisis trauma accident
Anticipated crisis Crisis which is expected or emerging, requires a timely Pregnant women need to undergo the anticipated crisis
action
Transcultural crisis An individual experiencing sudden transition from his/ A girl married to a person of other religion may
her culture to a different culture might undergo cultural experience transcultural crisis if there is lack of
shock or transcultural crisis adjustment between them.

2. In Phase II, an individual experiences a sense of

vulnerability because the failure of coping mechanism
still persists. So, anxiety might continue.
3. In Phase III, an individual tries to use problem-solving
skills but he/she tends to fail in this phase. So, further
disorganization takes place.
4. In Phase IV, there will be profound physiological and
psychological problems. Therefore, an individual might
have severe to panic level of anxiety. Referral to the
appropriate treatment measures is essential.
Figure 13.7: Caplen’s phases of crisis
384 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 13.8: Aguilera (1998) model of crisis response

Figure 13.8: Donna’s phases of crisis

Donna’s Model or Phases of Crisis

Donna’s model includes the following four phases:
1. Phase I takes place when an individual is exposed to the
crisis, he/she might get mild anxiety.
2. In Phase II, individual tries to use the coping mechanism,
which has been used in the past in order to prevent the
crisis; he/she might have a chance to have moderate
anxiety.
3. In Phase III, individual tries to cope with the available
internal or external resources; he/she might experience
severe anxiety.
4. In Phase IV, individual’s crisis might be unresolved; so,
he/she might experience panic anxiety (Figure 13.8).

Theories Related to Crisis Intervention

Emil Kraepelin Theory of Crisis Intervention
Emil Kraepelin emphasized that therapeutic intervention or
adherence to proper therapeutic regimen has been considered
a vital phenomenon during crisis.
Aguilera model of crisis response has been shown in
Flowchart 13.8. Figure 13.9: Kaplan’s theory of crisis sequence

Gerald Kaplan’s Theory of Crisis Sequence

Principles of Crisis Intervention
• Gerald Kaplan described that individuals undergo the
crisis sequence, which are pre-crisis, impact of crisis, • Motivate the patient to express feelings
crisis stage and post-crisis. • Listen to facts and feelings
• Precrisis is the duration that exists before the crisis phase. • Guide the patient in confronting reality
• Crisis is an emerging situation which requires immediate • Motivate the patient to focus on particular implication at
action. a time
• Impact of crisis denotes the psychological and physical • Clarify distortions by focusing on reality
trauma that an individual undergoes due to crisis. • Allow the patient to clarity doubts
• Postcrisis is the phase after the crisis, where an individual • Use specific and concise statements during conversation.
might have a chance of growth or deterioration
(Figure 13.9). Growth occurs when he/she utilizes the
Steps of Effective Crisis Intervention
supportive measures and coping mechanism in a better • Listen: Maintain a proper interpersonal relationship with
way; and deterioration occurs when supportive measures the patient and listen to his/her problems, which cause
and coping mechanism are not utilized properly. the crisis situation.
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 385

• Assess: Assess the precipitating factors such as low self- „ Group work: A group of people affected with
esteem, substance abuse, decreased cognition, low ability common traits of stressors is addressed here. Group
to handle situations, etc. Assess the perception of the members are given chances to express the common
event such as unresolved problem, anxious, depressed, experiences and concerns to foster hope and develop
stress, etc. mutual support. Health promotion activities need
• Develop the action plan: It can be developed using to be provided by family members, friends and
various coping patterns, family/social resources and individuals who have had previous exposure to the
supportive measures used in past. Action plan consists crisis situation.
of individual approach, generic approach, general „ Disaster response: Nurse has to extend his/her hands
supportive measures and environment manipulation. in helping out during the time of floods, earthquake,
The characteristics of action plan are simple, manageable, drought, nuclear accidents, fire and airplane crashes.
short term (24 hours to 3 days), achievable, focused and Nurse plays a vital role in helping people to deal with
should have a provision of follow-up. psychosocial stress.
„ Mobile crisis program: It includes on-site
Steps of effective crisis management are shown in Figure 13.10.
assessment, management of crisis, referral services to
1. Individual approach: An individual might provide
the appropriate centers and educational services to an
social support to promote coping skills, correct the
individual, families and community.
misconceptions, provide adequate information and help
„ Telephone contact: Counseling services through
restore psychological health.
telephone help an individual to enhance the coping
2. Generic approach: Identification of homogeneity in
skills and self-confidence. They also act as timely
the problems and handle them with critical incident
help to prevent crisis (For example, Sneha Suicide
debriefing using the following steps:
Prevention Center at Chennai promotes counseling
i. Fact: Find out or identify the reason for crisis situation
service via telephone to prevent suicidal attempt).
ii. Thought: Allow the individual to think why, what and
◆ Victim outreach program: Nurse has to identify
when it happens
the needs of victims and connect them with
iii. Reacting: Promote mental ventilation or catharsis
appropriate referrals as required. Nurse helps the
iv. Teaching: Teach by providing adequate suggestions
victims to undergo proper assessment, have right
but don’t force the individual to decide the suggestion
psychological support and regular follow-up.
provided as a final one.
◆ Health education: Educating the public helps
v. Re-entry: Enter into first phase of generic approach, if
them to be aware of available services in order to
the crisis remains unresolved.
deal with problems happened due to the crisis.
3. General support: It includes the following aspects of
„ Environmental manipulation: Change of environ-
supportive measures:
ment from crisis exposed place to the other place
helps them to vanish from the remembrance. ‘Out of
sight, out of mind’ is a proverb stating the importance
of environmental manipulation.
4. Close: This is the final step of crisis intervention required
to plan the follow-up care. Summarize and review the
action plan which is completed. Do anticipatory planning
for building new resources.

Nurse’s Responsibilities
• Determine the severity of crisis, which has happened
• Nurse should be empathetic while talking to an individual
who is affected due to crisis
• Explore the problem as much as possible
• Advise the individual to express emotions
• Nurse has to teach the importance and benefits of coping
skills that will help the individual recover from crisis.
• Offer the alternative possible solution to build the coping
Figure 13.10: Steps of effective crisis management skills.
386 Textbook of Psychiatric Nursing for BSc Nursing Students

Techniques of Crisis Intervention

Techniques of crisis intervention along with description and examples have been given in Table 13.20.
Table 13.20: Techniques of crisis intervention along with description and examples

Techniques of crisis Description Examples

intervention
Catharsis Emotional ventilation helps an individual get rid of stress. Nurse: Can you please share with me what
When you ventilate, your troubles become half and the made you feel distressed?
happiness becomes double. So, keep sharing opinions and Patient: Cried out and said, ‘I miss my wife so
troubles with others who are genuine to you much after this accident’
Clarification Motivating the client to express doubts Nurse: Do you have any doubts regarding this
Suggestion Nurse can give suggestion to the client to recover from Nurse: I would suggest you that…
crisis situation but it should not be forced as a decision to
be opted by the client
Reinforcement of Reinforcement is a part of motivation; it helps the client Nurse: Excellent, you have done a good job
positive behavior promote positive behavior. It can be either verbal (saying (verbal reinforcement)
good) or material based (giving token/food)
Exploring the solution Motivate the client to identify the possible solution, which Nurse: Can you verbalize the possible solution
is available for a particular problem to this problem?
Use of adaptive coping Use of appropriate stress management strategies helps Nurse: you can perform yoga and meditation
mechanism the client recover from crisis to relax yourself
Raising self-esteem Promotion of self-concept and self-esteem will help the Nurse: I am damn sure you are capable of
client to be confident and move forward to the next step performing this task.
of life

Crisis Resolution Characteristics

Crisis resolution refers to the steps or measures taken to solve • Crisis resolution is a rapid response.
a crisis situation (Flowchart 13.9). • It requires supportive measures and education.
• Crisis resolution services should be available round the
Flowchart 13.9: Seven steps intervention model to resolve the crisis clock (24 hours).
• Crisis resolution measures act like a gatekeeper between
outpatient and in-patient services.
• Services should end up with level of goal achieved and the
follow-up measures.

Key Principles
• Crisis needs to be worked out to resolve it as early as
possible.
• Holistic biopsychosocial approach needs to be adopted to
resolve crisis.
• Success of crisis resolution is highly dependent on
adherence to treatment.
• Education is highly required in order to enhance mental
health.
• Early identification of problem that causes a crisis will
help to resolve the crisis in earlier stage.
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 387

Factors Affecting the Effectiveness of Crisis Resolution

Services NURSES RESPONSIBILITY
• Length of involvement: Duration of working togetherness Nurse should maintain a good interpersonal relationship and
between the nurse and patient in order to resolve the crisis follow the principles of crisis resolution. Nurse has to work along
plays a vital role in solving crisis. with the crisis resolution team members in order to resolve the
• Previous exposure to psychological services: Client with crisis effectively. Nurse should act as an educator to teach the
supportive services which are readily available to solve the crisis.
previous exposure to psychological services might have
Nurse should make an action plan based on criteria and follow the
knowledge to understand the services in a better way. steps correctly. Check out the level of goal achieved intermittently
• Hours of service rendered: Crisis resolution services and proceed with the services till the goal has been achieved.
performed round the clock (24 hours) must be ready and Nurse has to take steps in order to enhance the coping skills of the
available to resolve crisis in a better way. patient. Nurse should follow-up the client in order to guide and
provide the supportive services.
• Referral services: Services referred to certain department
should have attitude of acceptance in order to perform
effective crisis resolution service.
• Crisis resolution team: Genuineness in the work of
GRIEF AND BEREAVEMENT
team members such as psychiatrist, psychiatric nurse,
Meaning
psychologist, social worker, occupational therapist plays
a vital role in resolving the crisis. The term ‘grief ’ came from the Latin word ‘gravare’ which
• Miscellaneous: Realistic appraisal of the event, availability means burden or something that causes distress. Differences
of support systems and coping skills. among grief, bereavement and mourning have been listed in
Crisis resolution may be successful or unsuccessful Table 13.21.
depending on the use of coping skills and problem-solving Table 13.21: Differences among grief, bereavement and mourning
ability. If an individual uses pathological adaptation of
crisis by ruminating about the loss without accepting it, this Grief Bereavement Mourning
might lead to prolonged grief reaction and depression. It is a normal process of It is the It is the outward
Sometimes, individual uses repression (defense mechanism) reacting to the loss of period after expression of
and tries to push out the stressors (incident and intense loved ones. a loss during loss and grief.
which grief is
emotions) out of consciousness, which leads to pseudo- experienced and
resolution (Flowchart 13.10). mourning occurs
Example: At the time of Example: Example: Crying
Flowchart 13.10: Crisis resolution grieving process, any sort Grief has been out due to pain
of actions or emotions or experienced for of loss
expressions to loss such a period of two
as anger, shock, disbelief, months
depression, resentment
etc. is elicited.

Definition
Grief is defined as physical, somatic, spiritual, emotional and
intellectual responses to the nature of loss. —Worden, 2005

Types of Grief
Grief is considered a normal reaction due to loss unless it
is not morbid (pathological and complicated). Presence of
one or more symptoms and duration of grief for >6 months
are considered the characteristics of morbid grief, which is
classified into pathological grief, complicated grief and grief at
death anniversary (Flowchart 13.11).
388 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 13.11: Types of grief

• Pathological grief is further classified into chronic grief, • Grief extended over a long period without resolution is
delayed grief and inhibited grief. considered complicated grief.
„ Chronic grief is the term used when grief reaction • Grief at death anniversary means the grieving process
persists for more than 6 months. takes place only at the time of death anniversary every year.
„ Delayed grief is onset after 2 weeks of actual loss. Miscellaneous griefs along with their description and examples
„ Inhibited grief means the denial/refusal of loss. have been given in Table 13.22.

Table 13.22: Miscellaneous griefs

Miscellaneous Description Example

types of grief
Anticipatory grief Grieving process takes place before the loss itself since Ms Sudha’s mother health has been deteriorating and
the loss has been expected by the individual doctor informed Ms Sudha that her mother will die
within 2 weeks. Grieving process starts when she gets
this information from the doctor.
Disenfranchised or Grief felt by an individual but not acknowledged by Mr Raj is undergoing grieving process due to the
ambiguous grief others death of his pet animal but the grieving process is not
acknowledged by his family members.
Time-limited grief Grieving process takes place within a limited time Ms Sudha exhibited grief response only for 4 hours
period after the death of her father.
Private or forbidden Individual who does not exhibit any signs of grief. Mr Raj does not show any grief sign after the death of
or absent grief Grieving process takes place but neither not shown his close friend but the grieving process takes place
outside nor identified by others within him.
Collective grief Grief which is felt by the group or community Natural disaster, death of any famous personality in
that area, terrorist attack, etc.
Masked grief Grieving process is exhibited in terms of symptoms or Mr Raj becomes more silent most of time and sleeps a
negative behavior, which is not said to be the actual lot during the grieving process but this behavior is out
character of the person. Connection between those of his character.
physical symptoms or negative behavior and grief is
difficult to identify
Exaggerated or Grief present with extreme feeling of anger, guilt, self- Mr Raj develops a feeling of enmity toward a person
distorted grief destructive behavior and hostility toward a particular because he feels that the person is responsible for the
individual loss.
Cumulative grief Grief takes place when multiple losses happen within a Ms Sudha experiences pathological grief due to
short duration of time sudden death of four members in her family.
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 389

Figure 13.11: Responses to grief and loss

Responses to grief and loss have been given in Figure 13.11. • Denial
• Anger
Grief Experiences • Bargaining
• Hurting: Individual feels hurt due to the painful • Depression
experiences during grief. • Acceptance
• Missing: Individual feels that he/she is missing the loved
Different stages of grief along with their description and
ones.
examples have been described in Table 13.23.
• Holding: Individual feels like holding the memories of
deceased. Dr Rando’s 6 Rs of Mourning
• Being stopped: Individual feels like that he/she is unable
Table 13.24 shows different phases of grief along with their
to perform all the activities.
• Seeking: Individual seeks help from others during grief. description.

John Bowlby’s Four Stages of Grief

Theories of Grief
John Bowlby used the Freud perspectives to describe grief. It is
Kubler-Ross Theory of Grief
a biological instinct for attachment.
Kubler Ross (1969) identified five stages of behavior and 1. Urge to recover the lost person
feelings that an individual experiences in response to the 2. Disequilibrium
actual or perceived or anticipated loss, which are as follows
3. Disorganization
(Fig. 13.12):
4. Reorganization

Worden’s Four Tasks of Mourning

Worden views the bereavement as active or self-determining
rather than a passive process. Worden explained that with the
use of social support and dealing with the problems, coping
process takes place.
1. Accepting the reality of loss
2. Working through the pain of grief
3. Adjusting to an environment which has changed due to
loss
Figure 13.12: Responses to grief-Kubler-Ross theory 4. Move on with present life
390 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 13.23: Stages of grief along with their description and examples

Stages Name of the grief stage Description Example (Phrase verbalized by the
as per Kubler Ross individual who is undergoing grief)
I Denial Refusing that it has not happened to me. It is a No, it is not true and it will not happen
projective defense mechanism that allows adequate to me….
time frame to develop the coping skills/ability
II Anger A negative emotion directed toward self or displaced Shout and say….Why did it happen to
to others (family members, caregivers, loved ones, me?
friends, God)
III Bargaining A state of bargain with God or supreme power in order Asking the God that, ‘I have never done
to reverse or postpone the loss any bad things to any one, why you
want to punish me like this?’
IV Depression A state where the full impact of loss has been realized I don’t want to talk to anyone else……
V Acceptance A feeling of peace and complete realization in regard I want to accept this…what to do…
with the loss happened

Table 13.24: Phases of grief along with their description as per Dr Rando

Phases of grief 6‘R’s of Mourning Description

as per Dr Rando
Avoidance Recognize the loss Understanding what has happened and really accepting that loved one has
been lost
Confrontation React to the separation Acknowledging the secondary losses. E.g., death of spouse also tends to loss of
financial security, loss of future ideas and lack of romantic intimacy.
Recollect and re-experience Remembering the memories of loved one
Relinquish old attachments Slowly begin to process the impact of loved one’s absence
Accommodation Readjust to the new world Readjusting to new roles and responsibilities and also understand how the loss
without forgetting the old world of loved one has changed your life pattern
Reinvest emotional energy Act of enjoying life with new friends or roles but it does not mean that this is a
replacement for loved ones.

Parke’s Four Phase Model of Grief • Individual counseling: Nurse counsels a single patient.
• Group counseling: Nurse counsels a group of patients.
1. Shock and numbness—similar to somatic distress
2. Yearning and searching (strong negative emotions might Based on the purposes of counseling, it is classified into:
express the anger toward the deceased) • Bereavement counseling: Counseling is provided to
3. Anguish, disorganized and identification address the practical issues of living without the loved one
4. Reorganization who has died recently.
• Family counseling: Counseling is provided to solve the
family issues.
COUNSELING
• Premarital counseling: Counseling provided before
Definition marriage is termed premarital counseling. This helps to
prevent marital disputes.
Counseling is an interactive process between the counselor • Problem solving counseling: Counseling is provided to
and counselee. Counselor is a person who provides help and solve a problem.
counselee is a person who seeks help. • Crisis intervention: Counseling is provided to resolve
the crisis situation.
Types of Counseling
Counseling to relieve personal distress:
Based on the number of members involved in counseling, it is • Special counseling: It is done to discuss the risks and
classified into: benefits.
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 391

Based on the approaches of counseling, it is classified into: • Principle of empathy: Nurse has to think from the
• Directive or counselor-centered counseling: Counselor patient’s point of view by standing in patient’s position
directs the counselee (patient) to solve the problem and take and then give reflections accordingly.
decision (counselor plays a predominant role in this type). • Principle of nonjudgment: Nurse should not criticize or
• Nondirective or patient-centered counseling: Counselee comment in a negative way with regard to the patient’s
(patient) himself or herself solves the problem and takes complaints.
decision (patient plays a predominant role in this type). • Principle of confidentiality: Nurse has to keep all the
• Eclectic counseling: Counselor will guide to take decision;
information about the patient secretly and assure the
at the same time counselee is also actively involved in the
patient about the same.
decision-making process.
• Principle of individuality: Nurse has to treat each and
Principles of Counseling every patient as unique and respect everyone.
• Principles of nonemotional involvement: Nurse should
• Principle of acceptance: Accept the patient with his/her not get involved with the patient emotionally and not get
physical, psychological, economical, social and cultural
carried away by their feelings.
conditions.
• Principle of communication: Communication should be Table 13.25 shows different techniques of counseling along
relevant, appropriate to the problem raised by the patient. with their description.

Table 13.25: Techniques of counseling along with their description

Techniques of counseling Description

Active listening Therapist actively listens and shows attentive interest during counseling.
Mnemonics
SOLER:
S : Sit facing the client
O : Open Posture
L : Lean forward toward client
E : Establish eye contact
R : Relax
Capping It is the universal skill of the therapist to change the direction of conversation from emotional to
cognitive in order to cut off the patient’s emotion.
Clarification Asking the patient to elaborate or state examples of vague ideas or thoughts. For example, nurse asking
doubt to the patient, whether did actually mean this?
Confrontation Counselor gently brings into the patient’s awareness that something is overlooked or avoided
Empathy Recognizing the patient’s feeling by standing up in patient’s situation. For example, nurse is saying to the
patient that, ‘I can feel how painful it is?’
Exploring Delving further into the idea or subject. For example, nurse is asking the patient, ‘can you explain it fully’?
Encouraging the description Asking the patient’s view about the present situation. For example, nurse is asking the patient, ‘what do
of perceptions you think about the present situation’?
Focusing Focus toward a single idea or word. For example, nurse verbalizes to client that ‘Can you describe the
event a little more’?
Immediacy Therapist talks immediately and openly with the patient in regard with any happenings that occur in the
therapy session. For example, nurse verbalizes to the patient that you look tensed when we talk about
your father.
Linking the patient to the Involving the family members of the patient in counseling process will enhance the patient’s social
social support support to solve problem.
Open-ended questions This will help the patient to put into detailed discussion. For example, nurse can ask ‘How do you feel
today’? (Open-ended question) instead of asking ‘Are you happy today’? (closed-ended question)
Paraphrasing Nurse attempts to give feedback about what the patient has just said in order to convey to the patient
that nurse or therapist is listening.
Contd…
392 Textbook of Psychiatric Nursing for BSc Nursing Students

Techniques of counseling Description

Proxemics Counselor analyzes the spatial movements of patient; by understanding the body orientation, counselor
can determine feelings, mood and reactions of the patient.
Reinforcement Providing feedback about the positive behaviors. For example, nurse is saying to the patient that ‘Good,
you have done a wonderful job’
Self-disclosure Counselor discloses personal information to the client during the counseling process if the patient gets
benefit out of this.
Trustworthiness Therapist has to be empathetic, warm and deliver unconditional positive regard in order to develop
trustworthiness with the patient so that rapport is developed.
Working alliance Counselor and patient work together in order to achieve a common goal in treatment process.

STRESS Models of Stress

Stress Adaptation Model Models of stress help the nurses to identify the productive and
unproductive responses to the stressors. Knowledge of these
Schafer (2000) defined stress as ‘arousal of body and mind in models helps the nurses to promote the patient’s coping skills
response to the demand made upon them’.
in order to adjust the unhealthy and unproductive responses
• Stress can be classified into Eustress and Distress.
(Table 13.26).
• Eustress is a normal level of stress that everyone undergoes
in day-to-day life. Distress is a negative perception of Table 13.26: Models of stress
event/situation that might lead an individual to have a
Models of stress Author Year
significant distress.
Stimulus-based model Holmes and Rahe 1960
Stressor Response-based model Hans Selye 1945
Stressor is defined as an event or situation or person which Transaction-based Lazarus 1966
causes stress. Stressor can be classified into internal stressor model
and external stressor.
• Internal stressor arises from inside. (Example: Hunger). Stimulus-Based Model
• External stressor arises from outside (Example: Teacher
As per stimulus-based model, stress is due to stimuli or life
forcing the student to study well). Stressors can also
events or circumstances which enhance the physiologic and
be classified based on the etiological factors such as
environmental factors, physiological factors, social factors psychological reactions that might enhance the chance of
and thoughts. individual’s vulnerability to get rid of stress.
Social Readjustment Rating Scale (SRRS) consists of 43 life
Extrinsic Factors changes which are positive and negative in nature considered
• Environmental factors: Air/water/noise pollution, to be stressful. This scale helps an individual in regard with the
crowd, heavy traffic, bad weather (extremely hot or cold stressor that he/she experiences within the life period. Low
climate). score in this scale does not mean that the individual is free
• Social factors: Loss of loved ones, unemployment, from stress; and high score in this scale does not mean that
financial problems, participation in social events due to the individual might experience serious problems. Mediating
compulsion of others, forced to work in a job which is not factors such as the individual’s perception about the event and
willing to him/her.
coping skills with the stressor play a vital role in determining
Intrinsic Factors the impact of stress.
• Thoughts: Negative thoughts/ideation, high
Response-Based Model
perfectionism, lack of self-motivation.
• Physiological factors: Lack of sleep or nutrition, As per response-based model, stress might affect a set of bodily
more hunger, sickness, physical injuries and hormonal changes described as general adaptation syndrome. This
imbalance. syndrome has the following three stages:
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 393

1. Alarm Reaction Stage Table 13.27: Stress responses in alarm reaction

Stimulation of hypothalamus, sympathetic nervous system and Organs Physiological responses in alarm
adrenal medulla might release catecholamine (epinephrine reaction
and norepinephrine), which leads to alarm reaction. • Heart rate increases
In the alarm reaction, there are two responses to the • Strength of cardiac muscle
stress, namely flight response and fight response. When contraction increases and so,
an individual feels stressed, either he/she should develop blood circulation quickly takes
place
the ability to fight against the stress or else the individual
should use the flight response by running away from the
stressor. For example, Mr Raj fails in all exams, it has been
informed by the class teacher that if it persists, he will not Heart
be permitted to next year of course. Mr Raj has a chance to • Respiratory rate increases
discontinue the course (flight response) or else put his efforts • Respiratory passages widen to
by understanding the subject and study well (fight response) get more oxygen
(Fig. 13.13).
Stress responses in alarm reaction have been given in
Table 13.27.

Lungs
• Digestive enzymes decrease
• Production of saliva occurs
• Liver converts the glycogen into
glucose and releases it into
• bloodstream (so that it provides
energy to fight with the stressor)
Gastrointestinal system
• Blood supply to skin and viscera
• gets constricted
• Blood supply to heart, lungs,
skeletal muscles and brain gets
dilated.
• RBC production increases

Blood vessel

2. Resistance Reaction Stage

Resistance reaction is the second stage of stress response. The
regulating hormones secreted by hypothalamus in resistance
reaction are growth hormone releasing hormone (GHRH),
corticotropin releasing hormone (CRH) and thyrotropin
releasing hormone (TRH). The regulating hormones stimulate
the anterior pituitary to release adrenocorticotropic hormone
(ACTH), human growth hormone and thyroid stimulating
hormone (TSH). ACTH stimulates the adrenal cortex to
release the adrenal hormones such as glucocorticoids and
mineralocorticoids. Human growth hormone stimulates the
liver and therefore, it supplies energy through glyconeogenesis
and lipolysis. Thyroid stimulating hormone stimulates the
thyroid gland and it supplies energy through increased
Figure 13.13: Alarm reaction breakdown of carbohydrates.
394 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 13.12: Transaction-based model

ABC Model of Stress (Prof. Cooper)

(A+B = C)
A : Activating event
B : Belief
C : Consequences
An activating event for Mr Ram is “he failed in two subjects”.
The belief is “he is unable to pass the examination” and the
consequence is “continuous failure in exams” which lead
to physiological responses such as his heart rate and blood
pressure increase and psychological response such as always
being depressed.
Figure 13.14: Resistance reaction
Effort Reward Imbalance Model of Stress
Resistance reaction allows the body to fight with stressors An organization getting more work from the employees but
for a long time and so, it is helpful to cope with a stressful not paying wages properly, when there is no professional
situation. If this fighting mechanism with the stressors growth and not promoting them to next level it might lead an
fails, then it will get into the next stage, namely exhaustion individual to have stress (Fig. 13.15).
(Fig. 13.14).
3. Exhaustion Reaction Stage
In this stage, tissues start dying and organs become weak due
to the long-term resistance which puts higher demand on
lungs, heart, blood vessels, glands and gastrointestinal system.
These organs might have higher chance to fail because of the
extreme strain given to that organ.

Transaction-Based Model
Transaction-based model has been shown in Flowchart 13.12. Figure 13.15: Effort reward imbalance model of stress
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 395

Flowchart 13.13: Socioenvironmental model of stress

Figure 13.16: Three channel model of stress reaction

Three Channel Model of Stress Reaction

Stress always depends on the perception of an event. ‘What
the individual thinks about it?’ is said to be first channel to
cause stress reaction. In Channel II, based on his/her thoughts,
he/she may perform flight or fight response, i.e., fight against
the stressor or else flight (escape) out of stressor. Channel III
denotes ‘What body does due to the stressor?’ i.e., physiological Flowchart 13.14: Bounce model of stress
response, e.g., heart rate and blood pressure increase and
the psychological response, e.g., being depressed may occur
(Fig. 13.16).

Psychosomatic Model of Stress

Udupa (1977) explained the concept of psychosomatic model
of stress, which has four phases, namely psychic phase,
psychosomatic phase, somatic phase and organic phase
(Table 13.28).
Table 13.28: Psychosomatic model of stress
Bounce Model of Stress
Phases Description Example
An individual might take stress as adaptive response or
Psychic phase Psychological symptoms Crave to smoke
a maladaptive response depending on the individual’s
are predominant cigarettes
perception. If an individual perceives a maladaptive response
Psychosomatic Psychological condition Smoking causes (negative sense) toward environment, then it also reflects back
phase alters the bodily function lung damage
the maladaptive response toward him/her (Flowchart 13.14).
Somatic phase Impairment of the bodily Lung damage
function damages the persists S-O-R Model of Stress
organ
S stands for stimuli, O stands for organism and R stands for
Organic phase Damage to an organ Chronic obstructive response (Flowchart 13.15). A stimulus is a provoking factor
leads to disease pulmonary disease
(COPD)
which motivates the organism to perform a desired response.
For example, parents act as stimuli who motivate the children
(organism) to secure good marks in exam (response).
Socioenvironmental Model of Stress Organism might perceive this in a positive sense (eustress) or
Pestonjee (1930) described that there are three factors which in a negative sense (distress). If the child perceives as adaptive
cause the stress, namely job and organization, intrapsychic response, then child will perceive the parents’ motivation in a
factor and social factor (Flowchart 13.13). An individual right way and secure good marks in exam. If the child perceives
with strong stress tolerance limit can cope with stressors but as maladaptive response, then child will perceive the parents’
repeated stressors might break the stress tolerance limit (STL) motivation in a wrong way by taking it as distress and will not
further leading to extreme level of stress. secure good marks in exam.
396 Textbook of Psychiatric Nursing for BSc Nursing Students

Flowchart 13.15: S-O-R model of stress Examples for three types of coping are given in Table 13.29.
Coping styles as per Nash and Roger (1995) have been
presented in Table 13.30.

Stress Busters Using Various Therapies

COPING MECHANISM Psychological therapies are found helpful to an individual
to come out of stress such as relaxation training (Jacobson
• According to Suzanne Lego (1996), coping mechanism progressive muscle relaxation and autogenic training),
is defined as a conscious method adopted by a person to breathing, meditation or mindfulness training, animal assisted
solve a problem. therapy or pet therapy, yoga, music therapy, guided imagery,
• According to Lazarus (1999), coping is an individual’s physical exercises, laughter therapy, diversional therapy,
effort to overcome psychological stress. occupational therapy, talk therapy, hypnotherapy, light
Lazarus and Folkman (1984) defined three types of coping as: therapy, dance therapy, etc.
1. Problem focused coping: Use of coping skills to deal with
an existing problem. Role of Nurse in Teaching the Coping
2. Emotion focused coping: Use of coping skills by dealing Mechanism to Patient
with emotions that arise out of problem. Advise the patient to adhere to the following instructions in
3. Cognitive focused coping: Use of coping skills by dealing order to use the coping mechanism and it might be helpful in
with stress with the help of existing knowledge. managing the stress.
Flowchart 13.16 shows the coping mechanism. • Engage in some personal growth-oriented activities
• Adopt healthy lifestyle practices such as maintaining
Flowchart 13.16: Coping mechanism the quality of sleep, eating healthy diet, doing yoga or
exercises, etc.
• Perform relaxation training such as Jacobson Progressive
muscle relaxation and autogenic training.
• Hear music to relax oneself.
• Use cognitive restructuring to avoid the negative view of
oneself and the problems in life.
• Avoid using substances such as alcohol, cigarettes, etc.
• Spend time with family members.
• Develop aesthetic sense within oneself

Table 13.29: Examples for three types of coping

Problem focused coping Emotion focused coping Cognitive focused coping

Individual leaves the job and plans to Father had a fear that child did not come Mr Ram felt stressed due to his sudden loss
proceed to do business, since there is no home from the school and later he of property, instead he put his hard work
proper salary or no job satisfaction present, remembered that he gave permission to and used appropriate tactics in order to
even though the organization promised to participate in sports today and then father regain his property
give the required salary. felt better.

Table 13.30: Coping styles as per Nash and Roger

Adaptive coping style Maladaptive coping style

(adjustment with environment) (nonadjustment with environment)
Detached Rationale Emotional Avoidance
• Not perceive the problems • Treat problem as challenge • Seeks attention and • Think everything as
as a threat • Have a logical approach to a Sympathy from others impossible
• Use sense of humor problem • Feel depressed, anxious, • Have more trust on fate
• Steps taken to solve the • Use a past experience to fearful, frustrated and being • Lack of self-confidence
issues solve the problem worried. • Not verbalizing the problems
• Have a take it easy policy to others.
CHAPTER 13 Psychiatric Emergencies and Crisis Intervention 397

• Enjoy the day-to-day life or else secondary to depression. Elderly abuse or assault
• Always remember there is no problem without a solution (Granny Bashing) is also increasing day by day. Social isolation
• Have a take it easy policy in life is an important key factor for depression. Elderly persons who
• Perceive the threat as challenging one experience more loss and are not able to complete the grief
• Have a healthy relationship with friends and relatives reaction have overload of bereavement which in turn leads to
• Keep sharing the problems with a genuine friend. depressive disorders. Stress management techniques will be
helpful to treat mild level of depression. Periodical screening
GERIATRIC CONSIDERATIONS and assessment are essential to identify the elderly mental
health issues at an early stage so that they do not lead to the
Elders might attempt suicide due to various issues in family stage of psychiatric emergency.

SUMMARY
• A psychiatric emergency is an acute disturbance of behavior, thought or mood of a patient that negatively impacts a patient’s ability
to function in his/her environment.
• Suicide is defined as ‘intentional way of killing oneself’ or ‘self-inflicted cessation of life which ends in a fatal outcome’.
• Imbalance in release of neurotransmitter, namely serotonin might provoke suicidal ideation
• Types of suicide based on social categories as per Emile Durkheim (1951) are egoistic suicide, altruistic suicide, anomic suicide and
Samsonic suicide or suicide of revenge. Miscellaneous types are parasuicide, cyber-suicide, copycat suicide and anniversary suicide.
• Risk factors and warning signs of suicide are signs of clinical depression, withdrawal or isolation from friends and family, sadness and
hopelessness, feeling trapped with unbearable pain, talking as being burden to others, lack of interest in previous activities or in what
is going on around them, physical changes such as lack of energy, different sleep patterns, change in weight or appetite, lack of self-
esteem, increased use of alcohol or drugs, presence of mood swings, being anxious, agitated or reckless, exhibiting rage or talks about
taking revenge, negative comment about self-worth, speaking or writing about death or suicide, giving their valuable possessions to
somebody and having more interest in personal wills or life insurances.
• Protective factors against suicide attempts are strong family or social support, easy access to clinical interventions, skills in problem
solving and conflict resolution, restricted access to the lethal means of suicide, strong support from the health care professional,
cultural and religious belief that discourage the suicide.
• Section 309 of IPC states that suicide attempt will be punishable with simple imprisonment which may extend to one year or fine or
both.
• SAD PERSONS rating scale is used to determine the suicidal risk.
• Nurse’s role to prevent suicide: Monitor the patient closely, accompany the patient wherever he/she goes, avoid keeping dangerous
objects near patient, sedate the patient if uncontrollable, encourage the patient to verbalize his/her thoughts related to suicide, if
necessary apply restraints to control the patient.
• Anger is a normal human emotion that may be handled and expressed assertively to solve the problem and it shows a productive
change. Aggression is an expression of anger in a socially inappropriate manner, may or may not cause significant harm to self or others
either physically, psychologically or verbal means of expressing anger.
• Biological risk factors of violence are central nervous system dysfunction/infections, imbalance in neurotransmission, frontal or
temporal lobe dysfunction, limbic system dysfunction and traumatic brain injury.
• Etiology of violence includes organic psychiatric disorders, nonorganic psychiatric disorders, medical disorders associated with
violent behavior such as neurologic illness, endocrine disorders, metabolic disorders, vitamin deficiencies, infections and temperature
disturbances.
• Smith’s stress model (1981) explained the assault cycle which has five stages of aggressive response to physical or emotional stress.
Stages are triggering phase, escalation phase, crisis phase, recovery phase and post-crisis depression phase.
• Management of violence includes reassurance, medications (Inj. haloperidol, Inj. chlorpromazine, Inj. diazepam), promotion of
psychological well-being and restraints (physical and chemical).
• Other psychiatric emergencies are panic attack, catatonic stupor, grief reaction, rape, conversion disorder, disaster victim and transient
situational disturbance.
• Medical emergencies related to psychiatry are delirium, serotonin syndrome, epileptic furor, overdose of psychotropic medications,
overdoses and withdrawal from addicting substances and extrapyramidal symptoms of psychotropic drugs (neuroleptic malignant
syndrome).
• Crisis is a sudden event in one’s life which disturbs homeostasis during which the usual coping mechanism can’t resolve a problem.
• Types of crises are maturational crisis or developmental crisis, situational crisis and social crisis, crisis reflecting psychopathology, post-
traumatic crisis, anticipated crisis and transcultural crisis.
• Steps of crisis intervention include individual approach, generic approach (handle with critical incident debriefing with the steps: fact,
thought, reacting, teaching and re-entry), general supportive measures such as group work, disaster response, mobile crisis program,
telephone contact (suicide prevention center), victim outreach program, health education and environmental manipulation.

Contd…
398 Textbook of Psychiatric Nursing for BSc Nursing Students

• Techniques of crisis intervention are catharsis, clarification, suggestion, reinforcement of positive behavior, exploring the solution, use
of adaptive coping mechanism and raising self-esteem.
• Grief is defined as physical, somatic, spiritual, emotional and intellectual responses to the nature of loss.
• Types of grief are normal grief and morbid grief. Morbid grief classifies into pathological grief, complicated grief and grief at death
anniversary. Other types of grief are anticipatory grief, disenfranchised or ambiguous grief, time-limited grief, private or forbidden or
absent grief, collective grief, masked grief, exaggerated or distorted grief and cumulative grief.
• Kubler Ross (1969) identified the five stages of grief: denial, anger, bargaining, depression and acceptance. Other theories are
Dr Rando’s 6 Rs of mourning, John Bowlby’s four stages of grief, Worden’s four tasks of mourning and Parke’s four phase model of grief.
• Schafer (2000) defined stress as ‘arousal of body and mind in response to the demand made upon them’.
• Models of stress are stimulus-based model, response-based model and transaction-based model. In response-based model, stress
might affect a set of bodily changes described as general adaptation syndrome. This syndrome has three stages, namely alarm,
resistance and exhaustion.

ASSESS YOURSELF

Long Answer Questions 4. ____________ is defined as physical, somatic,

spiritual, emotional and intellectual responses to the
1. Define psychiatric emergencies. Explain the common
nature of loss.
psychiatric emergencies in India.
a. Grief b. Stress
2. Define crisis. Explain the techniques of crisis
c. Stressor d. Distress
intervention and nurses’ responsibility during the crisis.
5. ______________ is the first phase in Smith’s Stress
Short Answer Questions Model (1981) of assault cycle.
a. Escalation phase b. Crisis phase
1. What are the characteristics of psychiatric emergencies?
c. Triggering phase d. Recovery phase
2. What are the psychosocial factors in the etiology of
suicide? 6. When the serotonergic agents are used along with
3. What is SAD PERSONS rating scale? Monoamine Oxidase Inhibitors (MAOI), it leads to:
4. What are the symptoms of panic attacks? a. Neuroleptic malignant syndrome
b. Serotonin syndrome
Short Notes c. Rabbit syndrome
d. Sundowning syndrome
Write short notes on:
7. ____________must be used with caution in patients
1. Stress adaptation model
with delirium, mainly the elderly, because it may
2. Theories of grief
cause anticholinergic toxicity (atropine psychosis).
3. Warning signs of suicide a. Benztropine b. Neurobion forte
4. Management of violent behavior c. Haloperidol d. Lorazepam
5. Types of suicide
8. Overdose with carbamazepine or tricyclic
antidepressants needs _________ monitoring.
Multiple Choice Questions
a. Cardiac b. Respiratory
1. Imbalance in ___________ neurotransmitters might c. Temperature d. None of these
provoke suicide.
9. An accidental and unanticipated loss that causes
a. Serotonin b. Dopamine
drastic negative changes in the environment is called:
c. Acetylcholine d. Norepinephrine
a. Situational crisis b. Maturational crisis
2. Types of suicide based on social categories as per Emile c. Social crisis d. Post-traumatic crisis
Durkheim are the following; EXCEPT ___________.
10. Stages of General Adaptation Syndrome are:
a. Egoistic suicide b. Altruistic suicide
a. Alarm b. Resistance
c. Anomic suicide d. Parasuicide
c. Exhaustion d. All of these
3. Suicide attempt will be punishable with simple
imprisonment as per _________ of IPC. Answer Key
a. Section 309 b. Section 308 1. a 2. d 3. a 4. a 5. c
c. Section 307 d. Section 306 6. b 7. a 8. a 9. c 10. d
 CHAPTER

Legal Issues in
Mental Health Nursing 14
LEARNING OBJECTIVE

At the end of this chapter, student will be able to explain the legal aspects of psychiatric nursing and will be able to apply them in clinical
practice.

CHAPTER OUTLINE
• Indian Lunacy Act (1912) • Forensic Psychiatry
• Mental Health Act (1987) • Narcotic Drugs and Psychotropic Substance Act (1985)
• Protection of Child from Sexual Offences (POCSO) Act (2012) • Role of Mental Health Nurse as per the Mental Health Care
• Offences Covered as per the Act Act (2017)
• Punishment for Offences Covered Under the Act • Nurse’s Responsibility in Admission Procedure
• Mental Health Care Act (2017) • Nurse’s Responsibility in Discharge Procedure
• Rights of Mentally Ill Patients • Nurse’s Responsibility in Regard to Legal Aspects

KEY TERMS
Mental Health Act (1987), Mental Health Care Act (2017), Indian Lunacy Act (1912) POSCO Act (2012), Rights of Mentally Ill Clients,
Forensic psychiatry, M’Naghten’s rule, Irresistible Impulse Act, Durham’s rule/Product rule, American Law Institute (ALI) test, Narcotic
and Psychotropic Substances Act (1985), Protection of Children from Sexual Offence (POSCO) Act (2012).

INDIAN LUNACY ACT (1912) The eight chapters Indian Lunacy Act (1912) are as follows:
1. Chapter I: Preliminary Information and Definition
2. Chapter II: Admission Procedure of Mentally Ill (Refer to
Table 14.5)
3. Chapter III: Procedure for Treatment and Discharge of
Mentally Ill
4. Chapter IV: Proceedings of Lunatics in Presidency Town
5. Chapter V: Proceedings of Lunatics Outside Presidency
It consists of four Parts, eight chapters and hundred sections. Town
Objectives of Indian Lunacy Act (1912) are improvement of 6. Chapter VI: Establishment of Asylums
asylums and care of lunatics in asylums. 7. Chapter VII: Expenses of Lunatics
400 Textbook of Psychiatric Nursing for BSc Nursing Students

8. Chapter VIII: Rules of State Government regarding the Nursing Implications

Care of Lunatics.
A nurse has to protect the patient’s rights in all circumstances.
Nurse has to ensure that nursing procedures in ward should
Acts for Mentally Ill
not violate the patient rights. Nurse can discuss the rights with
• Mental Health Act (1987) Chapter VIII focuses on mental health team.
protection of rights for mentally ill.
• In Universal Declaration of Human Rights (UDHR) MENTAL HEALTH ACT (1987)
„ Article 5: Mentally ill should not be tortured or
treated in cruel way. Introduction
„ Article 24(1): Everyone has a right for standard living Indian Mental Health Act was initiated by Parliament in 1987
for oneself as well as family including food, shelter, and came into effect in all states of India in 1993. Enactment of
clothing, medical and social services. this Act has been revised as Indian Lunacy Act (1912). It has
• In Persons with Disability Act (1995) 10 chapters with 98 sections.
„ Section 2: Mental illness is considered disability.
„ Article 66(1): Government and local authorities Objectives
might take care of expenses for rehabilitation to take • To protect mentally ill persons.
care of person with disabilities. • To guide the admission and discharge procedure in
psychiatric hospital/nursing homes.
Rights of Mentally Ill • To give legal aid to psychiatric patients
Rights of Self • To build the strong state and central mental health
• Right to spend reasonable money for one’s own expenses authorities.
• Right to see visitors • To have a proper maintenance charges of psychiatric
• Right to have reasonable use of communication media hospital/nursing homes.
• To prevent unnecessary hold of any individual labeled as
• Right to use personal storage space
mentally ill without proper proof.
• Right to wear own clothes
• Right to marriage. Chapter I (Preliminary Information and Definition)
Rights in Regard to In-patient Treatment • Mentally ill person: Individual seeking treatment for a
mental disorder.
• Right to have voluntary admission and voluntary • Mentally ill prisoner: Mentally ill prisoner is placed in a
discharge from hospital, if he/she is major. safe custody.
• Right to treat the patients with dignity, kindness and • Cost of maintenance: Cost required to maintain the
compassion. mental hospital/mentally ill person.
• Right to refuse electroconvulsive therapy. • Inspecting officer: Person appointed by State
• Right to refuse restraints/seclusion unless the emergency Government to inspect psychiatric hospital.
situation arises. • License: Document issued by the government when a
• Right to recreation. hospital meets the required standards.
• Right to eat nutritious food. • Licensee: Holder of license.
• Right to have environmental sanitation (clean toilets). • Licensed psychiatric hospital: Psychiatric hospital
• Right to access books, periodicals, newspaper in their licensed to perform as per act.
own language. • Licensing authority: Authority specified by the state
government to provide licensure.
Rights Related with Legal Aspects
• Medical officer: Registered medical practitioner.
• Right to manage/dispose property/execute the wills. • Medical officer in-charge: In-charge of psychiatric
• Right to get informed consent. hospital/nursing home.
• Right to witness. • Medical practitioner: Person who has recognized
• Right to access the one’s own records upon request. medical qualification and is registered under Medical
• Right to maintain confidentiality of records. Council of India.
CHAPTER 14 Legal Issues in Mental Health Nursing 401

• Minor: Individual below 18 years of age. medical officer in-charge of psychiatric hospital/
• Psychiatric hospital/Nursing home: Hospital established nursing home and admission under reception order is
by the government for the treatment of mentally ill. made.
• Psychiatrist: Medical practitioner with postgraduation 2. Reception order on producing the mental illness
(or) Diploma in Psychiatry and registered under Medical before magistrate: Individual behaving violently will
Council of India. be detained by the police and was produced in court
• Reception order: Order is made under this act for within 24 hours. Application has to be supported with
admission and detention of mentally ill in psychiatric the medical certificates and magistrate will issue the
hospital. reception order.
3. Reception order after inquest: District court directs
Chapter II (Mental Health Authority)
the individual for admission.
Central and State Authority appointed by government to 4. Admission and detention of mentally ill prisoner:
coordinate the services related to mental health as mentioned Mentally ill prisoner will be admitted in psychiatric
below: hospital as per the order of court.
• To provide advice to government in regard to mental • Admission in emergencies: Summary of the admission
health. procedure is shown in Table 14.6.
• To supervise the psychiatric hospitals/nursing homes.
• To issue/renew/cancel the license to psychiatric hospitals/ Chapter V (Regulations of Discharge under Various
nursing homes. Circumstances)
• Discharge of patient admitted on voluntary basis: On
Chapter III
the recommendation of two medical practitioners (one of
Regulations to establish and maintain the psychiatric hospitals/ these has to be a psychiatrist), medical officer in-charge
nursing homes.
can provide the directions to discharge the patient.
Chapter IV (Regulations of Admission under Various • Discharge of patient admitted under special
Circumstances) circumstances: Relatives/friends of mentally ill can
• Admission on voluntary basis request discharge to the medical officer with a bond
„ Major: When an individual feels himself/herself in assuring that mentally ill will not cause any harm to self
need of being admitted for the treatment in psychiatric or others.
hospital, then he/she can approach to medical officer. • Discharge of patient admitted on reception order:
Medical officer will enquire within 24 hours and if Patient who recovered from mental illness can apply
the individual requires treatment, then he/she will be for discharge to magistrate along with a certificate from
admitted. medical officer in-charge of psychiatric hospital/nursing
„ Minor: If volunteer is minor then guardian can apply home. If magistrate feels that patient is fit, the discharge
to medical officer for the treatment in psychiatric can be issued.
hospital. • Discharge of patient admitted by police: For patients
• Admission under special circumstances (Involuntary detained by police, patient might be discharged if the
admission) When an individual is not willing for family members of patient has given in writing that they
admission to get treatment in psychiatric hospital, then will take care of patient after discharge and also medical
his/her guardian or relative can apply to medical officer. officer in-charge of psychiatric hospital/nursing home
Medical officer will enquire within 24 hours and if found that the patient is fit, discharge will be granted.
the individual requires treatment, then he/she will be • Discharge of mentally ill prisoner: Hospital in-charge
admitted. has to report about the condition of patient every
• Admission under authority or order: A mentally ill 6 months to the authority. When patient is fit for discharge,
person is admitted in psychiatric hospital as per the order the same has to be reported to authority so as to hand over
passed by court/authority. the patient to prison officer for further proceedings.
It has four main categories: • Leave of absence: As per section 45, mentally ill person
1. Reception order on application: Relative or friend in hospital can be given limited time period (maximum
can apply to magistrate along with two medical of 6 months) to visit the family members provided the
certificates. Magistrate will obtain the consent from relatives of patient have signed the bond, stating that
402 Textbook of Psychiatric Nursing for BSc Nursing Students

patient will not cause any harm to self or others and take PROTECTION OF CHILD FROM SEXUAL
good care in leave period. It helps the patient to gain the OFFENCES (POCSO) ACT (2012)
required skills in community-based treatment.
Ministry of Women and Child Development introduced the
Chapter VI (Appointment of Guardian) Protection of Children from Sexual Offences (POCSO) Act,
As per Section 54, Guardian needs to be appointed for the 2012. The act was passed in Indian Parliament on 14.11.2012.
mentally ill patient who is unable to look after self and property. It also gives the details of special courts in regard to the
As per Section 97, if the mentally ill is not represented by legal protection against the sexual offenses. The basic concepts of
practitioner before court, then the district court or magistrate this Act are explained in the Table 14.1.
can assign a legal practitioner for the same. Table: 14.1 Basic concepts of POCSO Act, 2012
Chapter VII (Cost of Treatment) Act no. 32
As per Section 78, Government of the particular state will bear Year of Act 2012
the cost of treatment for mentally ill patient who is detained
Date of 19/06/2012
in the hospital, if the mentally ill doesn’t have any property or enactment
money.
Date of 14/11/2012
Chapter VIII (Protection of Human Rights) enforcement

Section 81 states that mentally ill should not be treated in Ministry Ministry of Women and Child Development
undignified or cruel manner and mentally ill should not Short title The Protection of Children from Sexual
be used for research purpose until the research is found Offences Act, 2012
beneficial to them after getting a consent from patient (in case Long title An Act to protect children from offences
of voluntary admission) and consent from relatives (in case of of sexual assault, sexual harassment and
involuntary admission). pornography and provide for establishment
of Special Courts for trial of such offences
Chapter IX (Establishment and Maintenance of and for matters connected therewith or
Psychiatric Hospital/Nursing Home) incidental thereto.

Article 6 (1) states that the psychiatric hospital/nursing home Total no. of 9
needs license to run successfully. Article 11(1b) states that chapters
license of psychiatric hospital/nursing home can be cancelled, Total no. of 46
if maintenance doesn’t meet the standards. sections

Chapter X (Procedure Followed by Medical Officer

In-charge) Primary Features of POCSO ACT, 2012
It deals with the clarification in regard to the procedure/ • The Act is a statute comprises 9 chapters and 46 sections
procedures followed by the medical-officer in-charge of (Table 14.2).
Psychiatric hospital/Nursing home. • The Act defines the child as any person below age of
eighteen years old.
Nursing Implications • The whole Act focuses on ensuring a healthy physical,
Knowledge on legal aspects in Psychiatry will guide the mental and social development of child.
nurse in: • The Act has set of laws which helps to protect the child
• Ethical decision making from sexual abuse, harassment and pornography.
• Protecting the rights of mentally ill • The Act provides a child-friendly reporting and
• Admission and discharge procedures of mentally ill investigating procedure. In every step of the psychological
• Role of mental health authority condition of abused child has been given the much-
• Quality treatment of mentally ill required devotion.
CHAPTER 14 Legal Issues in Mental Health Nursing 403

Table: 14.2 Chapters and Sections of POCSO Act, 2012

Chapters Title of Chapter Sections

I Preliminary 1. Short title, extent and commencement
2. Definitions
II Sexual Offences Against Children A. Penetrative Sexual Assault and Punishment Therefor
3. Penetrative Sexual Assault.
4. Punishment for Penetrative Sexual Assault.
B. Aggravated Penetrative Sexual Assault and Punishment Therefor
5. Aggravated Penetrative Sexual Assault.
6. Punishment for Aggravated Penetrative Sexual Assault.
C. Sexual Assault and Punishment Therefor
7. Sexual Assault.
8. Punishment for Sexual Assault.
D. Aggravated Sexual Assault and Punishment Therefor
9. Aggravated Sexual Assault.
10. Punishment for Aggravated Sexual Assault.
E. Sexual Harassment and Punishment Therefor
11. Sexual harassment.
12. Punishment for sexual harassment
III Using Child for Pornographic 13. Use of child for pornographic purposes.
Purposes and Punishment 14. Punishment for using child for pornographic purposes
Therefor 15. Punishment for storage of pornographic material involving child.
IV Abetment of and Attempt to 16. Abetment of an offence.
Commit an Offence 17. Punishment for abetment.
18. Punishment for attempt to commit an offence.
V Procedure for Reporting of Cases 19. Reporting of offences.
20. Obligation of media, studio and photographic facilities to report cases.
21. Punishment for failure to report or record a case.
22. Punishment for false complaint or false information.
23. Procedure for media.
VI Procedures for Recording 24. Recording of statement of a child.
Statement of the Child 25. Recording of statement of a child by Magistrate.
26. Additional provisions regarding statement to be recorded.
27. Medical examination of a child.
VII Special Courts 28. Designation of Special Courts.
29. Presumption as to certain offences.
30. Presumption of culpable mental state.
31. Application of Code of Criminal Procedure, 1973 to proceedings before a
Special Court.
32. Special Public Prosecutors.
VIII Procedure and Powers of 33. Procedure and powers of Special Court.
Special Courts and Recording of 34. Procedure in case of commission of offence by child and determination of age
Evidence by Special Court.
35. Period for recording of evidence of child and disposal of case.
36. Child not to see accused at the time of testifying.
37. Trials to be conducted in camera.
38. Assistance of an interpreter or expert while recording evidence of child.
IX Miscellaneous 39. Guidelines for child to take assistance of experts, etc.
40. Right of child to take assistance of legal practitioner.
41. Provisions of sections 3–13 not to apply in certain cases.
42. Alternative punishment.
42A. Act not in derogation of any other law.
43. Public awareness about Act.
44. Monitoring of implementation of Act.
45. Power to make rules.
46. Power to remove difficulties.
404 Textbook of Psychiatric Nursing for BSc Nursing Students

OFFENCES COVERED AS PER THE ACT Sexual Harassment

Individual commits sexual harassment, under this Act with
Penetrative Sexual Assault
the sexual intent of:
If a man penetrates his penis or any body part into the vagina, • Using any word or making a gesture or exhibiting any
mouth, urethra or anus of a child or makes the child to do so object or a body part with intention to be heard or seen
with him or any other person; or he applies his mouth to the by the child.
penis, vagina, anus, urethra of the child or makes the child to • Making a child to exhibit his or her body parts.
do so to such person or any other person. • Showing any object to a child which provokes or give
gratification for pornographic purposes.
Aggravated Penetrative Sexual Assault • Constantly and repeatedly watching the child either
One who commits the penetrative sexual assault in the directly (or) through digital means.
following conditions:
• If he is a police officer or armed or security force.
PUNISHMENT FOR OFFENCES COVERED UNDER
THE ACT
• Staff of jail or remand home or protection home or
observation home. • Aggravated penetrative sexual assault: Not less than
• Staff in the hospital, educational or religious organization. 20 years and fine.
It may be Government or private. • Penetrative sexual assault: Not less than 10 years (in case
• Individual uses deadly weapon or fire or heated substance of child below 16 years, not less than 20 years).
or a corrosive substance to hurt the sexual organ of the • Sexual assault: Not less than three years which may extend
child. up to 5 years.
• When the sexual assault causes the child mentally ill. • Aggravated sexual assault: Not less than 5 years which
• Individual makes the female child pregnant as the may extend to seven years.
consequence of penetrative sexual assault. • Sexual harassment of the child—Imprisonment of 3 years
• Individual who causes the child with human and fine.
immunodeficiency virus or any other life-threatening • Involving the child for propagating pornographic material
infection or disease or which might cause a death of the - imprisonment of either up to 3 years of imprisonment,
child or attempt to murder the child. or with fine, or both.
• Individual who commits the assault by taking the
advantage of a child’s mental or physical disability. MENTAL HEALTH CARE ACT (2017)
• Relative of child through blood adoption or guardian or
The Mental Health Care Act (2017) superseded the previous
in foster care or a person has a domestic relationship with
Mental Health Act (1987). In India, Mental Health Care Act
a parent of child or living in the same house commits
commenced in 7.4.17 and came into force on 7.7.18. It has 16
penetrative sexual assault on child.
chapters as described in Table 14.3.
• Individual who commits during the communal (or)
The revisions made in this act are listed here:
sectarian violence (or) at any natural calamity.
• Individuals who tried to commit suicide need to be given
• Person who makes the assaulted child to strip or parade
an opportunity for rehabilitation from government side,
naked in public.
instead of giving punishment for suicidal attempt.
Sexual Assault • Agency of people with mental illness is given a chance to
take decision with regard to health matters.
Individual with the sexual intent touches child’s vagina, anus, • Aims to protect the rights of mentally ill and assess the
penis or breast (or) does any other act with sexual intent which treatment for mental illness without any discrimination.
involves physical contact without penetration. • In addition, insurance company has a provision for mental
illness as they are providing for physical ailment.
Aggravated Sexual Assault • Electroconvulsive therapy (ECT) can be given only in case
The provisions of aggravated penetrative sexual assault of emergency along with anesthesia and muscle relaxant.
are when an individual induces or coerces a child to get • ECT should not be given for minors. Other agencies and
administered of any drug or chemical substance, to a police have to respect the people with mental illness.
child with an intention of the child attains an early sexual Various measures are suggested to tackle the stigma of
maturity. mental illness.
CHAPTER 14 Legal Issues in Mental Health Nursing 405

Table 14.3: Chapters and description of Mental Health Care Act (2017)

Chapter Description of Mental Health Care Act (2017)

I It has basic definitions and it includes postgraduate AYUSH doctors in mental health team
II Capacity to decide mental health treatment without any discrimination
III Advance directives
• Patient has a right to appoint a representative in order to take treatment decisions
• In case of minor, parents or care givers might act as representative
• It is not applicable in case of emergency
• If the psychiatrist or caregivers are not satisfied, they might approach the concerned board
IV Guidelines of choosing nominated representative
V Rights of mentally ill
• Right to access mental health care
• Right to community living
• Right to protect from cruel, inhuman and degrading treatment
• Right to equality and nondiscrimination
• Right to information
• Right to confidentiality
• Restriction on release of information in respect of mental illness
• Right to access medical records
• Right to have personal contacts and communication
• Right to legal aid
• Right to make complaints in regard to the deficiencies in provision of services
VI Gives direction to the government to implement the program
VII Gives provision of forming central mental health authority
VIII Gives provision of forming state mental health authority
IX Finance, accounts and audit
X Mental health establishments
• All mental health institutions have to be registered
• Provisions to commence the new mental health institutions
XI Constitution of mental health review boards. Board constitutes of:
• District judge as chair person
• Two members (one was psychiatrist and other was registered medical practitioner)
• Two members who are care givers of mentally ill represent the organizations of individual with mental illness
XII Admission, treatment and discharge (Table 14.7)
XIII Duties of police officer in respect to mentally ill: Police has to give protection to the wandering individuals with mental
illness at nearest police station
XIV It restricts unauthorized duty and medication
XV It deals with penalty and punishment
• Institutions which are unauthorized can be punished from `5000 – `50,000 as penalty for first time and up to `2 lakhs for
second time
• Individuals of who violate this Act are liable to penalty of `10,000 or jail or both.
XVI Miscellaneous: Power of central government to issue directions

RIGHTS OF MENTALLY ILL PATIENTS • Right to have reasonable use of communication media
• Right to use personal storage space
As per the Indian Lunacy Act (1912), the rights of mentally ill • Right to wear own clothes
patients are as follows: • Right to marriage

Rights of Self Rights in Regard with In-Patient Treatment

• Right to spend reasonable money for one’s own expenses • Right to have voluntary admission and voluntary
• Right to see visitors discharge from hospital, if he/she is major.
406 Textbook of Psychiatric Nursing for BSc Nursing Students

• Right to treat the patients with dignity, kindness and „ To have adequate sanitary conditions
compassion. „ To have reasonable facilities for recreation, education
• Right to refuse electroconvulsive therapy and religious practices.
• Right to refuse restraints/seclusion unless the emergency „ To privacy
situation arises „ For proper clothing to maintain his dignity
• Right to recreation „ To not be forced to undertake work in a mental
• Right to eat nutritious food health establishment and to receive appropriate
• Right to have environmental sanitation (clean toilets) remuneration for work when undertaken.
• Right to access books, periodicals, newspaper in their „ To have adequate provision for living in the community
own language. „ To have adequate provision for wholesome food,
space and access to articles to maintain the personal
Rights Related with Legal Aspects hygiene, in particular, women’s personal hygiene be
• Right to manage/dispose property/execute the wills adequately addressed by providing access to items
• Right to get informed consent that may be required during menstruation.
• Right to witness „ To say no to tonsuring (shaving of head hair)
• Right to access the one’s own records upon request „ To wear own personal clothes if so wished and to
• Right to maintain confidentiality of records. not be forced to wear uniforms provided by the
hospital.
As per the Mental Health Act (1987), the rights of mentally ill „ To be protected from all the forms of physical, verbal,
patients are as follows: emotional and sexual abuses.
Chapter VIII address about the rights of mentally ill
patients. Section 81 states that mentally ill should not be Right to Equality and Nondiscrimination
treated in undignified or cruel manner and mentally ill should
Every individual with the mental illness should be treated
not be used for research purpose until the research is found
equally as that of the individuals with physical illness. Patients
beneficial to them after getting a consent from patient (in case
has to be treated without any discrimination on basis of
of voluntary admission) and consent from relatives (in case of
gender, religion, culture, social class, sexual orientation, caste
involuntary admission).
and disability.
As per the Mental Health Care Act (2017), the rights of • Right to information: Mentally ill individual can appoint
mentally ill patients are as follows: a representative to review the reason for admission in
• Right to access mental health care: Mentally ill patients the concern board and also can obtain the information
have rights to access high quality, cost effective, affordable about the treatment progress if the language explained by
mental health care which is accessible geographically the doctors are not understandable. It is the duty of the
without any discrimination on basis of gender, religion, treating doctor or psychiatrist to provide the complete
culture, social class, sexual orientation, caste, political information to the patient about the treatment.
beliefs, disability provided in a good manner which is • Right to confidentiality: It is the right of the mentally
acceptable by the mentally ill patients. ill patient to maintain confidentiality. The information
• Right to community living: Mentally ill patients have a is only transferred to others for the public security or
right to live in, to be part of society and not be segregated safety, treatment purpose, when there is harm to others,
from society. Patients should not continue to remain in when there is threat to life and only to the nominated
the mental health facilities merely not because of that he representative.
or she does not have family support or homeless or due to • Restriction on release of information in respect of
the absence of community-based facilities. Government mental illness: Photograph or any other information
shall provide legal aid and to facilitate exercising his right about the mentally ill should not to be released in the
to the family home and living in the family home. media without the consent of the person with mental
• Right to protect from cruel, inhuman and degrading illness. The information of mentally ill either in the digital
treatment: Mentally ill patients have the rights: or virtual platform should be protected, i.e., confidentiality
„ To live in safe and hygienic environment need to be maintained.
CHAPTER 14 Legal Issues in Mental Health Nursing 407

• Right to access medical records: Mentally ill patients healthy mind. M’Naghten’s Rule—“not felt guilty on grounds
have right to access their own medical records. The nurse of insanity” So, he was not punishable under the law.
in-charge has to withhold the records from access in case
the patient causes harm to self or others. Irresistible Impulse Act
• Right to personal contacts and communication: As per the rule, person might know that, the action is illegal
Mentally ill patients have right to make telephone calls, but is unable to control the action due to mental illness.
send or receive e-mails, allow or restrict the visitors after
Durham’s Rule/Product Rule
the hospital admission.
In 1954, Durham test was framed on the basis of decision in
• Right to legal aid: An individual with mental illness shall
District of Columbia. Accused is not liable as criminal for
be entitled to receive free legal services to exercise any of
action due to effect of mental disease.
his rights given under this act.
• Right to make complaints about deficiencies in American Law Institute (ALI) Test
provision of services: Any person with mental illness Person is not responsible for criminal activity if he/she has
or his/her nominated representative, has the right to done the act as a result of ‘mental disease/defect’. The term
complain in regard to the deficiencies in provision of care, ‘mental disease/defect’ referred, does not include the criminal
treatment and service. activity or antisocial conduct.

FORENSIC PSYCHIATRY Crime Due to Psychiatric Disorder

It is a branch of medicine that deals with mental disorders and Individuals might be involved in criminal activity due to:
related legal aspects. The core aspects are as follows: • Psychosis (due to delusions and hallucinations).
• Criminal responsibility • Drug dependence and drug related violence.
• Crime due to psychiatric disorder • Antisocial personality disorder.
• Civil responsibility • Mood disorder.
• Laws related to psychiatric disorder • Confused/Excited mental state.
• Admission and discharge procedure in psychiatric
hospital (Tables 14.5, 14.6 and 14.7) Civil Responsibility
Contract
Criminal Responsibility As per Indian Contract Act (1872), contract is an agreement
Indian Penal Code (1860), Section 84 states that, “Nothing is enforced by law. Section 11 states, “every individual can
offence which is done by individual with unsound mind”. perform contract provided one who is major and having sound
mind.” Section 12 states that “person with unsound mind
M’Naghten Rule and occasionally with sound mind (lucid interval) can make
On 20th January 1843-Daniel M’Naghten, 29-year-old contract. However, person who is sound mind usually and
Scotsman planned to murder Sir Robert Peel, Prime Minister. occasional unsound mind, should not make contract when
But, he mistakenly gunshot Edward Drummond, Secretary of he/she is in unsound mind state.”
Sir Robert Peel. Lord Chancellor put panel of 14 judges, five
hypothetical questions were asked and “M’Naghten Rules” Management of Property
were framed based on these. Judge found two rules to identify If the relative of mentally ill filed a case that property of
the criminal responsibility of person by keeping M’Naghten mentally ill individual was not managed due to incapacity
Rules in mind. of individual being mentally ill, then the court can appoint a
• Rule 1: Person does not know/aware of nature and quality manager to look after the property to sell/dispose in order to
of action performed during the crime. settle the debt or expenses.
• Rule 2: When a person does not know what he has done
at the time of crime, then he might not be aware of what Marriage
was wrong. Hindu Marriage Act (1955) states, “if one of them among
It is also called ‘Legal Test’. Psychiatrist found that Daniel the couple was of unsound mind at the time of marriage
performed the act due to delusion of persecution and not with is considered null as per law. Party can file for divorce if
408 Textbook of Psychiatric Nursing for BSc Nursing Students

his/her mental illness is continuous for the period of two years. Year Laws related to psychiatry
If divorce has been filed for more than three years, then divorce
1986 Consumer Protection Act
can be granted with the condition that, other party needs to Juvenile Justice Act
pay maintenance charges for mentally ill person.”
1987 Indian Mental Health Act
Adoption 1992 Rehabilitation Council of India Act

Hindu Adoptions and Maintenance Act (1956) states, Section 1996 Person with Disabilities Act
7—“Hindu male, who is major and sound minded can adopt a
child with consent of wife unless the wife is of unsound mind.” NARCOTIC DRUGS AND PSYCHOTROPIC
Section 8—“Hindu female, who is major and sound minded SUBSTANCE ACT (1985)
can adopt a child with consent of husband unless the husband
is of unsound mind.” Person giving in adoption also has to be
with sound mind.

Witness
As per Indian Evidence Act (1872), mentally ill is not
competent to give evidence, provided the evidence can be
considered if given in lucid interval.

Testamentary Capacity
Indian Succession Act states that testamentary capacity of It has 6 chapters with 83 sections.
mentally ill is considered valid, provided psychiatrist has to
assess concentration, memory and orientation of testator Chapter I (Preliminary Information and
was normal before making will. Even the mentally ill with Definition of Terms)
delusions can make will if the delusions are not related with • Addict: Individual addicted to narcotic drug/psychotropic
disposal of property. substance.
• Narcotic drug: Cannabis, cocaine, opium and all
Right to Vote and Right to be a Member in Parliament manufactured drugs.
Under Act 326 by constitution of India, person with mental • Manufactured drug: Opium derivatives, medicinal
illness does not have privilege of voting. Under Act 102 by cannabis, poppy straw and other narcotic substance.
Constitution of India, “Individual is not qualified for being a • Psychotropic substance: Seventy-six substances are
member of parliament when he/she is unsound mind.” mentioned in schedule which are natural or synthetic
that change brain function and results in alterations
Laws Related to Psychiatry in perception, mood, consciousness, cognition, or
Laws related to psychiatry are mentioned in Table 14.4. behavior.
Table 14.4: Laws related to psychiatry Chapter II (Authorities and Officers)
Year Laws related to psychiatry Narcotics Control Bureau is the authority and its headquarter
is located at New Delhi. It is headed by Director General.
1869 Indian Divorce Act
It has five zonal offices at Chennai, Varanasi, Mumbai, Kolkata
1912 Indian Lunacy Act
and New Delhi. Committee appointed by Central Government
1925 Indian Evidence Act is Narcotic Drugs and Psychotropic Substance Consultative
Indian Succession Act
Committee which consists of Chairman (Head of Committee)
1939 Dissolution of Muslim Marriage Act and Committee Members (not more than 20 members).
1954 Special Marriage Act
1955 Hindu Marriage Act Chapter III (Prohibition, Control and Regulation)
1984 Family Court Act As per Section 8, no one can cultivate cannabis, coca and
1985 Narcotic Drugs and Psychotropic Substance Act
opium or possess or consume any psychotropic substances or
narcotic drugs except for the specified scientific or medicinal
Contd… reason.
CHAPTER 14 Legal Issues in Mental Health Nursing 409

Chapter IV (Offences and Penalties) Admission and discharge procedure summary as per
If an individual uses narcotic drug or substance he/she is Indian Lunacy Act (1912) is depicted in Table 14.5.
punishable with: • Voluntary patients— Patient has insight and seeking
• Imprisonment not less than 10 years and it can be admission.
extended up to 20 years. • In volitional patients— Patient not having insight and
• In case of repeated offence, imprisonment for not less refuse admission, e.g., psychosis.
than 15 years which can be extended up to 30 years. Non volitional patients—Patient not giving/refusing consent
• Fine not less than one lakh which can be extended up to for admission, e.g., mental retardation (severe).
two lakh rupees.
• In case of repeated offence, fine not less than 1.5 lakh Admission and discharge procedure summary as per
which can be extended up to three lakh rupees. Mental Health Act (1987) is given in Table 14.6.
• Possessing small quantities of heroin, opium or cocaine is • Admission of person with mental illness as independent
liable to simple imprisonment that can be extended to one patient in mental health establishment.
year or fine or both. • Independent admission and treatment.
• Discharge of independent patients.
Chapter V (Details the Procedure)
• Admission and treatment of persons with mental illness,
This chapter deals with power to issue warrant or authorization,
with high support needs, in mental health establishment,
duty of land holder or certain officers to give information about
up to thirty days (supported admission).
illegal cultivation of substances, disposal of seized narcotic
• Admission and treatment of persons with mental illness,
drugs and psychotropic substances, etc.
with high support needs, in mental health establishment,
Chapter VI (Miscellaneous Issues) beyond thirty days (supported admission beyond thirty
Government has to establish the de-addiction centers to days).
identify and treat the addicts. • Leave of absence.

Table 14.5: Summary of admission and discharge procedure as per Indian Lunacy Act (1912)

Type of Type of patient Admission application by Admitting Discharge Discharge

admission authority application by authority
Voluntary Voluntary Mentally ill Asylum in-charge Volunteer Asylum in-charge
with two visitors
Under special In volitional and Guardian/relative/friend of Medical officer Guardian/relative/ Magistrate
circumstances nonvolitional mentally ill in-charge friend of mentally ill
Reception In volitional and Husband/wife or close relative No application Three or more
order on nonvolitional visitors
application/ Petitioner Asylum in-charge
petition
Inquisition Magistrate
Reception Dangerous/ Police Magistrate No application Three or more
order without neglected/ visitors
application/ wandering Guardian/relative/ Asylum in-charge
petition mentally ill friend of mentally ill
Inquisition Magistrate
Inquisition Any mentally ill Guardian/relative/friend of Inquisition Magistrate
mentally ill (or) advocate
general (or) district collector
(or) public curator
Criminal Criminal Any order under Prisoners Order Visitor might Under the
lunatics lunatic Act/Army Act recommend appropriate
discharge Section
410 Textbook of Psychiatric Nursing for BSc Nursing Students

Table 14.6: Summary of admission and discharge procedure as per Mental Health Act (1987)

Type of Type of Admission application by Admitting Discharge Discharge authority

admission patient authority application by
Voluntary Voluntary Medical Volunteer Medical officer in-charge
Under special Guardian/relative/friend of officer in- Guardian/Relative/ Magistrate
circumstances mentally ill charge Friend of mentally ill
Reception order In volitional Guardian/relative/friend No application Medical officer in-charge and
on application/ and of mentally ill (or) medical two medical practitioners (one is
petition nonvolitional officer in-charge Psychiatrist)
Guardian/Relative/ Medical officer in-charge
Friend of mentally ill
Petitioner Medical officer in-charge
Magistrate Inquisition Magistrate
Mentally ill with Magistrate
certificate from
medical officer in-
charge
Reception Dangerous/ Police No application Medical officer in-charge and
order without Neglected/ two Medical Practitioners (one is
application/ wandering Psychiatrist)
petition mentally ill Guardian/Relative/ Medical officer in-charge
Friend of mentally ill
Petitioner Medical officer in-charge
Inquisition Magistrate
Mentally ill with Magistrate
certificate from
medical officer in-
charge
Inquisition Any mentally Guardian/relative/ friend Inquisition Magistrate
ill of mentally ill (or) advocate
general (or) district
collector (or) public curator
Criminal lunatics Criminal Any order under Prisoners Order Visitor might Under the appropriate
lunatic Act/Air Force Act/Army Act/ recommend discharge section (as per Act)
Navy Act

• Absence without leave or discharge. Teaching to Patient (or) Caregivers (or) Public
• Transfer of persons with mental illness from one
• Providing health teaching to the patient and family
mental health establishment to another mental health members.
establishment. • Promotion of mental health and preventive programs can
• Discharge planning be organized in order to create awareness to the public.
• Emergency treatment. • Educate the caregivers in regard to the importance
of making advance directives and nominate the
ROLE OF MENTAL HEALTH NURSE AS PER THE representative to protect the patient rights. Provide
MENTAL HEALTH CARE ACT (2017) information about the Insurance coverage (similar to
physical illness, coverage is applicable to patient suffering
Member of Mental Health Authority
with mental illness).
Mental Health Nurse with 15 years of experience is nominated • Inform the patient and caregivers that there will not be
as member of Central Mental Health Authority and State any discrimination or torturing in any means and there is
Mental Health Authority. no compulsion to wear hospital patient uniforms.
CHAPTER 14 Legal Issues in Mental Health Nursing 411

Treatment Miscellaneous
• Rendering quality nursing care to the patient. • Assisting in the admission and discharge procedures
• Electroconvulsive therapy should not be administered (Table 14.7).
without anesthesia (i.e., Direct ECT should not to be • Protecting out the rights of mentally ill patients.
administered). • If mental health nurse found the patient is incapable of
• Electroconvulsive therapy can be administered to minors take care oneself or found wandering then, nurse can
in exceptional cases after the prior intimation to the approach the in-charge of police to protect the patient.
board and after obtaining the informed consent from the • Proper documentation should be done to protect the
guardian. nurse and to avoid the legal consequences.
• Psychosurgery can be done if required after obtaining the
informed consent and approval from the board. NURSE’S RESPONSIBILITY IN ADMISSION
• No physical restraints to patient and if indicated, it has PROCEDURE
to be in least restrictive manner with the very close
monitoring for the patient to prevent any injuries. Nurse has to welcome the patient to the ward. Nurse has to
• Mental health nurse will ensure that the women with maintain interpersonal relationship with the patient to gain
mental illness will not be separated from her child if the trust. Ensure the legal issues before admission. Nurse needs to
age of the child is below 3 years. tie the identity band on the patient’s wrist. Nurse can collect the

Table 14.7: Summary of admission and discharge procedure as per Mental Health Care Act (2017)

Type of Type of Admission Admitting Discharge Discharge Planning /Procedure

admission patient application authority application
by by
Independent Voluntary Patient Medical officer in- Patient Medical officer in-charge (or) psychiatrist
admission (major) charge of the Hospital. Patient can discharge into
Independent Voluntary Guardian/ Medical officer in- Guardian/ the community or to a different mental
admission (minor) parents/ charge parents/ health establishment or where a new
relatives relatives psychiatrist is to take responsibility of the
person’s care and treatment
Supported Person Guardian/ Medical officer in- Guardian/
admission up to who are relative/friend charge relative/ Leave of absence
30 days incapable to of mentally ill friend of Medical officer or mental health
make mental (or) medical mentally ill professional in-charge may grant leave to
health officer in- any person with mental illness can absent
care and charge from the establishment subject to such
Supported treatment Application by Medical officer conditions, if any, and for such duration
admission beyond decisions the nominated or mental health
30 days representative professional Absence without leave or discharge
of a person in charge of a If any person absents oneself without
with mental mental health leave or without discharge from hospital,
illness establishment (two he or she shall be taken into protection
psychiatrists have by any Police Officer at the request of the
independently medical officer and shall be sent back to
examined the the mental health hospital immediately
person with
mental illness) Transfer of persons with mental illness
from one mental health hospital to
another hospital
It may subject to any general or special
order of Board, that the patient can
be removed from such mental health
hospital and admitted to another hospital
with consent of Central Authority
and also consent from the nominated
representative of the patient.
412 Textbook of Psychiatric Nursing for BSc Nursing Students

communication address/permanent address/contact details A nurse has to take informed consent or substitute
of patient. Nurse collects history from the patient, relatives, consent (patient with unsound mind is unable to give
friends, guardian, police, etc. Nurse has to perform head to consent so substitute consent from relatives/guardian can be
toe assessment (physical examination) including vital signs considered) as follows:
and mental status examination. Orient the ward routines/ • Admission and discharge of psychiatric patient
rules, e.g., activities in ward, meal timings, daily schedule, • Before electroconvulsive therapy
etc. Assign the bed to the patient depending on the patient’s • Prior to psychosurgery
condition, e.g., patient with high suicidal risk/psychiatric • Before any invasive investigations
emergencies has to be assigned infront of nurse’s station for • Narco-analysis
continuous observation/monitoring. Nurse has to document • Special drug therapy—disulfiram, clozapine
the admission notes and enter the admission in nominal • Involving the client in drug trial for research purpose.
register.
If the Patient Escaped from Mental Hospital
NURSE’S RESPONSIBILITY IN DISCHARGE Give immediate information to the nursing supervisor/
PROCEDURE medical superintendent/security officer of hospital. Family
members/relatives/guardian has to be informed that patient
Nurse has to provide discharge teaching to the patient and his escaped from hospital. Incident report has to be sent to
family members in regard to the treatment regimen and next supervisor in writing regarding the same. Hospital in-charge
follow up in outpatient department (OPD) visit. Nurse has to has to be informed about the same to the local police.
ensure the that patient leaves the ward with all his personal
belongings. Nurse has to give discharge summary to the family If Patient with Mental Illness Dead
members along with the investigation reports carried out in
Nurse has to hand over the dead body to the family members/
the ward, provided the proper signature is obtained in nursing
relatives/guardian. Postmortem is only needed if death is due
documents.
to accident/poisoning/assault/unknown bites, etc. If family
Nurse might explain the nearby rehabilitation centers
members/relatives/guardian are not nearby, information can
for routine care and also offer help to arrange wheel chair, if
be given telephonically and dead body can be kept for three
needed. Nurse can promote a right psychological support to
days in mortuary. If family members/relatives/guardians do
the client. In case of parole or leave of absence, patient has to not arrive to hospitals within three days, then the dead body
be given permission to attend family functions or any specific can be handed over to municipal authority.
purpose. During parole, relatives have to be explained about
the medications to be followed and regular monitoring of If Mentally Ill Patient is Pregnant
patient is also required (sleep pattern, communication, side
Detailed gynecological examination has to be performed
effects/extrapyramidal symptoms, allergy to medication).
during the admission process. If pregnancy occurs due to rape
Advice the caregivers to intimate any other specific issues
and the pregnant women is with unsound mind, then abortion
found during the parole.
can be done on considering humanitarian aspect. If baby has
developed and abortion is considerable risk to mother, then
NURSE’S RESPONSIBILITY IN REGARD TO LEGAL
necessary arrangements have to be made to hand over the baby
ASPECTS
to social welfare organization.
A nurse has to protect patient rights and she should also be
aware of the criminal and civil responsibility of psychiatric In Case of Criminal Lunatics
patients. Nurse has to protect the legal records properly and Care has to be taken in same way as that of other patients.
keep the patient information confidential (nondisclosure of Strict security has to be provided considering safety of self
information). and others.
CHAPTER 14 Legal Issues in Mental Health Nursing 413

SUMMARY
• Indian Mental Health Act initiated by Parliament in 1987. It has 10 chapters with 98 sections.
• The Mental Health Care Act (2017) superseded the previous Mental Health Act (1987). It has 16 chapters.
• Indian Lunacy Act (1912) consists of four Parts, eight Chapters and 100 Sections. Objective of this Act focus on the improvement of
asylums and care of lunatics in asylums.
• Mental Health Act (1987) Chapter VIII focuses on protection of rights for mentally ill.
• Protection of Children from Sexual Offence (POSCO) Act enacted in 2012. It consists of 9 chapters and 46 sections.
• Rights of mentally ill is categorized into rights of self, patient rights related to in-patients, rights related with legal aspects.
• Forensic psychiatry is a branch of medicine that deals with mental disorders with its related legal aspects. Forensic Psychiatry is
categorized into criminal responsibility and civil responsibility. Criminal responsibility are M’Naghten’s rule, Irresistible Impulse Act,
Durham’s rule/Product rule and American Law Institute (ALI) Test. Civil responsibility includes contract, management of property,
marriage, adoption, witness, testamentary Capacity, right to vote and right to be a member in parliament.
• Narcotic Drugs and Psychotropics Substance Act (1985) has 6 chapters and 83 sections.
• Various categories of admission procedure in Indian Lunacy Act/Mental Health Act are admission on voluntary basis, admission under
special circumstances, reception order with petition as well as without petition, inquisition and admission of criminal lunatics.

ASSESS YOURSELF

Long Answer Questions 4. Number of chapters in Indian Lunacy Act is ______.

1. Describe the admission and discharge procedures as per a. 8 b. 10
Mental Health Act. c. 12 d. 14
2. Explain the concepts of forensic psychiatry. 5. Narcotic Drugs and Psychotropics Substance Act is
enacted in ______.
Short Answer Questions a. 1985 b. 1988
1. List out the chapters and sections of POCSO Act? c. 1987 d. 1912
2. List out the name of the chapters in Narcotics Drugs and 6. Rehabilitation Council of India Act enacted in
Psychotropics Substance Act? ___________.
a. 1912 b. 1992
Short Notes c. 1914 d. 1985
Write short notes on: 7. Regulations of admission under various circumstances
1. Rights of mentally ill is explained in chapter ________ in Mental Health
2. Mental Health Act Act.
3. Indian Lunacy Act a. I b. II
4. M’Naghten’s Rule c. V d. IV
5. Nurses’ responsibility in admission and discharge 8. Protection of Human Rights is explained in chapter
procedure ______ in Mental Health Act.
6. Narcotic Drugs and Psychotropics Substance Act a. V b. VI
7. Nurses’ responsibility in legal aspects c. VIII d. VII
9. Protection of Children from Sexual Offence (POCSO)
Multiple Choice Questions
Act enacted in ________.
1. Indian Mental Health Act initiated by parliament in a. 2012 b. 1912
________. c. 2000 d. 1987
a. 1912 b. 1987
10. Protection of Children from Sexual Offence (POCSO)
c. 1988 d. 1908
Act has ______ chapters and ______ sections.
2. Indian Lunacy Act enacted in ___________. a. 10, 46 b. 9, 46
a. 1912 b. 1987 c. 9, 48 d. 10, 48
c. 1988 d. 1908
Answer Key
3. Number of chapters in Indian Mental Health Act is ___.
1. b 2. a 3. b 4. a 5. a
a. 8 b. 10
c. 12 d. 14 6. b 7. d 8. c 9. a 10. b
Notes
 CHAPTER

Community
Mental Health Nursing 15
LEARNING OBJECTIVE

After studying this chapter, student will be able to understand and practice the concepts of community mental health nursing.

CHAPTER OUTLINE
• Introduction • Institutionalization versus Deinstitutionalization
• Definition of Community Mental Health Nursing • Preventive Psychiatry
• Principles of Community Mental Health Nursing • Psychiatric Rehabilitation
• Issues in Community Mental Health Nursing • Mental Health Services by Various Agencies
• Development of Community Mental Health Services • Agencies/Organization Supporting to Promote Mental
• National Mental Health Policy Health—Abroad
• National Health Policy, 2002 • Issues in Mental Health Nursing for Special Populations
• National Mental Health Program, 1982 • Victims of Violence
• District Mental Health Program, 1996 • Psychiatric Aspects of HIV/AIDS

KEY TERMS
Psychiatric rehabilitation, Preventive psychiatry, National Mental Health Program, District Mental Health Program, Partial
hospitalization, Quarter way homes, Group homes, Foster homes, Sheltered workshop, Self-help group, Suicide prevention centers,
Premenstrual syndrome, Postpartum depression, Postpartum psychosis, Cycle of violence, HIV/AIDS.

INTRODUCTION

Community Mental Health Centers Act (1963) was initiated

by 35th United States’ President, John F Kennedy (Fig.15.1),
who brought the change in shifting the mental health care
from hospitals to the community.

DEFINITION OF COMMUNITY MENTAL HEALTH

NURSING

Community Mental Health Nursing is defined as, ‘decentralized

pattern of rendering mental health services/care to the needy Figure 15.1: John F Kennedy
416 Textbook of Psychiatric Nursing for BSc Nursing Students

person in the community, further it focuses on prevention of • Community mental health nursing focuses to strengthen
mental illness, promotion of mental health and rehabilitation the available resources with the required training and
of patients with mental disorder in the community’. education.

PRINCIPLES OF COMMUNITY MENTAL HEALTH ISSUES IN COMMUNITY MENTAL HEALTH

NURSING NURSING

• Community mental health nursing uses holistic approach • Lack of trained manpower and uneven distribution of
with the people residing in community by the integration manpower.
of mind, body and spirit. • Lack of budget to promote mental health in community
• Community mental health nursing must consider the area.
social setting where the client and family members live • Lack of knowledge and skills in general medical practitioner
together. The care should be based on their capabilities about taking care of mentally ill patients in community.
for the promotion of mental health. • Lack of awareness about the psychiatric illness in community.
• Community mental health nursing focuses on • Poor access to primary health centers to get treatment for
providing the psychosocial support, removal of stigma/ mental illness.
discrimination, prevention of mental illness and treatment • Persistence of stigma and discrimination about mental
of mentally ill-using accessible health care services. illness.

DEVELOPMENT OF COMMUNITY MENTAL HEALTH SERVICES (TABLE 15.1)

Table 15.1: Development of community mental health services

Phase Period Year Milestones of development

I Colonial period (before 1745 First mental asylum was started in Bombay
independence)
1781 First mental asylum was started in Calcutta
1794 First mental asylum was started in Madras
18th century More lunatic asylums were built
onwards
1841 Dorothea Dix was appointed as inspector of mental asylums to promote
humanity-based treatment measures. It resulted in establishment of
32 psychiatric hospitals in USA.
1908 ‘A Mind that Found Itself’—Book was written by Clifford W Beers. He was a
mentally ill patient who exposed awful conditions of psychiatric hospitals. So,
‘National Mental Health Association in USA’ was formulated and ‘Mental Hygiene
Movement’ began.
1900 Adolf Myer emphasized on the community mental health approach.
1955–1980 Era of deinstitutionalization in USA and other Western countries.
1940 Boston psychopathic hospital was launched in USA (This hospital is pioneer to
develop Milieu Therapy).
1946 • Col M Taylor, Superintendent of European Mental
Hospital (Ranchi) surveyed 17 hospitals and
found that poor care was rendered in them.
Based on this survey report, Bhore Committee
recommended to promote mental health care in
the hospitals.
• President Harry S Truman (33rd president of USA)
passed the Mental Health Act.
President Harry S Truman
Contd…
CHAPTER 15 Community Mental Health Nursing 417

Phase Period Year Milestones of development

II After Independence 1950 All India Institute of Mental Health (Now it is NIMHANS) was institutionalized at
Bangalore.
1955 Joint Commission on Mental Illness and health was formed.
1957 First mental hospital was started in Hyderabad.
Dr Vidyasagar, Medical Superintendent of Amritsar Mental Hospital involved the
family members in mental health care of a mental patient as it leads to faster
recovery. Hence, family wards were initiated in CMC Vellore and Mental hospital
at Bangalore.
1958 First mental hospital was started in Srinagar.
1960 First mental hospital was started in Jamnagar.
III 1961–1969 1961 Joint Commission on Mental Illness and Health (1955) published a book ‘Action
for Mental Health’.
1962 Mudaliar Committee recommends to establish Psychiatric Units in all districts of
India.
1963 Community Mental Health Centers Act was passed.
Rural Mental Health Program was started at Sakalwara, Bengaluru.
1966 First mental hospital was started in Shahdara, New Delhi.
1961–1969 Development of General Hospital Psychiatric Unit (GHPU).
IV 1970–1982 1970 Expert Committee of World Health Organization (WHO) and Indian Psychiatric
Society focuses on the development of General Hospital Psychiatric Unit (GHPU)
into Primary Health Centers (PHC) and Community Health Centers (CHC).
Community care approach was followed first in the below mentioned centers.
• Sakalwara village at Bengaluru
• Raipur Rani Block in Ambala District at Haryana.
1975 Community Mental Health Construction Act was passed to extend seven more
services
1. Services for children and adolescent
2. Services for elders
3. Services for patients with alcohol abuse
4. Services for patients with drug abuse
5. Screening the community people
6. Transitional services (Services framed to assist the person who had transition
from hospital to community)
7. Follow-up
1980 Community Mental Health Systems Act was passed.
District Mental Health Program at Bellary district in Karnataka was started.
1982 National Mental Health Program was launched.
V 1987–2012 1987 Indian Lunacy Act (1912) was replaced by Mental Health Act (1987).
1990’s • Increased in funding to promote mental health services in hospitals.
• Nongovernmental Organizations (NGO’s) took an active lead to improve
mental health.
• Growth of private sector in mental health services.
2008 WHO’s Mental Health Action Gap Program was launched
2011 WHO’s World Health Atlas demonstrated that mental health services were poor
because of inequitable distribution and insufficient resources.
Contd…
418 Textbook of Psychiatric Nursing for BSc Nursing Students

Phase Period Year Milestones of development

VI 2013–2020 Dr Margaret Chan, Director-General of World Health Organization (WHO)
formulated the comprehensive Mental Health Action Plan with five main
objectives
1. Empower the leadership and governance for mental health.
2. Provide the comprehensive, integrated and responsive mental health services.
3. Health/Social care services in community-based settings.
4. Implement the strategies for promotion of mental health and prevention of
mental illness.
5. Empower the information systems, evidence and research for mental health.
Mental Health Action Plan have six core principles listed below:
1. Universal health coverage: Equal treatment is rendered to all irrespective of
their religion, gender, race, age, social status and sexual orientation, etc.
2. Evidence-based practice: Treatment, preventive measures and promotion of
mental health services based on the current evidence.
3. Human rights: Protection of the rights of mentally ill.
4. Life course approach: Policies and protocols needs to be considered at all
stages of life course such as infancy, childhood, adolescence, adulthood and
old age.
5. Multisectoral approach: Coordination with the private sector and public
sector (health, employment, education, judicial, housing, etc.)
6. Empowerment of patients with mental disorders and psychosocial
disabilities.

National Institute of Mental Health and problems in children and to manage the psychosocial
Neurosciences (NIMHANS) problems of students by providing counseling to them.
• Training of village leaders, student volunteers and lay
National Institute of Mental Health and Neurosciences
volunteers: Training the village leaders might guide them
(NIMHANS) at Bengaluru has developed alternative measures
instead of hospital-based care, which are as follows: to act as a changing agent in society. College students who
• Domiciliary Care Program: Mental health professionals are involved in National Social Service (NSS) activities
and nurses render the mental health care at patient’s home can extend their social service to render mental health
in order to develop the social functioning and overall services.
improvement in health. • Student Development Program: Poor academic
• Extensive use of outdoor services: Family members performance is a common problem among students, so
are encouraged to treat the mentally ill patients in home special training program for school students in regard
set-up. The patient’s mental health can be improved by to study habits, tips for learning, writing pattern in
exposure to nature and by doing outdoor activities. There examination and the role of emotional factors in the
should be periodical visiting in Out Patient Departments learning are considered.
(OPD’s) and the patient should spend short-stay in • Involvement of Integrated Child Developmental
hospital, if needed. Services (ICDS) personnel in children mental health
• Organizing short-term course to private general care: Anganwadi workers are trained in regard to the
practitioners: Mental health professionals train the mental health care. It helps them to identify the children
private general practitioners by organizing the short-term with behavior problems or mental disorders and refer
courses in order to enhance the knowledge and skills. them to appropriate psychiatric hospital.
• Extension program by satellite clinics: Mental health • Nongovernmental voluntary organization:
professionals conduct monthly or weekly clinics at district „ Schizophrenia Research Foundation (SCARF),
headquarters or taluks. Local NGO’s help to conduct such Chennai.
camps regularly. „ Medico-Pastoral Association
• Promotion of mental health by training the school „ Richmond Fellowship of India, Bengaluru
teachers in regard to mental health care: Teachers „ Suicide Prevention Centers (e.g., Sneha at Chennai,
are trained to identify the mental health or behavioral Maithreyi at Puducherry).
CHAPTER 15 Community Mental Health Nursing 419

NATIONAL MENTAL HEALTH POLICY ◆ Promote intersectoral research.

◆ Provide the necessary inputs/conceptual
The policy has the plan of action that is required for promoting framework for health and policy planning.
mental health. ◆ Focused Information Education Communication
• Reformulating the National Mental Health Policy, (IEC) activities in collaboration with Indian
1982: Institute of Mass communication.
„ District Mental Health Program (DMHP) was field ◆ Enhancing public awareness.
tested in 1985 in Bellary District of Karnataka under ◆ Eradicating the stigma/discrimination related
the guidance of National Institute of Mental Health mental illness.
and Neurosciences (NIMHANS). • Organizing services
„ After pilot project, District Mental Health Program „ Providing mental health care in primary care setting.
(DMHP) was implemented during 9th Five-Year Plan „ Make psychotropic drugs available at all levels of
(1997–2002).
health care.
„ National Mental Health Program (NMHP) failed due
• Community mental health care facilities
to its one-dimensional nature.
„ Community care is more effective and cost-effective.
„ After in-depth situation analysis and extensive
„ It leads to early intervention.
consultations with stakeholders, the NMHP (1982)
„ Removes stigma.
underwent radical restructuring.
„ Different services such as day care centers, half way
„ It aimed at striking a judicious balance between
homes and long stay homes, sheltered workshops,
various components of the mental health care delivery
de-addiction center and suicide prevention center
system, with the specified budgetary allocations.
were provided.
• Revised NMHP, 2003: It is comprised of five closely
• Support to families
networked or interdependent strategic components, with
„ Providing financial support to families.
a total outlay of `19 billion during the 10th Five-Year Plan.
„ Offering public places to the community for the
The components of Revised National Mental Health
Program are as follows: meeting and organization of day care activities.
„ Redesigning the DMHP around a modal institution „ Nurses has to visit the patient’s home in order to
(Zonal Medical College) support patient’s family members.
„ Strengthening the medical colleges with a view to „ Involving them in the planning of the Mental Health
develop: Program.
◆ The manpower in psychiatric department. • Human resource development: It involves short-term
◆ Psychiatric treatment facilities at secondary level. training of:
◆ General Hospital Psychiatric Unit (GHPU). „ Medical students
„ Streamlining and modernization of mental hospitals „ General psychologists’
to transform from custodial care to: „ General social workers
◆ Tertiary centers of excellence „ General nurses
◆ Provide psychodynamic orientation „ Rehabilitation professionals
◆ Enhance the research and development in the field • Public mental health education: The goal of providing
of community mental health. mental health education to the public is:
„ Strengthening of central and state mental health „ To reduce the barriers to treatment
authorities: „ To reduce the stigma and discrimination
◆ To fulfill their role in monitoring the ongoing „ To recover human rights
Mental Health Program. • Private sector mental health care: Role of private sector
◆ Determine intersectoral collaboration and linkages is identified as the following:
with other national programs. „ Systematic recording
„ Research and training aim at: „ Clarifying treatment utilization
◆ Building an extensive database of epidemiology „ Working in medical colleges as consultants
◆ Therapeutic needs of community. „ Training Primary Health Center (PHC) personnel
◆ Development of better and most cost-effective „ Supporting Nongovernmental Organizations (NGOs)
intervention models. „ Encouraging public health education
420 Textbook of Psychiatric Nursing for BSc Nursing Students

• Support to voluntary organization The revised NHP, 2002 draft discusses the following:
„ Developing suicide prevention and crisis support cells • Extending public health services: India has a vast
„ Formation of self-help groups reservoir of practitioners in the Indian systems of
„ Organizing community-based housing facilities medicine and homeopathy, who have undergone formal
„ Setting up day care centers training in their own disciplines. The possibility of using
„ Sheltered employment facilities such practitioners in the implementation of state/central
„ Public mental health education government public health programs in order to increase
• Promotion and preventive interventions the reach of basic health care in the country was addressed
„ Life skill education programs for school children in the NHP, 2002.
„ Psychosocial care for the survivors of the disasters • Norms for health care personnel: It is observed that the
• Administrative support: At all levels in directorate of deployment of doctors and nurses in both public and
health services: private institutions is ad-hoc and significantly short of the
„ One administrative officer (psychiatrist) requirement for minimal standards of patient care. NHP,
„ Additional staff—statistician
2002 makes a specific recommendation in regard to this
At district level
deficiency.
„ Two mental health teams
• Nursing personnel: The ratio of nursing personnel in
◆ One is District Medical Officer (DMO)
the country vis-a-vis doctors/bed is very low according
◆ One in district hospital
to professionally accepted norms. There is also an acute
shortage of nurses, trained in super-specialty disciplines
NATIONAL HEALTH POLICY, 2002
for deployment in tertiary care facilities. NHP, 2002
The National Health Policy (NHP) was formulated in 1983 addresses these problems.
since the marked changes were required in the determinant • Mental health: Serious mental disorders require
factors relating to the health sector. Some of the policy hospitalization and treatment under trained supervision.
initiatives outlined in the NHP, 1983 have yielded results while Mental health institutions are woefully deficient in
in several other areas the outcome has not been as expected. physical infrastructure and trained manpower. NHP-
The NHP was revised in 2002. 2002 addresses itself to these deficiencies in the public
health sector.
Objective of NHP, 2002 • Alternative systems of medicine: The policy focuses on
To achieve an acceptable standard of good health among the building up the credibility to the alternative systems, by
general population of the country. encouraging evidence-based research to determine their
efficacy and safety. It also encourages certification and
Approaches of NHP, 2002 quality-marking of products to enable a wider popular
acceptance of these systems of medicine.
• To increase access to the decentralized public health system
Specific recommendations with regard to:
by establishing new infrastructure in deficient areas and by
upgrading the infrastructure in the existing institutions. • Nursing personnel
• To ensure a more equitable access to health services across „ Improving the skills of nurses.
the social and geographical expansion of the country. „ Increasing the ratio of degree holding nurses vis-a-vis
• To increase the aggregate public health investment diploma holding nurses.
through a substantial increase in contribution by the „ Need for Central Government subsidy for setting up,
Central Government. the running of and training facilities for nurses.
• To strengthen the capacity of the public health administration • Mental health
at the state level to render effective service delivery. „ Decentralizing mental health services.
• To enhance the contribution of the private sector in „ Upgrading the physical infrastructure of mental
providing health services to the society. health institutions.
• Primacy will be given to the preventive and first line „ Primary health care with emphasis on preventive,
curative initiatives at the primary health level through promotive and rehabilitative aspects.
increased sectoral share of allocation. „ Restructuring of health services.
CHAPTER 15 Community Mental Health Nursing 421

NATIONAL MENTAL HEALTH PROGRAM, 1982 „ Instead of exclusively centralizing and concentrating
mental health skills in specialized facilities, mental
The National Mental Health Program (NMHP) was an health care will be spread over the existing network
initiative of development in various fields, e.g., The Alma- of services.
Ata declaration on Primary Health Care, the commitment of „ The aim is to incorporate mental health awareness
the country to provide health services to all, the awareness and skills at the levels of health care.
regarding the magnitude of psychiatric disorders in the „ Mental health care must start at the grass-root level.
community and the availability of a large infrastructure for • Appropriate appointment of tasks in mental health
general health services. care: The tasks have to be performed at each level:
„ Community health volunteer (1/1000 population)—
Aims of NMHP to act as liaison between mental health care and the
During planning of mental health services for India, the community.
following three aims were taken into account: „ Multipurpose worker (1/5000 population)—
1. Prevention and treatment of mental and neurological Multipurpose worker is a first level full time health
disorders with their associated disabilities. personnel to provide health care service and act as
2. Use of mental health technology to improve general the first person to link with health service system by
health services. providing first aid care and follow-up service.
3. Application of mental health principles in total national „ Senior and more experienced primary health
development to improve quality of life. personnel (Health Supervisor, health inspectors,
Lady health visitors, etc.)—Entrusted with the tasks
Objectives of NMHP of early recognition and management of psychiatric
conditions on priority basis.
• To ensure availability and accessibility of minimum mental
„ Medical Officer—has the responsibility of organizing
health care for all in the foreseeable future particularly to
and supervising the primary level mental health
the most vulnerable and under privileged sections of the
care for the entire population under Primary Health
population.
Center (PHC).
• To encourage application of mental health knowledge in
„ The referral system will operate to help the individuals
general health care and in social development.
with mental health problems.
• To promote community participation in the mental health
• Equitable and balanced territorial distribution of
service development.
resources:
Targets of NMHP „ Coverage of unserved or underserved population
with highest priority.
• Representatives from all the states of India, in the field of „ Strengthen the mental health care in the regions with
psychiatry unites to form a national coordinating body. deficient or deprived mental health.
• Include the mental health as a component for the health • Integration of mental health care into general health
workers in their curriculum. services: This will facilitate the application of mental
• Doctors in Primary Health Centers (PHCs) will have two health skills when dealing with patients without gross
weeks training program regarding the mental health care. psychiatric disturbances. It will also enable the health
• Psychiatrist will be appointed at district level to organize worker to identify psychosocial problems under the
and supervise the mental health training program. disguise of physical complaints and manage them more
• Inclusion of community mental health components in adequately.
teaching institution. • Linkage to community development: An important
• Psychotropic medications should be included in the list of approach would be the involvement of State, District and
essential medications in India. Block leadership in the implementation of the mental
health program to ensure community involvement
Approaches to Achieve the Objectives in preventive efforts directed toward psychosocial
In order to achieve the objectives formulated above, the problems like alcohol or drug abuse, behavior problems
program will adapt the following approaches: of childhood and adolescence including delinquency, etc.
• Diffusion of mental health skills to the periphery of the • Mental health care: The service component will include
health care service system: three subprograms:
422 Textbook of Psychiatric Nursing for BSc Nursing Students

1. Treatment subprogram: Multiple levels of this prevention and control of alcohol-related problems.
subprogram are given below: Later, problems like addictions, juvenile delinquency
i. Village and subcenter level: Multipurpose workers and acute adjustment problems like suicidal attempts
and health supervisors under the supervision of are to be addressed.
Medical Officer (MO) to be trained for: • Mental health training: Mental health specialists like
¾ Management of psychiatric emergencies. psychiatrists would not be enough in the near future in
¾ Administration and supervision of maintenance our country to deliver mental health care to all those
treatment for chronic psychiatric disorders. who immediately require it. As an immediate solution,
¾ Diagnosis and management of grand mal we have to train a large number of health personnel of all
epilepsy, especially in children. categories as much as possible in the minimum essentials
¾ Liaison with local school teachers and parents of mental health tasks at their own level of performance.
regarding mental retardation and behavioral • Mental retardation and drug dependence: Mental
problems in children. retardation is not mental illness but often associated with
¾ Counseling problems related to alcohol and it as well as physical illness.
drug abuse. Often the mentally retarded first come to the notice of the
ii. Medical Officer of Primary Health Center (PHC) medical services. Therefore, health workers are able to counsel
aided by health supervisor to be trained for:
the parents, provide public education in this subject, teaching
¾ Supervision of multipurpose worker’s
them how to approach social welfare agencies for rehabilitation.
performance.
Simultaneously, Integrated Child Development Services
¾ To diagnose the patient’s condition.
(ICDS) personnel should know to refer the mentally retarded
¾ Treatment of functional psychosis.
recognized by them to medical agencies when indicated.
¾ Treatment of uncomplicated cases of psychiatric
disorders associated with physical diseases.
DISTRICT MENTAL HEALTH PROGRAM, 1996
¾ Management of uncomplicated psychosocial
problems. Government of India funded to launch the District Mental
¾ Epidemiological surveillance of mental morbidity. Health Program (DMHP) as per the guidelines of National
iii. District hospital: It was recognized that there Mental Health Program. In 1996, DMHP was launched in
should be at least one psychiatrist attached to every four districts under 9th Five-Year Plan and it extended to
district hospital as an integral part of the district 123 districts in 12th Five-Year Plan. In 1997, DMHP was
health services. The district hospital should have launched in Trichy, extended to Ramanathapuram and
30–50 beds. The psychiatrist in a district hospital Madurai in 2003. District Mental Health Program (DMHP) is
was envisaged to devote only a part of his time further extended into 13 districts.
in clinical care and greater part in training or
supervision of nonspecialist health workers. Aims to Launch District Mental Health Program
iv. Mental hospitals and teaching psychiatric units: by Government of India
The major activities of these higher centers of
• To develop the awareness about mental health in public.
psychiatric care include:
• To Promote the community participation in the mental
¾ Help in care of ‘difficult’ cases
health services by self-help group.
¾ Teaching
¾ Specialized facilities like occupational therapy • To integrate the mental health care with general health
units, psychotherapy, counseling and behavior services.
therapy. • To provide the accessible mental health services to the
2. Rehabilitation subprogram: The components of vulnerable and under-privileged people.
this subprogram include the maintenance treatment
Objectives
of epileptics and psychotics at the community level.
Rehabilitation centers at the district level and also the • To early detection of cases and to provide the prompt
higher referral centers were developed. treatment within the community.
3. Prevention subprogram: The prevention component • To decrease the stigma and discrimination.
is to be community-based, with the initial focus on • To reduce the work pressure of mental hospitals.
CHAPTER 15 Community Mental Health Nursing 423

• To give treatment and to provide rehabilitation services to • Survey has been conducted all over India to ensure the
the patient after the discharge from psychiatric unit. quality of services rendered through DMHP. Madurai in
Tamil Nadu is leading with high satisfactory score.
Components • Regular supervision is done by the district collector.
District Mental Health Program was developed based on the • Ten bedded psychiatric wards equipped with Boyle’s
‘Bellary Model’. It emphasized on the following components machine, BP apparatus and ophthalmoscope have been
such as: established.
• Early detection of cases and providing necessary treatment. • 60% of districts are able to render mental health care at
• Conduct short-term training program for general district level and 20% of them are able to render mental
physicians regarding the treatment process of mental health care at primary health level.
illness. Health workers also need to be trained. • At present DMHP has been achieved in 123 districts
• Information Education Communication (IEC): which is extendable to all districts (on progress).
Creating awareness among public.
• Monitoring and having a complete documentation.
Initiatives Taken and the Presence of
Treatment Gap
Administrative Plan of District Mental Health Treatment gap is present among the general health physicians
Program due to lack of knowledge so NIMHANS organizes three
DMHP has Central Mental Health Authority at National level, months training program to the doctors. It was observed that
State Mental Health Authority at state level, District Mental primary care doctors were reluctant of telepsychiatric services.
Health Team (DMHT) at district level and Community Health Mental Health Care Act (2017) states that, only the
Centers (CHCs)/Primary Health Centers (PHCs)/Trained emergency treatment can be provided by the general physician
staff members at sub-district or state level. DMHT includes (72 hours) and the further treatment has to be referred
program officer/psychiatrist, psychiatric nurse/trained to the higher-level center. There is no provision for the
general nurse, clinical psychologist, psychiatric social worker, nonmental health professionals to treat the psychiatric patient
community nurse/case manager, case registry assistant and in their follow-up. Hence, the resource building, workforce
record keeper as shown in the Flowchart 15.1. development with adequate proper legal framework is essential
for the successful progress of DMHP.
Milestones and Achievements in District Mental
Health program INSTITUTIONALIZATION VERSUS
DEINSTITUTIONALIZATION
• Psychiatrist has been appointed in all districts. Appointments
of psychologist/psychiatric social worker is in progress. Institutionalization means treating the patients in psychiatric
• Basic psychotropic agents/drugs are made available in ward after the admission procedure. Patients remains in the
Primary Health Centers (PHC). custodial care in this situation.
• Suicide prevention centers have been established in Deinstitutionalization means treating the patients in
16 districts. the community area whereas the patients visit the OPD’s or

Flowchart 15.1: Administrative plan of district mental health program

424 Textbook of Psychiatric Nursing for BSc Nursing Students

their family members/relatives. It is unable to take care all the

acute mentally ill patients in the community area.

PREVENTIVE PSYCHIATRY

Introduction
Mental illness is a leading cause of disability. So, it is found vital
to have a disease prevention and health promotion program.
This will help to prevent the mental illness and promote the
good mental health.

Definitions
Figure 15.2: Concepts of deinstitutionalization and • Preventive psychiatry is defined as, ‘services rendered in
reinstitutionalization
the community in order to prevent the mental illness and
Primary Health Centers (PHC) or day care centers or short promote the mental health’.
stay units for the continuity of treatment process. President • Preventive psychiatry is defined as, ‘prevention of
John F Kennedy brought a change of shifting the mental health mental illness by having an aim to reduce the incidence,
care from hospitals to the community by the initiation of prevalence, relapse, symptoms and risk factors of mental
Community Mental Health Centers Act (1963) (Fig. 15.2). illness and is also aimed to decrease the impact of illness
on the affected person’s family and community’.
World Health Organization (WHO): Conducted a survey in
 —Mrazek and Haggerty, 1994
2014 with 78 mental health experts representing 42 regions
from the World. World Health Organization (WHO) identified Main Features of Preventive Psychiatry
the five principles of deinstitutionalization:
1. Need to implement community-based services. • Focus on prevention as well as treatment.
2. Health workforce should be committed to change. • Rendering continuity of care.
3. Political support is required at the highest and broadest • Multidisciplinary team approach.
level. • Promotion of comprehensive services.
4. Timing is a key factor. • Rendering care by coordinating with the accessible nearby
5. Additional financial resources are required. community health centers

Causes of Deinstitutionalization Model of Preventive Psychiatry

There are three causes which made the changes in the society Gerald Caplan (1960) described the levels of prevention
in regard with deinstitutionalization: specific to psychiatry. Levels of prevention are classified into
1. Development of psychotropic drugs. primordial, primary, secondary and tertiary as shown in
2. Society has accepted that mentally ill should not be in Flowchart 15.2.
custodial care, instead proper treatment has to be given. Primordial Prevention
3. Initiation of funding to the community health centers.
The primordial prevention denotes the prevention of
Benefits of Deinstitutionalization modifiable and nonmodifiable risk factors. The modifiable risk
factors are smoking, alcoholism, continuous stressors, lack of
It helps the patient to integrate with the society and it also exercise/yoga/meditation, obesity, eating junk foods, etc. The
helps to protect the patient’s rights. nonmodifiable risk factors have genetic history/family history
of mental illness.
Demerits of Deinstitutionalization
It is difficult for the mental health professionals to coordinate Primary Prevention
with the community centers with the available resources. There Primary prevention denotes the promotion of health status
may be chances that the client misses out the regular treatment and specific protection by immunization. Primary prevention
to maintain drug adherence. Patients have to be taken care by interventions are shown in Table 15.2.
CHAPTER 15 Community Mental Health Nursing 425

Flowchart 15.2: Model of preventive psychiatry Interventions Description

Society • Development of the community
centered • Steps taken to fulfill of basic needs to society
interventions ▪ Food
▪ Water
▪ Shelter
▪ Clothing
▪ Education
▪ Health
• Promote the epidemiological investigation
▪ Data collection
▪ Analysis of data
▪ Interpretation/findings from data.

Secondary Prevention
Secondary prevention denotes the early diagnosis and
treatment. The health team members need adequate training,
Table 15.2: Primary prevention interventions so that they could conduct the general health checkup regularly,
examine the high-risk population periodically and monitor the
Interventions Description
patients regularly. The health team members can get help from
Individual At home
community leaders, balwadis, mahila mandals, industries/
centered • Provide antenatal care to mother.
Interventions • Dietary rectification to the infants who work areas and schools to perform a regular health check-up/
suffer with metabolic disorders. do referral services. Conducting this screening programs will
• Liberalize the laws of medical termination help to do further consultation with the specialist doctor and
of pregnancy, if required. can also perform the crisis intervention programs as shown in
• Training to the physically and mentally
Flowchart 15.3.
challenged children.
• Provide counseling to the parents if the
child is physically or mentally challenged. Flowchart 15.3: Concept of secondary prevention in model of
preventive psychiatry
At school
• Teaching the growth/development chart to
the parents and teachers.
• Identify the problems of children in school
and provide timely intervention.
Family centered • Teach the significance of having harmonious
interventions relationship among family members
• Help them to have an open healthy
communication among the family members
• Develop the parents-teachers association
• Encourage the child guidance clinic to
improve the child rearing practices
• Develop the educational services in mental
health
• Administer the marital therapy in case of
any marital problems
• Administer family therapy to develop
the healthy relationship among family
members
• Give crisis intervention to mentally
challenged children
▪ First aid centers
▪ Walk in clinics
▪ Mental health check-up
• Empower the social support for elders
• Encourage the mental health education
programs with the use of audio-visual aids.
Contd…
426 Textbook of Psychiatric Nursing for BSc Nursing Students

Tertiary Prevention prevention. The combined as well as coordinated utilization

Tertiary prevention focuses on the rehabilitation and limitation of medical, physical, psychological, educational, social and
of disability. Training in community living (TCL) concept was vocational measures will help to ensure the functional ability of
provided by “Stein and Test”. the individual. Rehabilitation helps to retain greatest amount
of function and independence as far as possible.
Description of this Model
Definitions of Rehabilitation
After the identification of high-risk patients, the nurse needs
to go to the community area to be with the client and approach • Rehabilitation is defined as the restoration of the person’s
the hospital along with the patient. health to his/her former capacity.
• Rehabilitation is defined as, ‘attempt to render best
Purposes of this Model possible role in community area in order to achieve
It will help the nurse and patient to have a mutual agreement the maximum range of activity, compatible with one’s
to set the realistic goals. The key concepts of this model are as personality and interest’. —Maxwell Jones, 1952
follows:
• Involvement of family members in the treatment Rehabilitative Nursing
program. It focuses on preventive activities, maintenance activities and
• Organize the recreational activities in hospital. restoration activities as explained in the Flowchart 15.4.
• Implementing the community-based programs
„ Day hospitals „ Half-way homes Goals of Psychiatric Rehabilitation
„ Night hospitals „ Ex-patient hostels
• To help the patient to achieve the highest level of
„ After care clinics „ Foster care homes
independence and maintain a satisfying, productive life.
• Liaison between the community health nurse and mental
• To reduce the disability
hospital.
• To build the coping skills
• Collaboration with the nearby agencies available in
• To improve the social functioning
community.
• To provide good psychological support.
• Health education to demolish the stigma about mental
illness.
Principles of Psychiatric Rehabilitation
• Monitor the attitude of community people toward mental
illness. • Psychiatric rehabilitation is a vital part of tertiary
Nurses should create awareness in the community people prevention, which focuses on disability limitation related
in order to develop healthy attitude toward mentally ill. to the course/episode of the disease.
• Psychiatric rehabilitation should start with assessment of
PSYCHIATRIC REHABILITATION skills in regard to the patient’s abilities.
• Psychiatric rehabilitation focuses on rebuilding the
Rehabilitation will help the individual to return to his/ strength of patient’s ego and build the psychological
her previous highest level of functioning. It is a vital part of well-being in order to perform the assigned job/
the community mental health program at tertiary level of occupation.

Flowchart 15.4: Concept of rehabilitative nursing

CHAPTER 15 Community Mental Health Nursing 427

Community Rehabilitation Facilities (Table 15.3)

Table 15.3: Community rehabilitation facilities

Community rehabilitation facilities Description

Partial hospitalization (or) day care It is an outpatient facility where clients undergo the assessment, treatment and rehabilitation
hospital/centers (or) day treatment during day time. Patient can return to his/her home after the treatment. This partial
program hospitalization is advised when the symptoms of mentally ill patients are in control and show
a good prognosis in treatment.
Halfway homes (or) sober house (or) It is an institution in which the patients with physical, emotional and mental disabilities or
recovery house individuals with criminal backgrounds learn or relearn the required skills to reintegrate in
society. In general, halfway homes are in two models:
• In first model: At the time of admission, patients are categorized based on the types of
disability, abilities to reintegrate with society, and the expected time-frame for performing
this.
• In second model: At the time of admission, patients are allotted separate individual rooms
to provide one-to-one services.

Quarter way homes It provides lower level of supervision than the half way homes. Here, mostly patient has to
take care of himself. In India, NIMHANS have an inbuilt quarter way home.
Group homes It is a small residential care facility present in the community, which has been allotted to
take care of the children and adults with chronic disabilities. These homes usually have six or
fewer occupants. Trained caregivers are present full time over there.
Foster homes When the parents are unable to take care of their children due to variety of reasons, foster
home is the place where the children are taken care of.
Foster care may be the informal one or arranged by the courts or by a social service agency.
Sheltered workshop It is an environment or organization which employs the persons with disabilities separately
from the other individuals.
Self-help group It is a voluntary association of persons who have common desire to overcome the mental
illness and promote the mental health.
For example, Alcoholic anonymous group, Al-anon and narcotic anonymous group. (Groups
consist of recovered patients from substance abuse who joined together to help the patients
to recover from addiction.

Suicide prevention centers • Sneha Suicide Prevention Center and Jeevan Suicide Prevention—Chennai
• One Life—Hyderabad
• Maithri—Kochi
• Medico-Pastoral Association and Sahai—Bengaluru
• AASRA, Sahara, Singing Soulz, Samaritans and Karma Holistic Café—Mumbai
• Serve, Lifeline Foundation and Defeat Depression—Kolkata
• Sanjivini Society for Mental Health, Sumaitri and Fortis—New Delhi
• The Mind Research Foundation—Chandigarh

• Psychiatric rehabilitation should enhance the Areas of Rehabilitation

competencies and capacities of the individual with the
The health care delivery system at various levels to promote
mental disorders.
mental health has been shown in Figure 15.3.
• Psychiatric rehabilitation should influence the positive
In general, area of rehabilitation is categorized into domestic,
expectations to the individual and family.
• Psychiatric rehabilitation focuses on the improvement of occupational and social aspects as shown in Flowchart 15.5.
abilities more than that of improving good insight. It is also classified into eight areas as mentioned below:
• Psychiatric rehabilitation focuses on the components such 1. Psychiatric: Management of symptoms and providing
as development of resources in patient’s environment, psychological treatment measures.
improvement of skills and interventions to improve the 2. Health and medical: Maintaining consistency in
functional ability. rendering health care.
428 Textbook of Psychiatric Nursing for BSc Nursing Students

Figure 15.3: Health care delivery system at various levels to promote mental health

Flowchart 15.5: Areas of rehabilitation

3. Basic living skills: Maintaining personal hygiene, Rehabilitation Team

development of skills to cook food, safety measures
Health care professionals consists of:
during travel, etc.
• Psychiatric/mental health nurse
4. Social skills: Relationship with the family members,
• Psychiatrist
friends, etc.
• Clinical psychologist/counselor
5. Vocational skills: Assistance in the preparation for
employment. • Psychiatric social worker
6. Educational skills: Participating in the educational • Occupational therapist
activities and teaching programs. • Recreational therapist and
7. Financial skills: Planning own personal budget. • Other health professionals involved in mental health
8. Community and legal: Usage of community resources rehabilitation.
and helping out in legal activities.
CHAPTER 15 Community Mental Health Nursing 429

Domains of Psychiatric Rehabilitation • Provide assistance to the patient for employment

opportunities meant for the mentally ill with the help of
Psychiatric Rehabilitation Association (PRA) at Virginia
social worker.
states that, there are seven domains focused for the successful
• Advice the patient and family members in regard with the
rehabilitation process as shown in Table 15.4.
importance of drug adherence.
• Monitor the patient and have a regular follow-up.
Role of Nurse in Rehabilitation
Assessment MENTAL HEALTH SERVICES BY VARIOUS AGENCIES
Nurse has to collect history from the individual and family Components of Support Systems/Available
members in order to obtain the baseline data. Nurse has to Services in Community
assess their values, health beliefs, cultural background, etc.
• Identification of mentally ill patients
Nurse also needs to assess the nearby available community
• Protection and advocacy to protect patient’s rights
resources for mentally ill. Nurse has to assess the severity of
• Mental health treatment
illness, onset, duration, factors contributing the mental illness, • Support to the family members
its impact on social/occupational impairment, its impact on • Rehabilitation services
activities of daily living, expectations of the patient and family • Income support and entitlement
members in regard with treatment, etc. • Health and dental services
• Housing
Interventions
• Peer support
• Create awareness among patients and their family members • Crisis response services
regarding the available resources in the community to
promote mental health and to treat the mental illness. Governmental Organizations
• Teach the patient and family members about stress • Central or state mental health authority protects the
management/coping skills and problem-solving mentally ill from discrimination and stigma.
techniques. • National Human Rights Commission monitor the
• Take measures to reduce the stigma and discrimination structure and functions of mental hospitals in all the
about the mental illness in community. states of India.
• Develop the structured daily activity schedule for the • National Mental Health Program (1982) helps in the
patient in order to promote the activities of daily living. modernization of government psychiatric hospitals,
• Encourage the patient to participate in the group activities promotes the manpower development scheme in
to promote the social skills and also motivate the patient 11th Five-Year Plan. Child and adolescent mental
to be part of self-help group. health care was rendered through National Rural Health

Table 15.4: Domains of psychiatric rehabilitation

Domains Focus Description

I Interpersonal competencies Skills to communicate, collaborate to have healthy relationships
II Professional role Practitioners need to provide the evidence-based best practices
III Community integration Community integration is designed to promote the personal, vocational and
social competency of the people in order to live successful life in the community.
Practitioners need to develop skills in order to promote community integration
IV Assessment, planning and outcomes Assess the strength and weakness of the individuals in order to promote his/her
skills and achieve the goal.
V Strategies for promoting resilience Helping the individuals to achieve their goals. It focuses on relapse prevention and
and recovery outreach programs
VI Systems competencies Helping the practitioners to improve the working knowledge on systems in order to
remove stigma, discrimination and to integrate the individual with the society
VII Supporting health and wellness Develop the healthy connections between body, mind and spirit to have a
sustained wellness life style
430 Textbook of Psychiatric Nursing for BSc Nursing Students

Mission (NRHM) in order to promote the school health, Nongovernmental Organization

Reproductive child health (RCH) and adolescence
• Disability special schools and disability rehabilitation
friendly clinic under 12th Five-Year Plan.
services for example, Sathya Special School in Puducherry
• District Mental Health Program is incorporated to
and School for Special Children in Chennai.
enhance the promotive and preventive action plan in
order to achieve positive mental health. It focuses on the: • Community facilities such as partial hospitalization,
„ School mental health services such as life skill halfway homes, quarter way homes, group homes, foster
education and counseling. homes, sheltered workshop, self-help groups and suicide
„ Suicide prevention services such as help lines, prevention centers as shown in Table 15.3.
Information Education Communication (IEC), • National trust for welfare of persons with mental
promotion of counseling centers and conducting the retardation, autism, cerebral palsy and multiple
sensitization workshops. sclerosis.
„ Promoting the college counseling services. • NGOs promoting mental health in India are enlisted in
„ Focus the stress management strategies in work place. Table 15.5.

Table 15.5: NGO’s in India promoting mental health

Sl. no. Place Name of the NGO Focus

1. New Delhi Sumaitri Voluntary Organization NGOs with the primary focus on mental
Sanjivani Society for Mental Health health and social service

Manas
Snehi
Aanchal Charitable Trust
Aasha Kiran
Indo Global Social Service Society (IGSSS)
The Earth Saviours Foundation
National Alliance for Access to Justice for Persons with Mental
Illness
Nav Jyoti Center
Association for Advancement and Rehabilitation of
Handicapped
Ashray Adhikar Abiyan NGO’s working for homeless children
Sudhinalaya
Mother NGO (MNGO)
Servants of the People Society, Model School for Mentally School for mental retardation
Deficient Children, YMCA Institute for Special Education and
Eclat Society for the Welfare of Mentally Retarded
Parents Association for the Welfare of Mentally Handicapped Vocational training for mental
retardation
Hindustan Scouts and Guides Association, Association for Social Treatment and counseling center for
Health in India, Association of National Brotherhood for Social drug deaddiction
Welfare, Youth and Masses
Jeevan Jyoti Missionaries of Charity Care of mental illness and
orthopedically handicapped individuals
Forum for Autism and Action for Autism Training and development of children
with autism/developmental disorders
Society of Social Services Day care center for elders
Contd…
CHAPTER 15 Community Mental Health Nursing 431

Sl. no. Place Name of the NGO Focus

2. Chennai Banyan Mental health
Schizophrenia Research Foundation (SCARF) Schizophrenia
Ashaa Family Psychiatric Rehabilitation
Atma Nirbhar Mental illness and employment projects
3. Madurai Akshaya trust Helping out the homeless, sick, elders
and mentally ill
4. Coimbatore HCA Mental Health Care Center Care of mental health
5. Kerala Alzheimer’s and related disorders society India Dementia
6. Bengaluru White Swan Foundation Knowledge services for mental health
and well-being
Amba for life Economic empowerment of the
intellectually challenged
Athma Sakthi Vidhyalaya Society Therapeutic community
Banjara Academy Counseling and mental health training
7. Kolkata Turning Point Mental Rehabilitation Center
Paripurnata, halfway home, center for psychosocial Psychiatric rehabilitation
rehabilitation
Antara
Anjali Mental health and human rights
organization
8. Goa Sangath, improving health across the life-span Mental health
9. Bangladesh Bangladesh Association for Child and Adolescent Mental Health Mental health of children and
(BACAMH) adolescence
10. West Bengal Manas Society for mentally disturbed persons,
their family and friends

AGENCIES/ORGANIZATION SUPPORTING TO • Friendship Bench Project, CBT for Depression

PROMOTE MENTAL HEALTH—ABROAD • Support for Addiction and Prevention
• Center for Child and Adolescent Mental Health University
Agencies in Africa of Ibadan
• Farm Radio Integrated Mental Health Project • Clowns Without Borders South Africa
• Treatment Not Chains, Campaign to Raise Funds • Kamili Mental Health Organization
• Mental Health Innovation Network Africa • Befrienders Uganda, Crisis Intervention and Suicide
• Neuro and Mental Health Organization Prevention
• African Mental Health Research Initiative (AMARI) • Habeeb Mental Health Foundation
• Nairobi Parenting Clinic • Thandanani Center for Persons with Severe Psychiatric
• New life rehabilitation for those addicted to drugs or Disability
alcohol • Healing Through Art, Stories from Swaziland
• Community Association for Psychosocial Services • Kenya Psychological Association
(CAPS) • Hugs for better Mental Health
• Mentally Aware Initiative • Reconnect-Health Development Initiative
• The Mandate Health Empowerment Initiative • South African Federation for Mental Health
• Sociotherapy Rwanda • Basic needs
• Mabel Mental Care Foundation, health care for the • NASM Afrique—New Approach Mental Health Africa
mentally challenged patients. • Talisman Foundation, temporary home and rehabilitation
• Gede Foundation, bringing stigmatized health burdens support for those with a mental illness
out of the shadows, Mercy for Life Foundation. • Bring joy to needy
432 Textbook of Psychiatric Nursing for BSc Nursing Students

• My Mind My Funk, Mental Health Information and • Aanhouwen, Work and Care Center
Support Hub—Mental Health in Primary Care Project • South African Depression and Anxiety Group
• Somalia Mental Health Foundation • Africa Mental Health Foundation
• Alan J Flisher Center for Public Mental Health (CPMH) • Community Mental Health and Psychiatry
• Community Mental Health Initiatives (CoMHI)
• Street Angels Foundation Uganda, to better the lives of Agencies in USA
slum and street children • The American Psychiatric Association
• Hope and Health Vision, creating a better world for • Orchid Mental Health Policy Global
vulnerable children • Substance Abuse and Mental Health Services
• Trauma Center for Survivors of Violence and Torture Administration
• Uvira Psycho-Social Rehabilitation Center • A Billion Minds and Lives
• Liberian Behavioral Health Services • The National Association of Psychiatric Health Systems
• Open Society Initiative for Eastern Africa: Encouraging • Me too Orchestra, music organization created for
open and informed dialogue about issues of public individuals with mental illnesses
importance • The National Alliance on Mental Illness
• Enabling Access to Mental Health, Mental Health • American Psychological Association
Coalition Sierra Leone • Psychological artificial intelligence for mental health care
• Mental Health Awareness Nigeria, fighting stigma • The Joint Commission
• Zimbabwe National Association for Mental Health • Crazywise documentary film on new ways of recovery
• Babungo Integrated Mental Health Care (BIMEHC) • Parity Implementation Coalition
• HOPE organization for Chronic Disease and Mental • Gaza Mental Health Foundation
Health Development • International Bipolar Organization
• For All Africa Foundation, advocacy and support for • Heart Mind International, psychosocial services and
people with a mental illness mental health at South Asia
• Normal Difference Mental Health Project, a group of • Agency for Health care Research and Quality
mental health activists • Project Semicolon, faith-based NGO in love and hope
• Kintampo Project, improving community mental health • American Association of Suicidology
services • Western Mass, Recovery Learning Community
• Carter Center building Mental Health Care in Liberia • American Psychiatric Nurses Association
• Mental Health Society Ghana (MEHSOG) • Haitian Mental Health (HMH) Network
• General Assistance and Volunteer Organization (GAVO) • Anxiety Disorders Association of America
• Bhaso, support groups for people living with HIV • Yale University Global Mental Health Program
• Horizon, Social Assistance Development Organization • Bazelon Center for Mental Health Law
• GSH-HIV Mental Health Group • Centers for Disease Control and Prevention
• One Mind Kenya, Mental Health Awareness Campaign • Postpartum Support International (PSI)
• Lagos State Mental Health Team • Centers for Medicare and Medicaid Services
• Mental Health Foundation Nigeria • Global Mental Health News website
• African Palliative Care Association • Depressive and Bipolar Support Alliance
• Cape Mental Health Society • ASHA International, Promoting Mental Health
• Comcare, affordable, stable accommodation for adults Awareness, Hope and Holistic Wellness
with chronic psychiatric disabilities • Institute of Medicine
• International Network Toward Alternatives and Recovery • The NGO Committee on Mental Health in consultative
(INTAR) relationship with United Nations
• Central Gauteng Mental Health Society • Mental Health America (previously National Mental
• National Organization of Users and Survivors of Health Association)
Psychiatry Rwanda • International Mental Health Research Organization
• Kenya Society for the Mentally Handicapped (KSMH) (IMHRO)
• Youth on the Move, Empower Talents with Epilepsy • Mental Health Liaison Group
• Tiyatin Health • The Marcé Society for Perinatal Mental Health
• Regional Psychosocial Support Initiative for Children • National Association for Rural Mental Health
CHAPTER 15 Community Mental Health Nursing 433

• Trust Circle—International Peer-Centered Mental Health • International Society for Psychological and Social
Network Approaches to Psychosis
• National Association of Anorexia Nervosa and Associated • Psycho-Rehabilitation Center for Victims of Violence,
Disorders Torture and Stress Impact
• Psychologists for Social Responsibility • Gulbenkian Global Mental Health Platform
• National Association of Country Behavioral Health and • Global Mental Health-Map
Developmental Disability Directors • Epapsy
• Center for Victims of Torture, care for those who have • Mental Disability Advocacy Center
been tortured and advocacy • Cares, Brothers of Charity and Mental Health Care
• National Association of State Mental Health Program • St Camille de Lellis Foundation—Psychiatric
Directors Rehabilitation
• National Center for Health Statistics • Association for the Improvement of Mental Health
• The Citizens Commission on Human Rights (CCHR) Programs
• National Council for Community Behavioral Health care • Antares Foundation
• Peers Envisioning and Engaging in Recovery Services • Reference Centers for Psychosocial Support
(PEERS) • Mental Disability Rights Initiatives Serbia
• National Guidelines Clearinghouse
• The Chester M Pierce, MD Division of Global Psychiatry Agencies in UK
• National Institute of Mental Health • Promise Global (Alliance of humane care in mental
• International Association for Women’s Mental Health health)
• The National Institute of Alcoholism and Alcohol Abuse • International Mental Health Collaborative Network
• The Minds Foundation, Mental Health Care in Rural • Clowns without Borders (joy with the children in crisis)
India • Men Tell Health (concern on men and mental health)
• National Institute on Drug Abuse • Social felt, touch and care
• Peter Alderman Foundation • Richmond Psychosocial Foundation
• The World Mental Health Organization • International Center for Recovery Action in Education,
• The Siwe Project—Promoting mental health education Research and Practice
and awareness among the global black community • McPin Foundation—Mental Health Research
• Salus World, Psychosocial Care after Emergencies • Amadou UK Mental Health Matters
• International Medical Corps, Mental Health Program • Careif—International Mental Health Charity
• Black Dog Tribe—social place to share mental health
Agencies in Australia issues.
• Mandala Foundation
• Mental Health First Aid Australia ISSUES IN MENTAL HEALTH NURSING FOR
• Asia Australia Mental Health
SPECIAL POPULATIONS
• Prahran Mission Mental Health Problems in Women
• International Association for Youth in Mental Health
World Health Organization (WHO) states the mental health
• Center for International Mental Health
facts about women as listed below:
• Trauma Recovery Blog of Eva Alisic
• Unipolar depression might be 2nd leading cause of
worldwide disability by 2020, which is twice commonly
Agencies in Europe
seen in women.
• Lisbon Institute of Global Mental Health • One in five men and one in 12 women develop dependence
• International Psychosocial Organization to alcohol during their lives in the developed countries.
• World on the Ground—Mental Health Platform • Lifetime prevalence of violence against women is 16–50%.
• Fracarita International for Mental Health Projects World In the lifetime of women, at least one in five suffers from
Wide rape or attempted rape.
• Samaritans—24 hours Emotional Support Helpline • Increased prevalence rate of sexual violence in women
• Global Alliance of Mental Illness Advocacy Networks might increase the chances of Post-traumatic Stress
• Center for Crisis Psychology Disorder (PTSD) in women.
434 Textbook of Psychiatric Nursing for BSc Nursing Students

• 41.9% of depressive disorders are due to neuropsychiatric • Nutritional supplements: Taking 1200 mg of dietary
disorders, especially among women when compared to calcium will reduce the symptoms of premenstrual
men (29.3%). dysphoric disorder. Intake of magnesium, vitamin B6 and
• Leading mental health problems of elders (majority are L-tryptophan is also helpful to decrease the symptoms of
women) are depression, dementia and organic brain premenstrual dysphoric disorder.
syndrome. • Birth control pills: Consuming the birth control pills
with no pill-free interval or else with a shortened pill-
Premenstrual Syndrome free interval will decrease the symptoms of Premenstrual
Definition syndrome and Premenstrual dysphoric disorder in some
It is the combination of physical, emotional, mood and women.
behavioral disturbances present in women before few days of • Life style modification: Quit smoking, caffeine and
menstrual flow due to the interaction of neurochemicals in alcohol. Avoid stressful triggers. Practice regular exercises,
brain and the sex hormones. yoga and meditation.

Epidemiology Puerperal Blues (or) Postpartum Blues (or) Baby Blues

Around 80% of women experience premenstrual syndrome, in Definition
which 2–5% will experience severe symptoms. It is a less severe form of postpartum depression. Onset of
Clinical Features depressive episode happens within few days after the delivery
Psychological symptoms such as irritability, anger, high level of baby and the depressive symptoms reduce within one or two
of stress/fear/anxiety, restlessness, depression, being more weeks.
sensitive, episodes of crying and presence of mood swings. Epidemiology
Physical symptoms such as weight gain, fatigue, breast Around 70% of women who delivered baby suffer with
tenderness, ache, bloating, sleep disturbances and changes in postpartum blues.
appetite (over craving of food or loss of appetite).
Clinical Features
Treatment
Crying spells, irritability, fatigue, anxiety, restlessness,
Mostly natural methods such as exercise, emotional support, insomnia, mood changes, poor concentration, sadness, etc.
relaxation, decreased intake of salt, quit smoking/alcohol is
sufficient. Medications are required only if the symptoms are Treatment
complicated. Antianxiety drugs, drugs to suppress ovulation/ Eating a balanced diet, relaxation techniques and to ensure
oral contraceptives, analgesics and diuretics (decrease the psychological support.
water retention) might be helpful.
Postpartum Depression
Premenstrual Dysphoric Disorder Definition
Definition Episodes of depression occurs after the delivery. If the
A severe form and disabling extension of premenstrual depression episode is present during pregnancy and within
syndrome. one year after the delivery, it is termed as perinatal depression.
Epidemiology Epidemiology
Prevalence of Premenstrual Dysphoric Disorder (PMDD) is About 13% of women who delivered baby suffers with
estimated to affect 5–8% of menstruating women. postpartum depression.
Clinical Features Risk factors
In addition to the clinical features of premenstrual syndrome, low self-esteem, poor social support, stressful life events,
extreme mood shifts which interrupts the work and the depression or anxiety during pregnancy, low socioeconomic
relationship issues, may be present. status, poor relationship with husband, negative cognitive
Treatment attributions, history of depression, etc.

• Antidepressants: Selective Serotonin Reuptake Inhibitors Etiology

(SSRI) such as fluoxetine and sertraline will decrease the Hormonal changes (decreased estrogen), unbearable stressors,
emotional symptoms, food cravings, fatigue and sleep sleep deprivation, fragile baby, difficulty in breast feeding and
pattern disturbances. lack of family support, etc.
CHAPTER 15 Community Mental Health Nursing 435

Clinical Features Postpartum Psychosis (or) Puerperal Psychosis

It includes all the classic features of depression. Edinburgh Definition
Postnatal Depression Scale can be used as a screening tool. It is a serious mental illness in which the episodes of depression
Treatment occur after the delivery. Here, depressive symptoms accompany
• Antidepressants: Tricyclic antidepressants such as psychotic illness.
nortriptyline and desipramine, Selective Serotonin Epidemiology
Reuptake Inhibitors (SSRIs) group of antidepressants About 13% of women who have delivered baby suffer with
such as fluoxetine and sertraline, Serotonin and postpartum depression.
Norepinephrine Reuptake Inhibitors (SNRIs) group of
antidepressants such as venlafaxine and duloxetine are Risk factors
useful to treat postpartum depression. Family history of mental illness, history of depression or
• Psychological treatment: Interpersonal psychotherapy, bipolar disorder or schizophrenia, trauma during pregnancy,
cognitive behavioral psychotherapy, couples therapy and prenatal depression, autoimmune thyroid dysfunction,
family therapy are helpful. abnormal mutation of chromosome 16, and complications
• Nutritional supplements and herbal supplement: related to delivery, etc.
Adequate intake of vitamin B2 (Riboflavin) will prevent Clinical Features
the risk of developing postpartum depression. Diet
Hallucinations, delusions, manic mood, low mood,
rich in omega 3 fatty acids will reduce the symptoms
suspiciousness, restlessness, confusion, phobia, etc.
of postpartum depression. Herbal supplements such as
St. John wort is useful to treat postpartum depression. Treatment
Comparison of postpartum blues and postpartum depression Antidepressants, antipsychotics and mood stabilizers (lithium)
is given in Table 15.6. can be administered. Psychotherapy such as cognitive behavior
therapy is useful. Electroconvulsive therapy (ECT) is indicated
Table 15.6 Comparison of postpartum blues and postpartum
depression if there is a presence of strong suicidal risk.
Prognosis
Characteristics Puerperal blues Postpartum
(or) postpartum depression Symptoms may be seen from 2 to 12 weeks. It takes 6 months
blues (or) baby to year for complete recovery. It is considered complicated
blues mental illness when compared with postpartum depression.
Onset Within a week Weeks to months
Duration Days to weeks Weeks to year if Mental Health Problems in Elders
not treated
World Health Organization (WHO) in 2017, stated that
History of mood Absent Mostly present approximately 15% of elders suffer with mental illness. WHO
disorder
also added that, there is 6.6% disability (Disability Adjusted Life
Family history of Absent Mostly present Years—DALY) among elders. Unipolar depression occurs in
mood disorder
7% of general population and it accounts for 5.7% individuals
Anhedonia No Often living with disability. Around 50 million people worldwide
Sleep disturbances Sometimes present Mostly present are living with dementia and it is expected to increase to
Guilt feeling Absent/mild Excessive and often 82 million in 2030 and 152 million by 2050.
seen Chicago Methodist Senior Services, USA states that
Thoughts to harm Rare Often there are four warning signs that need to be observed earlier to
baby identify the mental health problems as listed below:
Mood liability Yes Often (sometimes 1. Memory problems
with unipolar 2. Social withdrawal
depression)
3. Changes in personal care
Tearful eyes Yes Yes 4. Changes in mood
436 Textbook of Psychiatric Nursing for BSc Nursing Students

Delirium, dementia, depression and paranoid disorders

are common mental disorders seen in elders. Delirium and
dementia have been described in Chapter 12 (organic brain
disorders). Depression is described in Chapter 7 (Mood
disorders). Paranoid disorders have been described in chapter
6 (Schizophrenia). Anxiety and stress might be comorbid
disorders among elders who are suffering with depression.
Late-onset schizophrenia may also occur among elders. The
causes of depression in elders is loneliness, widowed/separated Figure 15.4: International day to eliminate
violence against women
spouse/death of spouse, retirement, loss of income, health
deterioration, presence of physical illness, sensory deficits, low • Female genital mutilation
social status, etc. Antidepressants and psychosocial therapies • Trafficking
are helpful. • Force and early marriage
• Intimate partner violence includes physical, sexual and
Mental Health Problems in Children and emotional abuse.
Adolescent • Sexual violence due to conflicts between husband and
The common psychiatric illness in children and adolescent age wife.
group are mental retardation, autism spectrum disorder (ASD), The health consequences of violence are as follows:
Attention Deficit Hyperactive Disorders (ADHD), anxiety • Physical injuries
disorders, eating disorders, mood disorders, schizophrenia, • Death
Oppositional Defiant Disorder (ODD), Tourette syndrome • Sexually transmitted diseases
and conduct disorder. The warning signs of poor mental health • Unintended pregnancies
in children are mood changes, behavioral changes, lack of • Depression
concentration, unexplained weight loss, self-harm, verbalizing • Post-traumatic stress disorder
more physical symptoms and influence of substance abuse. • Harmful use of substances
Counseling, psychotherapy and psychotropic agents based on Violence against women is preventable and the risk
the diagnosis are helpful. The above said childhood disorders factors at multiple levels have been explained in Table 15.7.
have been described in Chapter 11 (Child Psychiatry). Child
Abuse has been explained in Chapter 11 (Child Psychiatry). Cycle of Violence

VICTIMS OF VIOLENCE Dr Lenore Walker in 1979 developed the cycle of violence.

It has three phases (Figure 15.5) as mentioned below:
Violence is the expression of physical force or verbal force
toward self or other with intention to hurt or to cause pain. Table 15.7: Risk factors and interventions for violence against
women at various levels
Domestic violence (or) domestic abuse (or) spouse abuse (or)
intimate partner abuse is the violence that takes place against Level Risk factor Interventions
the women by men/husband. Individual History of violence in Parenting program
World Health Organization states that, one in three childhood to prevent the
women (or) girls experience the physical (or) sexual violence maltreatment of child
in their lifetime, mostly by her husband/intimate partner. Only Relationship Men have more control Create the gender
52% of married women can take their own decisions in regard over women equality attitudes to
with sexual relations, use contraceptive devices and take health men
care. Percentage of women who experience the physical or Family Inequality in gender Steps taken to promote
sexual violence by the intimate partner or husband in their life norms that create equality in gender
violence against norms
period ranges from 15% to 17%
women
United Nations General Assembly has designated 25th
Community/ Lack of education Policies and law is
November as the International Day for the Elimination of
Society and employment made to promote
Violence Against Women as depicted in Figure 15.4. opportunities for the education and
The various forms of violence against women are as follows: women employment chances to
• Honor killings women
CHAPTER 15 Community Mental Health Nursing 437

PSYCHIATRIC ASPECTS OF HIV/AIDS

Acquired Immunodeficiency Syndrome (AIDS) is caused by

Human Immunodeficiency Virus (HIV). The virus is called
retrovirus because the molecular structure always keeps on
changing so no medication has been found to cure AIDS,
however, the life span of AIDS patient can be increased by
taking the antiretroviral (ART) drugs such as didanosine,
lamivudine, stavudine, zidovudine, doravirine, nevirapine,
Figure 15.5: Cycle of violence
etc. World Health Organization insists to start the ART drugs
Phase 1: Tension building phase irrespective of their CD4 count. WHO also recommends
to start the pre-exposure prophylaxis to the individuals at
• Build-up: Tension between the individuals in the
substantial risk of HIV.
relationship will rise and abusing each other begins.
• Stand-over: A threat or frightening takes place for the National AIDS Control Society (NACO) initiated the
individual who experiences the abuse. Behavior of the Integrated Testing and Counseling Center (ITCC) in 1977 in
abuser increases and the victim feels that the release of the government hospitals. Their main functions are conducting
tension is impossible one. diagnostic tests, creating awareness in regard with the modes
Phase 2: Acute explosion (or) Acting out phase of HIV transmission and promoting the behavioral changes
The violence will reach peak level in this phase. Perpetrator to decrease the vulnerability and to promote the treatment
might experience a release of tension and this behavior might services.
become habitual. Around 60–70% of patients with HIV infection suffer
with AIDS related dementia. They suffer with forgetfulness,
Phase 3: Honeymoon Stage
lack of concentration, mental slowness, disorientation and
• Remorse: Here, perpetrator may feel ashamed, withdrawn problem with short-term memory. Around 10% of HIV
in oneself and try to justify the actions to self and others.
patients present with neurological complaints. The comorbid
• Pursuit: Perpetrator may promise to never be violent
psychiatric disorders among AIDS patients are depression,
again and perpetrator also tries to say that the violence
mood disorders, adjustment disorders, anxiety disorders and
happened due to alcohol, job stress or some other cause,
presence of psychotic symptoms.
etc. Perpetrator try to compensate the violence by
providing gift or helping out the victim well. At this point,
the victim who experiences violence, feels confused. Role of Psychiatric Nurse
• Denial phase: Both the individuals in the relationship Nurse has to provide counseling to the patient before and
might refuse about the abuse and violence. Intimacy after testing the HIV. Nurse needs to assess the patient’s risk
might increase and they live happy during this phase. of getting HIV infection and educate the patient to reduce
Over the period of time, this phase may pass and the cycle the transmission of HIV infection. Psychiatric nurse should
may begin again. watch the HIV patients for signs indicating the mental status,
Role of nurse to prevent the violence against women emotional and negative behavioral changes. Early treatment
is to give the comprehensive health care to the survivors. is the best way to reduce the impact of the behavioral/
Nurse has to gather data, prevalence in regard with violence psychological changes in HIV patients in order to promote
against women. Nurse has to foster and inform the preventable their sense of well-being. The multimodal approach such
programs and help out in framing the policies to prevent as antiretroviral medications, symptomatic management,
the violence against women. Nurse has to play the role of an treatment of comorbid neurological/psychiatric disorders,
advocate to voice out the violence against women as a public counseling services, etc. are helpful to take care of the patient
health problem. with HIV infection.
438 Textbook of Psychiatric Nursing for BSc Nursing Students

SUMMARY
• Community Mental Health Centers Act (1963) initiated by 35th United States President John F. Kennedy brought a change of shifting
the mental health care from hospitals to the community.
• Community mental health nursing is defined as, ‘decentralized pattern of rendering mental health services/care to the needy in the
community, further it focus on prevention of mental illness, promotion of mental health and rehabilitation of patients with mental
disorder in the community’.
• Lack of trained manpower, budget constraints, lack of knowledge and skills of general physicians, poor access to PHC’s, Persistence of
stigma and discrimination about mental illness are the issues prevailing in community mental health nursing.
• Development of community mental health services categorized as Colonial Period (Before Independence), after Independence,
1961–1969, 1970–1982, 1987–2012 and 2013–2020.
• Mental Health Action Plan by WHO have six core principles such as universal health coverage, evidence-based practice, human rights,
life course approach, multisectoral approach and empowerment of patients with mental disorders and psychosocial disabilities.
• NIMHANS, Bengaluru developed the alternative measures instead of hospital-based care such as Domiciliary Care Program, Extensive
use of outdoor services, organizing short-term course to private general practitioners, extension program by satellite clinics, promotion
of mental health by training the school teachers with regard to mental health care, training of village leaders, student volunteers,
tertiary. Student development program, Involvement of Integrated Child Developmental Service (ICDS) personnel in children mental
health care and Nongovernmental voluntary organization.
• Institutionalization means treating the patients in psychiatric ward after the admission procedure. Patients will be in the custodial
care.
• Deinstitutionalization means treating the patients in the community area whereas the patient will visit the OPD’s or Primary health
centers or day care centers or short stay units for the continuity of treatment process.
• National Mental Health Program was launched in 1982, Revised National Mental Health Program was launched in 2003, and District
Mental Health Program (DMHP) was launched in 1996.
• Preventive Psychiatry is defined as, ‘services rendered in the community in order to prevent the mental illness and promote the mental
health’.
• Gerald Caplan (1960) described the levels of prevention such as primordial, primary, secondary and tertiary.
• Rehabilitation is defined as the restoration of the person’s health to his/her former capacity.
• Rehabilitative nursing focuses on preventive activities, maintenance activities and restoration activities.
• Psychiatric rehabilitation helps to gain independence, reduce the disability, to build the coping skills/social functioning and to get good
psychological support.
• Areas of rehabilitation is categorized into domestic, occupational and social aspects. The other eight areas are psychiatric, health or
medical, basic living skills, social skills, vocational skills, educational skills, financial skills, community and legal aspects.
• Rehabilitation team consists of psychiatric/mental health nurse, psychiatrist, clinical psychologist/counselor, psychiatric social worker,
occupational therapist, recreational therapist and other health professionals involved in mental health rehabilitation.
• Psychiatric Rehabilitation Association (PRA) at Virginia states that, there are seven domains for the successful rehabilitation process
such as interpersonal competencies, professional role, community integration, assessment, planning and outcomes, strategies for
promoting resilience and recovery, systems competencies, supporting health and wellness.
• The governmental organizations helping to promote the mental health are Central or State Mental Health Authority, National Human
Rights Commission, National Mental Health Program and District Mental Health Program.
• Mental health problems in women are premenstrual syndrome, puerperal blues (or) postpartum blues (or) baby blues, postpartum
psychosis (or) Puerperal Psychosis.
• Delirium, Dementia, Depression and paranoid disorders are common mental disorders seen in elders.
• The common psychiatric illness in children and adolescent age group was mental retardation, Autism Spectrum Disorder (ASD),
Attention-deficit/hyperactivity disorder (ADHD), anxiety disorders, eating disorders, mood disorders, schizophrenia, oppositional
defiant disorder (ODD), Tourette syndrome and conduct disorder.
• International day to eliminate violence against women is celebrated on 25th November, every year.
• Dr Lenore Walker in 1979 developed the cycle of violence—tension-building phase, acting out phase and honeymoon phase.
• National AIDS Control Society (NACO) initiated the Integrated Testing and Counseling Center (ITCC) in 1977 at government hospitals
to diagnose the HIV infection, counsel and treat the patients living with HIV.
CHAPTER 15 Community Mental Health Nursing 439

ASSESS YOURSELF

Long Answer Questions 3. The other names of postpartum blues ___________.

1. Write the principles and issues in community mental a. Puerperal blues b. Baby Blues
health nursing. Explain the development of community c. Both a and b d. Premenstrual syndrome
mental health services in India. 4. District Mental Health Program (DMHP) was
2. Discuss the levels of prevention in psychiatry. launched in _______________.
3. Explain the goals, principles, domains and role of nurse a. 1996 b. 1982
in psychiatric rehabilitation. c. 2003 d. 2005
5. Perpetrator may promise to never be violent again in
Shotrt Answer Questions ________ phase of violence cycle.
1. Define Community Mental Health Nursing. a. Tension-building phase b. Acting out
2. Define psychiatric rehabilitation. c. Honeymoon stage d. None of these
6. National AIDS Control Society (NACO) initiated the
Short Notes Integrated Testing and Counseling Center (ITCC) on
1. Revised National Mental Health Program __________.
2. Institutionalization versus Deinstitutionalization a. 1977 b. 1966
3. Role of nurse in rehabilitation c. 1955 d. 1982
4. Mental health services by various agencies 7. Anhedonia is present in________.
5. Mental health problems in women a. Puerperal blues b. Puerperal depression
6. Mental health issues among elders c. Both a and b d. None of these
7. Mental health issues among children 8. First mental asylum was started in Madras in_____.
8. District Mental Health Program (DMHP) a. 1792 b. 1794
9. Psychiatric aspects of HIV/AIDS c. 1894 d. 1795
10. Community facilities in psychiatry
9. ________level of prevention focuses on psychiatric
rehabilitation.
Multiple Choice Questions
a. Primordial b. Primary
1. Revised National Mental Health Program was c. Secondary d. Tertiary
launched in ______. 10. Community Mental Health Centers Act was started in
a. 1996 b. 1982 a. 1992 b. 1994
c. 2003 d. 2005 c. 1999 d. 1963
2. ________ level of prevention focuses on the prevention Answer Key
of risk factors.
1. c 2. a 3. c 4. a 5. c
a. Primordial b. Primary
6. a 7. b 8. b 9. d 10. d
c. Secondary d. Tertiary
Notes
Do you Know?

• Anaclitic depression means the infant will develop • Alprazolam is the benzodiazepine which has
the symptoms of crying, lack of sleep, weight loss, antidepressant effect.
developmental delay, apathy and will become susceptible • Fluoxetine (SSRI) has the longest half-life (4–6 days).
to get infection followed by the death of mother. • Imipramine is the drug of choice for nocturnal
• Lesions in the left frontal lobe of the brain are seen in post- enuresis.
stroke depression, whereas lesions in the right frontal lobe • Imipramine and fluoxetine in smaller doses are helpful in
are seen in post-stroke mania. treating panic attack.
• Individuals have higher risk of depression during cocaine • Monoamine Oxidase Inhibitors (MAOIs) should not be
withdrawal. given with amphetamine or any Central Nervous System
• Thought stopping techniques will be helpful for the long- acting drug because they lead to hypertension.
lasting auditory hallucination. • Tricyclic antidepressants (TCAs) are contraindicated in
• Age of onset for childhood schizophrenia is around 6 Narrow Angle Closure Glaucoma.
years and age of onset for late onset schizophrenia is more • Electroconvulsive therapy (ECT) is highly effective in
than 45 years of age. patients suffering from psychotic depression with suicidal
• Drug amoxapine has both antipsychotic and risk and patients with catatonic schizophrenia.
antidepressant effects. • Headache is the most common complaint by the patients
• Use of tricyclic antidepressants has to be avoided in after ECT.
patients with human immunodeficiency virus infection • Drug Lithium has to be avoided before ECT because it
due to the increased risk of oral candidiasis. will reduce the seizure threshold and also cause postictal
• Sexual dysfunction related to the alcohol and delirium.
psychotropics is listed in the following table: • Ugo Cerletti and Lucio Bini were the first psychiatrists
who used ECT for patients with schizophrenia. Jarvie was
Alcohol and psychotropic Sexual dysfunction the first psychiatrist who used ECT for treating depressive
agents
patients. Friedman and Wilcox were the first psychiatrists
Alcohol Prolong the penile erection to use unilateral ECT.
with no ejaculation • Drug Donepezil can be used to decrease the cognitive side
Antipsychotics (thioridazine) Retrograde ejaculation effects after ECT.
Tricyclic antidepressants Delay the ejaculation • Thiamine improves the post-ECT recovery.
• D’ Elia Position is the best site to place the electrodes in
Selective serotonin reuptake Delay the orgasm
inhibitors (SSRI)
unilateral ECT.
• Clozapine and Olanzapine are the only antipsychotics
• SSRI and Clomipramine are effective in the treatment of which are helpful to treat both positive and negative
obsessive compulsive disorder (OCD). symptoms in the same patient.
442 Textbook of Psychiatric Nursing for BSc Nursing Students

• Dopamine receptor blockage due to antipsychotics leads to • Use of Methylphenidine in children with attention
suppression of testosterone in males, hyperprolactinemia deficit hyperactive disorder (ADHD) may cause Tourette
(breast enlargement) and galactorrhea (discharge of milk syndrome and growth suppression.
from breast) in females. • Amphetamine is used for the treatment of ADHD,
• Use of Carbamazepine and Sodium Valproate in the first endogenous obesity and narcolepsy.
trimester of pregnancy will increase the risk of neural • Amphetamine will decrease the effect of hypoglycemic
tube defects in fetus. agents.
• Use of lithium in pregnancy has risk of Ebstein anomaly • Nurse has to administer the long acting psychotropics
in fetus. (Flupenthixol decanoate, Fluphenazine decanoate,
• Lithium is the drug of choice for treatment of resistant Haloperidol decanoate, Risperidone decanoate,
depression or refractory depression. Pipothiazine decanoate, etc.) in a Z track method of
• Long term use of Lithium might cause renal side effects Intramuscular injection (deep IM injection) in order to
and hypothyroidism. prevent the skin irritation.
Syndromes in Psychiatry

Punch-drunk syndrome or boxer’s syndrome or dementia Ganser syndrome or nonsense syndrome or balderdash
pugilistica, also called Chronic Traumatic Encephalopathy syndrome, syndrome of approximate answers or
(CTE), is commonly seen in alcoholics and boxers due to the hysterical pseudodementia or prison psychosis is defined
repeated cerebral concussions which result in weakness of as rare dissociative disorder characterized by saying the
limb, unsteady gait and mental dullness. approximate answers to the question raised along with other
Ekbom syndrome or delusional parasitosis is a mental dissociative symptoms such as amnesia, fugue and visual
disorder characterized by patient’s conviction that he or she is pseudohallucination.
infested with parasites. Diogenes syndrome or senile squalor syndrome refers to
Amotivational syndrome is similar to the signs of depression presence of self-neglect, withdrawal from others and tendency
in which individual lacks interest to complete the task, poor to hold the rubbish things due to the dysfunction of frontal
concentration and sense of apathy is seen. This syndrome is lobe.
commonly seen among patients with Marijuana abuse. Other syndromes which have been discussed in the chapters
De clerambault syndrome or erotomania is a delusional idea and Glossary are as follows:
in which an individual thinks that a higher professional and • DiGeorge syndrome or Velocardiofacial syndrome or
social standard person is in love with him/her. Shprintzen syndrome or Conotruncal anomaly face
Cotard syndrome or corpse syndrome or cotard delusion syndrome or Takao syndrome or Sedlackova syndrome
is a rare psychiatric disorder in which the person strongly or Cayler cardiofacial syndrome or 22q 11.2 deletion
believes that he is dead or does not exist or has lost the internal syndrome
organs or blood. • Othello syndrome or delusion of infidelity or Delusion of
Clumsy child syndrome is a term not in use nowadays, instead jealousy or Morbid Jealousy
the term has been changed to Developmental Coordination • Alice in Wonderland syndrome or Todd’s syndrome or
Disorder (DCD) or Dyspraxia which means perceptomotor Lilliputian hallucination or Dysmetropsia
dysfunction characterized by difficulty in jumping, delay in • Asperger’s syndrome
sitting and walking. • Capgra syndrome
Savant syndrome or idiot savant or autistic savant is defined • Child battered syndrome or child abuse
as individuals with significant mental disabilities able to • Down syndrome
demonstrate certain abilities excess than the average. For • Munchausen syndrome by proxy or factitious disorders
example, artistic ability, doing fast calculation, good music • Depersonalization—derealization syndrome
ability, etc. • Fetal alcohol syndrome
Empty nest syndrome denotes the symptoms of depression • Fragile X syndrome
elicited due to the loneliness or isolation. • Kluver-Bucy syndrome
444 Textbook of Psychiatric Nursing for BSc Nursing Students

• Korsakoff syndrome • Premenstrual syndrome

• Lacunar syndrome or status lacunaris or Lacunar state • Rett’s syndrome
• Lesch-Nyhan syndrome • Serotonin syndrome
• Neuroleptic malignant Syndrome • Sun downing syndrome
• Night eating syndrome • Tourette syndrome
• Pickwickian syndrome or obesity hypoventilation syndrome • Van gogh syndrome
• Prader willi syndrome • Widower’s syndrome
Psychotropic Drugs

Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs and route
Chlorpromazine Oral Depresses Schizophrenia, Comatose state, Central nervous Assess or Monitor
300–1500 the Schizoaffective myelosuppression, system: EPS- • Patient’s behavior and
Trade name: mg/day cerebral disorder, severe akathisia, dystonia, emotional status.
Largactil cortex, Mania, cardiovascular tardive dyskinesia, • Extrapyramidal symptoms
hypotha- depression, disease, central Parkinson’s disease. (EPS)
lamus and Delusional nervous system Cardiovascular • Blood pressure for
Classification: IM limbic disorder, depression, system: Orthostatic hypotension
Dopamine 25–100 system Delirium, subcortical brain hypotension, • Complete Blood Count (CBC)
receptor mg/day which dementia, damage, liver ECG changes, to explore blood dyscrasias
antagonist controls Tourette damage, closed tachycardia • Patient producing fine
the activity, syndrome, angle glaucoma, Eye: Blurred vision, tongue movement to
aggression Huntington’s hypertension or glaucoma evaluate the signs of tardive
Functional Frequency and blocks disease, hypotension Gastrointestinal dyskinesia.
Classification: bd or tds neurotrans- Borderline system: Nausea, • Serum drug level.
Antipsychotics mission personality vomiting, (Therapeutic serum level is
produced disorder, Diarrhea 50–300 mcg/mL.
by Substance Genitourinary Toxic serum level is
Chemical dopamine and induced system: Urinary >750 mcg/mL).
Classification: at synapse psychotic retention, enuresis, Patient Teaching
Phenothiazines and also disorder amenorrhea, • Advise to take high fiber diet
exhibits impotence and more intake of water.
a strong Hematology: • Avoid excessive exposure to
alpha Anemia, sunlight while on drug and
adrenergic leucopenia, use protective sunscreens.
anti- leukocytosis, • Advise the patient to get up
cholinergic agranulocytosis from the bed slowly.
action. Integumentary Miscellaneous
system: Rash, • Don’t give this drug
dermatitis subcutaneously because
Respiratory it causes severe tissue
system: Dyspnea, necrosis
respiratory • Avoid skin contact with oral
depression concentrate and syrup to
prevent contact dermatitis.
• Dilute the injection with
Normal saline to prevent
irritation at the injection
site.
 446
Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
Haloperidol Oral Antipsychotic, Schizophrenia, Angle-closure Central nervous system: Assess or monitor
5 mg Antiemetic and Schizoaffective Glaucoma, EPS-akathisia, dystonia, • Patient’s behavior and emotional
Trade name: Antidyskinetic disorder, Central nervous tardive dyskinesia, pseudo- status.
Serenace agent which blocks Mania, System depression, Parkinsonism, drowsiness, • Extrapyramidal symptoms (EPS)
postsynaptic depression, Myelosuppression, headache. • Blood pressure in standing and lying
Classification: Parental dopamine Delusional Parkinson’s disease, Seizures, neuroleptic posture
Dopamine 5–100 mg receptors, disorder, Severe cardiac malignant syndrome. • Monitor the patient for fine tongue
receptor interrupts nerve Borderline problems, hepatic movements, mask like facial
antagonist impulse movement personality disease Cardiovascular system: expression, rigidity, and tremors.
and raises the disorder, Orthostatic hypotension, • Serum drug level.
Functional turnover of Substance Hypertension, ECG changes, „ Drug therapeutic serum level is

Classification: dopamine in the induced psychotic Tachycardia. 0.2–1 mcg/mL

Typical brain. disorder, „ Toxic serum level >1 mcg/mL.

antipsychotics Delirium, Eye: Blurred vision,

Dementia, glaucoma, dry eyes Patient teaching
Chemical Tourette’s syndrome, • Avoid alcohol during therapy.
Classification: Huntington’s disease. Gastrointestinal system: Dry • Avoid exposure to sunlight and any
Butyrophenone mouth, nausea, vomiting, condition may cause dehydration.
anorexia, constipation, • Take sips of water to prevent dry
diarrhea, jaundice, weight mouth.
gain, hepatitis. • Avoid hot water bath to prevent the
hypotension.
Genitourinary system:
Urinary retention, dysuria,
enuresis, impotence,
amenorrhea

Integumentary system:
Rash, dermatitis.

Respiratory system:
Laryngospasm, dyspnea,
respiratory depression
Textbook of Psychiatric Nursing for BSc Nursing Students
Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
Quetiapine Adults Combination of • Schizophrenia Be cautious in • Excess sleep Assess or monitor
300–400 dopamine type • Schizoaffective Parkinson’s disease, • Weight gain Side effects
Trade name: mg /day 2 (D2) and disorders hemodynamic • Headache
Seroquel serotonin type 2 • Autism instability, previous • Increased pulse rate Patient teaching
(5-HT2) • Bipolar disorders myocardial • Palpitations • Advise to take medication with food Psychotropic Drugs
Classification: Children antagonisms. • Mania and infarction, Increased • Dizziness in order to avoid the stomach upset
Atypical and Psychosis. cholesterol level • Rashes • Don’t stop the medicine suddenly
Antipsychotic adolescents in blood, thyroid • Blurred vision • Drug may cause fainting so avoid
agent 100–350 problems, seizures, • Abdominal pain driving
mg/day renal impairment, • Postural hypotension • Avoid drinking alcohol
Chemical respiratory disease. • Constipation • Take plenty of water
Classification: Route • Anorexia
Dibenzothiazepine Oral Not to be used • Vertigo
in patients with • Weakness
hypersensitivity to • Diabetes mellitus
blood dyscrasias, • Yellowish discoloration
bone marrow of eyes
suppression, severe • Dysuria
hepatic dysfunction • Hyperlipidemia and
or coma. Hypothyroidism

Ziprasidone Adults – • Combination of • Schizophrenia • Hypersensitivity • Dry mouth Assess or monitor

Oral its antagonistic • Bipolar affective • Recent • Dizziness • Serum potassium and magnesium
Trade name: function at D2 disorder Myocardial • Somnolence • Check out extrapyramidal symptoms
Zeldox, 20–100 mg receptors in • Acute mania Infarction • Drowsiness (neuroleptic malignant syndrome),
Ziprasidone bd mesolimbic • Depression • Previous • Headache fever, confusion, stiffness
Hydrochloride, pathways at • Anxiety Arrhythmias • Vomiting
Ziprasidone Intramus- 5HT2 receptors • Aggressive and use of • Nausea Miscellaneous
Mesylate cular in frontal cortex. behavior antiarrhythmics • Hypertension • Take medication with food to
10 mg in • Reduction • Dementia • Cardiac failure. • Postural hypotension prevent gastric upset.
Classification: Q2H or of positive • Attention deficit • Cough • Don’t give this drug to the patients
Atypical 20 mg Q4H symptoms is due hyperactivity Use with caution • Running nose with heart attack or congestive heart
antipsychotic. to antagonism disorder (ADHD) • Seizures • Mood changes failure history.
at D2 receptors • Obsessive • Dementia • Extrapyramidal symptoms
and reduction compulsive • Diabetes • Rashes
in negative disorder (OCD) • Obesity • Dysmenorrhea
symptoms • Autism • Constipation
because • Post-Traumatic • Abdominal pain
of 5HT2A Stress disorder.
antagonism.
447
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Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
Imipramine Oral Blocks the reuptake • Depression • Heart disorders • Sedation Assess or monitor
75–300 of norepinephrine with psychotic • Recovery period • Dry mouth • Complete Blood Count
Trade name: mg/day (NE) and serotonin symptoms after myocardial • Tremors • Blood Glucose level
Antidep, tofranil (5-HT) in nerve • Depressive infarction • Constipation • Liver and Renal Function test
terminals, thereby episode • Not to be given • Tachycardia • Baseline ECG (If risk of Arrhythmias
Classification: it increases level • Dysthymia to younger • Urinary retention is present)
Tertiary tricyclic of NE and 5-HT at • Secondary children less than • Arrhythmias • Suicidal risk in patients
antidepressant receptor site. depression due to 6 years of age • Mydriasis • Sleep pattern, mood and behavior
drugs hypothyroidism • Usage within • Agranulocytosis • Bowel and bladder function
• Reactive 2 weeks of • Orthostatic hypotension • Blood pressure
depression MAOIs. • Cholestatic jaundice • Pulse rate
• Cushing’s • Sedation
Syndrome • Tremors Patient teaching
• Pathological grief • Withdrawal • Take medicines with food or milk to
• Separation anxiety • Syndrome prevent gastric upset.
disorder • Acute organic syndrome • Don’t crush the film-coated tablets
• Enuresis • Seizures • Take sips of water and use chewing
• Somnambulism • Weight gain gums to prevent dry mouth
• Night terrors • Tiredness • Ask patient to change the position
• Panic attacks • Drowsiness and insomnia. slowly to prevent fainting
• Social phobia
• Agoraphobia
• Chronic pain
• Obsessive
Compulsive
disorder
• Depersonalization
• Post-traumatic
stress disorder
• Migraine
headache
• Gastric ulcer.
Textbook of Psychiatric Nursing for BSc Nursing Students
Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
Clomipramine 150–250 Blocks the • Obsessive • Heart disorders • Somnolence Assess or monitor
mg/day reuptake of compulsive • Recovery period • Dizziness • Complete blood count
Trade name: oral neurotransmitters disorder after myocardial • Xerostomia • Blood glucose level
Anafranil (norepinephrine • Depression infarction • Blurry vision • Liver and renal function test
and serotonin) at • Panic disorder • Pregnancy • Constipation • Baseline ECG (If risk of arrhythmias Psychotropic Drugs
Classification: Central Nervous • Phobias • Hepatic and renal • Sexual dysfunction is present)
Tertiary tricyclic System presynaptic • Pain disorders. disease • Impotence • Suicidal risk in patients
antidepressant membranes by • Usage of • Hyperpyrexia • Sleep pattern, mood and behavior
increasing their clomipramine • Increased weight • Bowel and bladder function
availability at within the • Delay in urination and • Blood pressure
postsynaptic 2 weeks of MAOI Urinary retention • Pulse rate
receptor sites. medication • Orthostatic hypotension
intake. • Palpitation Patient teaching
• Seizures • Take medicines with food or milk to
• Tachycardia prevent gastric upset.
• Profuse sweating • Don’t crush the film-coated tablets
• Altered concentration • Take sips of water and use chewing
• Increased appetite gums to prevent dry mouth
• Arrhythmias • Ask patient to change the position
slowly to prevent fainting

Lamotrigine 50 mg/ Inhibits the • Generalized tonic- • Hypersensitivity Central nervous system Assess or monitor
Day glutamate clonic seizures • Pregnancy Dizziness, Ataxia, headache• Duration, type and intensity of
Trade name: Oral (excitatory • Bipolar disorder. • Lactation and tremors Seizure.
Apo-lamotrigine, neurotransmitter) • Sign of skin rashes
Lamictal, Lamictal release, at Use with caution Eye: Nystagmus, diplopia and • Renal and hepatic function test
XR voltage sensitive • Altered cardiac blurred vision
sodium channels, function Patient teaching
Classification: thus decreasing • Hepatic and renal Hematology: Anemia, • Advise the patient to do periodic
Anticonvulsant seizures. impairment disseminated intravascular ophthalmic examination
• Patients below Coagulation, leukopenia and • Taper the drug for 2 weeks before
16 years of age thrombocytopenia. discontinuing and do not discontinue
the drug abruptly
Gastrointestinal system: • Advise the client to report, if
Nausea, vomiting, and yellowish skin discoloration, change
Hepatotoxicity. in the urine color, fever, rashes,
unusual bleeding and abdominal
Miscellaneous: pain occur
Stevens-Johnson syndrome,
Toxic epidermal necrosis,
Multiple organ failure and
Suicidal ideation.
449
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Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
Sertraline 25–50 mg Inhibits reuptake of Major depressive Hypersensitivity, Central nervous system: Assess or monitor
serotonin in Central disorder, Obsessive Pruritus with Insomnia, Agitation, Tremor, • Complete blood count
Trade name: Oral Nervous System compulsive disorder, Cholestatic Liver Seizure, Neuroleptic • Renal function test
Zoloft by increasing Panic disorder, Disease, Premature Malignant Syndrome. • Bowel activity
the serotonergic Bulimia Nervosa, Ejaculation, Breast • Stool consistency
Classification: function Post-traumatic stress Cancer Patients Cardiovascular system: • Suicidal risk
Selective disorder, Social Taking Tamoxifen, Palpitations, chest pain. • Mental Status Examination (Mood
Serotonin anxiety disorder, Hot Flashes During and Affect)
Reuptake Premenstrual Menopause, Men Eye: Vision abnormalities, • Pulse rate
Inhibitors dysphoric disorder with Prostate yawning. • Blood pressure
-Antidepressant Cancer secondary • Weight
to Androgen Endocrine system: Syndrome
Deprivation of Inappropriate Antidiuretic Patient teaching
Therapy. Hormone Secretion (SIADH) • Take this medicine with food to
prevent gastric distress
Gastrointestinal system: • Avoid taking the drug at night time
Diarrhea, nausea and to prevent insomnia
constipation. • Care givers of patient have to
monitor the patient due to increased
Genitourinary system: suicidal risk because as the energy
Micturition disorder. level comes up in the depressive
client, there is an increased risk of
Skin: Increased sweating, suicide
rash, hot flashes. • Teach the patient and his family
members that drug will take
2–4 weeks to get the complete
therapeutic effect
• Avoid taking alcohol
• Take sips of water to prevent dry
mouth
• Report Headache, fatigue, tremors
and sexual dysfunction immediately
Textbook of Psychiatric Nursing for BSc Nursing Students
Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
Olanzapine Oral Antagonizes Positive and Narrow angle Central nervous system: Assess or monitor
5–10 mg/ dopamine negative symptoms glaucoma, urinary Agitation, headache, • Liver function test before starting
Trade name: day histamine of schizophrenia, out flow obstruction sleep deficit, nervousness, olanzapine
Zyprexa muscarinic, schizoaffective and paralytic ileus. hostile behavior. • Patient’s behavior and mental status.
alpha-adrenergic disorders, depression • Blood pressure. Psychotropic Drugs
Classification: and serotonin (when combine with Use with caution Cardiovascular system:
Atypical receptors. other drugs), bipolar Low WBC count, Tachycardia and Patient teaching
antipsychotic- mania. Smoking, alcohol Orthostatic hypotension. • Don’t stop drug abruptly
Serotonin consumption, high • Avoid tasks which require mental
dopamine cholesterol level, Other adverse effects: alertness because the drug causes
antagonists sleep apnea, family Weight gain, constipation, drowsiness
history of diabetes Seizures and neuroleptic • Instruct the patient to notify if
and cardiac disorder malignant syndrome. become pregnant.
• Avoid dehydration mainly during
Drug interactions exercise or exposure to extreme
Antianxiety agents, heat.
Muscle relaxants, • Take sips of water and use chewing
Opioids, cough sugarless gum to prevent dry mouth.
relievers and • Diet and exercises are important to
Antihistamine drugs prevent weight gain.
• Take olanzapine early in the day to
reduce insomnia.
Alprazolam Oral Enhance the Anxiety disorder, • Hypersensitivity • Ataxia Assess or monitor
0.25–0.5mg inhibiting effect insomnia, • Acute angle • Transient mild • Patient motor response (agitation).
of gamma premenstrual, closure somnolence
Trade name: aminobutyric acid syndrome and glaucoma. • Light-headedness or Patient teaching
Alprax, Apo- (GABA)—inhibitory irritable bowel • Severe chronic Headache • Use of alprazolam in pregnancy
Alpraz, Novo- neurotransmitter syndrome. obstructive • Slurred speech might lead to Central Nervous
Alprazolam pulmonary • Dry mouth System depression
disease (COPD) • Confusion • Don’t stop drug abruptly
• Myasthenia • Depression • Take sips of water and use chewing
gravis • Blurred vision sugarless gum to prevent dry mouth.
Classification: • Pregnancy and • Restlessness • Drowsiness usually disappears with
Antianxiety drug lactation • Constipation the continued therapy.
(Benzodiaz- • Acute alcohol • Abdominal cramps • Patient has to change the position
epines), Sedatives intoxication with • Diarrhea slowly
and hypnotics reduced vital • Nausea • Stop smoking and consuming alcohol
signs. • Vomiting
• Tremors
• Irritability
• Seizure
• Diaphoresis
• Insomnia
451
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Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
Acamprosate Tablet Anti- craving To reduce craving • Hypersensitivity Central nervous system: Assess or monitor
available medication effect in patients with • Cirrhosis with Headache and dizziness • Mood changes
Trade name: form is 333 (Enhances alcohol dependence severe hepatic • Depressive symptoms
Acamprol mg. the GABA syndrome dysfunction Cardiovascular system: • Suicidal risk
neurotransmitter • Pregnancy and Chest pain and vasodilation
system. It interferes lactation Patient teaching
with glutamate • Renal disease Gastrointestinal system: • Drug adherence is vital
action. It also act Nausea, vomiting, diarrhea • Avoid tasks which require mental
on calcium channel and dry mouth. alertness because the drug causes
and decreases drowsiness
CNS excitability Respiratory system: Dyspnea • Report the doctor if the patient has
that might lead to side effects.
decrease in the Skin: Pruritus
craving effect)
Miscellaneous: Weight loss,
dehydration

Clozapine Oral Antagonizes • Positive and • Hypersensitivity • Agranulocytosis Assess or monitor

Alpha-Adrenergic, negative • Bone marrow • Decreased WBC • Liver function test and Renal
Trade name: 25 mg may Histamine, symptoms of suppression • Fatigue function test and complete blood
Sizopin gradually Dopamine, schizophrenia • Central • Polymorphonuclear count before starting Clozapine.
increase Muscarinic • Schizoaffective nervous system leukocytes • Weekly monitor the WBC count
Classification: to 300 mg and Serotonin disorders depression • Hypotension for the first six months and then
Atypical per day Receptors. • Schizophrenia • Coma • Seizure biweekly monitoring can be done
Antipsychotics in divided is not effective • Lactation • Sialorrhea if the WBCs are in the acceptable
doses. with typical • Patients below • Sedation range. If level of WBCs is less than
antipsychotic 16 years of age • Constipation 1500/mm3, discontinue the drug.
drugs • Tachycardia
• Side effects • Weight gain Patient teaching
of typical • Anticholinergic effects • Avoid tasks which require mental
antipsychotics alertness and motor skills because
Use with Caution the drug causes drowsiness and the
• Glaucoma drowsiness will subside with the
• Heart disease continued therapy
• History of seizures • Don’t discontinue the drug abruptly
• Myocarditis • Take seizure precautions
• Liver failure • Ask the client to report the
• Urine retention symptoms such as sore throat,
• Renal dysfunction weakness, fever and lethargy
• Benign prostrate
Hyperplasia
• Altered respiratory
function
Textbook of Psychiatric Nursing for BSc Nursing Students
Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
Donepezil 5–10 mg/ Acetylcholinest- Mild to moderate Hypersensitivity Central nervous system Assess or monitor
day erase Dementia Headache, insomnia, • Cognitive ability of the client.
Trade name: inhibitor (Alzheimer’s type) seizures and dizziness. • Heart rate because bradycardia may
Aricept (Increase acetyl- occur.
choline concentra- Cardiovascular system: • Side effects of this drug Psychotropic Drugs
tion by inhibiting Chest pain and vasodilation
hydrolysis of Patient teaching
cholinesterase Gastrointestinal system: • Importance of taking the medication
enzyme) Nausea, vomiting, anorexia regularly.
and diarrhea. • This drug may cause dizziness; so,
take medication before going to bed.
Genitourinary system: • Avoid alcohol and other drugs such
Urinary frequency. as sedatives and tranquilizers.
• Take small and frequent meals,
Respiratory system: Dyspnea frequent mouth care, use chewing
and bronchitis gum, which may reduce nausea.
• Advise the client to intimate suicidal
Miscellaneous Weight loss thoughts and nervousness.
and dehydration

Phenergan 50 mg for Sedative/hypnotics, To sedate the patient, Hypersensitivity, • Sedation Assess or monitor
sedation Anti-emetics, H1 prevent vomiting, prostate • Disorientation • Vital signs
Generic name: and 10–25 receptors blockers, used to reduce pain hypertrophy, • Confusion • Level of sedation
Promethazine mg every antihistamines and for the purpose comatose patient, • Fatigue • Nausea and vomiting
4 hours for effect. It also blocks of anesthesia bladder neck • Dizziness
antiemetic the cholinergic obstruction and • Nervousness Miscellaneous
action receptors in narrow angle • Bradycardia or • Give deep intramuscular injection
vomiting center glaucoma Tachycardia because administration into
which prevents • Hypertension or subcutaneous tissue will cause
nausea and hypotension necrosis
vomiting • Dry mouth • Arteriospasm and gangrene of
• Hepatitis artery may happen when this drug is
• Constipation administered through intra-arterial
• Blood dyscrasias route.
• Extrapyramidal symptoms
• Blurred vision
• Rashes
• Tinnitus
• Diplopia
• Photosensitivity
453
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Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
Risperidone Oral Antiadrenergic, Schizophrenia, Hypersensitivity, Central nervous system: Assess or monitor
0.5–6 mg antiserotonergic, Schizoaffective cardiac diseases, Headache, Hypersomnia and • Blood urea nitrogen levels
Trade name: per day antidopaminergic disorder, bipolar seizure disorder, epilepsy • Renal and liver function test
Sizodon and disorder, irritable Parkinson’s disease, • Serum alkaline phosphate
antihistaminergic behavior associated hyperprolactinemia, Cardiovascular system: • Mental status examination
Classification: action. with autism and kidney and liver Dizziness, tachycardia, • Blood pressure
Atypical other psychotic dysfunction. orthostatic hypotension and • Heart rate
antipsychotics disorders. syncope. • Weight
Use with Caution
Low WBC count, Gastrointestinal system: Patient teaching
dementia, sleep Constipation, abdominal pain • Avoid tasks which require mental
apnea, high and vomiting alertness and motor skills because
cholesterol level, QT the drug causes drowsiness
prolongation (heart Miscellaneous: Erectile • Drink more water to reduce
rhythm) glaucoma dysfunction, weight gain, constipation.
and cataract mood changes, sleep apnea, • Notify the doctor if there are gait
tremors, hyperglycemia, Skin disturbances, palpitations, breathing
Drug Interactions rashes, tardive dyskinesia difficulty, severe dizziness, pain
Antihistamine and neuroleptic malignant or swelling in breasts, unusual
agents, Opioids, syndrome. movements, trembling fingers,
cough relievers, rashes and visual disturbances
antianxiety agents • Avoid drinking alcohol
and muscle • Change the position slowly as this
relaxants. drug causes orthostatic hypotension.

Fluoxetine 20 mg/ Inhibits the Depressive disorder, Hypersensitivity, Central nervous system: Assess or monitor
hydrochloride day and serotonin uptake Bulimia nervosa, pregnancy, Nervousness, headache, • Complete Blood Count (CBC)
maximum in the central anxiety disorder lactation, history of drowsiness and fatigue • Renal Function test
Trade name: 80 mg/day nervous system especially obsessive- seizure, severe liver • Liver Function test
Auscap, fluohexal, by increasing compulsive disorder dysfunction and Cardiovascular system: • Bowel and Bladder function
Levan, Novo- serotonergic (OCD) and Panic renal impairment. Palpitations. • Patient’s Behavior, mood and sleep
fluoxetine, Prozac activity. attacks pattern
ENT: Nasal congestion, • Suicidal risk determination
Classification: Use with caution pharyngitis and sinusitis.
Antidepressants Cardiac problems, Patient teaching
Serotonin- seizure disorder, Gastrointestinal system: Dry • Take medication with milk and food
Specific reuptake Diabetes Mellitus, mouth, nausea, anorexia and to prevent gastric distress.
inhibitors Pregnancy and diarrhea or constipation. • Take the last dose of medication
Patient with high before 4 pm to prevent insomnia at
suicidal risk Genitourinary system: night.
Sexual dysfunction. • Quit alcohol
Textbook of Psychiatric Nursing for BSc Nursing Students
Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
Musculoskeletal system: • Ask the patient to report headache,
muscle pain. fatigue, sexual dysfunction and
tremors.
Respiratory system: Upper • Take adequate water to prevent dry
Respiratory tract infection, mouth. Psychotropic Drugs
respiratory distress and
cough

Skin: Rashes and Pruritus

Disulfiram Oral Alcohol Abstinence for Suspected alcohol Metallic or garlic taste, Assess or monitor
250 mg/day dehydrogenase more than 48 intake, rubber/ headache, drowsiness/ • Complete Blood Count (CBC)
once a day. inhibitors (alcohol hours of alcohol cobalt/nickel allergy, fatigue, dermatitis, halitosis, • Liver function test
dehydrogenase intake, failure or psychotic patients, nausea/vomiting and • Mental status examination
is the enzyme contraindicated with hypersensitivity, impotence/lack of libido/
which prevents naltrexone, previous pregnancy/ sexual dysfunction Patient teaching
the conversion good response to breastfeeding, Adverse reactions • Disulfiram is not to be taken if
of ethanol into disulfiram and client cognitive Polyneuritis, hepatotoxicity, patient has consumed alcohol
acetaldehyde) has both cocaine and impairment, optic neuritis and peripheral within 12 hours because it leads to
alcohol dependence uncontrolled neuritis Disulfiram-Ethanol Reaction (DER).
hypertension, high • Disulfiram-Ethanol Reaction (DER)
suicidal risk, history includes trouble in breathing,
of stroke/myocardial nausea, vomiting, throbbing pain in
infarction, severe head and neck, sweating, increased
personality disorder, thirst, dizziness, palpitations, blurred
severe cardiac, vision, confusion and weakness.
renal and hepatic Severe Disulfiram-Ethanol Reaction
dysfunction. includes unconsciousness, cardiac
Drug interactions failure, respiratory failure, seizures
Phenytoin, and death
Warfarin, ethanol • Don’t use hand sanitizer, perfume,
(cause disulfiram alcoholic beverages and food
ethanol reaction), (vinegars, marinades, sauces,
metronidazole extracts, etc.), perfumes, after shave
(flagyl), tricyclic lotions, cough syrup, etc. which have
antidepressants alcohol content.
(particularly
amitriptyline) and
benzodiazepines
(increase sedative
effect)
455
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Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
Lithium (Lithium 600–900 Lithium enhances Bipolar disorder, Cardiovascular Headache, Mental dullness, Assess or monitor
Carbonate, mg/day the reuptake of Schizophrenia, disease, renal Fatigue, ECG Changes • Therapeutic lithium level has to be
Lithium Citrate) given as Norepinephrine Eating disorder, disease, severe (T wave flattening, QRS 0.6–1.2 mEq/L; and >2 mEq/L is said
divided or and Serotonin Neutropenia, dehydration or widening and sinus to be toxic level.
single dose in presynapse, Headache, Epilepsy, sodium depletion, node dysfunction), • WBC count
initially destroy the Asthma, Overactive Patients on Hypothyroidism, Weight • Renal function test
catecholamines thyroid, Tourette’s diuretics, patients gain, Polyuria, Metallic taste, • Thyroid function test
in synapse and syndrome, Tardive with the high risk of Increased Thirst, Goiter, • Glucose level
enhance post Dyskinesia, lithium toxicity Tremors, Gastrointestinal
synaptic sensitivity Aggression, Attention Upset, acne, rashes, Patient teaching
Deficit Hyperactive Ataxia, Nystagmus, Muscle • Retention of sodium and water has
Disorder (ADHD) weakness, Delirium, hair to be avoided.
loss, psoriasis, Peripheral • More intake of oral fluids/water.
Neuropathy, Intracranial • Follow up and regular check-up is
hypertension, Myasthenia vital to prevent lithium toxicity
gravis like syndrome,
lower seizure threshold,
neuromuscular irritability,
Memory disturbances,
dysphoria and slow reaction
time
Amphetamine Adult It is a Attention deficit Hypersensitivity, Physical effects Patient teaching
Trade name(s): Narcolepsy noncatecholamine Hyperactive disorder Heart disease, • Hypertension or • Don’t take amphetamines along
• Adzenys ER - 5–60 mg; sympathomimetic (ADHD), Narcolepsy, Arteriosclerosis, Hypotension with the fruit juices rich in vitamin C
(Extended Obesity – amine which Depression Hypertension, • Raynaud’s phenomenon because it decreases absorption
Release) 5–10 mg enhances the and Obsessive- Agitation, history • Erectile dysfunction • Inform the doctor immediately if
• Adzenys maximum release of Compulsive disorder of depression, • Tachycardia there are signs of heart problems
OET (Oral up to catecholamines (OCD) tics, or Tourette’s • Abdominal pain such as chest pain, breathing
Disintegrating 30 mg; (mainly syndrome, Bipolar • Anorexia difficulty, etc. signs of psychosis such
Tablet) Attention dopamine and disorder, Suicidal • Weight loss as hallucination, aggression, hostile
• Evekeo Deficit norepinephrine) ideation, glaucoma, • Nausea behavior, paranoia, etc., signs of
• Dyanavel XR Hyperactive from the storage hyperthyroidism and • Rashes circulatory problems such as bluish
disorder site at presynaptic use of Monoamine • Acne or pale colour skin, numbness, feel
Adzenys ER terminals. Oxidase Inhibitors • Xerostomia cold, etc.
– 12.5 mg/ Anorexigenic (MAOIs) within the • Nose bleeding • Take the missed dose as early as
day effect is mainly past 14 days • Profuse sweating possible but don’t take double dose.
secondary to the • Seizures • Don’t share amphetamine with
central nervous • Tics others because it has addiction
system-stimulating • Dysuria potential.
effect and the
site of action is
hypothalamic
center.
Textbook of Psychiatric Nursing for BSc Nursing Students
Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
Psychological effects
• Increased alertness
• Mood swings
• Change in libido
• Insomnia Psychotropic Drugs
• Obsessive behavior
• Grandiose
• Anxiety
• Irritability

Diazepam Oral Gamma– Anxiety disorder, Pre-existing CNS Central nervous system: Assess or monitor
Trade name: 2–10 mg Aminobutyric preanesthetic depression, Angle Dizziness, confusion, • Patient’s Blood Pressure, Pulse rate,
Valium, acid (GABA) and medication, skeletal Closure glaucoma, drowsiness, headache, respiratory rate, rhythm before
Valpam other inhibitory muscle relaxants, Coma, respiratory anxiety, tremors, fatigue, giving diazepam
Classification: neurotransmitters alcohol withdrawal depression and depression, insomnia, • Motor responses such as trembling,
Antianxiety will bind with syndrome, tremors, severe uncontrolled hallucinations, ataxia, agitation, autonomic responses such
drug, Sedatives/ the specific status epilepticus, pain. fatigue. as cold, clammy extremities and
Hypnotics benzodiazepine panic attack, tension diaphoresis.
-Benzodiazepines receptors in limbic and headache. Cardiovascular system:
and cortical areas Orthostatic hypotension and Patient teaching
of the Central tachycardia • Ask the client to lie in recumbent
Nervous System, position for up to 3 hours after
GABA inhibits Eye: Blurred vision, mydriasis the parenteral administration
the excitatory and nystagmus of diazepam to decrease the
stimulation and hypotensive effect.
therefore, it Gastrointestinal system: Dry • Teach the patient that drowsiness
controls emotional mouth, nausea, vomiting, disappears with continued therapy.
behavior. This drug anorexia and diarrhea or • Ask the patient to change position
also suppresses the constipation. slowly to prevent dizziness.
spread of seizure • Ask patient to take the diazepam
activity which is Hematology: Neutropenia with food to reduce gastric distress.
caused by seizure • Abrupt withdrawal of diazepam
producing foci Skin: Rashes, dermatitis and may cause irritability, insomnia and
in the thalamus, Itching sometimes seizures.
cortex and limbic • Avoid tasks which require mental
system Respiratory System: alertness and motor skills because
Respiratory depression. the drug causes drowsiness
• Avoid alcohol or other CNS
depressants along with diazepam
457
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Name of the Dosage Action Indications Contraindications Side effects Nurse’s responsibility
drugs
During the time of administration
• Intramuscular administration has to
be given as deep IM.
• Do not mix IV diazepam with any
other drug.
• Give slow IV injection because
respiratory or cardiac arrest can
occur
• Monitor vital signs during IV
administration.
• Prevent extravasation because it
can cause phlebitis and venous
thrombosis.
Textbook of Psychiatric Nursing for BSc Nursing Students
Know the Differences

1. Defense mechanism and coping mechanism

Defense mechanism Coping mechanism

It is a false coping mechanism that gives a temporary relief It helps to deal with the stressors and cope with situations.
from the psychological stressors.
Example: Rationalization, sublimation, regression, repression, Example: Yoga, meditation, relaxation therapy, play therapy,
etc. etc.

2. Psychosis and neurosis

Categories Aspects Psychosis Neurosis

Etiology Stressful events More significant Less significant
Genetic factors More significant Less significant
Clinical manifestations Personality Affected Not as a whole (only part of the personality is
involved)
Disorganized speech Present Absent
Disorganized behavior Present Absent
Delusions and hallucinations Present Absent
Cognitive disturbances Common Rare
Disturbances in perception Common Rare
and thinking
Insight Absent Present
Reality testing and Judgment Absent Present
Risk of self–harm High Low
Treatment Medications Major Tranquilizers Minor tranquilizers
ECT Useful Not useful
Psychotherapy Not much useful Very useful
Prognosis Poor Good
Example Schizophrenia, Anxiety disorder, Phobia and obsessive-
Schizoaffective compulsive disorder
disorder and bipolar
disorder
460 Textbook of Psychiatric Nursing for BSc Nursing Students

3. Hallucination and illusion

Hallucination Illusion
Misperception without an external stimulus. Misperception with an external stimulus.
Types—Auditory, visual, olfactory, gustatory, tactile or haptic, hypnagogic, Types—Pareidolic, completion and affect.
hypnopombic, command or telological, liliputian, kinesthetic, functional, reflex,
extracampine and autoscopy.

4. Echopraxia, echolalia, perseveration and coprolalia

Echopraxia Echolalia Perseveration Coprolalia

Mimic the activities done by Mimic the words spoken by Persistent repetition of Repeated use of obscene
others others words beyond the point of words
relevance

5. Ambivalence and conflict

Ambivalence Conflict
Coexistence of two opposing forces or impulses, desires, ideas Coexistence of two opposing forces or impulses, desire, ideas
or emotions in one individual. or emotions between two individuals.

6. Flight of ideas and loosening of association

Aspects Flight of ideas Loosening of association

Definition Rapid shifting of one idea to other idea with the Rapid shifting of one idea to other idea without
presence of common context. having any common context.
Example Nurse asking patient, did you have breakfast? Nurse asking patient, did you have breakfast?
Answer: I like to eat idly. I feel biryani is good always. Answer: I like to travel more. I hate the rich
Sweets are available in the canteen. persons. I feel sleepy now. I don’t know where my
mother went now.
Explanation of the The common context in the above example is ‘food’. There is no common context in the above said
Example Patient is shifting from one idea to other but all are example.
about food whereas association is not good. There is
no common context.

7. Circumstantiality and tangentiality

Circumstantiality Tangentiality
Speech of the individual reaches the goal or center point of Speech of the individual does not reach the goal or center point.
the question raised only after the unwanted speech.
Nurse: Did you have your breakfast? Nurse: Did you have your breakfast?
Patient: I like to go home now, I feel sleepy, I would like Patient: I like to go home now, I feel sleepy, I would like to see my
to see my mother, I had my breakfast (At last, patient mother (Patient talks something but never answers to question
verbalized the answer that he had breakfast after unwanted whether he had breakfast or not).
speech).

8. Delusion and overvalued idea

Delusion Overvalued ideas

Delusion is a strong fixed unshakable belief irrespective of Overvalued ideas give more importance to one’s own idea.
their socio-cultural background.

E.g., when patient says, ‘I strongly believe that I am a God’ E.g., when patient says, ‘It is mandatory to pray to God before
denotes the Delusion of grandeur. every meal’ denotes overvalued idea.
Know the Differences 461

9. Functional and reflex hallucination

Functional hallucination Reflex hallucination

Misperception within the same sensory stimuli (For example, Stimulus in one sensory field produces hallucination in another
each hallucination belongs to auditory sensory stimuli). (For example, one sensory field was touch, i.e., feel of pain and
other sensory field was auditory, i.e., hearing sneezing sound).
Patient verbalizes that, ‘I am hearing voices when I hear the Patient verbalizes that ‘I feel painful when I hear a sneezing
birds sound.’ sound’.

10. Hypnogogic and hypnopompic hallucination

Hypnogogic hallucination Hypnopompic hallucination

Misperception when going to sleep. Misperception while awakening from sleep.
Patient verbalizes that, ‘I feel that a ghost is speaking to me Patient verbalizes that ‘I feel that a ghost is speaking to me
daily when I am getting into sleep’. daily when I am awakening from sleep’.

11. Micropsia and macropsia

Micropsia Macropsia
Objects appear smaller than the original size. Objects appear larger than the original size.

12. Pelopsia and teleopsia

Pelopsia Teleopsia
People/objects/things appear closer than the original place. People/objects/things appear far away than the original place.

13. Retrograde amnesia and anterograde amnesia

Retrograde amnesia Anterograde amnesia

It means loss of memory to the events happened before the It means loss of memory to the events happened after the
injury or onset of illness. injury or onset of illness.

14. Delirium and dementia

Aspects Delirium Dementia

Other Names Acute confusion state, Organic brain syndrome, Chronic brain syndrome and chronic brain
Acute organic reaction, Toxic psychosis and failure.
Metabolic encephalitis
Onset Acute Gradual/insidious
Nature Reversible Irreversible
Duration Days to weeks Months to years
Course Fluctuating Progressive
Attention Impaired Normal until severe
Consciousness Fluctuating/altered Rarely alters/clear
Decreased awareness of self Present Present
Perception Illusions, hallucinations common Hallucinations not common
Speech Slow, incoherent Repetitive difficulty finding words
Disorientation To time is common To time, person and place occurs
Illness, med. toxicity Often Rarely
Outcome Excellent if corrected early Poor
Diurnal disruptions Present Present
Psychomotor changes Increased/decreased Often normal
462 Textbook of Psychiatric Nursing for BSc Nursing Students

15. Dementia and pseudodementia (depression)

Aspects Dementia Pseudodementia (Depression)

Complaints of cognitive impairment Rarely Mostly
Emphasis achievements Patient emphasis achievements Patient emphasis disability
Patient be unconcerned on symptoms Patient communicates distress
Mood Labile affect Depressed
Mental status exam • Makes mistakes • Say don’t know
• Impairment recent memory • Not such
• Confabulation
• Poor performance test
History No such history History of depression
Age Elders Non-specific
Organic symptoms Yes No
CT and EEG Abnormal Normal
Cooperation Cooperative Uncooperative
Behavior With cognitive impairment Not such
Benzodiazepam Worsen the disease May improve sleep only
Barbiturates

16. Cortical and subcortical dementia

Aspects Cortical dementia Subcortical dementia

Presence of lesion in • Frontal • Thalamus
• Parietal • Basal ganglion
• Temporal • Brain stem
• Occipital
• Hippocampus
Severity Severe Mild to moderate
Motor activities Normal • Tremors
• Dystonia
• Dysarthria
• Flexed or extended posture
• Chorea
• Ataxia
• Rigidity
Decline in short term memory/ Bradyphrenia (Decreased cognitive speed) Recall by cues done in partial way
cognition/recall and recall by cues done in very little way
Depressive symptoms Not common Common
Delusions Simple Complex
Miscellaneous (5A’s) • Aphasia Nil
• Amnesia
• Agnosia
• Apraxia
• Acalculia

17. Lewy body dementia and Parkinson’s disease dementia

Aspects Lewy body dementia Parkinson’s disease dementia

Onset of dementia Mostly precedes motor symptoms or Mostly follows motor symptoms
within onset of motor symptoms
Type of dementia Cortical Sub-cortical
Contd…
Know the Differences 463

Aspects Lewy body dementia Parkinson’s disease dementia

Motor symptoms at diagnosis 50% 100%
Cognitive fluctuation Present Absent
Visual hallucination Present Absent
Resting tremors Not prominent Prominent

18. Mood and affect

Mood Affect
It is a sustained and persistent emotional feeling. It is outward expression of thoughts as feelings.

19. Hypomania and mania

Aspects Hypomania Mania

Duration of symptoms 4 days >1 week
Psychotic features Absent May or may not
Social and occupational dysfunction Absent Present
Insight into illness Present Absent

20. Endogenous and exogenous depression

Aspects Endogenous depression Exogenous depression

Meaning Prefix ‘Endo’ means within (due to Prefix ‘Exo’ means outside (caused by external factors—
hereditary or biochemical imbalance) unemployment, divorce, sudden death of loved ones)
Other names • Psychotic depression • Neurotic depression
• Autogenous depression • Reactive depression
• Biological depression
Predominant factors Biological factor Environmental factor
Stress Present Present
Premorbid personality • Cyclothymic personality • Anxious personality
• Dysthymic personality • Obsessive personality
Insomnia Early morning awakening Struggle in getting into sleep
Psychotic feature • Psychomotor retardation • Psychomotor agitation
• Suicidal attempts • Suicidal attempts are not common
• Delusions • Other features are absent
Individual feeling Better when alone Better in group
Mood Sad in morning Sad in evening
Treatment Antidepressants and ECT Antidepressants and psychotherapy
Relapse Common Not common

21. Endogenous and atypical depression

Aspects Endogenous depression Atypical depression

Appetite Decreased Increased
Weight Loss of weight Gain of weight
Worsening of symptoms Morning Evening
Insomnia Middle or in late phase of sleep Initial phase of sleep and sometimes hypersomnia
Interpersonal hypersensitivity (fear of Absent Present
being rejected by others)
464 Textbook of Psychiatric Nursing for BSc Nursing Students

22. Primary and secondary transsexualism

Aspects Primary transsexualism Secondary transsexualism

Onset Early childhood Late
Prognosis Good Poor
Category Homogenous Heterogenous
Types • Male to female primary transsexualism Majority are male to female secondary
• Female to male primary transsexualism transsexualism
Common feature Wish to change anatomical sex organ

23. Anorexia nervosa and bulimia nervosa

Aspects Anorexia nervosa Bulimia nervosa

Age of onset 14–16 years 18–24 years
Lifetime prevalence 1–3% 0.5–1%
Gender Female
Main symptoms Fear of being obese
Weight loss 85% of expected weight Normal or decreased
Menses Amenorrhea (3 consequent cycles) Irregular menses (sometime amenorrhea)
Sexual desire Absent or decreased libido Normal or increased libido
Complications Starvation, decreased blood pressure and Dental/enamel erosion, dehydration,
temperature and shock hypokalemia, esophageal tear
Post binge anguish Absent Present
Awareness of illness Absent Present
Types Restricted type (not eating food) Purging type
Binge eating/Purging type Direct—Vomiting
Indirect—Laxatives usage, Enema
Non-purging type (starvation, Exercise)

24. Type I and Type II schizophrenia

Aspects Type I schizophrenia Type II schizophrenia

Symptoms Positive symptoms Negative symptoms
Course of illness Acute Chronic
Cognitive deficit Absent Sometimes present
Ventricles Normal Dilated
Response to drugs Good Poor
Prognosis Better Poor

25. Transference and Counter transference

Aspect Transference Counter transference

Meaning Transfer of client’s feeling toward the nurse. Nurse is emotionally dependent on patient.
Types • Negative or hostile transference (feeling of • Reactions of intense love or caring.
anger or enmity that the client has expressed • Reactions of intense disgust or hostility.
toward the nurse). • Reactions of intense anxiety, especially in response to
• Positive or Dependent transference (client is resistance by the patient.
emotionally dependent on nurse).
Know the Differences 465

26. Reassurance and false assurance

Reassurance False assurance

It is a therapeutic technique of communication or counseling. It is a non-therapeutic technique of communication.
Giving psychological support by providing assurance with the Assurance given to the patient with manipulation of fact.
original fact.
Nurse verbalizing to HIV patient that taking antiretroviral If nurse verbalizes to the patient that HIV will get cured soon, it
medications will prolong your lifespan and enhance the is an example of false reassurance.
capacity of daily living is an example of reassurance.

27. Phobia and anxiety

Phobia Anxiety
Phobia is irrational fear of something. Anxiety is defined as, ‘feeling of uncertainty, apprehension,
uneasiness or tensed feeling of an individual to any situation’.

28. Obsession and thought insertion

Obsession Thought insertion

It is one’s own intrusive thoughts that put an individual into Thoughts of others are inserted into patient’s mind.
compulsive acts.

29. Adjustment disorder and post-traumatic stress disorder

Adjustment disorder Post-traumatic stress disorder

Presence of significant behavioral or emotional symptoms in It is an anxiety disorder, in which the individual might experience
response to the psychosocial stressors. stress after an extreme overwhelming traumatic event.
Here, the stressors are within the human experience such as Here, the stressors are outside the human experience such
job loss, marriage, childbirth, divorce, economic problems, as sudden disaster (e.g., earthquake, flood, drought, etc.), or
etc. terrorist attack, severe accidents, etc.

30. Depersonalization and derealization

Depersonalization Derealization
Detachment from one’s own identity or oneself. Individual feels that people or things around him/her are
unreal.

31. Abstract thinking and concrete thinking

Abstract thinking Concrete thinking

It refers to the hidden meaning of the concept or phrase which It gives the literal meaning of the words or sentences and do
is not directly seen. not go beyond the level to explain it.

32. Autistic thinking and realistic rhinking

Autistic thinking Realistic thinking

Thinking which is not real or logical, composed of fantasies and Thinking which is logical and based on the reality.
day dreaming.

33. Déjà vu, Jamais vu, Deja pense, Deja entendu and Jamais entendu

Déjà vu Jamais Vu Deja pense Jamais pense Deja entendu Jamais entendu
Familiar of unfamiliar Unfamiliar of the Familiar of Unfamiliar of the Familiar of Unfamiliar of the
situations familiar situations unfamiliar thoughts familiar thoughts unfamiliar auditory familiar auditory
perception perception
466 Textbook of Psychiatric Nursing for BSc Nursing Students

34. Tics and Tourette syndrome

Tics Tourette syndrome

It is a sudden, repetitive and nonrhythmic motor movement Georges Gilles de la Tourette was the first to identify this
or vocalization which involves discrete muscle groups. neurodevelopmental disorder. Tic disorder for at least one year
duration with the presence of one vocal tics and two motor tics
denotes Tourette syndrome.

35. Eustress and distress

Eustress Distress
Perceives the stress in positive way which improves the overall Feels unpleasant due to the stress which decreases the overall
performance with the effective use of coping mechanism. performance which might lead to physical or mental fatigue.

36. Mental ventilation and catharsis

Mental ventilation Catharsis

Sharing of thoughts or ideas which may or may not be felt as Technique to release the emotional tension by ventilating the
psychological burden to an individual. psychological burden along with emotions.

37. Attention and concentration

Attention Concentration
Focus on the particular thing or concept. Sustained attention is termed concentration.

38. Normal, abnormal and maladaptive behavior

Normal behavior Abnormal behavior Maladaptive behavior

Behavior which adheres to the socially Behavior which has strong deviation from Abnormal behavior persists for the longer
acceptable norms. the socially acceptable norms. duration.

39. Suicide and homicide

Suicide Homicide
Killing oneself Killing others

40. Conversion disorder and somatization disorder

Conversion disorder Somatization disorder

Internal psychological conflicts are exhibited as physical Complaints of recurring and multiple somatic symptoms which
symptoms. are no longer considered diagnosis.

41. Conduct disorder and antisocial personality disorder

Conduct disorder Antisocial personality disorder

Disorder in which the patterns of disruptive and violent or It is a type of personality disorder in which the patterns of
antisocial behavior are present. Individual will have problems in disruptive and violent or antisocial behavior are present.
following rules.
It is usually termed when the antisocial behavior is elicited It is usually termed when the antisocial behavior is elicited
below 18 years of age. above 18 years of age.

42. ICD-11 and DSM-5

ICD-11 DSM-5
International Classification of Diseases – 11th revision Diagnostic Static Manual 5th edition
Codes given by World Health Organization Codes given by American Psychiatric Association
Know the Differences 467

43. Decorticate and decerebrate posture

Aspects Decorticate posture Decerebrate posture

Arms Adducted, flexed Adducted and extended
Wrist Flexed on the chest Pronated
Feet Plantar flexion of the feet Plantar flexion of the feet
Problems in the brain Cerebral hemisphere and cervical spinal tract Pons and midbrain

44. Typical and atypical antipsychotics

Aspects Typical antipsychotics Atypical antipsychotics

Other names First generation Second generation antipsychotics or newer antipsychotics
Antipsychotics or older
Antipsychotics
Extrapyramidal symptoms High risk to get Low risk to get
Side effects More likely to cause More likely to cause metabolic side effects
neurological side effects
Withdrawal symptoms High Less
Example Haloperidol, Clozapine, olanzapine, risperidone, quetiapine, etc.
Chlorpromazine,
Thioridazine, fluphenazine,
etc.

45. Stereognosis and barognosis

Aspects Stereognosis Barognosis

Other names Haptic perception or tactile gnosis Baresthesia
Definition Ability to perceive the object with tactile Ability to evaluate the weight of the objects
perception in the absence of auditory and visual
perception.
468 Textbook of Psychiatric Nursing for BSc Nursing Students

46. Grief and depression

Grief Depression
Intense emotional pain due to the loss of loved ones.
Loss of interest or pleasure due to loss of loved ones. Pervasive loss of interest or pleasure.
Withdrawal from the activities or meeting the person or Withdrawal from the activities in general.
situations due to death.
Intrusive images about the deceased. Intrusive images are uncommon.
Preoccupied with the deceased. Sense of guilt, shame and low Preoccupied with the sense of guilt, shame and low self esteem.
self-esteem related to the deceased.
Pervasive dysphoric mood is present. Emotions might be triggered by the reminders of loss.

47. Sedatives and hypnotics

Sedatives Hypnotics
Drugs produce the calming and relaxing effect. Drugs that induce sleep.
It reduces anxiety. It initiates and maintains the sleep.
Sedatives in larger dose produce hypnotic effect. Hypnotics in larger doses produce the effect of general
anesthesia.
Site of action of this drug is Limbic system. Site of action of this drug is reticular activating system.

48. Hallucination and pseudohallucination

Hallucination Pseudohallucination
Misperception without any external stimuli which occurs in It is false hallucination involuntary sensory experience which
objective space. occurs in subjective space.
Example: Voices heard from outside is termed complex Example: One’s own thought being heard is termed
auditory hallucination. pseudohallucination.

49. Yoga and exercise

Aspects Yoga Exercises

Meaning Integration of body, mind and spirit Physical activity which promotes the
health
Oxygen consumption Reduced Increased
Calorie consumption Moderate to high Low
Movements Rapid Slow and dynamic
Toning of muscle tone Enhances muscle strength but it is not a primary Primary concern
concern
Special equipment Not required Required
Risk of injury Low High
Age restrictions No Elders need to avoid the strenuous
activities

50. Euthymia, euphoria, elation, exaltation and ecstasy

Euthymia Euphoria Elation Exaltation Ecstasy

Normal Mood Mild elevation of mood Moderate elevation of mood Severe elevation of mood Very severe elevation
(Seen in hypomania) with psychomotor agitation with grandiose delusion of mood with extreme
blissfulness
Know the Differences 469

51. Weber’s test and Rinne’s test

Weber’s test Rinne’s test

Test is performed to assess cochlear nerve function. Tuning Test is performed to assess cochlear nerve function. Keep the
fork is kept in middle of head. Normal individuals will hear the tuning fork in mastoid bone and then near to patient’s ear after
sound equally by both ears. If lateralization toward one side is striking it. When air conduction is more than bone conduction,
felt it denotes hearing loss. it is normal. If the bone conduction is more than air conduction
it denotes conductive hearing loss.

52. Indian Lunacy Act and Mental Health Act

Aspects Indian Lunacy Act Mental Health Act

Year of commencement 1912 1987
Chapters 8 10
Act number 4 14
Terms involved Lunatics, Lunatic asylum and Criminal Mentally ill, Psychiatric Hospital, and Nursing
Lunatics homes
Authority No such provision Central and State Mental Health authority
established
License system License has to be obtained to commence and
maintain the psychiatric hospital or nursing
homes.
Out patient facility Established for those who doesn’t need
admission.
Psychiatrist and social workers Included
involved as visitors board member
Voluntary admission Medical officer can admit the voluntary Medical officer has power to admit the
patient with the permission obtained from voluntary patient.
at least two boards of visitors.
Involuntary admission No such provision Medical officer can admit the involuntary
patient with two medical certificates.
Human rights protection No such provision Guidelines established
Inspecting officer Appointed to monitor the hospital facilities,
medical records, patient care and report the
same to licensing authorities.
Leave of absence Guidelines made are less flexible Permitted to all patients except the patients
in prison.

53. Epileptic seizures and dissociative convulsions or hysterical fits

Aspects Epileptic seizures Dissociative convulsions or hysterical fits

Clinical pattern Stereotyped Purposive body movements
Place of incident Anywhere Safe place
Time of day Anytime, even happen during sleep Never happen during sleep
Speech Absent May present
Tongue bite May present Absent
Injury May occur Very rare
Urine and fecal incontinence May occur Very rare
Duration Shorter Prolonged
Turning of head Unilateral Side to side turning is present
Eye gaze Staring gaze if the eyes are open Avoidant gaze
470 Textbook of Psychiatric Nursing for BSc Nursing Students

Aspects Epileptic seizures Dissociative convulsions or hysterical fits

Neurological signs Present Absent
Amnesia Complete Partial
Stress 25% of patients have stress Majority of them have stress
Post-ictal confusion Present Absent
Eeg Abnormal Normal
Serum prolactin Raised in postictal period Normal

54. Oral movements in rabbit syndrome and tardive dyskinesia

Oral movements in rabbit syndrome Oral movements in tardive dyskinesia

Chewing movements are regular and rapid Orofacial choreoathetoid movements are present with
decreased rapidness. Tongue and other parts of the mouth are
not involved
Objective Structured
Clinical Evaluation (OSCE)

INTRODUCTION PURPOSES OF OSCE

Curriculum requires students to integrate basic and clinical • To test each component of clinical competence uniformly
sciences. No single method of assessment can effectively test and objectively for all students.
the three individual aspects of learning, namely knowledge, • To assess the extent of achievement of each student in
attitudes and skill. A vast variety of evaluation procedures are every practical skill.
available for measuring the results of teaching and learning. • To improve the objectivity and reliability of clinical
Evaluation procedure can be classified into qualitative and evaluation.
quantitative techniques. • To evaluate a set of predetermined clinical competencies.
The teaching learning process and evaluation in nursing • To reduce patient and examiner variability.
education are designed on the basis of three domains-
cognitive, affective and psychomotor in varying degrees. IMPORTANCE OF OSCE
Providing fair and reasonable clinical evaluation is one of the • OSCE allows the student to appreciate more on its
most important and most challenging faculty roles. Objective purpose.
structured clinical evaluation was designed to test the clinical • Learners can benefit more from its pedagogical values.
competence while simultaneously improving objectivity and • OSCE allows to institute different modalities including
reliability. the traditional method of studying anatomy on cadavers,
by dissection, manipulation.
MEANING • Exploration of surface anatomy, medical imaging
methods and therapeutic procedures such as open
OSCE is a method of clinical/practical examination where surgery, laparoscopy and arthroscopy.
predetermined decisions are made based on the competencies • In OSCE, multiple stations are designed and each station
to be tested with the use of checklists incorporating important has a specific objective.
skills. The candidates rotate through a number of stations at • OSCE is more objective, reliable and a valid tool to
which they are asked to carry out a specific task. assess practical aspects of integrated problem-based
• ‘O’ stands for Objective. curriculum.
Every student gets the same patient (same chance). • Organization of OSCE requires team work, logistics but
• ‘S’ stands for Structured. at the same time a large number of students can be tested
„ Several skills are tested at one time. with standard setting in a short period of time.
„ Each skill is tested at a separate station. • OSCE appropriately tests students’ grasping power.
„ The examiner has a checklist for doing the marking. • OSCE is motivating, inspiring and interesting.
472 Textbook of Psychiatric Nursing for BSc Nursing Students

• OSCE is based on the curriculum which demands higher • Identify the important learning needs.
cognitive skills. • The blueprint of OSCE is developed as a part of the master
• There is a need to develop objective tools to assess higher blueprint.
cognitive skills like clinical application. • Formulates a blueprint.
• Objectives tested in an OSCE assess higher cognitive • Prepare table of specification.
and psychomotor skills, i.e., ability to relate clinical • Represent every aspect of the course.
information with structural material (plastic models, • Faculty member is assigned for a particular unit/block.
cadaveric specimen, photomicrographs, etc.). • Prepare objectives (Unit/block committee).
• Write questions in accordance with specific objectives.
SKILLS TESTED BY OSCE • The members through a concerted effort correct the
questions as needed.
• OSCE helps to assess the capacity for observation, analysis • Ensure clarity, sound factual content and appropriate
and interpretation.
emphasis on the clinical application.
• OSCE can be structured to achieve the desired mix of
• Ensure that the questions are not ambiguous and the
different elements being assessed, each element receiving
students are able to answer each question within time
the desired weightage.
limit.
• Test skills of identification, interpretation of results in
STATIONS
clinical context.
• The students during the examination move around a • Finally, the questions are sent to the Phase Director who
number of stations spending a specific amount of time at appoints three to six judges to evaluate the questions and
each station. set up minimum pass level, the questions are then handed
• On a signal, he/she moves on to the next station. over to assessment office for execution.
• The time allowed is the same for all the stations. • (A) related to identification of a structure
• The stations must be designed accordingly. 4–10 minutes • (B) a secondary question involving application of
are given at each station. knowledge.

OSCE PROCESS MERITS OF OSCE

• The questions for each station are written in accordance • It is objective, reliable, valid and discriminatory.
with the blueprint of the block. • All students are exposed to same standardized questions.
• Organization of OSCE for the “end of block” examination. • It covers a wide spectrum of learning domains.
• The answer key is prepared before examination. The OSCE • It tests a wide range of skills in a short period of time.
questions (stations) are reviewed by a multidisciplinary • Learning objectives can be achieved.
committee before they are administered. • The content and complexity of the exam can be controlled
• A clinical scenario is given at each station and students by the examiners.
are informed about integrated questions. • It gives a reasonable idea of the achievement of the student
• These would incorporate knowledge components in every objective of practical exercises.
including structural, functional, clinical, radiological and • It helps to test the analytical abilities of students.
microscopic aspects. • Organization is easy.
• For example, for a given clinical scenario, students are • Questions bank can be made.
asked to: • A large number of students can be examined in a short
„ Identify the labeled or tagged structures involved time.
„ Interpret physiological/pathological laboratory data.
„ Identify the labeled structure on a radiograph. DEMERITS OF OSCE

BLUEPRINT FOR OSCE • Substantial faculty hours are required to construct, review
and develop integrated multidisciplinary questions.
• Organize a meeting with the appropriate resource persons, • The availability of quality cadaveric dissections, images,
HODs and faculty. laboratory and physiological data sets.
Objective Structured Clinical Evaluation (OSCE) 473

• It takes a lot of time, effort and team work on the part of • Encircle the station number in your answer books. This
examiners. will be your first station and then follow the sequence.
• All stations must invariably demand equal time, and they • A bell will ring at the beginning of OSCE marking the
require careful organization. start of examination.
• Rotate clockwise around 28 stations including 4 rest
INSTRUCTIONS TO STUDENTS stations spending 90 seconds (1.5 minutes) at each
station.
Before the start of OSCE, the following instructions are given • Clear instructions are given at each station as to what you
to students: should do.
• Bring your own pen/pencils and wear white lab coats. • Do not touch or move the models, specimens or
• Electronic devices like mobile phones, tabs, etc. are not plastinated specimen.
allowed in the examination hall. • Do not move the microscopic slides, only fine adjustments
• Cheating in any respect is strictly prohibited and the knobs can be used.
regulation of the university will be applied. • A bell will ring at the end of examination and remain
• Write your name and ID on each sheet of answer books. at your station from where the answer books will be
• Upon entering the OSCE examination hall, stand on each collected.
station with face opposite to station.

EXAMPLE FOR OSCE IN MENTAL HEALTH NURSING

SET: 1 (OSCE Stations)

OBJECTIVE STRUCTURED CLINICAL EVALUATION (OSCE)

TEST MAP (BASED ON BLUEPRINT)
Blueprint cell Item title (Condition) Competence tested Proposed test item
A 1 Anxious personality disorder Examination Mental status examination

B 2 Couplet (A) assessment on suicidal Diagnostic measures Simulated patient with suicidal ideas
ideas
C 3 Couplet (B) psychotherapeutic Therapeutic procedure Simulated patient with suicidal ideas
counseling
D 4 Violent behavior Identification Simulated patient with violent behavior by
VideoShow (video editing software)
E 5 History collection Simulated patient with paranoid personality
Paranoid personality disorder disorder
F 6 Obsessive compulsive disorder (OCD) Therapeutic procedure Simulated patient with OCD personality
personality order disorder
G 7 Histrionic personality disorder Data interpretation Case scenario

H 8 Narcissistic personality disorder Identification of abnormal Case scenario

finding
I 9 Dependent personality disorder Data interpretation Case scenario
474 Textbook of Psychiatric Nursing for BSc Nursing Students

Sl. Program Domains of clinical experience

no. component
No. of Communication Examination Procedure Cognitive skills
stations
HT OC MSE VSI TP DP IATF DI DM PS

A B C D E F G H I J

1. Anxious 1 1
personality
disorder
2. Couplet (A) 2 1
assessment on
suicidal ideas
3. Couplet (B) 3 1 1 1
psychotherapeutic
counseling
4. Violent behavior 4 1 1 1

5. Paranoid 5 1
personality
disorder
6. OCD personality 6 1 1 1 1
disorder
7. Histrionic 7 1
personality
disorder
8. Narcissistic 8 1 1
personality
disorder
9. Dependent 9 1
personality
disorder
Total

Key Words:
• HT : History taking • DP : Diagnostic procedure
• DI : Data interpretation • VSI : Virtual sign identification
• OC : Other communication • DM : Decision making
• IATF : Identification of abnormal test finding • TP : Therapeutic procedure
• PE : Physical examination • PS : Problem solving
Artifacts for every station:
Simulation Examiner Examinee
Scenario printout Examiner instruction Simulation client
Sheet printout Student response sheet
Evaluation scoring sheet printout Response sheet collection box
Table
Chair
Writing pad
Pen
Eraser
Pencil
Gong bell
Objective Structured Clinical Evaluation (OSCE) 475

STATION 1–ANXIOUS PERSONALITY DISORDER

Instructions to the Examinee

Ms X aged 28 years came with complaint of avoiding social gathering and family functions. Her mind is preoccupied with being
criticized or rejected and she also shows extreme anxiety, nervousness and low self-esteem. She wants to be alone always and feels
embarrassed, blushes and cries. Perform mental status examination.

Participant number: ________ Date: ___________

Instructions to the Examiner

• Observe the examinee, check whether the examinee makes appropriate assessment of the client.
• Consult the examinee about the assessment performed.

Skill Station
Mental status examination

Objectives
At the end of simulation, the examinee:
• Observes and assesses the client
• Documents the disorder
CRITERIA FOR IDENTIFICATION OF TYPES OF PERSONALITY DISORDER
Steps Tasks Scores Yes No
1. Greet the client/establish the rapport 1
2. The examinee asks questions and explores verbal comments/
information
1. Social withdrawal 2
2. Fear of criticism 2
3. Excessive preoccupation with being rejected. 2
4. Extreme anxiety and aloofness 2
3. Interprets signs and symptoms and infers the diagnosis. 1
Total 10

Pass score = 8/10 (80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Instructions for the Simulated Anxious/Avoidant Personality Disorder

You are playing the role of a 28-year-old female having complaint of avoiding social gathering and family functions. Your mind is
preoccupied with being criticized or rejected and you also show extreme anxiety, nervousness and low self-esteem. You want to
be alone always and feel embarrassed, blush and cry and show signs of anxiety in front of others.

OSCE—Response Sheet
Station 1: Mental Status Examination—Anxious personality disorder
Registration No: Documentation—Assessment of mood disturbances for anxious personality disorder
476 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 2–SUICIDAL IDEATION

Instruction to the Examinee

Mr X aged 30 years is a divorcee with complaints of suicidal ideas, sudden changes in mood, passing negative comments on her
parents about future, feeling of extreme sadness, hopelessness and lack of interest in personal appearance, friends and social
activities. He says repeatedly that I want to die and end my life. Assess the warning signs or clues of suicidal ideas.

STATION 2 –COUPLET-(A) SUICIDAL IDEAS (ASSESSMENT)

Register number: ________ Date: ______

Instruction to the Examiner

• Kindly check whether the examinee interprets correctly.
• If the student assesses and identifies the warning signs of suicidal ideas, give 1 mark. If no warning signs are seen, 0 mark
has to be given.

Objectives
At the end of simulation, the examinee:
Assesses and observes the response of the client carefully.
Sl. no. Tasks Scores Yes No
1. Greet and welcome the client with warmth 2
2. Identify the warning signs of suicidal ideas
Behavioral clues: Sudden changes in mood, sadness 2
Verbal clues: I want to die and end my life 2
Situational clues: Client got divorce recently 2
Nonverbal clues: Lack of interest in personal appearance, family and social activities
3. The examinee documents the inference regarding the client’s signs and symptoms 2
Total 10

Pass score = 8/10 (80%)

Student score =____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

STATION 2–COUPLET-(A) ASSESSMENT ON WARNING SIGNS OF SUICIDAL IDEAS

Instruction to the Simulated Suicidal Ideas Patient

You are playing the role of a 30-year-old divorcee with complaints of suicidal ideas, sudden changes in mood, passing negative
comments on your parents about future, feeling of extreme sadness, hopelessness and lack of interest in personal appearance,
friends and social activities. You say repeatedly that I want to die and end my life.

OSCE–RESPONSE SHEET

Station 2 –Couplet-(A) Assessment

Registration no:
Documentation: Assessment
Objective Structured Clinical Evaluation (OSCE) 477

STATION 3–PSYCHOANALYTICAL COUNSELING

Instruction to the Examinee

Mr X aged 30 years is a divorcee with complaints of suicidal ideas, sudden changes in mood, passing negative comments on her
parents about future, feeling of extreme sadness, hopelessness and lack of interest in personal appearance, friends and social
activities. He says repeatedly that I want to die and end my life. There is a need of counseling for behavior modification.

STATION 3–(PSYCHOANALYTICAL COUNSELING)

Register number: ________Date: _______

Instruction to the Examiner

Observe the examinee while counseling the client and assess whether counselor adheres to the steps involved in the checklist
during counseling.

Skill Station
Therapeutic

Objectives
At the end of simulation, the examinee:
Observes, assesses and counsels the client for behavior modification.
CHECKLIST: COUNSELING
Sl. no. Tasks Scores Yes No
1. Greet and welcome the client with warmth 1
2. The examinee tends to promote insight and awareness 2
3. The examinee explores whether the client has reduced
resistance in behavior 2
4. The examinee examines and helps the client for open 2
communication
5. The examinee promotes the client to change behavior 2
through counseling
6. The examinee interprets the change of behavior 1
TOTAL 10

Pass score = 8/10 (80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Instruction to the Simulated Patient with Suicidal Ideation

You are playing the role of a 30-year-old divorcee with complaints of suicidal ideas, sudden changes in mood, passing negative
comments on your parents about future, feeling of extreme sadness, hopelessness and lack of interest in personal appearance,
friends and social activities. You say repeatedly that I want to die and end my life.
478 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 4–VIOLENT BEHAVIOR AND SELECTION OF APPROPRIATE MEDICINE

Instruction to the Examinee

Mrs X aged 25 years has a history of domestic violence toward others and violence to self, and her behavior is cruel toward
others and animals. She frequently engages in assault behavior. She is uncooperative, irrational and feels humiliated. Identify the
condition and write appropriate drug.

Register number: ___________Date: ___________

Instructions to the Examiner

Observe the examinee and consult whether the selection of drug displayed is appropriate.

Skill Station
Virtual identification of diagnosis and analyze the appropriate medication.

Objectives
At the end of simulation, the examinee:
Observes the video and selects the medication displayed.
CRITERIA FOR IDENTIFICATION OF THE DIAGNOSIS AND
SELECTION OF APPROPRIATE MEDICATION
Sl. no. Tasks Scores Yes No
1. Assess the client status 2
2. The examinee observes and identifies the symptoms of violent behavior: 6
• Domestic violent act
• Cruel behavior toward others
• Assault behavior
• Uncooperativeness
• Irrational
• Feels humiliated
3. Identify the client diagnosis and analyze the appropriate medication. 2
Total 10

Pass score = 8/10 (80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Artifacts
• Video tap
• Laptop
• Headset
Objective Structured Clinical Evaluation (OSCE) 479

STATION 5–PREMORBID PERSONALITY ASSESSMENT (HISTORY TAKING)

Instruction to the Examinee

Mrs X aged 38 years has mistrust about all realms of life, has difficulty in maintaining job, feels insecure, assumes her partner to
be unfaithful, and she is stubborn about her suspiciousness. She finds it difficult to maintain intimate relationship with others.
She likes to be alone and self-thinking. She has lack of proper sleep and diet. Assess the premorbid personality of the client.

Register number:_________ Date:________

Instruction to the Examiner

• Observe the examinee while assessing and identifying the personality of the client.
• If the student assesses and identifies the component of personality, give 1 mark. Else, 0 mark has to be given.

Skill Station
Assessment—History collection

Objectives
At the end of assessment, the examinee:
• Identifies the personality of the client
• Documents the inference of the client

Sl. no. Tasks Scores Yes No

1. Establish rapport with the client 1
2. The examinee asks lead questions and explores verbal comments/information: 1
• On attitude to self (hopes and attitude) 1
• Social relationships (relationship with family, friends and others) 1
• Moral and religious standards 1
• Responsibility at work place (relationship with coworkers, job satisfaction) 1
• Mood (love, anger, frustration) 1
• Habits (sleeping, eating, elimination) 1
• Fantasy life (daydreaming) 1
3. The examinee documents the inference regarding the client’s premorbid personality. 1
TOTAL 10

Pass score = 8/10 (80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Instruction to the Simulated Patient

You are playing the role of a 38-year-old female who has mistrust about all realms of life, difficulty in maintaining job, feels
insecure and assumes her partner to be unfaithful. You are stubborn about your suspiciousness. You find it difficult to maintain
intimate relationship with others. You like to be alone and self-thinking. You have lack of proper sleep and diet.
480 Textbook of Psychiatric Nursing for BSc Nursing Students

Instruction to the Informant of Simulated Patient

You are playing the role of a parent of a 38-year-old female who has mistrust about all realms of life, difficulty in maintaining
job, feels insecure and assumes her partner to be unfaithful. She is stubborn about her suspiciousness. She faces difficulty in
maintaining intimate relationship with others. She likes to be alone and self-thinking and has lack of proper sleep and diet.

STATION 6–COUNSELING FOR BEHAVIOR MODIFICATION

(PATIENT WITH OCD PERSONALITY DISORDER)

Instruction to the Examinee

Ms X aged 25 years washes hands at regular intervals throughout the day due to fear of contamination and arranges household
things perfectly. She performs tasks to seek relief from anxiety. She has some stereotyped behavior such as repeated clearing of
throat and counting steps.

Participant number:________ Date:___________

Instructions to the Examiner

Observe the examinee while counseling the client and assess whether counselor adheres to the steps provided in the checklist
during counseling.

Skill Station
Therapeutic

Objectives
At the end of simulation, the examinee:
• Observes and assesses the client
• Counsels the client for behavior modification
CHECKLIST: COUNSELING
Sl. no. Tasks Scores Yes No
1. Greet and welcome the client with warmth 1
2. Assess the client’s symptoms and confirm the condition 1
3. The examinee explains the situation and encourages to utilize coping strategies 2
to overcome problems
4. The examinee encourages the client to constantly observe his/her behavior and 2
teaches to utilize “self-control technique” to overcome ritualistic behavior.
5. The examinee explores some diversional activities to divert the client’s mind 2
6. The examinee examines and helps the client for open communication 1
7. The examine interprets the change of OCD behavior 1
Total 10

Pass score = 4/5 (80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Objective Structured Clinical Evaluation (OSCE) 481

Instructions to the Simulated Client

You are playing the role of a 25-year-old female who washes hands at regular intervals throughout the day due to fear of
contamination and arranges household things perfectly. You perform tasks to seek relief from anxiety. You have some stereotyped
behavior such as repeated clearing of throat and counting steps.

STATION 7–DIAGNOSIS AND MANAGEMENT OF HISTRIONIC PERSONALITY DISORDER

Instruction to the Examinee
Ms X aged 25 years is admitted in female ward with complaints of excessive emotionality and attention-seeking behavior,
excessive concern about her physical appearance, and self-centeredness. She shows very poor tolerance of frustration and delayed
gratification, and exhibits suicidal attempts frequently.
Answer the following questions:
1. Identify the condition.
2. List out any two symptoms.
3. Write any three nursing management steps.

Participant number: ________ Date: ___________

Instructions to the Examiner

Identify the correct answer and give scores.

Skill Station
Unmanned

Objective
At the end of assessment, analyze the examinee’s critical thinking and decision making.
CRITERIA FOR IDENTIFICATION OF DIAGNOSIS AND APPROPRIATE MANAGEMENT
Sl. no. Tasks Scores Yes No
1. Histrionic personality disorder 2
2. • Traumatic emotionality 2
• Constance seeking of reassurance
Others: self-centered, poor tolerance
3. Nursing management. 2
• Establish and maintain therapeutic nurse-client relationship
• Provide immediate positive feedback 2
• Provide safe and calm environment
Others: Promo te effective communication strategies 2
Total 10

Pass score = 8/10 (80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

482 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 8–IDENTIFY THE TYPES OF NARCISSISTIC PERSONALITY

Instruction to the Examinee

Read the scenario carefully and identify the type of narcissistic personality and document it.
• Scenario 1: People who are more self-centered.
• Scenario 2: Intense contempt for themselves, but projects outward into others: drives other people away from them by
hypercritical and jealous comments and behavior
• Scenario 3: Enjoys with superiority feelings by manipulating the situations.
• Scenario 4: People who tend to be aggressive, athletic, exhibitionistic, enjoy by showing off body, clothes and overall
manliness.

STATION 8

Participant number: ________ Date: ___________

Instructions to the Examiner

Identify the correct answer and give scores.

Skill Station
Unmanned

Objective
At the end of assessment, analyze the examinee’s critical thinking and decision making.
CRITERIA FOR IDENTIFICATION OF SUBTYPES OF NARCISSISTIC PERSONALITY DISORDER
Sl. no. Tasks Scores Yes No
1. Craving narcissists 2
2. Paranoid narcissists 2
3. Manipulative narcissists 2
4. Phallic narcissists 2
5. Inference and documentation 2
Total 10

Pass score = 8/10 (80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Objective Structured Clinical Evaluation (OSCE) 483

STATION 9–DEPENDENT PERSONALITY DISORDER

Instruction to the Examinee

Mrs X aged 35 years came with complaints of fear of separation, strong need for constant reassurance and support. She expects
subordination for her own needs, faces difficulties in decision making and exhibits low self-esteem and self-confidence.
Answer the following:
1. Identify the type of personality disorder.
2. Mention any two drug therapy.
3. Mention any two therapeutic management needed.
4. Write one possible nursing diagnosis based on symptoms.

STATION 9

Participant number: ________ Date:___________

Instructions to the Examiner

Identify the correct answer and give scores.

Skill Station
Unmanned

Objective
At the end of assessment, analyze the examinee’s critical thinking and decision making.
CHECKLIST FOR SCORING
Sl. no. Tasks Scores Yes No
1. Dependent personality disorder 2
2. Antidepressants 4
Sedative and tranquilizers
3. Psychotherapy 2
Cognitive behavior therapy
4. Fear and anxiety related to separation as evidenced by facial expression 2
Total 10

Pass score = 8/10 (80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

484 Textbook of Psychiatric Nursing for BSc Nursing Students

TEST MAP (BASED ON BLUEPRINT)

Blueprint cell Item title (condition) Competence tested Proposed test item
A 1 Positive reinforcement Examination Simulated child with habit of thumb sucking
B 2 Amnesia Assessment Visual image
C 3 Psychometric Assessment Assessment Visual image
D 4 Admission procedure Examination Simulated patient
E 5 Paraphilias Assessment
F 6 Dysgraphia Assessment Simulated video
G 7 Dyscalculia Assessment Simulated video
H 8 Discharge procedure Assessment

Sl. no. Program component Domains of clinical experience

Communication Examination Procedure Cognitive skills
HT OC MSE VSI TP DP IATF DI DM PS
A B C D E F G H I J
1. Positive reinforcement 1
2. Amnesia 1 1
3. Psychometric assessment 1 1
4. Admission procedure 1 1
5. paraphilia 1
6. Dysgraphia 1 1
7. Dyscalculia 1
8. Discharge procedure 1
Total

Key words:
• VSI : Virtual sign identification • IATF : Identification of abnormal test finding
• HT : History taking • TP : Therapeutic procedure
• DI : Data interpretation • PE : Physical examination
• DM : Decision making • DP : Diagnostic procedure
• OC : Other communication • PS : Problem solving
Objective Structured Clinical Evaluation (OSCE) 485

STATION 10–BEHAVIOR THERAPY- POSITIVE REINFORCEMENT

Instruction to the Examinee

Mr X aged 8 years is brought to the child guidance clinic by his parents, with the habit of thumb sucking. He is not able to
concentrate on his studies, has poor academic performance, does not interact with others, and shows frustration and sleeplessness.
• Identify the problems of the child.
• Use the appropriate behavior technique to resolve his problem.
• Implement appropriate behavior technique.
• Mention any two suggestions for family counseling.

Participant number: ________ Date: ___________

Instructions to the Examiner

• Observe the examinee, check whether the examinee makes appropriate assessment of the client.
• If the student assesses and identifies the behavior technique give 1 mark. If the student does not identify the behavior
technique, 0 mark has to be given.

Skill Station
Manned station–behavior therapy – Positive reinforcement

Objective
At the end of simulation, the examinee assesses and observes the response of the client carefully.
Criteria for Using Behavior Therapy—Positive Reinforcement
Steps Tasks Scores Yes No
1. Greet the child and parents/establish rapport 2
2. Assess the problems of the child by observing and obtaining information from parents 2
Thumb sucking
3. Identify the appropriate behavior technique to resolve his thumb sucking 2
Behavior therapy-positive reinforcement
Give some token for his inappropriate behavior (not sucking the thumb)
4. Give any two appropriate suggestions to the family 4
• Always start by talking to your child about why thumb sucking is a bad habit. Positive
motivation to quit is half the battle.
• Thumb and finger sucking spreads germs and makes people sick.
• Sucking pushes teeth forward and can make you look funny, and you might need brace.
• Other kids will think you are still a baby or might tease.
• As long as you suck your thumb, it is hard to learn how to speak the right way. You
might sound funny.
Sticker chart or positive reward system: Make a sticker chart and provide lots of praise
and positive rewards for success. At first, your child might need a sticker for every hour he
or she goes without sucking.
Praise, all day: Find a way to remind yourself or your child’s caregiver to praise your child
for not sucking at least once an hour. Consider setting an alarm or reminder on your phone.
Total 10

Pass score = 4/ 5(80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

486 Textbook of Psychiatric Nursing for BSc Nursing Students

Instructions to the Simulated Child with Habits of Thumb Sucking

You are playing the role of a 8-year-old child who has the habit of thumb sucking, is not able to concentrate on his studies, has
poor academic performance, does not interact with others, and shows frustration and sleeplessness.
Station 10: Behavior therapy
Registration no:
Documentation: Asses the problems of the child and provide family counseling.

STATION 11–AMNESIA
Instruction to the Examinee
Mr Surya aged 40 years who met with an accident was admitted in male acute ward with complaints of head injury, inability to
recall, and confusion about time and place.
• Identify the symptoms and mention the condition
• Formulate a nursing diagnosis
• Write three nursing interventions.

STATION 11

Register number: _______ Date: ______

Instruction to the Examiner

• Kindly check whether the examinee interprets correctly.
• If the student assesses and identifies the symptoms, give 1 mark. If the student does not assess and identify the symptoms,
0 mark has to be given.

Skill Station
Unmanned Station–Amnesia

Objectives
At the end of simulation, the examinee:
• Identifies the symptoms
• Formulates a nursing diagnosis
• Writes nursing interventions
Sl. no. Tasks Scores Yes No
1. Identify the picture and mention the symptoms 2
Amnesia
2. Impaired memory as evidenced by memory loss/ behavioral changes 2
Chronic confusion related to memory impairment
3. Nursing interventions: 6
• Using memory aid
• Use object cues: A timer set to remind the persons to turn off the stove
• Use telephone reminders for a person who remains unsupervised at home
• Identify family members or support systems
• Use reminiscence therapy
Total 10

Pass score = 4/5 (80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Objective Structured Clinical Evaluation (OSCE) 487

STATION 12–PSYCHOMETRIC ASSESSMENT

Instruction to the Examinee

Identify the types of psychological tests in psychometric assessment and abbreviate the questionnaire.

Picture completion test Ink blot test

Arrangement of equipment Fire accident—what is your immediate action?

MMPI stands for?

488 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 12

Register number: ________Date: ________

Instruction to the Examiner

Identify the appropriate type of psychological test and abbreviate the questionnaire.

Skill Station
Unmanned Station — Identify the name of the test by visualization

Objectives
At the end of simulation, the examinee:
• Identifies the appropriate psychological test
• Abbreviates the questionnaire.

Sl. no. Tasks Scores Yes/No

1. Identify the appropriate psychological test
2
Picture completion test—Intelligence test

2
Ink blot test—Personality test

2
Arrangement of equipment—Aptitude test

2
Fire accident—what is your immediate action?—Attitude test

MMPI—Minnesota Multiphasic Personality Inventory

TOTAL 10

Pass score= 4/5 (80%)

Student score=____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Objective Structured Clinical Evaluation (OSCE) 489

STATION 13–ADMISSION PROCEDURE

Instructions to the Examinee

A woman aged 45 years is looking untidy, wandering on the street, and does not know about her identity.
• What is your immediate action?
• Mention any three types of admission.
• Which type of admission you will prefer?

Register number: _______Date: ______

Instruction to the Examiner

• Observe the examinee, check whether the examinee makes appropriate assessment of the client.
• If the student assesses and identifies the types of admission, each type give 1 mark, else 0 mark has to be given.

Skill Station
Manned Station—Admission Procedure

Objectives
At the end of assessment, the examinee:
• Is able to take immediate response
• Enlists the types of admission
• Documents the admission type.

Sl. no. Tasks Scores Yes No

1. Immediate response of the examinee 2
Calling the police
2. Any three types of admission
• Admission on voluntarily basis
• Admission under special circumstances 2
• Admission under reception order 2
• Admission through police 2
3. Which type of admission will suit this scenario? 2
Admitted by police
TOTAL 10

Pass score = 4/5 (80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

490 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 14–SEXUAL DISORDER

Instructions to the Examinee

Mr X aged 45 years comes with complaints that he is very fond of nonliving objects associated with human body, frequently
wears the clothes of opposite sex and has intimate relationship with pet animals.
• Identify the classification of disorder.
• Mention three signs and symptoms.
• What type of therapy can be given?

STATION 14

Participant number: ________ Date: ___________

Instructions to the Examiner

• Observe the examinee, check whether the examinee makes appropriate assessment of the client.
• If the student assesses and identifies the sexual disorder, its signs or symptoms and therapy, each type give 2 mark, else 0
mark has to be given.

Skill Station
Unmanned Station—Analyze the appropriate types of disorder.

Objective
At the end of simulation, the examinee identifies the disorder and symptoms.
Criteria for Examinee Regarding Identification of Symptoms and Therapy
Sl. no. Tasks Scores Yes No
1. Classifications of disorder
Sexual disorder 2
2. Three sign and symptoms
• Fetishism 2
• Transvestism 2
• Zoophilia 2
3. Therapy
Aversion therapy 2
TOTAL 10

Pass score = 4/5 (80%)

Student score =____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Objective Structured Clinical Evaluation (OSCE) 491

STATION 15–PERVASIVE DEVELOPMENTAL DISORDER-DYSGRAPHIA

Instructions to the Examinee

• Observe the video and identify the disorder
• Make a nursing diagnosis
• Write three possible nursing interventions

Participant number: ________ Date: ___________

Instructions to the Examiner

• Observe the examinee, check whether the examinee makes appropriate assessment of the client.
• If the student assesses and identifies the name of disorder, its skill deficit and any three nursing interventions; each type give
2 mark, else 0 mark has to be given.

Skill Station
Unmanned Station—Virtual identification and analysis of the disorder

Objectives
At the end of simulation, the examinee:
• Identifies the type of disorder
• Identifies the skill which is deficient in the child
• Writes three nursing interventions for improving skill

Sl. no. Tasks Scores Yes No

1. Classifications of disorder 2
Pervasive developmental disorder—dysgraphia
2. Skill deficit
Difficulty in writing 2
3. Any three nursing interventions: 6
• Helps the child to hold pen
• Additional time to copy
• Don’t penalize spelling error
• Breakdown the assignments
Total 10

Pass score = 4/5 (80%)

Student score =____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

492 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 16–DYSCALCULIA

Instruction to the Examinee

• Observe the video and identify the disorder.
• Which skill is deficient for the child?
• Write three possible nursing interventions for improving the skill.

STATION 16

Participant number: ________ Date: ___________

Instructions to the Examiner

• Observe the examinee, check whether the examinee makes appropriate assessment of the client.
• If the student assesses and identifies the name of disorder, its skill deficit and any three nursing interventions; each type give
2 mark, else 0 mark has to be given.

Skill Station
Unmanned station and virtual identification

Objectives
At the end of simulation, the examinee:
• Identifies types of disorder
• Makes a nursing diagnosis
• Writes three nursing interventions

Sl. no. Tasks Scores Yes No

1. Classifications of disorder 2
Pervasive developmental disorder- dyscalculia
2. Skill deficit:
Difficulty in working with numbers or maths 2
3. Any three nursing interventions:
• Allow extra time 2
• Use games, colors, images to identify the number 2
• Use fingers to count the numbers 2
TOTAL 10

Pass score = 4/5 (80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Objective Structured Clinical Evaluation (OSCE) 493

STATION 17– DISCHARGE PROCEDURE

Instruction to the Examinee

Mr X is 45 years old man was admitted in psychiatric hospital. After the treatment he is about to discharge. mention the different
types of discharge has been possible to Mr X
Mention different aspects of discharge procedure.

STATION 17

Participant number: ________ Date: __________

Instruction to the Examiner

If the student assesses and identifies the types of admission, each type give 1 mark. Else 0 mark has to be given.

Skill Station
Assessment—Discharge

Objectives
At the end of assessment, the examinee enlists the types of discharge procedure

Sl. no. Tasks Scores Yes No

1. Types of procedure
• Discharge on voluntary basis 2
• Discharge under special circumstances 2
• Discharge under reception order 2
• Discharge admitted by police 2
• Leave absence 2
TOTAL 10

Pass score = 4/5 (80%)

Student score =____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

494 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 18–PREMORBID PERSONALITY ASSESSMENT (HISTORY TAKING)

Instruction to the Examinee

Mrs X aged 45 years shows loss of interest, helplessness, hopelessness, lack of activity, inappropriate guilt, and feels tired and
worthless. Assess the premorbid personality of the client.

Instructions to the Examiner

• Observe the examinee while assessing and identifying the personality of the client.
• If the student assesses and identifies the component of personality, give 1 mark. Else 0 mark has to be given.

Skill Station
Manned station: Assessment—History collection

Objectives
At the end of assessment, the examinee:
• Identifies the personality of the client.
• Documents the inference of the client.

Sl. no. Tasks Max. Registration no. and marks obtained

marks

1. Establishes rapport with the client 1

2. The examinee asks lead questions and explores verbal 1
comments/information
3. • On attitude to self (hopes and attitude) 1
• Social relationships (relationship with family, friends 1
and others)
• Moral and religious standards 1
• Responsibility at work place (relationship with 1
coworkers, job satisfaction)
• Mood (love, anger, frustration) 1
• Habits (sleeping, eating, elimination) 1
• Fantasy life (daydreaming) 1
4. The examinee documents the inference regarding the 1
client’s premorbid condition.
TOTAL 10

Pass score = 8/10 (80)

Signature of the internal examiner Signature of the external examiner

Objective Structured Clinical Evaluation (OSCE) 495

STATION 19–CAGE QUESTIONNAIRE AND PSYCHOLOGICAL TEST

Instruction to the Examinee

Mr X aged 35 years has complaints of hand tremors and visual hallucination, and has been diagnosed with chronic alcoholism,
Identify the appropriate psychological test and abbreviate the questionnaire.

Instruction to the Examiner

Observe the examinee while identifying the appropriate psychological test and abbreviating the questionnaire.

Skill Station
Therapeutic

Objectives
At the end of simulation, the examinee:
• Identifies the appropriate psychological test.
• Abbreviates the questionnaire.

Sl. no. Tasks Max. Registration no. and marks obtained

marks

1. Identify the appropriate psychological test 2

2. Abbreviation
C – Have you ever had to cut down alcohol
intake? 2
A – Have you ever been annoyed by people 2
criticizing alcohol? 2
G – Have you ever felt guilty about drinking? 2
E – Have you ever needed an eye opener drink?
TOTAL 10

Pass score = 8/ 10 (80)

Signature of the internal examiner Signature of the external examiner

496 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 20–OBSESSIVE COMPULSIVE DISORDER, CHECKERS

Instruction to the Examinee

Mrs X aged 45 years has repeated multiple doubts of the door not being locked and gas knob being left open, and she continues
to check to remove her doubt.
• Identify the clinical type.
• Mention three psychopharmacological treatment.
• Write the appropriate therapy for the particular condition.

Instruction to the Examiner

Kindly check whether the examinee identifies the symptoms correctly and infers the diagnosis and its pharmacological treatment,
therapies.

Skill Station
Therapeutic

Objectives
At the end of assessment, the examinee:
• Identifies the clinical type.
• Specifies the psychopharmacological treatment and its therapy.

Sl. no. Tasks Max. Registration no. and marks obtained

marks

1. Obsessive Compulsive Disorder—Checkers 2

2. Psychopharmacological Treatment
• Antidepressants—Clomipramine 75–300 2
mg/day, Fluoxetine 20–80 mg/day
• Benzodiazepines—Alprazolam, 2
Clonazepam.
• Antipsychotics—Haloperidol, risperidone, 2
Olanzapine.
3. Therapy 2
Thought stoppage technique
TOTAL 10

Pass score = 8/10 (80)

Signature of the internal examiner Signature of the external examiner

Objective Structured Clinical Evaluation (OSCE) 497

STATION 21–SOMATOFORM DISORDER–THERAPEUTIC PROCEDURE

Instruction to the Examinee

Ms Y, a 19-year-old student of college, always takes 4–5 days leave prior to menstruation and complains of headache, irritability,
depression, crying spells, anxiety and restlessness. From college, it was reported that she has been unable to write examination
due to lack of attendance. Identify the possible diagnosis and write three possible etiological factors.

Instruction to the Examiner

Observe the examinee for identification of provisional diagnosis and plan for nursing interventions.

Skill Station
Simulated patient for identification of diagnosis and three etiological factors.

Objectives
At the end of simulation, the examinee enhances the Client’s ability to cope with her menstruation process.

Sl. no. Tasks Max. Registration no. and marks obtained

marks

1. Greet the patient and establish rapport with 2

the patient.
2. Identification of provisional diagnosis— 2
Somatoform autonomic dysfunction—
Premenstrual syndrome
3. Etiology: 6
• Biological factors—Faulty luteinization,
Excess of estrogen and progesterone
deficiency.
• Psychological factors—education,
expectations and attitudes toward
menstruation and femineity.
• Social factors—environmental factors
Total 10

Pass score = 8/10 (80)

Signature of the internal examiner Signature of the external examiner

498 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 22–OBSESSIVE COMPULSIVE DISORDER

Instruction to the Examinee

Ms Y aged 25 years washes hands at regular intervals throughout the day due to fear of contamination and arranges household
things perfectly. She performs tasks to seek relief from anxiety. She has some stereotyped behavior such as repeated clearing of
throat and counting steps. Counsel the client with appropriate measures.

Instructions to the Examiner

Observe the examinee while counseling the client and assess whether counselor adheres to the steps given in the checklist during
counseling.

Skill Station
Manned Station: Therapeutic

Objective
At the end of simulation, the examinee observes, assesses and counsels the client for behavior modification.
CHECKLIST: COUNSELING
Sl. no. Tasks Max. Registration no. and marks obtained
marks

1. Greet and welcome the client with warmth 1

2. Assess the client’s symptoms and confirm the 1
condition
3. The examinee explains the situation and encourages 1
to utilize coping strategies to overcome problems
4. The examinee encourages the client to constantly 2
observe his/her behavior and teaches to utilize “self-
control technique” to overcome ritualistic behavior.
5. The examinee explores some diversional activities to 2
divert the client’s mind
6. The examinee examines and helps the client for open 2
communication
7. The examinee interprets the change of OCD behavior 1
TOTAL 10

Pass score = 4/5 (80%)

Signature of the internal examiner Signature of the external examiner

Objective Structured Clinical Evaluation (OSCE) 499

STATION 23–HISTRIONIC PERSONALITY DISORDER

Instruction to the Examinee

Ms X aged 25 years is admitted in female ward with complaints of excessive emotionality and attention-seeking behavior,
excessive concern about her physical appearance, and self-centeredness. She shows very poor tolerance of frustration and delayed
gratification, and exhibits suicidal attempts frequently.
Answer the following questions:
• Identify the condition.
• List out any two symptoms.
• Write any three nursing management steps.

Instruction to the Examiner

Identify the correct answer and give scores.

Skill Station
Unmanned

Objective
At the end of assessment, analyze the examinee’s critical thinking and decision making.
CRITERIA FOR IDENTIFICATION OF DIAGNOSIS AND APPROPRIATE MANAGEMENT
Sl. no. Tasks Max. Registration no. and marks obtained
marks

1. Histrionic personality disorder 2

2. • Traumatic emotionality 2
• Constance seeking of reassurance
Others: self-centered, poor tolerance
3. Nursing management:
• Establish and maintain therapeutic nurse-client 2
relationship
• Provide immediate positive feedback 2
• Provide safe and calm environment 2
Others: Promote effective communication
strategies
TOTAL 10

Pass score = 8/10 (80)

Signature of the internal examiner Signature of the external examiner

500 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 24–PICA

Instruction to the Examinee

Mr X aged 7 years is admitted to the child psychiatry ward with complaints of abdominal pain and distension. Examination
shows long pink and round worms in stool. Blood count shows eosinophilia. Her mother told he has a habit of eating non-food
items such as mud and paper.
Answer the following:
• What is the diagnosis related to these problems?
• Mention any two etiologies.
• Draw three possible nursing diagnosis based on the complaints.

Instructions to the Examiner

• Kindly check whether the examinee interprets correctly.
• If the student answers correctly, give 1 mark. Else 0 mark has to be given.

Objectives
At the end of simulation, the examinee:
• Is able to identify the symptoms
• Formulates a nursing diagnosis

Sl. no. Tasks Max. Registration no. and marks obtained

marks

1. PICA 2
2. Nutritional deficiency 2
Psychological factors
3. Nursing Diagnosis 2
• Acute pain (abdomen) related to disease
condition as evidenced by facial expression
• Imbalanced nutrition pattern less than body 2
requirement related to unhealthy eating habit
as evidenced by weight loss
• Disturbed bowel elimination related to worm 2
infestation as evidenced by the presence of
round worm in stool
TOTAL 10

Pass score= 8/10 (80)

Signature of the internal examiner Signature of the external examiner

Objective Structured Clinical Evaluation (OSCE) 501

STATION 25–IDENTIFICATION OF TYPES OF DELUSIONS

Instruction to the Examinee

Observe the images and identify the types of delusions.

(1) (2) (3)

(4) (5)

Instruction to the Examiner

• Kindly check whether the examinee interprets correctly.
• If the student answers correctly, give 1 mark. Else 0 mark has to be given.

Objectives
At the end of simulation, the examinee:
• Is able to identify the types of delusions
• Is able to document the types of delusions

Sl. no. Tasks Max. Registration no. and marks obtained

marks

1. Delusion of grandeur 2
2. Delusion of persecution 2
3. Delusion of infidelity 2
4. Hypochondriacal delusions 2
5. Delusion reference 2
TOTAL 10

Pass score = 8/10 (80)

Signature of the internal examiner Signature of the external examiner

502 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 26–IDENTIFICATION OF THERAPY (THERAPEUTIC PROCEDURE)

Instruction to the Examinee

Identify the name of the therapy which involves the patient in his/her own environment to provide therapeutic experience.
Answer the following:
• Name of the therapy.
• Write any one objective of the therapy.
• List out two elements of the therapy.
• List out two advantages of the therapy.
• Enlist two disadvantages of the therapy.

Instructions to the Examiner

• Kindly check whether the examinee interprets correctly.
• If the student answers correctly, give 1 mark. Else 0 mark has to be given.

Objective
At the end, the examinee identifies the name of the therapy which involves the patient in his/her own environment to provide
therapeutic experience.

Sl. no. Tasks Max. Registration no. and marks obtained

marks

1. Milieu therapy 2
2. Objective: To use patient’s social environment to 2
provide a therapeutic experience.
3. Two elements: 2
1. Free communication
2. Shared responsibilities
4. Two advantages: 2
1. Gains self-confidence
2. Develops leadership skills
5. Two disadvantages: 2
1. Role blurring between staff and patients.
2. Group responsibilities can easily become
nobody’s responsibility.
TOTAL 10

Pass score = 8/10 (80)

Signature of the internal examiner Signature of the external examiner

Objective Structured Clinical Evaluation (OSCE) 503

STATION 27–DRUG IDENTIFICATION (THERAPEUTIC PROCEDURE)

Instruction to the Examinee

Mr X aged 45 years shows loss of interest, helplessness, hopelessness, lack of activity, inappropriate guilt, and feels tired and
worthless. Identify the diagnosis and the type of drug prescribed for Mr X.
Read the questions carefully and document the answers.
• Identify the diagnosis.
• Identify the type of drug.
• Enlist two indications of the drug.
• Enumerate two contraindications of the drug.
• Enlist two side effects of the drug.

Instructions to the Examiner

• Kindly check whether the examinee interprets correctly.
• If the student answers correctly, give 1 mark. Else 0 mark has to be given.

Objectives
Examinee will be able to identify the anti-depressants has been appropriate to treat depression. Moreover examinee will list out
the indications, contra-indications and side effects of the same.

Skill Station
Assessment (Drug identification)
The examinee has to identify the disorder and prescribe the type of drug, and observe indications, contraindications, actions and
side effects.

Sl. no. Tasks Max. Registration no. and marks obtained

marks

1. Depression 2
2. Antidepressants 2
3. Two indications: 2
1. Depressed mood
2. Agitation
4. Two contraindications: 2
1. Type 1 and Type 2 diabetes mellitus
2. Epilepsy
5. Two side effects of the drug: 2
1. Blurred vision
2. Drowsiness
TOTAL 10

Pass score = 8/10 (80)

Signature of the internal examiner Signature of the external examiner

504 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 28–GENERALIZED ANXIETY DISORDER

Instruction to the Examinee

Ms X aged 15 years is studying in 10th standard and waiting for public examination. She is admitted in inpatient ward with
complaints of tremors, sweating, poor concentration in studies and unpleasant and vague sense of apprehension.
• Identify the possible diagnosis.
• Formulate one nursing diagnosis.
• Write three possible nursing interventions.

Instructions to the Examiner

Observe the examinee for identification of provisional diagnosis and plan nursing intervention.

Skill Station
Identification of diagnosis and planning nursing interventions.

Objective
At the end, the examinee prepares the client to cope with her studies.

Sl. no. Tasks Max. Registration no. and marks obtained

marks

1. Identification of provisional diagnosis – 2

Generalized anxiety disorder.
2. Nursing diagnosis: 2
1.
3. Nursing interventions: 6
Specify the client’s identification of threat.

Discuss the reality of situation wopith the client

Include the client in making decisions related to

selection of alternative coping strategies.
TOTAL 10

Pass score = 8/10 (80)

Signature of the internal examiner Signature of the external examiner

Objective Structured Clinical Evaluation (OSCE) 505

STATION 29–DEPRESSIVE DISORDER

Instructions to the Examinee

You have video in the laptop, switch on and watch it.
• Observe the symptoms and infer the provisional diagnosis.
• Formulate appropriate nursing diagnosis for this video.
• Write three nursing interventions for this diagnosis.

Instructions to the Examiner

Kindly check whether the examinee observes the video, identifies the symptoms correctly and infers the diagnosis and its nursing
interventions promptly.

Skill Station
(Virtual Sign Identification)

Objectives
At the end of the VideoShow, the examinee observes and documents the response about the VideoShow carefully.
Sl. no. Tasks Max. Registration no. and marks obtained
marks

1. Infers the diagnosis—Depression 2

2. Nursing diagnosis—Disturbed mood (Depressed) 2
related to disease condition as evidenced by
facial expression
3. Nursing interventions: 6
• Assess the client’s coping abilities
• Help the client meet psychological needs
• Help the client cope with current situation
TOTAL 10

Pass score = 8/10 (80)

Signature of the internal examiner Signature of the external examiner

506 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 30–MANIA

Instruction to the Examinee

Ms Y aged 36 years came with complaints of having severe elevation of mood, restless with on – the - toe –on – the - go activity,
having increased thoughts and talks about politics, cine field, normal public, economics and so on for the past one month.
Collect the history from the informant, write the presenting chief complaints and document the provisional diagnosis.
Participant number: ________ Date: ___________

Instructions to the Examiner

• Observe the examinee, check whether the examinee collects appropriate history from the informant.
• Consult the examinee about the provisional diagnosis of the patient.

Skill Station
History Taking

Objectives
At the end of the session, the examinee communicates, collects history from the informant and identifies the provisional
diagnosis.
Criteria for Identification of Mania
Steps Tasks Scores Yes No
1. Greet the client and informant/establish rapport with them. 2
2. The examinee asks questions and specifies verbal comments/information
• Exaltation
• Increased psychomotor activity 6
• Thought racing
3. Document the provisional diagnosis. 2
Total 10

Pass score = 8/10 (80%)

Student score = ____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Instructions to the Simulated Patient—Mania

You are playing the role of Ms Y aged 36 years who came with complaints of having severe elevation of mood, restless with on –
the – toe – on – the – go activity, having increased thoughts and talks about politics, cine field, normal public , economics and so
on for the past one month.

Instruction to the Informant

You are the mother of Ms Y, who has chief complaints of having severe elevation of mood, restless with on – the – toe – on – the
– go activity, having increased thoughts and talks about politics, cine field, normal public, economics and so on for the past one
month. Narrate the chief complaints about the patient when examinee collects history.
Objective Structured Clinical Evaluation (OSCE) 507

STATION 31–BIPOLAR MOOD DISORDER-VIRTUAL SIGN IDENTIFICATION

Instructions to the Examinee

You have video in the laptop, switch on and watch it.
• Write the clinical picture of bipolar affective disorder.
• Observe and identify the symptoms.
• Infer the provisional diagnosis.

Participant number: _________ Date: _________

Instruction to the Examiner

Kindly check whether the examinee writes the clinical picture, identifies the symptoms correctly and infers the diagnosis
promptly.

Objectives
At the end of the VideoShow, the examinee observes and documents the response about the VideoShow carefully.

Sl. no. Tasks Scores Yes No

1. The examinee writes the clinical picture about bipolar affective disorder 2

2. The examinee identifies the signs and symptoms:

• Mood swings 2
• Speech disturbances 2
• Hyperactivity 2
3. Infers the diagnosis—Bipolar affective disorder 2
Total 10

Pass score = 4/5 (80%)

Student score =____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

508 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 32–PHOBIA-DIAGNOSTIC PROCEDURE

Instruction to the Examinee

Ms X aged 19 years is unable to perform activities in the college in front of faculty including classmates and does not participate
in group activities and avoids these activities by being continuously absent from the college. She is diagnosed to have social
phobia.
• Define social phobia.
• Specify the ICD-10 Classification.
• Mention the specific psychosocial therapy which can be used to alleviate the symptoms.

Register number: _________ Date: _________

Instruction to the Examiner

Observe the examinee whether she is able to define and specify the ICD-10 Classification and mention the specific psychosocial
therapy which can be used to alleviate the social phobia.

Skill Station
Diagnostic procedure

Objectives
At the end of simulation, the examinee is able to define and specify the ICD-10 Classification and mention the specific
psychosocial therapy which can be used to alleviate the social phobia.

Sl. no. Tasks Scores Yes No

1. Greet the patient and maintain rapport with the patient 2
2. Definition: 2
Social phobia is characterized by irrational fear of performing activities in the presence
of others or interacting with others often leading to persistent avoidance of the feared
activity.
ICD – 10 Classification: 2
F40.1 – Social Phobia
Psychosocial treatment: 2
Behavior therapy
3. Documentation 2
TOTAL 10

Pass score = 4/5 (80%)

Student score =____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Instruction to the Simulated Phobic Patient

You are playing the role of a 19-year-old woman who is unable to perform activities in the college in front of faculty including
classmates and does not participate in group activities and avoids these activities by being continuously absent from the college.
You are diagnosed to have social phobia.
Objective Structured Clinical Evaluation (OSCE) 509

STATION 33–POST-TRAUMATIC STRESS DISORDER-IDENTIFICATION OF SYMPTOMS

Instruction to the Examinee

Mr Z aged 32 years is working in the Indian Army. Six months ago, he was caught by Pakistan Army and was made to undergo
physical and mental torture, where he was forced to tell secrets of the Indian Army’s plan. Presently, he is experiencing recurrent,
intrusive recollection of that particular torture event. He feels detached from reality and is unable to experience pleasure. Identify
the possible diagnosis and also identify three abnormal symptoms he is experiencing.

Participant number: ________ Date: ___________

Instructions to the Examiner

Observe the examinee for identification of provisional diagnosis and also abnormal symptoms.

Skill Station
Simulated patient for identification of diagnosis and also abnormal symptoms.

Objective
At the end of simulation, the examinee will be able to identify the abnormal symptoms.

Sl. no. Tasks Scores Yes No

1. Greet the patient and establish rapport with the patient. 2
2. Identification of provisional diagnosis—Post-Traumatic Stress Disorder. 2
3. Abnormal Symptoms:
• Flashbacks 2
• Numbness 2
• Anhedonia 2
TOTAL 10

Pass score = 4/5 (80%)

Student score =____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Instructions to the Simulated Client

You are playing the role of Mr Z, who is aged 32 years and working in the Indian Army. Six months ago, you were caught by
Pakistan Army and were made to undergo physical and mental torture, where you were forced to tell the secrets of the Indian
Army’s Plan. Presently, you are experiencing recurrent, intrusive recollection of that particular torture event. You feel detached
from reality and are unable to experience pleasure.
510 Textbook of Psychiatric Nursing for BSc Nursing Students

STATION 34–SCHIZOID PERSONALITY DISORDER-VIRTUAL SIGN IDENTIFICATION

Instruction to the Examinee

Ms Y aged 26 years is working in an IT company, has ingrained characteristics of being alone, humorless and is unable to
experience pleasure in the working area along with her coworkers. Identify the personality type and also specify three common
signs and symptoms based on the characteristics.

Participant number: ________ Date: ___________

Instructions to the Examiner

Observe the examinee for identification of personality type and specify three common signs and symptoms.

Skill Station
Laptop with video for virtual sign identification.

Objectives
At the end of the VideoShow, the examinee:
• Is able to identify the personality type.
• Specifies three common signs and symptoms.

Sl. no. Tasks Scores Yes No

1. Greet the patient and establish rapport with the patient. 2
2. Identification of provisional diagnosis—Schizoid Personality Disorder. 2
3. Signs and symptoms:
• Aloof 2
• Apathy 2
• Anhedonia 2
TOTAL 10

Pass score = 4/5 (80%)

Student score =____
Pass – Yes/No

Signature of the examiner Signature of the OSCE coordinator

Instructions to the Simulated Client

You are playing the role of Ms Y, who is 26-year-old and works in an IT company. You have ingrained characteristics of being
alone, humorless and are unable to experience pleasure in the working area along with your coworkers.
Viva-Voce

BASICS OF MENTAL HEALTH NURSING 8. What is the scope of psychiatric nursing?

• Basic roles
1. Define mental health. „ Patient care
“An adjustment of human beings to the world and to each „ Education
other with a maximum of effectiveness and happiness.”  „ Supervision
 — Karl Menninger, 1983 „ Ward management
2. Define mental illness. „ Interpersonal relationship
Mental illness is a maladjustment in living which „ Communication
produces disharmony in life. „ Role in other therapies
• Expanded roles
3. List out the members of mental health team.
„ Registered psychiatric nurse
Psychiatrist, mental health nurse, psychologist,
„ Nurse practitioner
counselor, psychiatric social worker, occupational
„ Clinical nurse specialist
therapist, pharmacist, speech therapist, etc.
„ Nurse clinician
4. List out the roles of mental health nurse. „ Nurse researcher
Psychiatric home care nurse, forensic psychiatric nurse, „ Nurse counselor
geropsychiatric nurse, psychiatric nurse educator, „ Case manager
community mental health nurse. • Extended roles
5. What are the main features of mental illness? „ Community mental health nurse
• Disturbances in body (decreased sleep, appetite, „ Psychiatric home care nurse
„ Forensic psychiatric nurse
libido)
„ Psychiatric consultation—liaison nurse
• Disturbances in mental functions (abnormal
„ Geropsychiatric nurse
thoughts/perception/attention/concentration)
„ Parish nurse
• Changes in activities (neglected physical care, poor
social sense and strange behavior) 9. What are the characteristics of a mentally healthy
• Somatic complaints (aches or pain) person?
• Has the ability to make adjustments
6. What is the continuum of mental health?
• Has a sense of personal worth
• From low mental health to high mental health.
• Solves his own problems
• From high mental disorder to low mental disorder.
• Can make own decisions
7. What are the models used to explain the concept of • Has a sense of responsibility
normal and abnormal behavior? • Can give and accept love
Medical, statistical, sociocultural and behavior models. • Lives in the world of reality
512 Textbook of Psychiatric Nursing for BSc Nursing Students

• Has emotional maturity ¾ Standard 5f: Community mental health

• Has a variety of interests in life nursing services, including
• Has developed a philosophy of life reintegration of health
care consumers into the
10. What are the standards of psychiatric nursing?
community
• Standards of Care
◆ Standard 6: Evaluation
„ Standard I: Assessment
„ Standards of Education
„ Standard II: Diagnosis
◆ Standard 7: Academic excellence
„ Standard III: Outcome identification
¾ Standard 7a: Personal academic
„ Standard IV: Planning
development
„ Standard V: Implementation
¾ Standard 7b: Capacity building
◆ Standard Va: Counseling standard
„ Standards of Administration
◆ Standard Vb: Milieu-therapy standard
◆ Standard 8: Administrative efficiency
◆ Standard Vc: Self-care activities standard
¾ Standard 8a: Personal vision, commitment,
◆ Standard Vd: Psychobiological interventions
technical expertise
◆ Standard Ve: Health teaching
¾ Standard 8b: Team building
◆ Standard Vf: Case management
¾ Standard 8c: Quality assurance
◆ Standard Vg: Health promotion and health
¾ Standard 8d: Continuing nursing
maintenance
education
◆ Standard Vh: Psychotherapy
¾ Standard 8e: Leadership
◆ Standard Vi: Prescription of pharmacological
¾ Standard 8f: Performance appraisal
agents
¾ Standard 8g: Organizational and
◆ Standard Vj: Consultation
professional advancement
„ Standard VI: Evaluation
„ Standards of Evidence-Based Practice and
• Standards of Professional Performance Research
„ Standard I: Quality of care ◆ Standard 9: Responsible and ethical conduct
„ Standard II: Performance appraisal of research and integration into
„ Standard III: Education practice
„ Standard IV: Collegiality ¾ Standard 9a: Research ethics
„ Standard V: Ethics ¾ Standard 9b: Integration of research into
„ Standard VI: Collaboration practice
„ Standard VII: Research ¾ Standard 9c: Teaching scientific rigor to
„ Standard VIII: Resource utilization young nurse investigators
• Indian Nursing Council Standards (2019) „ Other Standards of Professional Performance
„ Standards of Practice ◆ Standard 10: Self-care and self-awareness
◆ Standard 1: Assessment ◆ Standard 11: Ethics
◆ Standard 2: Nursing diagnosis ◆ Standard 12: Communication
◆ Standard 3: Expected outcomes of care ◆ Standard 13: Culturally sensitive care
◆ Standard 4: Planning ◆ Standard 14: Legally safe practice
◆ Standard 5: Implementation
11. What are the conceptual models in psychiatric
¾ Standard 5a: Nursing care delivery to
nursing?
health care consumers
Existential model, psychoanalytical model, behavioral
¾ Standard 5b: Assistance in the delivery of
model and interpersonal model.
biological therapies
¾ Standard 5c: P sychotherapeutic 12. What are the principles of psychiatric nursing?
interventions • Accept the client exactly as he/she is
¾ Standard 5d: S afe and therapeutic • Use self-understanding as a therapeutic tool
environment • Use of consistent behavior might contribute to the
¾ Standard 5e: Health education client’s security
Viva-Voce 513

• Give reassurance in an acceptable and subtle manner (Mania and Depression), Organic (Delirium,
• Change the client’s behavior by emotional experience Dementia and Amnesia)
rather than rational interpretation • Neurosis: Anxiety disorders, Phobia, Obsessive
• Avoid unnecessary increase in client’s anxiety Compulsive Disorders (OCD), somatoform
• Use objective observation to understand client’s disorders, post-traumatic stress disorder (PTSD) and
behavior conversion disorders.
• Maintain a realistic nurse-client relationship • Others: Child psychiatric disorders, substance
• Avoid physical and verbal forces as much as possible abuse, personality disorders and Psychophysiological
• Provide nursing care to the patient as a person not on disorders.
the control of symptoms
• Give all explanations of procedures and routines 5. What is the ICD-11 code for schizophrenia?
according to the client’s level of understanding 6A20
• Many procedures are modified but basic principles 6. What is the ICD-11 code for acute and transient
remain unchanged psychotic disorder?
6A23
CLASSIFICATION OF PSYCHIATRIC DISORDERS
7. What is the ICD-11 code for personality disorder?
1. What is meant by ICD Classification? 6D10
ICD stands for International Classification of Diseases.
8. What is the ICD-11 code for generalized anxiety
This classification list is provided by World Health
disorder?
Organization (WHO).
6B00
2. What are the components of ICD-11 and DSM-5
9. What is the ICD-11 code for bipolar II disorder?
Classification?
• Schizophrenia spectrum and other psychotic 6A61
disorders 10. What is the ICD-11 code for cyclothymic disorder?
• Bipolar and related disorders 6A62
• Depressive disorders
• Anxiety disorders 11. What is the ICD-11 code for bipolar affective disorder?
• Obsessive-Compulsive and related disorders F31
• Trauma- and Stressor-related disorders 12. What is the ICD-11 code for panic disorder?
• Dissociative disorders 6B01
• Somatic symptom and related disorders
• Feeding and eating disorders 13. What is the ICD-11 code for anorexia nervosa?
• Elimination disorders 6B80
• Sleep-wake disorders 14. What is the ICD-11 code for bulimia nervosa?
• Sexual dysfunctions 6B81
• Gender dysphoria
• Disruptive, impulsive and conduct disorders 15. What is the ICD-11 code for binge eating disorder?
• Substance-related and addictive disorders 6B82
• Neurocognitive disorders 16. What is the ICD-11 code for hypoactive sexual desire
• Personality disorders disorder?
• Paraphilic disorders HA00
• Other mental disorders
17. What is the ICD-11 code for OCD?
3. What is meant by DSM Classification?
6B20
DSM stands for Diagnostic and Statistical Manual
of Mental Disorders. It was published by American 18. What is the ICD-11 code for amnestic disorder?
Psychiatric Association (APA). 6D72
4. What is the Indian Classification of Mental disorders? 19. What is the DSM-5 code for schizophrenia?
• Psychosis: Functional (Schizophrenia), Affective 295.90
514 Textbook of Psychiatric Nursing for BSc Nursing Students

20. What is the DSM-5 code for bipolar II disorder? 15. When did the Indian Nursing Council (INC)
296.89 incorporate the Psychiatric Nursing subject in BSc
Nursing curriculum?
21. What is the DSM-5 code for OCD?
1965
300.3
16. List out the phases in the evolution of mental health
22. What is the DSM-5 code for bulimia nervosa?
nursing.
307.51 • Phase 1: Emergence of Mental Health Nursing
23. What is the DSM-5 code for generalized anxiety • Phase 2: Development of Work Role of Psychiatric
disorder? Nurses
300.02 • Phase 3: Development of Undergraduate Psychiatric
Nursing Education
HISTORICAL DEVELOPMENT OF PSYCHIATRIC • Phase 4: Development of Graduate Psychiatric
Nursing Education
NURSING
• Phase 5: Development of Research in Psychiatric
1. Who is known as mother of psychiatric nursing? Nursing
Hildegard Peplau
PERSONALITY THEORIES
2. Who is referred to as the father of modern psychiatry?
Philippe Pinel 1. What are different personality theories?
3. Who is considered the father of American psychiatry? Psychoanalytic theory, Jung’s theory, Erikson’s theory,
Benjamin Rush Roger’s theory, Bandura’s theory.
2. Which is the pleasure principle for psychoanalytical
4. Who is the father of psychobiology?
theory?
Adolf Meyer
Id
5. When is the World Mental Health Day celebrated?
3. How many stages of personality development are there
October 10
as per Erickson?
6. When is the World Schizophrenia Day celebrated? 8 stages:
May 24 1. Trust vs Mistrust
2. Autonomy vs shame
7. When is the World No Tobacco Day celebrated?
3. Initiative vs Guilt
May 31
4. Industry vs Inferiority
8. When is the World Suicide Prevention Day celebrated? 5. Identity vs Role confusion
September 10 6. Intimacy vs Isolation
7. Generativity vs Stagnation
9. When is the World Alzheimer’s Day celebrated?
8. Ego integrity vs Despair
September 21
4. What are the structures of mind?
10. Who is the father of therapeutic community? Id, Ego and Superego
Maxwell Jones
11. Who is the founder of interpersonal theory? STRUCTURE OF BRAIN
Harry Sullivan
1. What are the different parts of brain?
12. Who were the proponents of Alcoholics Anonymous? Cerebrum, cerebellum, brain stem, limbic system.
Dr. Bob and Bill Wilson
2. Which is the structural and functional part of the brain?
13. Name the proponent of cognitive therapy. Neuron
Aaron Beck
3. What are the parts of a neuron?
14. Name the proponent of group therapy. Axon, Dendrites, Myelin sheath, Schwann cells, Nucleus,
Joseph Pratt cell body
Viva-Voce 515

4. Which part of brain is considered emotional brain? 3. What are the various aspects in history collection
Limbic system format?
5. What are the components of limbic system? • Demographic data
‘BATCH’ – Mnemonic to remember • Presenting chief complaints
• B : Basal ganglia • Present psychiatric history
• A : Amygdala • Medical, surgical history, obstetrical history [for
• T : Thalamus and hypothalamus females]
• C : Cingulate gyrus • Family history
• H : Hypothalamus • Personal history

6. How many lobes are there in brain? 4. What is the genogram symbol for pregnancy?
Brain has four lobes, namely frontal lobe, temporal lobe,
parietal lobe and occipital lobe.
7. What constitutes brain stem?
Brain stem includes midbrain, pons, medulla oblongata
and cranial nerves.
8. What is pineal body?
Pineal body is located in the thalamus and contains
5. What are the genogram symbols for monozygotic and
secretory cells that emit melatonin hormone.
dizygotic twins?
9. What is neurotransmission?
Neurotransmission is the fundamental process that
transfers information between neurons.
10. What are the steps that occur in neurotransmitters?
Neurotransmitter
1. Synthesis
2. Package
3. Release
4. Binding MENTAL STATUS EXAMINATION
5. Stopping of chemical signal
1. What is mental status examination (MSE)?
11. Name some neurotransmitters. Assessment of the patient to assess the present mental
Some examples of neurotransmitters are dopamine, status and to diagnose patient condition.
norepinephrine, epinephrine, serotonin, GABA,
acetylcholine. 2. What are the purposes of mental status examination?
• Provide a guideline to decide the treatment
PSYCHIATRIC HISTORY COLLECTION modalities
• To assess the patient condition with the treatment
1. What is psychiatric history collection? regimen.
His + story= History means inquiry or the knowledge
acquired by investigations. History is collected from 3. What is the format of mental status examination?
friends, police and strangers who might know the • General appearance and behavior
patient. It is vital to have strong knowledge about patient. • Speech
• Mood
2. What are the purposes of history collection?
• Thought
• To know about the patient
• Disorders of perception
• Pathway for health assessment
• Cognitive functions
• Provides baseline data about the patient
• To understand the past treatment and outcomes 4. What is the method of performing MSE for
• To compare the patient symptoms before the onset uncooperative patients?
of illness Kirby’s method
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5. What is omega sign? 16. Define thought block.

Omega sign is a peculiar sign of depression in which the Thought block is a condition of sudden interruption
patient has furrowed brow due to sustained contraction of thoughts exhibited by silence from a few seconds
of corrugator muscle. to minutes which is commonly seen in patients with
schizophrenia.
6. Define echopraxia.
Echopraxia is defined as desire to mimic activities 17. What is mutism?
performed by other individual; it is seen in schizophrenia. Mutism is complete absence of speech seen in patients
7. Define automatic obedience. with depression, negative symptoms of schizophrenia
Automatic obedience is performing an action and in catatonic stupor.
instructed by other irrespective of thinking about the 18. Define aphonia.
consequences due to the specified action which is seen Aphonia is defined as the inability to produce voiced
in schizophrenia. sound due to laryngeal nerve damage or secondary
8. Define circumstantiality. thyroidectomy and also due to underlying psychological
Circumstantiality is the result of a nonlinear thought problems.
pattern and it is a pattern of speech which has a mix 19. What is clang association?
of relevant and irrelevant information. It happens when Clang association is grouping of rhyming words
the focus of a conversation drifts, but often comes back irrespective of their meaning; it is seen in patients with
to the point. schizophrenia.
9. Define tangentiality. 20. What is delusion?
Tangentiality is a phenomenon in which a person Delusion is a strong fixed unshakable belief irrespective
deviates from one topic/idea to another without ever of sociocultural background.
reaching a conclusion.
21. What is the delusion of persecution?
10. Define neologism. Delusion of persecution refers to having a strong
Neologism refers to coining of new words. suspicious belief that others are trying to harm him/her.
11. Define ambivalence. 22. What is the delusion of grandeur?
Ambivalence refers to the coexistence of two opposing Strong unshakable belief that he/she is an important
forces or impulses, desires or emotions. famous personality or has superior knowledge or
12. Define “word salad”. ideation or power.
Word salad refers to mixture of words that are 23. What is delusion of infidelity or delusion of jealousy
incoherent. or Othello Syndrome?
13. Define perseveration. Strong unshakable belief that his/her spouse has
Perseveration refers to persistent repetition of words extramarital relationship with another person.
beyond the point of relevance.
24. What is delusion of thought broadcasting?
14. What is pressure of speech? Strong unshakable belief that one’s own thoughts
Pressure of speech is a rapid speech delivered with have been projected/displayed in mass media such as
urgency that is apparently inappropriate to the situation. television, newspaper, internet, etc.
It is a hallmark symptom of mania. Pressure of speech
25. What is delusion of control?
is also seen in patients with schizophrenia, anxiety
Strong unshakable belief that one’s own thoughts or
disorder and attention deficit hyperactivity disorder.
action has been controlled from outside.
15. What is thought retardation?
26. Define nihilistic delusion?
Thought retardation is defined as the reduction of
Strong unshakable belief that the world does not exist.
thoughts in one’s mind leads to reduced content of
speech, which is seen in patients with depression, 27. What is delusion of reference?
dementia, nervousness, memory impairment and Strong unshakable belief that the other person is referring
schizophrenia. oneself with a neutral event in the environment.
Viva-Voce 517

28. What is amnesia? • Grade VI: True emotional insight—Aware of one’s

Memory loss own mental illness and how the family
29. What is retrograde amnesia?
Retrograde amnesia means loss of memory of the events NEUROLOGICAL EXAMINATION
that happened before the injury or onset of illness. 1. What are the various aspects of neurological assess-
30. What is anterograde amnesia? ment?
Anterograde amnesia means loss of memory of the • Level of consciousness
events that happened after the injury or onset of illness. • Mental status assessment
• Cerebral function
31. What is Déjà vu?
• Cranial nerve function
Familiarity with unfamiliar things.
• Sensory function
32. What is Jamais Vu? • Motor function
Unfamiliarity with familiar things. • Cerebellar function
• Reflexes
33. What is confabulation?
False filling of memory gaps. 2. List down the cranial nerves.
34. What is illusion? • Olfactory
Misperception of an external stimulus. • Optic
• Oculomotor
35. What are the types of illusion? • Trochlear
Affect illusion, completion illusion, pareidolic illusion. • Abducent
36. What is hallucination? • Trigeminal
Misperception without an external stimulus. • Facial
• Vestibulocochlear
37. List out the types of hallucination. • Glossopharyngeal
Auditory, visual, olfactory, gustatory, tactile or • Vagus
haptic, functional, reflex, extracampine, hypnogogic, • Accessory
hypnopompic, command or teleological, Lilliputian, • Hypoglossal
kinesthetic, macropsia and micropsia.
3. What is Weber’s test?
38. How do you assess personal judgment? Tuning fork is kept in the middle ear. If lateralization
Asking the patient about his/her future plans. is felt on one side, it denotes hearing loss. Normal
39. How do you assess social judgment? individuals will hear sound in both ears equally.
Observation made by the examiner that how patient is 4. Define Rinne’s test.
being socialized with others. Keep the tuning fork in mastoid bone and then to
40. What are the various test judgments? patient’s ear. After striking, air conduction is more than
Rain test, fire test, envelope test and child cry test. bone conduction, which is normal. If bone conduction is
more than air conduction, it denotes conductive hearing
41. Define insight.
loss.
Patient’s awareness of his/her own mental illness.
5. What is Romberg test?
42. How do you grade the insight?
To assess the balance or equilibrium of the patient’s
• Grade I: Complete refusal of illness
body. Ask the patient to stand straight when the eyes are
• Grade II: Slight awareness of being ill
closed. Aware of patient has a risk of fall.
• Grade III: Awareness of being sick attribute toward
external or physical factor 6. How do you advise the patient to perform tandem
• Grade IV: Awareness of being sick, due to something walk test?
not known to oneself Patient is asked to walk over the heel in straight line.
• Grade V: Intellectual insight (awareness about one’s This is done to assess unsteadiness or staggering or
own mental illness in detail) imbalance gait.
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7. What is stereognosis or haptic perception or tactile THERAPEUTIC COMMUNICATION

gnosis?
Ability to perceive and recognize the object using tactile 1. Define communication.
sense. Communication is an interaction process between the
sender and receiver. The receiver receives the message
8. Define baragnosis or baresthesia.
exactly what the sender intended to say. Both receiver
It is the ability to evaluate the weight of objects, or to and sender have a common understanding of a message.
differentiate objects of different weights, by holding or
lifting them. It is done to assess the loss of ability to sense 2. What are the types of communication?
weight. • Verbal
• Nonverbal
9. How do you perform Caloric test (test to assess • Formal
oculovestibular reflex)? • Nonformal
Caloric test is performed to assess the coordination of • Intrapersonal
eye and ear muscles. Pouring of cold water in the ear will • Interpersonal
move the opposite eyeballs, and the pouring of warm • Horizontal
water in the ear will move the same side of eyeballs. • Vertical
• Chain
10. How do you assess biceps reflex?
• Meta
Arm gently flexed at elbow, tap the biceps brachii tendon.
It leads to flexion of forearm. 3. What is therapeutic relationship?
Relationship maintained between the nurse and patient
11. How do you assess triceps reflex?
to gain mutual respect and trust.
Tapping of triceps brachii tendon in elbow. It leads to
extension of forearm. 4. What are the phases of nurse-patient relationship?
• Pre-orientation phase
12. How do you assess patellar reflex?
• Orientation phase
Tapping of quadriceps femoris tendon (present below • Identification phase
patella). It leads to extension of leg. • Intervention phase
13. How do you assess the gag reflex? • Maintenance phase
Stimulation with tongue blade at the back of throat and • Termination phase
pharynx. 5. List out the types of psychological tests.
14. What is agnosia? • Paper pencil test
Inability to recognize the objects with senses. • Individual and group test
• Speed and power test
15. What is apraxia? • Computer assisted test
Inability to perform learned motor activities. • Aptitude test
16. What is Glasgow Coma Scale (GCS)? • Intelligence test
GCS is the scale to assess the level of consciousness. • Interest test
It consists of eye response, verbal response and motor • Personality test
response. Total score is 15. 6. What are the components of nurse-patient relationship?
TEACH
17. What is the minimal Score of GCS?
• T : Trust
3
• E : Empathy
18. What is the score of GCS determining comatose • A : Autonomy
patient? • C : Caring attitude
<7 • H : Hopefulness
Viva-Voce 519

7. What are the barriers of communication? 14. Define process recording.

Physical, psychological and environmental barriers. Process recording is a method of recording nurse-patient
interaction, done by nurses in psychiatric setup.
8. What are the therapeutic impasses?
• Resistance 15. What is the format of process recording?
• Transference • Patient profile
• Countertransference • Objectives
• Preparation of patient and environment
9. Mention some therapeutic communication techniques.
• Date, time and place of recording
• Offering self
• Context of interaction
• Silence
• Listening 16. Name few theories of communication.
• Empathy Ruesch’s theory, transactional analysis, neuro-linguistic
• Questioning programming
• Restating
• Broad openings DEFENSE MECHANISM
• Verbalizing
1. Define defense mechanism.
• Seeking clarification
Defense mechanism is an unconscious psychological
• Sharing perceptions
mechanism that reduces anxiety from harmful stimuli.
• Summarizing
2. Name some defense mechanisms.
10. What are the nontherapeutic communication
Displacement, repression, denial, rationalization,
techniques?
reaction formation, undoing, acting out, etc.
• Defending
• Requesting 3. Define displacement.
• Indicating the external source Unconscious manner of letting the feelings toward a less
• Belittling feelings threatening object.
• Stereotyped comments
4. Define rationalization.
• Denial Try to make excuses to convince self that he/she is not
• Parroting wrong.
11. Define ethics. 5. Define reaction formation.
Ethics is a branch of philosophy that deals with the Converting the unconscious wishes or ideas or impulses
study of values and moral standards related to nursing which are perceived as dangerous or unacceptable by
profession. their opposites.
12. What is SWOT Analysis? 6. Define regression.
• S : Strength Temporary state of the ego put into the earlier stage
• W : Weakness of development instead of handling the unacceptable
• O : Opportunities impulses as an adult.
• T : Threats
7. Define repression.
13. What is Johari window? How many quadrants are Unconscious way of suppressing the negative feelings
there in Johari window? which pose threat.
• Joseph Luft and Harry Ingham (1950) described the
8. Define suppression.
model of interpersonal relationship.
A conscious way of pushing out the negative thoughts
• Other names are Disclosure or Feedback Model of
or feelings.
Self-Awareness and Information Processing Tool.
• It has four quadrants. Quadrant 1- Arena, Quadrant 9. Define altruism.
2- Blind spot, Quadrant 3- Hidden and Quadrant 4- Constructive social service to others which gives
Unknown personal satisfaction.
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10. Define sublimation. 12. When was the National Mental Health Policy
Sublimation refers to transformation of socially formulated?
unacceptable impulses or thoughts into socially 2002
acceptable actions or behavior, resulting in a long-term
13. When was the National Society for Mental Hygiene
conversion of the initial impulse.
founded?
11. Define identification. 2002
Unconscious modeling of one’s self toward another
14. What is M’Naghten Rule?
person’s character and behavior. Daniel M’Naghten murdered Edward Drummond,
secretary of Sir Robert Peel, Prime Minister in his insane
LEGISLATIONS IN MENTAL HEALTH NURSING mind. But he was not punished under law because the
gun shot happened due to the delusion of persecution.
1. When was the Indian Mental Health Act enacted?
1987 15. What are the various types of admission procedure as
per the Mental Health Act?
2. When was the Indian Lunacy Act enacted?
• Admission on voluntary basis
1912
• Admission under special circumstances (Involuntary
3. When was the Mental Health Care Act enacted? admission)
2017 • Admission in emergencies
• Admission under authority or order
4. When was the Rehabilitation Council of India Act
„ Reception order on application
enacted?
„ Reception order on producing the mental illness
1992
before magistrate.
5. When was the Persons with Disability Act enacted? „ Reception order after inquest: District court
1996 directs the individual for admission.
„ Admission and detention of mentally ill
6. When was the Narcotics and Substance Abuse Act
prisoner: Mentally ill prisoner will be admitted
enacted?
in psychiatric hospital as per the order of court.
1985
16. What are the various types of discharge procedure as
7. When was the POCSO Act enacted?
per the Mental Health Act?
2012
• Discharge of patient admitted on voluntary basis
8. How many chapters and sections are there in the • Discharge of patient admitted under special
Indian Mental Health Act? circumstances
10 chapters and 98 sections • Discharge of patient admitted on reception order
• Discharge of patient admitted by police
9. How many chapters, parts and sections are there in the
• Discharge of mentally ill prisoner
Indian Lunacy Act?
• Leave of absence
8 chapters, 4 parts and 100 sections
17. What is the nurse’s role in regard to the legal aspects
10. How many chapters are there in the Mental Health
in psychiatry?
Care Act?
• Ethical decision making
16 chapters
• Protecting the rights of mentally ill
11. How many chapters and sections are there in the • Admission and discharge procedures of mentally ill
Narcotics and Substance Abuse Act? • Role of mental health authority
6 chapters and 83 sections • Quality treatment of mentally ill
Viva-Voce 521

ADJUSTMENT DISORDER, SOMATOFORM • Continuous amnesia

DISORDER AND PHOBIA • Generalized amnesia
• Systematized amnesia
1. Define adjustment disorder.
12. Define dissociative fugue.
Adjustment disorder is defined as the presence of
Dissociative fugue is characterized by episodes of
significant behavioral or emotional symptoms in
wandering away from home. During wandering,
response to the psychosocial stressors.
individual assumes new identity along with complete
2. Define somatoform disorder. amnesia of previous life.
Somatoform disorder is a mental illness in which
13. Define multiple personality disorder.
multiple bodily signs and symptoms are elicited but
Individual is dominated with one or two personalities in
the medical evaluation does not reveal any
which one personality is manifested at a time.
abnormalities.
14. Define trance and possession disorder.
3. Classify somatoform disorders.
Control of one’s personality by spirit. One personality
• Somatization disorder
is aware. It is different from other personality
• Conversion disorder
disorders.
• Hypochondriasis
• Body dysmorphic disorder 15. What is Ganser’s syndrome?
• Persistent somatoform pain disorder Commonly seen in prison inmates having characteristic
feature of ‘Vorbeireden’.
4. Define somatic symptom disorder.
Presence of one or more somatic symptoms which cause 16. What is the meaning of Vorbeireden?
significant personal distress in patient. Saying approximate answer

5. Define dissociative disorder. 17. What are the different treatment therapies for
Dissociative disorder is defined as lack of integration of dissociative disorder?
consciousness, emotions and identity. • Behavior therapy
• Psychotherapy
6. Who identified the concept of dissociation?
• Insight oriented therapy
Mr Pierre Janet
• Psychodynamic psychotherapy
7. Which is the most common type of dissociative • Psychoanalysis
disorder? • Drug therapy
Dissociative amnesia
18. Define hypochondriasis.
8. Which is an active mechanism of repression? Hypochondriasis is an anxiety disorder which is
Dissociation characterized by being preoccupied with health concerns
that might cause impairments or personal distress in
9. What are the clinical features of dissociative disorder?
one’s life.
• Motor symptoms: Tics, abnormal gait, aphonia,
paralysis 19. Name some somatoform autonomic dysfunction.
• Sensory symptoms: Blindness, deafness • Hyperventilation syndrome
• Visceral symptoms: Urinary retention, diarrhea, • Irritable bowel syndrome
vomiting • Premenstrual syndrome
10. Define dissociative amnesia. 20. Define neurasthenia.
Dissociative amnesia is most commonly seen in young In neurasthenia, individual has persistent and distressing
adults. Before amnesia caused by stressors, during complaints of body weakness and he feels exhausted
amnesia caused by clouding of consciousness and post even after a minimal effort.
amnesia due to aware of disturbances in memory.
21. Define depersonalization disorder.
11. What are the different types of dissociative amnesia? Depersonalization disorder occurs when you repeatedly
• Localized amnesia feel that you are observing yourself from outside your
• Selective amnesia body and the individual feel that he/she is not real one.
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22. What is the drug of choice for anxiety disorders. 9. What is the continuum or levels of anxiety?
Lorazepam • Normal
• Euphoria
23. What is claustrophobia?
• Mild anxiety
Fear of closed places
• Moderate anxiety
24. What is the name given for extreme fear of travel? • Severe anxiety
Hodophobia • Panic anxiety
25. What is the peculiar symptom of post traumatic stress 10. What are the symptoms of anxiety disorders?
disorder (PTSD)? • Physiological symptoms: Headache, vertigo, nausea
Flashbacks and vomiting, tachycardia
26. What are the two characteristic features of • Psychological symptoms: Depression, irritability,
Vorbeireden? social isolation, anger
Ganser’s syndrome and hysterical pseudodementia • Behavioral symptoms: Hypervigilance, restless, pacing
• Cognitive symptoms: Lack of concentration,
memory loss, inability to perform a task, preoccupied
ANXIETY DISORDERS
with something.
1. Which is called central stress response system? 11. What are the clinical features of anxiety disorders?
The Hypothalamic Pituitary Adrenal [HPA] axis • Exaggerated worry and tension
2. What is circadian rhythm? • Restlessness
Sleep-wake cycle • Irritable
• Difficulty in concentrating
3. What is neurotic disorder?
• Insomnia
Neurotic disorder is a less severe form of psychotic
• Tension headache
disorder in which the patient exhibits excess of prolonged
• Palpitation
emotional response to the stressors.
• Sweating, tremors
4. Who introduced the concept of anxiety?
12. What are the clinical features of panic disorder?
Sigmund Freud
• Acute onset of severe anxiety
5. Define anxiety. • Palpitation, increased heart rate, tremors
Anxiety is defined as feelings of uncertainty, • Chest tightness, breathing difficulty
apprehension, uneasiness or tension that an individual • Hot flushes, cold chills, fear of dying, fear of fainting
shows in a given situation.
13. What are the clinical features of post-traumatic stress
6. What are the different types of anxiety disorders? disorders?
• Trait anxiety • Flashbacks while awake
• State anxiety • Nightmares during sleep
• Signal anxiety • Hypervigilance
• Free floating anxiety • Startled easily
• Emotional numbness, irritability
7. What is the concept of anxiety response?
• Lack of concentration
Responding to a dangerous situation leads to Fright
response, Flight response and Flight response 14. What are the clinical features of phobic anxiety?
• Acute anxiety
8. What are the etiologic factors for anxiety?
• Tension
• Genetic factors
• Irritability
• Biological factors
• Individual tries to escape from triggers
• Psychoanalytical factors
• Sociocultural factors 15. What are different types of phobias?
• Cognitive factors • Simple phobia
Viva-Voce 523

• Social phobia • Psychodynamic factors

• Agoraphobia • Behavioral factors
• Hormonal factors
16. Name some simple phobias.
• Psychosocial factors
• Acrophobia
• Algophobia 23. What are the different types of obsessive-compulsive
• Claustrophobia disorders?
• Hematophobia Washers, Checkers, Pure obsessions, Primary obsessive
• Leukophobia slowness.
• Zoophobia
24. What is the pharmacotherapy for OCD?
• Nosophobia
• Benzodiazepines
17. What is the duration of persisting symptoms required • Antidepressants
for diagnosis of anxiety disorders? • Antipsychotics
• Generalized anxiety disorder: at least 6 months
• Phobia: at least 6 months 25. What are the different therapies used for treating
• Panic disorder: at least 1 month OCD?
• Obsessive compulsive disorder: at least 2 weeks • Psychotherapy
• PTSD: at least 1 month • Behavior therapy
• Thought stopping technique
18. Mention some rating scales in anxiety disorders. • Rubber band method
• Hamilton Rating Scale • Electroconvulsive therapy
• State trait anxiety rating scale—Generalized anxiety • Psychosurgery
disorders
• Panic disorder severity scale—panic disorder 26. Define acute stress reaction.
• Social phobia inventory—social phobia An immediate and clear relation exists between the
• Yale-Brown Obsessive Compulsive Scale [Y-BOCS]- stressor and the onset of symptoms such as anger,
OCD depression.
• Impact of Event Scale- PTSD 27. Define post-traumatic stress disorder (PTSD)?
19. What is the pharmacotherapy for anxiety disorders? PTSD is an anxiety disorder in which an individual might
• Benzodiazepines develop the re-experiencing symptoms or avoidance
• Antidepressants symptoms after witnessing extreme, overwhelming
• Beta blockers traumatic event when the individual felt intense fear.

20. What are the treatment modalities for anxiety 28. What are the predominant symptoms of PTSD?
disorders? • Hyperarousal
• Cognitive behavior therapy • Re-experiencing the trauma
• Behavior strategies • Emotional numbness
• Relaxation training 29. What are the types of PTSD?
• Psychoeducation
• Acute PTSD
• Skill training
• Chronic PTSD
• Bibliotherapy
• Delayed onset PTSD
21. Define obsessive obsession and compulsion.
30. Name a few etiological factors of PTSD.
• Obsession: Repetitive thoughts, images, doubts
• Serious injury
make a person senseless and irrational.
• Unnatural death
• Compulsion: Repetitive actions are performed
• Kidnapped
followed by obsessions.
• Terrorist attack
22. What are the etiological factors for OCD? • Natural or man-made disaster
• Genetic factors • Life-threatening illness
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31. How is PTSD assessed? 5. Define mood disorder.

• Interviews: PTSD symptom scale interview Mood disorder is a mental health condition in which
• Self-report Questionnaire: Post-Traumatic an individual experiences long periods of extreme
Diagnostic Scale happiness, extreme sadness or both.
• For children: Child PTSD Symptom Scale
6. Who coined the terms “mania” and “depression”?
32. What are the treatment modalities for PTSD? Hippocrates
• Exposure therapy
• Cognitive therapy 7. What is the duration required to diagnose mood
• Stress inoculation training disorders?
• Behavior therapy • Hypomania: 4 days
• Pharmacotherapy: SSRIs, antianxiety drugs, mood • Mania: 1 week
stabilizers, tricyclic antidepressants • Depression: 2 weeks
• Cyclothymia and dysthymia: 2 years
COMMUNITY MENTAL HEALTH NURSING 8. What are the stages of mania?
• Stage I: Hypomania
1. When was the National Mental Health Program
• Stage II: Acute mania
(NMHP) launched?
• Stage III: Delirious mania
1982
9. Define hypomania.
2. What are the roles of community psychiatry nurse?
Hypomania is a mood disorder in which the
Counselor, crisis worker, educator, researcher,
symptoms are not severe, and it does not cause
community consultant
noticeable impairment in social and occupational
3. What are the components of the Mental Health functioning.
Program?
Treatment, rehabilitation, prevention 10. Define acute mania.
In acute mania, intensified symptoms such as euphoria,
4. What are the objectives of NMHP? elation are present in a patient and the patient requires
• To ensure availability and accessibility of mental hospitalization. The patient has psychotic features and
health care for vulnerable and underprivileged poor impulse control.
population.
• To encourage mental health knowledge in general 11. What are different types of mood disorders?
health care • Manic episode
• To promote community participation. • Depressive episode
• Bipolar mood disorder
MOOD DISORDERS • Recurrent mood disorder
• Mixed mood disorder
1. Define mood.
12. What are the levels of manic episodes?
Mood is a persistent and sustained emotional feeling.
• Euphoria
2. Define affect. • Elation
Affect is an outward expression of feeling. • Exaltation
3. What are different types of mood? • Ecstasy
• Elevated mood 13. What are the signs and symptoms of mania?
• Normal mood • Irritable mood
• Depressed mood • Increased psychomotor activity
4. What is the continuum of affect? • Grandeur thought
• Flat affect • Pressure of speech
• Restricted affect • Raised perceptual activity
• Blunt affect • Decreased sleep
• Labile affect • Absence of insight
Viva-Voce 525

14. What are the etiologies of mood disorder? • Neurochemical factors

• Neurotransmitters: Serotonin and dopamine • Endocrine theory
decrease in depression and increase in mania • Psychosocial factors
• Biopsychosocial factors: Social pressure, social • Organic causes
isolation, feeling of helplessness, worthlessness, • Circadian rhythm imbalances
hopelessness.
24. What are the clinical symptoms of depression?
• Psychological factors: Loss of loved ones,
• Physical symptoms
aggressiveness, negative view, stressors
„ Blurred vision
15. What is the pharmacotherapy for mood disorders? „ Dry mouth
• Lithium „ Headache
• Carbamazepine „ Chest pain
• Sodium valproate „ Abdominal discomfort
• Anticonvulsant • Psychological and emotional symptoms
• Calcium channel blockers „ Anhedonia
16. Who discovered lithium? „ Feeling of guilt
Johan August Arfwedson „ Insomnia
„ Psychomotor retardation
17. What is the mechanism of action of lithium? „ Lack of interest
Lithium causes changes in the structure of brain, „ Crying spells
anterior cingulate, hippocampus, amygdala. It modulates
the neurotransmitters such as dopamine, GABA 25. What are the types of depression?
and shows effects at intracellular level by inhibiting • Mild depression
proteins. • Moderate depression
• Severe depression
18. What are the side effects of lithium? • Endogenous depression
• L- Leukocytosis
• Exogenous depression
• I-Insipidus
• T-Tremors 26. Mention the scales used to assess depression.
• H-Hypothyroidism • Beck Depression Inventory
• U-Urinary [Primary] • Hamilton Rating Scale for depression
• M-Miscellaneous [weight gain, ECG changes, 27. Define endogenous depression.
fatigue, nystagmus, muscle weakness] The prefix ‘Endo’ in the term ‘Endogenous’ means
19. What are the grades of lithium toxicity? ‘within’. Endogenous depression can be hereditary or
• Grade I: 1.5- 2.5 due to biochemical imbalance. Other name is psychotic
• Grade II: 2.5-3.5 depression. The individual feels sad in morning,
• Grade III: > 3.5 experiences psychomotor retardation and delusion.
Relapse is common.
20. What are the scales used to assess mania?
• Young mania rating scales 28. Define exogenous depression.
• Mood disorder questionnaire The prefix ‘Exo’ in the term ‘Exogenous’ means ‘outside’.
• Semantic differential feelings and mood scales Exogenous depression is caused by external factors.
Other name is neurotic depression. The individual feels
21. Frame some nursing diagnosis for mania.
sad in evening. Psychotic features are absent. Stress is
• Risk of self-directed violence
present. Relapse is not common.
• Risk for violence towards others
• Impaired nutrition less than body requirements 29. What are the treatment modalities for depression?
• Individual psychotherapy
22. Define depression.
• Family therapy
Depression is a part of manic-depressive psychosis.
• Cognitive therapy
23. What is the etiology of depression? • Behavior therapy
• Brain anatomy • Occupational therapy
• Genetics • Relaxation therapy
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30. Frame some nursing diagnosis for patients with • Mood stabilizers
depressive disorder. • Anxiolytics
• Risk of injury • Antiepileptics
• Risk of violence • Antiparkinsonian
• Impaired nutrition less than body requirements
3. Define antipsychotics.
• Impaired social interaction
Antipsychotics are the medications used to treat
• Impaired family coping skills psychotic disorders.
• Risk of suicide
• Self-care deficit 4. How are antipsychotics classified?
• Hopelessness related to negative view • Typical antipsychotics
• Atypical antipsychotics
31. What is cyclothymia?
Cyclothymia is characterized by a period of depressive 5. What are other names used for antipsychotics?
symptoms and hypomania. • D2 receptor blockers
• Neuroleptics
32. Define dysthymia. • Antischizophrenic drugs
Dysthymia is a persistent depressive disorder in which • Major tranquilizers
mild depressive symptoms persist for at least two years.
6. What is the mechanism of action of antipsychotics?
33. What is empty nest syndrome? Antipsychotics block the D2 receptors in the mesolimbic
Empty nest syndrome refers to the feelings of sadness and mesofrontal systems.
and anxiety that some parents feel when their children
move out of the family home. Such a situation makes 7. Name any two drugs of typical antipsychotics.
parents prone to depression and anxiety. Chlorpromazine and haloperidol.
8. Name any two drugs of atypical antipsychotics.
34. What is the other name for stage 3 mania?
Clozapine and ziprasidone.
Delirious mania
9. Define extrapyramidal symptoms.
35. What is bipolar II disorder?
Extrapyramidal symptoms are the serious neurologic
Bipolar II disorder involves periods of hypomania and
symptoms and major side effects of antipsychotics.
periods of depression.
• Acute dystonia
36. Carbamazepine is a major side effect of which • Pseudoparkinsonism
syndrome? • Akathisia
Stevens-Johnson syndrome • Tardive dyskinesia
37. What is the other name for mood disorder? 10. What are the indications for antipsychotics?
Affective disorders • Organic mental disorders
• Functional disorders
38. Classify mood disorders.
• Mood disorders
• Unipolar disorders
• Childhood disorders
• Bipolar disorders
• Neurotic disorders
39. What is bipolar I disorder?
11. What is rabbit syndrome?
Bipolar I disorder involves mania and depression.
Rabbit syndrome is presence of orofacial tremors.

PSYCHOPHARMACOLOGY 12. Define antidepressants.

Antidepressants are the drugs which are used for the
1. Define psychopharmacology. treatment of depressive illness.
Psychopharmacology is the study of drugs used to treat
13. What are the indications of antidepressants?
psychiatric disorders with psychoactive medications.
• Neurotic and stress related disorders
2. How are psychotropic drugs classified? • Medical disorders
• Antipsychotics • Eating disorders
• Antidepressants • Childhood psychiatric disorders
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14. How are antidepressants classified? 24. Which is the drug of choice for mood stabilizer?
• Tricyclic antidepressants Lithium
• Selective serotonin reuptake inhibitors
25. Mention blood lithium levels.
• Serotonin norepinephrine reuptake inhibitors
Therapeutic levels = 0.8–1.2 mEq/L
• Monoamine oxidase inhibitors Prophylactic level= 0.6–1.2 mEq/L
• Atypical antidepressants
26. What is the Lithium toxic level?
15. What is the mechanism of action of antidepressants? > 2.0 mEq/L
Antidepressants increase catecholamine levels in the
brain, block the reuptake of norepinephrine at the nerve 27. Define psychostimulants.
terminals, thus increase the norepinephrine levels at the Stimulants are those which enhance the mental and
receptor site. physical function by increasing the alertness and
wakefulness. For example, Caffeine and Nicotine.
16. What is the mnemonic of serotonin syndrome?
HARM 28. What are antabuse drugs?
• H : Hyperthermia Antabuse drugs are used in the treatment of substance
• A : Autonomic instability abuse, e.g., Disulfiram is the Antabuse drug used for
• R : Rigidity patient with Alcohol dependence syndrome.
• M : Myoclonus
PSYCHOTHERAPY
17. What are anxiolytics?
Anxiolytics are otherwise called antianxiety drugs. Most 1. Define psychotherapy.
of them belong to benzodiazepine group of drugs. Psychotherapy is defined as the way to help the people
with mental illness or emotional difficulties. It helps to
18. What are indications for antianxiety?
control or remove the symptoms and increase the sense
Anxiety disorders, mood disorders, sleep disorders and
of well-being.
psychotic disorders.
2. What are the stages of psychotherapy?
19. What is the mechanism of action for antianxiety
• First stage is the assessment
drugs? • Second stage is therapeutic work
Antianxiety drugs stimulate the GABA to bind in • Third stage is conclusion
postsynaptic receptor and release negativity ion in
postsynaptic neuron. 3. What are the psychoanalytic techniques?
• Free association
20. How are antianxiety drugs classified? • Dream analysis
• Benzodiazepines • Treatment alliance
• Barbiturates • Acting out interpretation
• Nonbarbiturates
• Nonbenzodiazepines 4. What are the indications for psychotherapy?
• Stress related disorder
21. Define Parkinson’s disease. • Personality disorder
Parkinson’s disease is a neurogenerative disorder caused • Psychosomatic disorder
due to degeneration of substantia nigra of midbrain and • Neurotic disorders
caused imbalance of dopamine. • Depression
22. What is the mechanism of action for antiparkinsonian • Identity problems
drugs? 5. Define catharsis.
Antiparkinsonian drugs help to balance dopamine and Freud and Breuer defined catharsis as “the process of
acetylcholine in central nervous system. reducing or eliminating a complex by recalling it to
conscious awareness and allowing it to be expressed.”
23. What are mood stabilizers?
Mood stabilizers are used for the treatment of bipolar 6. What are the types of psychotherapy?
affective disorder. • Individual psychotherapy
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• Group psychotherapy 13. What are the types of behavior therapy?

• Interpersonal psychotherapy • Classical conditioning
• Superficial psychotherapy • Operant conditioning
• Deep psychotherapy
14. What are the techniques of behavior therapy?
• Educational psychotherapy
• Systemic desensitization
• Re-educative psychotherapy
• Flooding
• Reconstructive psychotherapy
• Social skill training
• Supportive psychotherapy
• Shaping
7. What are the goals of psychotherapy? • Aversion therapy
• Enhance the coping skills • Token economy
• Problem solving ability • Time out
• Promote the sense of control 15. What are the indications for behavior therapy?
• Strengthen the ego • Bipolar disorder
• Create the deeper insight • Obsessive compulsive disorder
• Provide a therapeutic relationship with patients • Social anxiety
• Promote the positive attitude • Phobia
8. Define cognitive therapy. • Substance abuse
Cognitive therapy is a form of psychotherapy in which • Tics
the distorted cognitions are modified into positive • Nocturnal enuresis
cognitions. • Sexual dysfunction

9. What are the indications of cognitive therapy? 16. Who is the pioneer of cognitive behavior therapy?
• Depression Aaron beck
• Bipolar disorder 17. What are the techniques of cognitive behavior therapy?
• Panic disorder • Cognitive rehearsal
• Post-traumatic stress disorder • Validity testing
• Generalized anxiety disorder • Writing in a journal
• Eating disorder • Guided discovery
10. What are the components of cognitive therapy? • Self-instructional coping methods
• Cognitive techniques • Homework
• Behavioral interventions • Problem solving methods
• Didactic aspects • Computer assisted therapy

11. Name some cognitive techniques. 18. Define therapeutic community.

• Guided discovery Therapeutic community is a drug free treatment in which
• Role play the individuals with addictive behavior join together in a
• Imagery structured manner to promote drug free society.
• Thought recording 19. What are the components of therapeutic community?
• Daily records of thoughts • Daily community meetings
• Cognitive rehearsal • Patient government
• Activity scheduling • Staff meetings
• Assertiveness techniques • Living and learning opportunities
• Relaxation therapy
20. What are the stages of therapeutic community?
12. Define behavior therapy. • Induction and treatment
Behavior therapy is a form of psychotherapy in which • Primary treatment
various techniques are used to change maladaptive • Vocational skill training
behaviors. • Re-entry
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21. Define Milieu therapy. 30. Who are the indicators for family therapy?
Milieu means environment or surroundings. It is the • Family conflicts
scientific structuring of the environment to elicit the • Issues of families
behavioral changes and enhance the psychological • Stressors among family members
health and functioning of the individual. • Relationship issues
• Generation gap
22. What are the characteristics of Milieu therapy?
• Distribution of power 31. What are the functions of family?
• Open communication • Communication function
• Structured interactions • Boundary function
• Work related activities • Supportive function
• Biological function
23. What are the concepts of Milieu therapy?
• Socialization function
• Containment
• Psychological function
• Validation
• Protective function
• Structured interaction
• Educational function
• Open communication
• Recreational function
24. Who are all the Milieu team members?
32. What are types of family therapy?
• Psychiatrist
• Individual family therapy
• Psychiatric nurse
• Conjoint family therapy
• Clinical psychologist • Couples family therapy
• Occupational therapist • Multiple family therapy
• Recreational therapist • Network therapy
• Music therapist • Psychodynamic family therapy
• Art therapist • Structural family therapy
• Chaplin • Strategic family therapy
25. Define supportive psychotherapy. 33. Define group therapy.
Supportive psychotherapy is defined as psychotherapeutic Group therapy is a type of psychotherapy in which the
approach which integrates various components as, mentally ill patients are placed in groups, guided by
cognitive behavioral, psychodynamic and interpersonal therapist, to talk, interact and discuss the problems with
techniques which help to decrease psychological conflict the therapist for the purpose of changing maladaptive
and strengthen the patient’s defenses. behavior.
26. What are the techniques of supportive therapy? 34. List out the components of group therapy.
Directive techniques Explanatory techniques • Members
Advice Motivation • Duration
Teaching Empathy
• No. of sessions
• Norms
Change of environment Reassurance
• Cohesion
Cognitive restructuring Containment
• Role
Modeling Reality testing • Power
• Communication
27. What is the fundamental unit of human life?
Family 35. List out the types of group therapy.
• Open group therapy
28. Who is the mother of family therapy?
• Closed group therapy
Virginia satir
• Small group therapy
29. Define family therapy. • Primary group therapy
Family therapy is a form of psychotherapy in which the • Large group therapy
issues, problems or conflicts existing among the family • Secondary group therapy
members are addressed and the solution is identified. • Homogenous group therapy
530 Textbook of Psychiatric Nursing for BSc Nursing Students

• Heterogenous group therapy • Free play

• Psychodrama • Individual play
• Interpersonal group therapy • Group play
• Encounter group therapy • Structured play
• Community group therapy • Unstructured play
• Directive play
36. What are the stages of group therapy?
• Nondirective play
• Initial stage
• Working stage 42. What are the phases of play therapy?
• Termination stage • Introductory phase
37. What are the therapeutic techniques of group therapy? • Honeymoon phase
• Acceptance • Rebellious phase
• Approval • Working through phase
• Clarification • Termination phase
• Information giving 43. Define psychodrama.
• Reinforcement Psychodrama is a form of psychotherapy in which the
• Support dramatization or dramatic presentation of the group is
• Teaching done to gain self-insight.
• Listening
• Limit setting 44. What are the phases of psychodrama?
• Silence • Warm-up
• Structuring • Shaping
• Themes • Discussion

38. Define play therapy. 45. Mention the psychodrama techniques.

Play therapy is a form of psychotherapy in which • Mirroring
the therapist utilizes the child’s fantasy and symbolic • Doubling
medium of play to have communication with him and • Role play
understand him. • Role training
• Future projection
39. What are the theories of play? • Magic shop
• Natural theory • Empty chair
• Energy theory
• Practice theory 46. List out the principles of psychodrama.
• Recreation theory • Action principle
• Catharsis theory • Social atom principle
• Discovery theory • Potentiality
• Pleasure principle theory • Spontaneity
• Catharsis
40. Enlist the indications for play therapy.
• Surplus reality
• Children with:
• Tele principle
„ Aggression
„ Temper tantrums 47. Define music therapy.
„ Poor bladder and bowel control Music therapy is defined as utilization of music in
„ Who are neglected treatment, training, education and rehabilitation of
„ Excess worries children and adults who are suffering from physical or
„ Low self esteem mental disorder.
„ Learning disorder
48. What is the mechanism of action of music therapy?
„ Differently abled children
Stimulation of endorphins, peptides and natural opiates
41. Mention the types of play therapy. leads to the synchronization of body rhythms with
• Controlled play musical rhythms, thereby it gives calming effect.
Viva-Voce 531

49. What are the types of music therapy? illness to improve the psychological, physical health,
• Active music therapy recovery and well-being.
• Passive music therapy
58. What are the indications for recreational therapy?
50. Enlist the various aspects of music therapy. • Psychiatric disorders
• Anxiolytic music therapy • Developmental disability
• Algolytic music therapy • Childhood disorders
• Tensolytic music therapy • Substance abuse
• Psychotic music therapy • Geriatrics with cognitive deficits
• Patholytic music therapy
59. How do you classify recreational therapy?
51. Name the areas where music therapy sessions are • Based on the place of recreational activity:
conducted. „ Indoor activity
• Counseling rooms „ Outdoor activity
• Rehabilitation centers • Based on the benefits of recreational activity:
• Physical therapy units „ Motor development
• Massage therapy rooms „ Sensory development
• Labor rooms „ Intellectual development
• Operation rooms
• Patient waiting halls 60. What are the recreational activities for psychiatric
disorders?
52. Define dance therapy.
• Schizophrenia—Carrom, chess
Dance therapy is defined as psychotherapeutic use
• Depression—Walking, jogging
of movement as process which promotes physical,
• Mania—Volley ball, football
emotional, cognitive integration of the individual.
• Dementia—Craft works
53. Who is the pioneer of modern music therapy? • Anxiety disorders—Music listening
Marian chace. • Childhood and adolescent disorders—Gross motor
54. What are the Stages of dance therapy? activities
• Preparation 61. Who is the father of modern phototherapy?
• Incubation Niels Finsen
• Illumination
62. What are the indications for Light therapy?
• Evaluation
• Skin disorders
55. What are the techniques of dance therapy? • Retinal conditions
• Body movements • Mood and sleep related disorders
• Props
• Imagery movement 63. What is the mechanism of action of Light therapy?
• Space awareness
• Memory movements
• Group coordination
56. What are the settings of dance therapy?
• Hospitals
• Rehabilitation center
• Psychiatric setups
• Education sector
• Day care centers
57. Define recreational therapy.
Recreational therapy is a systematic process which
utilizes the recreation and other activity-based
interventions based on the needs of individuals with
532 Textbook of Psychiatric Nursing for BSc Nursing Students

64. Define relaxation therapy. 73. Name some asanas.

Relaxation therapy is a component of body mind • Padmasana
intervention which the therapist provides to the • Dhanurasana
participants for mind relaxation. • Sarvangasana
• Savasana
65. Define autogenic training.
• Vajrasana
Autogenic training is defined as relaxation therapy
• Sasankasana
that involves the daily practice of sessions of around
• Chakrasana
15 minutes usually thrice a day. The technique helps
alleviate symptoms of stress. During each session, a 74. What is pranayama?
series of self-statements or visualisations is repeated that Breathing practices in the Yoga.
induces a state of relaxation.
75. Define meditation.
66. What is assertiveness training? Meditation is defined as an experience of relaxing the
Assertiveness training is a training to verbalize one’s body, mind and spirit.
own willingness in polite manner in order to protect
76. List out the types of meditation.
one’s own rights. Important technique is ‘Broken
• Breathing meditation
record.’
• Metta meditation
67. What is Jacobson Progressive Muscle Relaxation? • Chakra meditation
Jacobson Progressive Muscle Relaxation is a relaxation • Gazing meditation
therapy in which a series of guided steps focus on • Object meditation
tightening and relaxing specific muscle groups that help • Mantra meditation
in dealing with anxiety. • Sound meditation
• Third eye meditation
68. Define Guided imagery.
Guided imagery is a form of relaxation therapy in which 77. Define biofeedback.
the therapist helps the participants relax by evoking the Biofeedback is defined as the psychophysiological
mental images or recreating the sensory perception of therapy in which the individual is also able to monitor the
sound, taste, movement and smell. physiological changes in the body due to psychological
stressors.
69. What are the types of guided imagery?
• Voluntary 78. What are the phases of biofeedback?
• Involuntary • Initial evaluation
• Direct method • Skills training
• Use audio or video tapes • Therapy
• Individual
79. List out the types of biofeedback.
• Group
On the basis of physiological function - brain waves
70. What are the stages of guided imagery? breathing, heart rate, galvanic skin response, temperature
• Image generation and muscle contraction.
• Image maintenance On the basis of devices used – mobile device, wearable
• Image inspections device.
• Image transformations
80. Define Alternative and Complementary Medicine.
71. When is the International Yoga Day celebrated? Alternative and Complementary Medicine is defined
June 21 as group of diverse health care systems, practices and
products that are not presently considered to be a part of
72. What are the branches of Yoga?
conventional medicine.
• Hatha yoga
• Raja yoga 81. What are the major domains of alternative and
• Karma yoga complementary medicines?
• Bhakthi yoga • Alternative medicine system
• Jnana yoga • Mind body interactions
• Tantra yoga • Biologically based therapies
Viva-Voce 533

• Body based therapies 93. What are the indications of occupational therapy?
• Energy therapies • Substance abuse
• Mood disorders
82. Define Acupuncture.
• Anxiety disorders
Acupuncture is stimulating the points in the body
• Childhood psychiatric disorders
to correct the imbalance in energy flow through the
• Antisocial personality disorders
channels known as Meridians.
94. Mention the various settings of occupational therapy.
83. What is Naturopathy?
• Psychiatric hospitals
Naturopathy is the way of life in which the body innately
• Nursing homes
maintains the health and heals oneself.
• Special schools
84. What is homeopathy? • Rehabilitation centers
Homeopathy means ‘treat like with like.’ • Group homes
• Halfway homes
85. What is hypnosis?
Hypnosis is a trance like state in which the patient has 95. What are all the occupational therapy activities?
been put in a heightened focus and concentration. • Task activities, e.g., crafts, wood works
• Activities enhancing fine motor skills, e.g., drawing,
86. What are the modes of application of aromatherapy?
typing
• Direct inhalation • Activities enhancing the cognition, e.g., poetry,
• Topical application discussion
• Aerial diffusion • Activities involving communication, e.g., drama,
87. Define Tai-chi. social skill training
Tai-chi means ‘moving meditation.’ A series of 96. What are all the occupational therapy activities for
continuous slow movements with the mind and breath psychiatric disorders?
coordination. • Manic, e.g., games
88. Define bioelectromagnetic therapy. • Depression, e.g., craft works
Bioelectromagnetic is the usage of electromagnetic fields • Anti-social personality disorder, e.g., painting
in the body for a therapeutic purpose by Static and Pulse • Dementia, e.g., cover making
method. • Childhood psychiatric disorder, e.g., drawing,
painting
89. What is Reiki? • Anxiety disorders, e.g., washing clothes
Reiki means Universal life force. The purpose is direct
access to universal, transcendental, radiant and light 97. Enlist the process of occupational therapy.
energies at various levels of energy. • Selecting a model
• Assessment
90. Define reflexology. • Treatment
Reflexology is called ‘Zone therapy.’ Massaging the • Evaluation
specific areas of hands or feet in order to reduce stress,
pain and illness in the body. 98. Define Electroconvulsive therapy.
Electroconvulsive therapy is defined as therapy in
91. Define occupational therapy. which convulsions are induced by passing a brief pulse
Occupational therapy is defined as application of goal- of electric current through brain via electrodes for a
oriented and purposeful activity for the assessment and therapeutic purpose.
treatment of patients with physical, psychological and
99. List out the types of Electroconvulsive therapy (or)
developmental disabilities.
How can you classify ECT?
92. What are the basic elements of occupational therapy? • Sine wave ECT
• Patient • Brief pulse ECT
• Therapist • Ultra-brief pulse ECT
• Purposeful activity • Direct ECT
• Context • Modified ECT
534 Textbook of Psychiatric Nursing for BSc Nursing Students

• Unilateral ECT 108. What is the placement of ECT electrodes?

• Bilateral • Bitemporal placement
• Right unilateral
100. What are the indications of ECT?
• Bifrontal
• Depression
• Schizophrenia 109. Mention some psychiatric neurosurgeries.
• Postpartum psychosis • Anterior cingulotomy
• Anterior capsulotomy
101. What are the contraindications of ECT?
• Thalamotomy
• Absolute contraindications—Increased intracranial
• Hypothalamotomy
pressure • Amygdalotomy
• Relative contraindications—Myocardial infarction, • Limbic leucotomy
cerebrovascular accident
• Major physical illness, Cardiac and Respiratory 110. Define deep brain stimulation.
problems Deep brain stimulation is defined as implanting the
electrodes in central parts of the brain, the electrodes
102. What is the mechanism of action of ECT? produce the impulses to regulate the abnormal impulses.
Exact mechanism is unknown. The effects of The stimulation is controlled by the pacemaker like
neurotransmitters get balanced in the monoamine device that implanted under the skin of the chest.
system and affect the neuroendocrine and HPA axis.
111. What are the indications of deep brain stimulation?
103. What is the frequency of ECT? • Parkinson’s disease
3 times a week, 6–10 times ECT can be given and the • Epilepsy
maximum of 24 ECT. • Dementia
104. What is the protocols for ECT administration? • Cluster headache
Twice a week, 6–12 sessions, minimum electrical dose is • Major depression
required to induce generalized seizures. 112. Who used ECT at first in modern times?
105. What are the complications of ECT? Ladislas Meduna
• Memory loss 113. What is the minimum seizure duration required for
• Respiratory arrest the efficacy of ECT?
• Fracture 10–20 seconds
• Dysrhythmia
106. What are the articles required for ECT administration? SCHIZOPHRENIA
• ECG electrodes and monitor 1. Who coined the word ‘schizophrenia’?
• Pulse oximetry Eugen Bleuler
• Stethoscope
• Reflex hammer 2. What is the meaning of schizophrenia?
• Venflon The prefix in the term ‘Schizophrenia’—‘Schizo’
• Suction device means ‘split’ and, the suffix ‘phrenia’ means ‘mind’.
• Oxygen cylinder So, Schizophrenia means split mind.
• AMBU bag 3. Define schizophrenia.
• Airways Schizophrenia is a psychotic disorder characterized by
• Intubation kit abnormalities in emotion, thinking and cognition.
107. What are the medications used for ECT? 4. What are the etiological factors for schizophrenia?
• Anticholinergics, e.g., Atropine • Neurochemical factors
• Anesthetics, e.g., Methohexital propofol • Genetic factors
• Muscle relaxant, e.g., Succinylcholine • Neuropathological factors
Viva-Voce 535

• Neuroendocrinology factors • Social isolation

• Environmental factors • Self-care deficit
• Ineffective health maintenance
5. What are the 4 As of schizophrenia?
• Impaired verbal communication
1. Autistic thinking
• Ineffective family coping
2. Ambivalence
3. Affect 12. Which is the most common type of schizophrenia?
4. Associative loosening Paranoid schizophrenia
6. What is the diagnostic evaluation of schizophrenia? 13. Which rate of Dopamine level caused schizophrenia?
• Assessment scales for psychotic symptoms—Brief Increased level of dopamine
Psychiatric Rating scale
14. Which is the most common type of hallucination in
• Assessment scales for cognitive deficits—Wechsler
psychiatric disorders?
Adult intelligence scale
Auditory
• Assessment scales for personality problem—
Rorschach inkblot test 15. Define rehabilitation.
• Single photon emission computed tomography Rehabilitation means restoring the health status of
(SPECT) and positron emission tomography (PET) mentally ill patients as early as possible.
• Magnetic resonance imaging (MRI)
16. What is bouffee delirante?
• Diffusion tensor imaging
Bouffee delirante means short lived psychosis. It is
7. What are the three phases of schizophrenia? characterized by hallucination, delusion, confused state
1. Prodromal phase and amnesia after attack and polymorphous symptoms.
2. Psychotic phase
17. What is the classical trial of psychoneurotic
3. Residual phase
schizophrenia?
8. What are the positive and negative symptoms of • Pan anxiety
schizophrenia? • Pan neurosis
• Pan sexuality
Positive Symptoms Negative Symptoms
Hallucination Apathy 18. Mention some psychosocial intervention for
Delusion Blunt affect schizophrenia.
• Psychoeducation
Bizarre behavior Anhedonia
• Social skill training
Disorganized thoughts Alogia
• Cognitive training
• Token economy
9. What are the types of schizophrenia?
• Family intervention
• Paranoid schizophrenia
• Psychosocial weight management
• Hebephrenic schizophrenia
• Catatonic schizophrenia 19. What is the required duration to diagnose paranoid
• Simple schizophrenia schizophrenia?
• Residual schizophrenia 1 month
• Undifferentiated schizophrenia
20. What is Capgras syndrome?
10. What are the treatment modalities for schizophrenia? Capgras syndrome is defined as the delusion of doubles
• Pharmacotherapy or delusional misidentification syndrome.
• Psychotherapy
21. What is another name for Capgras syndrome?
• Transcranial magnetic stimulation
Imposter syndrome
• Community-based treatment
• Psychiatric rehabilitation 22. Who classified the schizophrenia as Type I and Type II?
T J Crow
11. Frame nursing diagnosis for schizophrenia.
• Disturbed thought process 23. Define Pfropf schizophrenia.
• Disturbed sensory perception Schizophrenia occurs with mental retardation.
536 Textbook of Psychiatric Nursing for BSc Nursing Students

SEXUAL DISORDERS 13. Define zoophilia.

Zoophilia is sexual pleasure with animals.
1. How can you classify the sexual disorder?
• Gender identity disorder 14. Define necrophilia.
• Disorders of sex deviation Necrophilia is sexual pleasure with dead bodies.
• Disorders related to sexual maturation
15. Define fetishism.
• Sexual dysfunction
Fetishism is sexual pleasure with objects.
2. What is transsexualism?
People having the feeling of discomfort with one’s own 16. Define fetishistic transvestism.
anatomical sex organs. Fetishistic Transvestism is sexual pleasure with clothes
3. What is transvestism? of opposite sex.
Wearing the dress of opposite gender for the purpose of 17. Define voyeurism.
sexual excitement.
Voyeurism is sexual pleasure by observing the sexual
4. What are the treatment options for transvestism? activity of opposite sex.
• Counseling and psychotherapy
• Sex reassignment surgery 18. What is sexual dysfunction?
• Mastectomy Sexual dysfunction is a significant dysfunction in
• Castration human response cycle which is not due to an organic
• Phalloplasty cause.
5. What is dual-role transvestism? 19. What are the disorders related to appetitive phase?
Dual-role transvestism is wearing opposite gender’s dress
• Sexual aversion disorder
to enjoy the experience of opposite sex on temporary
basis. • Hypoactive sexual desire disorder
• Excessive sexual desire disorder
6. Name the types of homosexuality.
• Obligatory homosexuality 20. What are the disorders related to excitement phase?
• Preferred homosexuality • Male erectile disorder
• Bisexuality • Female sexual arousal disorder
• Situational homosexuality
• Latent homosexuality 21. What are the disorders related to orgasmic phase?
• Male orgasmic disorder
7. What is the normal human sexual response cycle?
• Appetitive phase • Female orgasmic disorder
• Excitement phase • Premature ejaculation
• Plateau phase
22. What is nonorganic vaginismus?
• Orgasmic phase
• Resolution phase Spasm of lower vagina causes interference with the
coitus.
8. Define exhibitionism.
Exhibitionism is showing of sex organs to stranger. 23. What is nonorganic dyspareunia?
9. Define frotteurism. Male or female has pain in genital area during coitus.
Frotteurism is sexual pleasure with rubbing others. 24. Which is the peak state of sexual excitement?
10. Define sadism. Orgasmic phase
Sadism is sexual pleasure with humiliating others.
25. What are gender identity disorder?
11. Define masochism. • Transsexualism
Masochism is sexual pleasure with getting humiliated. • Dual-role transvestism
12. Define pedophilia. • Intersexuality
Pedophilia is sexual pleasure with children. • Gender identity disorders of childhood
Viva-Voce 537

26. Define personality. 36. What are types of personality disorders?

Personality is an enduring quality of a person and these • Paranoid personality disorder
qualities develop into personality traits. • Schizoid paranoid personality disorder
• Schizotypal paranoid personality disorder
27. Define personality disorders.
• Antisocial paranoid personality disorder
Personality disorders are types of mental disorders in
• Borderline paranoid personality disorder
which an individual has rigid and unhealthy pattern of
• Histrionic paranoid personality disorder
thinking, functioning and behaving.
• Narcissistic paranoid personality disorder
28. Which personality disorder is more common in • Avoidant paranoid personality disorder
psychiatric setups? • Dependent paranoid personality disorder
Borderline personality disorders • Obsessive compulsive paranoid personality disorder
29. Which personality disorder is more common than 37. Define antisocial personality disorders.
single type? Antisocial personality disorders violate the social norms
Mixed personality disorders and lead to criminal activities.
30. Which personality disorder is more common among 38. What are the criteria of antisocial personality
prison inmates? disorders?
Antisocial personality disorders • No concern for others
31. What is the etiology of personality disorders? • Decreased frustration
• Increased levels of testosterone • No guilty
• Increased levels of dopamine and serotonin • Blame others with rationalization
• Impulsivity • Violation of social norms
• Change in electrical conductance 39. What are borderline personality disorders?
32. What is the DSM-5 classification of personality Borderline personality disorders consist of tendency
disorders? to act out of impulsivity without considering the
• Cluster A [odd and eccentric] consequences along with unstable effects.
• Cluster B [dramatic, emotional] 40. What is the other name for borderline personality
• Cluster C [anxious or fearful] disorders?
33. What is DSM-5 classification of personality disorders? Emotionally unstable personality disorder.
• Negative affectivity 41. What are the types of Borderline personality disorders?
• Detachment • Impulsive type—unstable emotions
• Antagonism
• Borderline type—unstable emotions along with self-
• Disinhibition
image
• Psychoticism
42. What is the treatment for borderline personality
34. What are the risk factors of personality disorders?
disorders?
• School dropouts
• Dialectical Behavior therapy
• Unemployment
• Psychotherapy
• Unmarried
• Mentalization based therapy
• Divorced
• Emotional regulation training
• History of child abuse
• ECT
• Neglect from parents
• Pharmacotherapy
35. What are the protective factors of personality
43. Define eating disorders.
disorders?
Eating disorders are characterized by severe form of
• A string trusting relationship
disturbances in eating pattern leading to life-threatening
• Married
conditions.
• Employed
• Good IPR 44. What are the types of eating disorders?
• Extrovert • Anorexia nervosa
538 Textbook of Psychiatric Nursing for BSc Nursing Students

• Bulimia nervosa substance, which results in tolerance toward the

• Binge eating substance and leads to withdrawal symptoms.
45. What are the complications of eating disorders? 4. Define withdrawal.
• Cardiovascular Withdrawal symptoms occur when blood level of abused
• Endocrine drug gets decreased and the symptoms ceased when that
• Fluids and electrolytes substance has been taken by the individual.
• Gastrointestinal
5. Define intoxication.
• Dental
Intoxication occurs when substance-related symptoms
• Renal
occur due to the strong exposure to the substances.
• Musculoskeletal
• Psychological 6. Define detoxification.
Detoxification is the process of eliminating or
46. What are the types of anorexia nervosa?
• Restricted type neutralizing the toxins from the human body.
• Binge eating/ Purging type 7. What is the common substance abuse in India?
• What are the types of bulimia nervosa? • Alcohol
• Purging type • Cannabis
• Non purging type • Hypnotics
47. What is the assessment of eating disorders? • Cocaine
• Questionnaires: Eating attitude test, body image • Barbiturates
assessment • Nicotine
• Waist to hip ratio • Opioids
• Body mass index 8. What is modified Mann’s Index of addiction?
• Ratio to skin fold Modified Mann’s Index of addiction denotes the
• Assess the body fat addiction level of various substances which has been
48. What are the signs and symptoms of eating disorders? arranged from lower to higher; Caffeine has low
• Lethargy and fatigue addiction index and heroin has high addiction index.
• Anemia 9. What are the stages of craving?
• Severe abdominal pain • Normal craving
• Constipation • Excessive craving
• Enlarged parotid glands • Obsessional craving
• Dental and enamel erosion • Compulsive craving
• Muscle wasting
10. What are the etiological factors for substance abuse?
49. Define Russel’s sign.
• Social causes: Peer pressure, unemployment, high
Russel’s sign are callus knuckles due to self-induced
work pressure, love failure, lack of affection
vomiting.
• Biological causes: Imbalance in neurotransmitters,
hereditary factors, co-morbid illness
SUBSTANCE ABUSE • Psychological factors: Loneliness, low self-esteem,
1. Define substance abuse. low coping skills, poor impulse control
Substance abuse is the maladaptive pattern of substance 11. What are the complications of substance abuse?
use leading to clinically significant distress or impairment Neurological, Cardiopulmonary, Musculoskeletal,
in recurrent substance use. Gastrointestinal and Reproductive.
2. Define tolerance. 12. Define alcohol.
Tolerance is the increase in the level of substance use in Alcohol is a natural product obtained by the reaction of
order to get the same desired effect. fermented sugar with yeast spores.
3. Define dependence. 13. What is the DSM-5 Classification of Alcoholism?
Dependence is the compulsive and repeated use of • 305.00 Alcohol use disorder (mild)
Viva-Voce 539

• 303.90 Alcohol use disorder (moderate or severe) 22. Define aversion therapy.
• 303.00 Alcohol intoxication Aversion therapy is the treatment to arouse the
• 291.81 Alcohol withdrawal unlikeness or feel likely to be hated of alcoholism.
• 291.9 Unspecified alcohol-related disorder
23. What is electrical aversion?
14. What are the common alcoholic beverages? Ask the client to smell the alcohol. Low volt electrical
• Beer • Scotch stimuli administered immediately when he smells
• Wine alcohol. Desired response will be changed by undesired
• Gin
• Whisky electrical stimuli.
• Rum • Vodka 24. What are the approaches to quit alcohol?
15. What are the blood alcohol concentration levels? • Aversion therapy
• 20–100—Slow motor activity • Motivational interview
• 100–200—Lack of coordination • Cognitive therapy
• 200–300—Alcohol blackout • Behavior therapy
• 300–350—Hypothermia • Contingency management
• 350–400—Coma • Cue’s exposure therapy
• >400—Death might occur • Relapse prevention

16. What are the phases of alcoholism? 25. What are the alcohol withdrawal syndromes?
• Pre alcoholic • Delirium tremens
• Early alcoholic • Alcohol withdrawal seizures
• True alcoholic • Alcohol hallucination
• Chronic alcoholic • Alcohol pellagra

17. Name five species of Jellinek’s alcohol dependence. 26. What is Wernicke’s Korsakoff syndrome?
Alpha, Beta, Gamma, Delta and Epsilon. Wernicke’s Korsakoff syndrome is a neurological
disorder caused by the lack of thiamine (vitamin B1) in
18. What is the diagnostic evaluation for alcohol abuse? which damage to neuron occurs.
• Blood alcohol levels
• Liver function test 27. What is Wernicke’s encephalopathy?
• Hematologic studies Wernicke’s encephalopathy is characterized by cerebellar
• Urine toxicology ataxia, mental confusion, palsy of 6th cranial nerve,
• Serum electrolytes hypothermia and peripheral neuropathy.
• Electrocardiogram (ECG) 28. What are the classical triad of Wernicke’s
19. Define CAGE questionnaire. encephalopathy?
• C : Cutdown • Ataxia
• A : Annoyance • Confusion
• G : Guilt • Ophthalmoplegia
• E : Eye opening 29. Define Korsakoff ’s syndrome.
20. What are the assessment tools for problem drinkers of Korsakoff ’s syndrome is characterized by gross memory
alcoholism? disturbance, confabulation, confusion, disorientation,
poor attention span.
• Michigan Alcoholism Screening Test [MAST]
• CAGE questionnaire 30. What is Marchiafava bignami disease?
• Alcohol Use Disorders Identification Test [AUDIT] Marchiafava bignami disease is a neurological disease of
• Paddington Alcohol Test [PAT] alcoholism which occurs due to demyelination of corpus
callosum, optic tract and cerebellar peduncles.
21. What are the assessment tools for alcohol withdrawal?
• Modified Selective Severity Assessment [MSSA] 31. Define Othello syndrome.
• Clinical Institute Withdrawal Assessment for Alcohol Othello syndrome is called morbid jealousy. It is a
Revised [CIWA-Ar] delusion that a life partner is not faithful.
540 Textbook of Psychiatric Nursing for BSc Nursing Students

32. What is blackout? • Systemic complications: Hypertension, CAD,

Blackout is transient short term memory loss that may COPD, Alteration in immune response.
be partial or complete in relation with intoxication state.
44. Which are the Central Nervous Stimulants?
33. What is fetal alcohol syndrome? • Psychomotor stimulants: Dopamine, Serotonin
Alcohol affects the fetus when consumed by pregnant • Cellular stimulants: Caffeine, Nicotine
women. It leads to mental retardation.
45. What are the common CNS stimulants?
34. Define alcoholic anonymous [AA]. • Amphetamines
Alcoholic Anonymous helps the people suffering from • Nonamphetamines
alcohol addiction disorder. • Miscellaneous—Caffeine, Cocaine and Nicotine
35. Who founded alcoholic anonymous [AA]? 46. What is cocaine?
Bill Wilson and Dr Bob Smith Cocaine is an alkaloid and it has physiological effects on
central and peripheral nervous system. It is commonly
36. What are the types of Alcoholic Anonymous [AA]
used with opioids and amphetamines.
Meetings?
• Closed meetings 47. What are the phases of cocaine withdrawal?
• Open meetings • Crash
• Speaker meetings • Post-crash
• Discussion meetings • Extinction
• Step meetings
48. Define Nicotine abuse.
37. What is Al-Anon? Nicotine is an addictive substance present in tobacco
Al-Anon is a mutual support group for families and products. It has 4000 chemicals. Cigarette smoking,
friends of alcoholics. pipe smoking, tobacco chewing are the ways of nicotine
abuse.
38. What is Alateen?
Alateen is a subgroup of Al-Anon. It is a mutual support 49. What are the intoxication effects of Nicotine?
group for families and friends of alcoholics especially Lung carcinoma, Emphysema, Heart disease,
teenagers. Oropharyngeal carcinoma.
39. What is the usual dose of Disulfiram per day? 50. What are the 6 D techniques in smoking cessation?
250 mg. • Decide to quit smoking
• Drink plenty of water
40. What is the action of Disulfiram?
• Deep breathing exercise
Aldehyde Dehydrogenase Inhibitors
• Diet in balanced proportion
41. What is Cannabis? • Diversional activities
Cannabis is derived from ‘hemp plant’. It has more • Daily activities
than 400 chemicals and the cannabinoid receptors
51. What is meant by Hallucinogen?
can be substituted in basal ganglia, cerebellum and
Hallucinogens are substances which alter the individual’s
hippocampus of the brain.
sensory perception of reality and induce hallucinations.
42. What is the common preparation of cannabis?
52. What are types of Hallucinogens?
• Marijuana
• Natural hallucinogens
• Hashish
• Synthetic hallucinogens
• Hashish oil
53. What are the common inhalants?
43. What are the complications of cannabis use?
Aerosols, varnish remover, thinners, petrol and solvents.
• Psychiatric complications: Anxiety, Hypomania,
Paranoid psychosis, Organic psychosis, 54. Which is an antidote for Cocaine overdose?
Schizophrenia. Amyl nitrite.
Multiple Choice Questions

1. What is the antidote of narcotics or heroin poisoning? 8. Parkinson’s disease is characterized by deficiency of
(AIIMS Jodhpur Nursing Officer Exam – 2020) ______________ neurotransmitter.
a. Naloxone b. Atropine sulphate (AIIMS Jodhpur Nursing Officer Exam – 2020)
c. Digibind d. Flumazenil a. Dopamine b. GABA
c. Serotonin d. Acetylcholine
2. Which of the following is a delusional disorder?
(NIMHANS – 2019) 9. __________causes Extra Pyramidal Symptoms.
a. Trance b. Capuras syndrome (AIIMS Jodhpur Nursing Officer Exam – 2020)
c. Dissociative fugue d. Ganser’s syndrome a. SSRI b. Antipsychotics
c. Mood Stabilizers d. Antianxiety agents
3. What is the purpose of using Succinylcholine in ECT?
10. Which of the following causes delirium? Ans.
(AIIMS Jodhpur Nursing Officer Exam – 2020)
a. Muscle relaxant b. Muscle contraction (AIIMS Jodhpur Nursing Officer Exam – 2020) 1. a
a. Alcohol consumption b. Brain tumor 2. b
c. Both a and c d. Reduces oral secretion
c. Head trauma d. All of these 3. c
4. According to psychosocial theory of Erikson, which 4. a
behavior is seen in toddler age group? 11. Paranoid thoughts are described as: 5. a
(AIIMS Jodhpur Nursing Officer Exam – 2020) (AIIMS Jodhpur Nursing Officer Exam – 2020) 6. d
a. Hallucinations b. Anxiety disorders 7. a
a. Autonomy Vs Shame
c. Illusions d. Delusions 8. a
b. Trust Vs Mistrust 9. b
c. Generativity Vs Stagnation 12. Which of the following conditions is example for 10. d
d. Ego integrity Vs despair acute organic mental disorder? (JIPMER – 2020) 11. d
5. Normal value of Serum Lithium test is: a. Schizophrenia b. OCD 12. d
c. Manic Psychosis d. Delirium 13. a
(AIIMS Jodhpur Nursing Officer Exam – 2020) 14. d
a. 0.6–1.2 mEq/L 13. A patient is brought to emergency unit after RTA. 15. c
b. 0.10–0.32 mEq/L Patient’s motor response is 3 on GCS. This means the
c. 1–1.8 mEq/L patient’s response is: (JIPMER – 2020)
d. 1.2–2.2 mEq/L a. Decorticate posture b. Decerebrate posture
6. Drug of choice for alcohol withdrawal symptoms are: c. Withdraws from touch d. Withdraws to pain
(AIIMS Jodhpur Nursing Officer Exam – 2020) 14. Disulfiram is used for the treatment of:
a. Labetalol b. Metoclopramide (JIPMER – 2012)
c. Digoxin d. Chlordiazepoxide a. Hallucination b. Mania
7. Which antipsychotics is most common to cause c. Catatonia d. Alcoholism
amenorrhea? (AIIMS Jodhpur Nursing Officer Exam – 2020) 15. Another term for superego is: (JIPMER – 2012)
a. Risperidone b. Sertraline a. Self b. Ideal self
c. Paroxetine d. Citalopram c. Conscience d. Subconscious
 542 Textbook of Psychiatric Nursing for BSc Nursing Students

16. Making up stories to fill the memory gaps is: 26. A client with paranoid schizophrenia has a delusion
(JIPMER – 2012) of persecution. He tells the nurse, “The CIA is out to
a. Reaction formation b. Sublimation get me. They are spying on me.’ The nurse’s best initial
c. Confabulation d. Lying response is: (AIIMS Bathinda 2019)

17. Persistent fear of severe medical illness: a. I didn’t want to hurt you
b. How would they spy on you here?
(JIPMER – 2012)
c. Tell me how they are trying to get you
a. Conversion b. Regression
d. I know the CIA wound not want to hurt you
c. Sublimation d. Hypochondriasis
27. False sensory perception in the absence of real
18. Use of Carbamazepine in psychiatry is:
external stimuli is: (AIIMS Bathinda 2019)
(JIPMER – 2012)
a. Illusion b. Hallucination
a. Mood stabilizer b. Antidote
c. Depersonalization d. Déjà vu
c. Anticonvulsant d. Neuroleptics
28. For most nurses, the difficult part of nurse client
19. An irreversible side effect of antipsychotics is:
relationship is:  (AIIMS Bathinda 2019)
(JIPMER – 2012)
a. Developing an awareness to self and professional
a. Akathisia
role in relationship
b. Tardive dyskinesia
b. Remaining therapeutic and professional at all times
c. Tremor
c. Accepting responsibility in identifying and
d. Sleeplessness
evaluating the real needs of the client
20. Type of speech in which one repeats, what the others d. Being able to understand and accept the client
just said is:  (JIPMER – 2012) behavior
a. Neologism b. Echopraxia
29. Vital aspect of crisis resolution is:
c. Echolalia d. Association
(AIIMS Bathinda 2019)
21. Antipsychotics decrease the psychotic symptoms by: a. Meet all dependency needs
(RRB – 2019 Shift I) b. Encourage socialization
Ans. a. Blocking the action of dopamine in brain c. Involve the person in therapy sessions
b. Blocking the reuptake of NE and 5-HT d. Support ego strengths
16. c
c. Inhibiting MOA
17. d 30. Vital component in nursing care plan of patient with
d. Depressing the CNS
18. a organic brain deterioration is: (AIIMS Bathinda 2019)
19. b 22. Normal IQ for the human being is: (RRB – 2019 Shift I) a. Extensive Re-education Program
20. c a. 80–100 b. 90–110 b. Introduction of new leisure activities
21. a
c. 110–120 d. 120 and above c. Details of protective and supportive care
22. a
23. d 23. Standards of mental health practices are published by: d. Plans to involve the new client in group therapy
24. d (RRB – 2019 Shift I) 31. Defense mechanism in which the emotional conflicts
25. c a. State Nursing Council are expressed through sensory, motor or somatic
26. c
b. TNAI disability is: (AIIMS Bathinda 2019)
27. b
28. b c. INC a. Dissociation b. Compensation
29. d d. American Nurses Association c. Psychosomatic d. Conversion
30. c 24. What are the immediate side effects of ECT? 32. In approaching the client with the period of over
31. d
(RRB – 2019 Shift I) activity is: (AIIMS Bathinda 2019)
32. a
33. a
a. Fractured and dislocated bones a. Use of firm, warm and consistent approach
b. Permanent memory loss and brain damage b. Physically control the hyperactivity
c. Myocardial infarction and cardiac arrest c. Allow the patient to participate in any activity
d. Temporary memory loss and confusion d. Let the client know the staff will not tolerate the
25. Which disease is the fatal brain disorder caused by destructive behavior
Prion Protein?  (RRB – 2019 Shift I) 33. A 19-year-old female was admitted in ICU after being
a. Pick’s disease found unconscious. Her BP is 82/50 mm Hg. She is
b. Lewy body 5’4” tall and weighs 35.8 kg. She appears malnourished
c. Creutzfeldt-Jakob disease and dehydrated. After regaining consciousness, she
d. Mad Cow disease reported difficulty in eating and she can’t remember
Multiple Choice Questions 543

what she ate for the last 24 hours. She has irregular 43. As adult, throwing a temper tantrum when he does
menstrual period for past 1 year. She refused food not get his own way is an example of:
since she feels that she was obese. The nurse suspects (AIIMS Raipur Shift II – 2019)
the case of: (AIIMS Bathinda – 2019) a. Regression b. Repression
a. Anorexia nervosa b. Bulimia nervosa c. Sublimation d. Undoing
c. Reactive depression d. Schizophrenia 44. Which mental disorder is characterized by fantasy,
34. Nurse demonstrates the active listening by: extreme withdrawal, hallucination, delusion and
(AIIMS Bathinda – 2019) inability to communicate especially in children?
a. Repeating everything what the client says (AIIMS Raipur Shift II – 2019)
b. Agreeing with the client a. Juvenile delinquency
c. Assuming relaxed posture and leaning toward the b. Autism
client c. Social anxiety disorder
d. Smiling and nodding continuously through the d. Mutism
interview 45. Which of the following is not a physical assessment
35. Meaningless and incoherent mixture of words and finding in Parkinson’s disease?
phrases is: (AIIMS Raipur Shift I – 2019) (AIIMS Bhubaneswar Shift II – 2019)
a. Word salad b. Verbigeration a. Absence of cognitive impairment
c. Paralalia d. Neologism b. Mask like expression
c. Pill rolling tremors
36. Normal therapeutic value of Serum Lithium test is: d. Dysarthria
(AIIMS Raipur Shift I – 2019)
a. 0.8 – 1.2 mEq/L b. 0.1 – 1.0 mEq/L 46. Which of the following is not true about brief
c. 2 – 4 mEq/L d. 1 – 3 mEq/L cognitive therapy? 
 (AIIMS Bhubaneswar Shift II – 2019)
37. What is the normal intracranial pressure? a. It uses here and now approach
(AIIMS Raipur Shift I – 2019) b. It uses goal directed approach
a. 0–10 mm Hg b. 5–10 mm Hg c. It uses time limited approach
c. 5–15 mm Hg d. 30–40 mm Hg Ans.
d. It puts great emphasis on cause of problem
34. c
38. What is the ‘Problem defining phase’ of interpersonal 47. Which one of the following theories states that 35. a
relationship as per ‘Peplau’s theory’? integrated social or cultural factors cause anxiety? 36. a
(AIIMS Raipur Shift I – 2019) (AIIMS Bhubaneswar Shift II – 2019) 37. c
a. Orientation phase b. Identification phase a. Psychoanalytic theory 38. a
c. Resolution phase d. Exploitation phase b. Biological theory 39. c
40. b
39. The period of acceptance of loss during which the c. Integrated theory
41. a
person learns to deal with loss is known as: d. Cognitive behavioral theory 42. b
(AIIMS Raipur Shift I – 2019) 48. The type of loss in which the client is aware that a loss 43. a
a. Idealization b. Bereavement will occur is known as: 44. b
c. Mourning d. None of these (AIIMS Bhubaneswar Shift II – 2019) 45. a
46. d
40. Flow of information between the persons at the a. Anticipatory loss b. Observable loss
47. c
same hierarchical level helps in improving _______ c. Actual loss d. Perceived loss 48. a
communication. (AIIMS Raipur Shift III – 2019) 49. In Schizophrenia, gradual subtle behavior changes 49. b
a. Oral b. Horizontal occur in:  (AIIMS Bhubaneswar Shift II – 2019) 50. b
c. Upward d. Downward 51. a
a. Premorbid phase b. Prodromal phase
41. Nerve that maintains the hearing and balance is: c. Onset phase d. Progressive phase
(AIIMS Raipur Shift II – 2019) 50. Antidepressant used in children for depression is:
a. Vestibulocochlear b. Vagus (NIMHANS – 2019)
c. Facial d. Trochlear a. Amitriptyline b. Fluoxetine
42. Nerve that conveys the special sensory information to c. Benzodiazepines d. Naloxone
the smell is:  (AIIMS Raipur Shift II – 2019) 51. Antidote of opioids is:  (NIMHANS – 2019)
a. Optic b. Olfactory a. Naloxone b. Fluphenazine
c. Oculomotor d. Trochlear c. Benzodiazepines d. Flumazenil
 544 Textbook of Psychiatric Nursing for BSc Nursing Students

52. Immediate management of Wernicke’s encephalopathy b. Paranoid, schizoid and schizotypal

is to: (NIMHANS – 2019) c. Avoidant, obsessive and dependent
a. Administer Thiamine d. Avoidant, schizoid and antisocial
b. Administer steroids 62. Major cause of mortality associated with anorexia
c. Order EEG nervosa: (NIMHANS – 2019)
d. Prescribe Tab. Disulfiram a. Obesity b. Malnutrition
53. Delusion of grandiosity is present in: c. Electrolyte imbalance d. Nausea and vomiting
(NIMHANS – 2019) 63. Drug of choice for catatonia is: (NIMHANS – 2019)
a. Depression b. Mania a. Benzodiazepines b. Carbamazepine
c. Dissociative disorder d. Schizophrenia c. Haloperidol d. Sodium valproate
54. False fixed ideas or belief is known as: 64. Directive counseling is also known as:
(NIMHANS – 2019) (NIMHANS – 2019)
a. Hallucination b. Delusion a. Personal counseling
c. Illusion d. Confabulation b. Group counseling
55. Which of the following is not an antipsychotic c. Client centered counseling
medication? d. Counselor centered or prescriptive counseling
a. Haloperidol b. Risperidone 65. Neurotransmitter between neuron and muscle cell is:
c. Imipramine d. Olanzapine (Kerala PSC – 2018)
56. Parents of autistic child should be taught to: a. Serotonin b. Acetylcholine
(NIMHANS – 2019)
c. Dopamine d. Endorphin
a. Be consistent 66. A strategy of effective communication where the
b. Set limit interviewer validates the information from the client
c. Change the routine frequently without changing out the meaning of the statement is:
d. All of the above (Kerala PSC – 2018)
57. Disulfiram Ethanol reaction is characterized by: a. Clarifying b. Focusing
Ans. c. Summarizing d. Paraphrasing
(NIMHANS – 2019)
52. a 67. A process of redirecting the energy produced by
a. Bradycardia, sweating and hypertension
53. b
b. Bradycardia, blurred vision and hypertension unacceptable desires or activities so that they become
54. b
55. c c. Tachypnea, vomiting and hypertension acceptable is: (Kerala PSC – 2018)
56. a d. Headache, hypotension and chest pain a. Reaction formation b. Sublimation
57. d c. Projection d. Identification
58. Global loss of memory, cognition and personality is
58. b 68. Suitable method to handle the overactive aggressive
known as: (NIMHANS – 2019)
59. b
a. Delirium patient is: (Kerala PSC – 2018)
60. c
61. b b. Alzheimer type of dementia a. 
Accept the criticism and verbal attack without
62. c c. Dissociative disorder punishment
63. a d. Conversion disorder b. Avoid the person and neglect him for a while
64. d c. Fire the person and apply restraints
65. b 59. A recurrent recollection of flashbacks/images/ d. Try to cheer up, give praise
66. d thoughts in dream is: (NIMHANS – 2019)
67. b a. Acute stress disorder 69. Extrapyramidal side effects of antipsychotics are
68. a b. Post-traumatic stress disorder managed with the following drugs except:
69. d c. Sleep disorder (Kerala PSC – 2018)
70. c d. Psychosomatic disorder a. Anticholinergic drugs b. Antihistamines
c. Dopamine drugs d. Barbiturates
60. Preoccupation with details/rules, lists, order is seen
in which type of personality? (NIMHANS – 2019) 70. A 47-year-old female client with the diagnosis of
a. Narcissistic b. Histrionic depression has been hospitalized for three days.
During this time, she has not maintained her personal
c. Obsessive-Compulsive d. Borderline
hygiene and shows no interest in wearing a clean dress
61. Cluster A personality disorder includes: and combing her hair. In working with a depressed
(NIMHANS – 2019) client, the nurse should understand that depression is
a. Antisocial, borderline and narcissistic most directly related to person’s: (NIMHANS – 2019)
Multiple Choice Questions 545

a. Experiencing poor IPR with others 79. Which electrolyte has to be maintained in lithium
b. Remembering his/her traumatic childhood therapy? (AIIMS Delhi – 2018)
c. Having experienced a sense of loss a. Sodium b. Potassium
d. Stage in life c. Calcium d. Magnesium
71. A client has been on long term phenothiazine 80. Delirium tremens are withdrawal symptoms of:
(Thorazine) 400 mg/day. Patient had jerky choreiform (AIIMS Delhi – 2018)
movements, lip smacking, neck and back tonic a. Alcoholism b. Cocaine
contractions. This indicates that the patient has c. Opioid d. Cannabis
developed: (NIMHANS – 2019)
81. Drug of choice for Bipolar Affective Disorder is:
a. Tardive Dyskinesia b. Dystonia
c. Parkinsonism d. Akathisia (AIIMS Delhi – 2018)
a. Lithium carbonate
72. A patient diagnosed as BPAD is being discharged from b. Chlorpromazine
hospital with lithium medication. Most important c. Bupropion
information to impart to the client and his family in d. Benzodiazepines
the discharge teaching is the patient should:
(NIMHANS – 2019)
82. Which of the following is the negative symptom of
a. Have adequate sodium intake Schizophrenia? (AIIMS Delhi – 2018)
b. Restrict sodium intake a. Delusion b. Anhedonia
c. Restrict his fluid intake c. Hallucination d. Clang association
d. Avoid tyramine rich foods 83. Which of the following is the positive symptom of
73. Publication of a false statement about an individual Schizophrenia? (AIIMS Delhi – 2018)
made either verbally or in some other form to the a. Stupor b. Apathy
third person: (Kerala PSC – 2018) c. Delusion d. Alogia
a. Battery b. Displacement 84. Major depressive episodes are characterized by low
c. Depersonalization d. Defamation mood for at least: (AIIMS Delhi – 2018)
74. Anxiety is caused by: a. 1 week b. 2 weeks Ans.
a. Subjectively perceived threat c. 4 weeks d. 8 weeks
71. a
b. An objective threat 85. All of the following are assessed in mental status 72. a
c. Masked depression examination, except: (AIIMS Delhi – 2018) 73. d
d. Hostility turned to oneself a. General appearance b. Judgment 74. a
c. Prejudice d. Intelligence 75. b
75. Which of the following is used in drug dependence to
76. b
prevent relapse? (Kerala PSC – 2018) 86. Which of the following food should be avoided when 77. b
a. Naloxone b. Naltrexone the patient is on Mono-amine Oxidase Inhibitors 78. a
c. Neuroleptic d. Nomifensine (MAOIs)? (AIIMS Delhi – 2018) 79. a
76. Informal communication is also known as _________ a. Calcium rich food 80. a
81. a
communication. (Kerala PSC – 2018) b. Gluten rich food
82. b
a. Diagonal b. Grape wine c. Tyramine containing food
83. c
c. Cross wine d. Horizontal d. Alanine containing food 84. b
77. A chronic alcoholic patient blames his family 87. Parrot like repetition of word spoken by another 85. c
environment for his alcoholism. Which of the person is known as: (AIIMS Jodhpur SNO – 2018) 86. c
87. a
following defense mechanism was used by the patient? a. Echolalia
88. c
(AIIMS Delhi – 2018) b. Neologism
a. Denial b. Projection c. Echopraxia
c. Rationalization d. Sublimation d. Dyscalculia
78. Which drug is used for prophylaxis of manic- 88. Which part of mind is associated with practical reality
depressive disorder? (AIIMS Delhi – 2018) principle? (AIIMS Jodhpur SNO – 2018)
a. Lithium b. Valproate a. Hyper-ego b. Super-ego
c. Haloperidol d. Phenytoin c. Ego d. Id
 546 Textbook of Psychiatric Nursing for BSc Nursing Students

89. The part of mind copes with quarreling among young 99. Which of the following is a long-term effect of
children by placing them in separate rooms is using: ‘Medical complication of Alcoholism’?
(AIIMS Jodhpur SNO – 2018) (AIIMS Bhopal – 2018)
a. Time out b. Reinforcement a. Korsakoff psychosis b. Depression
c. Shaping d. Punishment c. Delirium tremens d. Paranoia
90. A nurse who enters the patient’s room with cognitive 100. Which of the following features is present only in
impairment asks what is the date, month, year and dementia when compared to delirium?
where the patient is. The nurse is attempting to assess: (AIIMS Bhopal – 2018)
(AIIMS Jodhpur SNO 2018) a. Misperception
a. Perseveration b. Confabulation b. Hallucination
c. Orientation d. Delirium c. Vivid illusions
d. Systematized delusions occur early
91. False sensory perception with no basis in reality are
known as: (AIIMS Jodhpur SNO – 2018) 101. Movement of eyeballs is the function of which cranial
a. Delusions b. Illusions nerve? (AIIMS Bhopal – 2018)
c. Hallucination d. Loose association a. Olfactory b. Oculomotor
c. Optic d. Accessory
92. Deficiency of which neurotransmitters in brain will
cause Alzheimer’s disease? (AIIMS Jodhpur SNO – 2018) 102. “No, not me” reaction of patient is seen in which stage
a. Acetylcholine b. GABA of terminal illness or death? (AIIMS Bhopal – 2018)
c. Serotonin d. Dopamine a. Bargaining b. Denial
c. Anger d. Acceptance
93. Drug of choice for nocturnal enuresis is:
(AIIMS Jodhpur SNO – 2018) 103. In Alzheimer disease, plagues are more common in:
a. Imipramine b. Trazodone a. Thalamus b. Hypothalamus
c. Chlorpromazine d. Sertraline c. Hippocampus d. Brain stem

94. Unshakable and persistent ideas are: 104. Which of the following is not a medico-psychiatric
(AIIMS Jodhpur SNO – 2018) condition? (AIIMS Bhopal – 2018)
Ans. a. Hyperthyroidism b. Agitated depression
a. Compulsions b. Delusions
89. a c. Angina d. Insulinoma
90. c
c. Hallucinations d. Illusions
91. c 95. The part of mind that distinguishes right from wrong 105. What is the difference between Direct ECT and
92. a and acts as a censor of behavior is known as: Modified ECT?
93. a
(AIIMS Jodhpur SNO – 2018) a. Low volt shock is given
94. b b. Anesthesia or Muscle relaxant will be given
95. c
a. Libido b. Id
c. Super-ego d. Ego c. Pain killer will be given
96. b d. No such differences
97. c 96. Omega sign is seen in: (AIIMS Bhopal – 2018)
98. a 106. Example of Sublimation is: (AIIMS Bhopal – 2019)
a. Anxious to specific b. Depressed patient
99. a
c. Deluded patient d. Negativistic patient a. Blaming the teacher for failing in exam
100. d b. Women has no memory of being sexually assaulted
101. b 97. Disorder of recurrent pulling out one’s hair is called: as child
102. b (AIIMS Bhopal – 2018) c. Child starts bedwetting after the birth of sibling
103. c
a. Pyromania b. Kleptomania d. A young man who is dealing with aggression by
104. b
c. Trichotillomania d. Rhinotillexomania playing football
105. b
106. d 98. Diagnostic interview with sodium amytal or hypnosis 107. Correct order of response to stress is:
107. a is a special feature of: (AIIMS: Bhopal – 2018) (AIIMS Bhopal – 2019)
a. Post-traumatic neurosis a. Alarm-Resistance-Exhaustion
b. Mania b. Resistance-Exhaustion-Alarm
c. Hyperventilation syndrome c. Exhaustion-Resistance-Alarm
d. Phobia d. Resistance-Alarm-Exhaustion
Multiple Choice Questions 547

108. From the age group of 1–3, stages of development are: 117. A person changing the subject or cracking joke in an
(AIIMS Bhopal – 2019) attempt to compensate for defects by using strategies
a. Oral stage b. Anal stage to avoid demonstrating failures in intellectual
c. Genital stage d. Phallic stage performance is called: (AIIMS Bhopal SNO – 2018)
a. Catastrophic reaction
109. Behavior of diabetic patient who eats sweets regularly
b. Sundowner syndrome
indicates: (AIIMS Bhopal – 2019)
c. Affective impairment
a. Displacement b. Fixation
d. Thought insertion
c. Denial d. Dislocation
118. Neurotransmitter released by motor neuron at the
110. Separation of thought or memory from its associated
neuromuscular junction is: (AIIMS Bhopal SNO – 2018)
feeling or emotion is known as: (AIIMS Bhopal – 2019)
a. Dopamine b. Adrenaline
a. Idealization b. Projection
c. Noradrenaline d. Acetylcholine
c. Intellectualization d. Isolation
119. Presenting the patient with ‘hypothetical situation’
111. An organic mental disorder among the following is:
helps in the assessment of: (AIIMS Bhopal SNO – 2018)
(AIIMS Bhopal – 2019)
a. Insight b. Abstract thinking
a. Bipolar disorder b. Conversion disorder
c. Judgment d. Comprehension
c. Schizophrenia d. Vascular dementia
120. Concept of health which emphasizes the health as
112. As per Erickson’s psychosocial theory, development
‘sound mind in a sound body in a sound family in
task of toddler is: (AIIMS Bhopal SNO – 2018)
sound environment’ is: (AIIMS Bhopal SNO – 2018)
a. Trust/Mistrust
a. Ecological concept
b. Autonomy/Shame and doubt
b. Physical concept
c. Industry/Inferiority
c. Psychological concept
d. Initiative/Guilt
d. Holistic concept
113. Which is not a part of 4 A’s of Bleuler?
121. Perception without stimulus is:
(AIIMS Bhopal SNO – 2018)
(AIIMS Bhubaneswar – 2018)
a. Ambivalence b. Associative learning
c. Avolition d. Autistic thinking
a. Delirium b. Illusion Ans.
c. Delusion d. Hallucination 108. b
114. When MAOIs are administered, patient has to be 109. c
122. Formed visual hallucination are seen in the lesion of:
caution against: (AIIMS Bhopal SNO – 2018) 110. d
(AIIMS Bhubaneswar – 2018)
a. Involving in active physical exercises 111. d
a. Occiput b. Parietal
b. Use of medicine with elixir base 112. b
c. Temporal d. Frontal 113. c
c. Prolonged sun exposure
d. Ingesting wine and aged cheese 123. Biochemical etiology of Alzheimer’s disease is: 114. d
a. Epinephrine b. Acetylcholine 115. b
115. As per the Kubler-Ross theory of grief, which behavior 116. a
c. Serotonin d. Dopamine
is being observed in stage II?(AIIMS Bhopal SNO – 2018) 117. c
a. Depression b. Anger 124. Stranger anxiety develops by the age of: 118. d
c. Bargaining d. Denial a. Birth b. 6 months after birth 119. c
c. 8 months after birth d. 3 months after birth 120. a
116. Crisis which is precipitated by unanticipated stressful 121. d
event which creates the disequilibrium by threatening 125. Best test to diagnose the organic mental disorder is: 122. c
one’s sense of biological, social or psychological a. Bender gestalt test 123. b
integrity is: (AIIMS Bhopal SNO – 2018) b. Sentence completion test 124. c
a. Situation crisis b. Adventitious crisis c. Rorschach test 125. a
c. Social crisis d. Maturational crisis d. Thematic appreciation test
Notes
Appendices

APPENDIX 1 II. Chief complaints/presenting complaints (list with

duration)
HISTORY COLLECTION FORMAT „ Use verbatim technique (write the patient’s complaint
exactly what the patient verbalized or note down what
I. Demographic data the informant verbalized, exactly in his/her words)
„ Name „ According to patient:
„ Age „ According to informant:
„ Gender e.g., Unable to sleep properly for past 10 days;
„ Education Hearing voices for past eight days;
„ Occupation Loss of appetite for past three days.
„ Monthly income Organize and write the chief complaints in such a way
„ Universal Hospital Identity Number (UHID No.)/In that, ‘complaint with longer duration are written first and
Patient Number (IP No.)/Out Patient Number (OP of shorter duration at last’.
No.) III. 
Present psychiatric history/nature of the current
„ Ward/OPD episode
„ Unit „ Onset
„ Marital status ◆ Abrupt (symptoms occur within 48 hours)
„ Nationality ◆ Acute (symptoms occur within two weeks)
„ Religion ◆ Insidious (symptoms occur from several weeks to
„ Date of admission and time months)
„ Diagnosis „ Intensity—Same/increasing/decreasing
„ Doctor’s in-charge „ Duration—Days, weeks or months
„ Address „ Course—Continuous/episodic
„ Informant (Name/Relationship) „ Precipitating factors—Yes/no (if yes, describe the
„ Reliability of informant: Criteria’s to collect history factors such as stressful events of life, non-adherence
from reliable informant are as follows: to medications)
◆ Informant must be living with patient for at least „ History of current episode (write in detail about the
last two years presenting complaints)
◆ Informant should not have any communication „ Associated disturbances—It includes the present
deficit (hearing/vision problems) medical problems (e.g., Disturbances in sleep pattern,
◆ Informant should be sound minded person problems with appetite, interpersonal relations with
(i.e., not suffering from mental illness) others, social functioning with others, problems faced
„ Information (reliable or not, adequate or not) in occupation, etc.)
550 Textbook of Psychiatric Nursing for BSc Nursing Students

IV. Past psychiatric history Pedigree/Family tree/Genogram

„ Number of episodes with onset, duration of each
episode, intensity and course
„ Complete or incomplete remission of symptoms
„ Treatment details and its side effects of extrapyrami-
dal effects, if any
„ Prognosis of the previous treatment/hospitalization
„ Previous suicidal attempts
„ Description of any precipitating factors if present.
V. Medical history, surgical history, obstetrical history
(If the patient is female)
„ Medical history: Significant medical problems or
previous hospitalization
„ Surgical history: Any previous surgeries
„ Obstetrical history (if the patient is female)
◆ Last menstrual period (LMP)
◆ Number of children
◆ Problems associated with pregnancy, delivery and
puerperium
◆ Abortion (if any):
VI. Family history
„ Family genogram: Draw three generation chart
include grandparents. Include the particular
generation which has specific psychiatric family
history.
„ Types of family: Joint/nuclear/extended
„ Consanguinity: Present/absent
VII. Personal history
Birth history:
„ Prenatal history: Fetus having exposure to radiation,
maternal infections and other maternal complications
„ Natal history: Type of delivery (Normal/caesarean/
vacuum/forceps), newborn cried at birth, neonatal
infections and other complications
„ Birth defects: If yes, specify
„ Postnatal complications: Convulsions/cyanosis/
neonatal infections/jaundice/any other
„ Milestones: Normal or delayed
Childhood history
„ Primary care giver:
„ Feeding pattern: Breast feed/Artificial feed „ Central nervous system infections
„ Age at weaning „ Malnutrition
Behavior during childhood Schooling/educational history
„ Excessive temper tantrum: Yes/No „ Age of joining in school
„ Feeding habits or pica: Yes/No „ Academic performance in the school
„ Habit disorders: Yes/No (if yes specify) „ Relationship with peer group
Illness during childhood „ Relationship exist with teachers
„ Seizures „ Learning disability and attention deficit in childhood
„ Neurotic disorders „ Reason for discontinuation from school
Appendices 551

Play history • Habits

„ Games interested to play „ Sleeping pattern: Regular/insomnia/early morning
„ Relationship with playmates awakening/sleep disorders (specify)
Emotional problems during adolescence „ Eating pattern: Regular/binge eating/crave to eat
Smoking/alcoholism/drug abuse/delinquency/running more/frequent starvation/eating disorders (specify)
away from home/any others „ Elimination pattern: Regular/dysuria/oliguria/
Occupational history anuria/constipation/fecal incontinence/any
„ Age of joining the job diagnosed diseases.
„ Relationship with colleagues, subordinates and „ Ill health habits: Use of drug, smoking, alcohol,
supervisors tobacco
„ Frequent change of job—if so, give details with
rationale APPENDIX 2
„ Frequent absenteeism in job.
Menstrual history HISTORY COLLECTION FORMAT FOR PATIENT
„ Age of attaining puberty WITH ALCOHOL DEPENDENCE SYNDROME
„ Menstrual cycles are regular/irregular
„ Abnormalities if any (dysmenorrhea, menorrhagia, I. Demographic data:
etc.) „ Name
Sexual history „ Age
„ Source and extent of knowledge about sex „ Gender
„ Any extramarital relationship (ask if the information „ Education
is found to be essential) „ Occupation
Marital history „ Monthly income
„ Name, age, education and occupation of spouse „ Universal Hospital Identity Number (UHID No.)/In
„ Duration of marriage life Patient Number (IP No.)/Out Patient Number (OP
„ Love or arranged marriage No.)
„ Number of marriage „ Ward/OPD
„ Bonding in marital relationship „ Unit
Premorbid personality „ Marital status
• Attitude to others in social, family and sexual „ Nationality
relationship „ Religion
• Attitudes to Self: Selfish/feel proud/over concerned/ „ Date of admission and time:
egocentric/dramatizing/self-conscious/satisfied about „ Diagnosis
self/unhappy or dissatisfied about self. „ Doctor’s In-charge
• Moral and religious attitudes and standards
„ Address
• Mood
„ Informant (name/relationship)
„ Stability of the mood: Stable/anxious/irritable/
„ Reliability of informant
worrying/mood swings.
II. Chief complaints/presenting complaints (list with
„ Ability to express and control anger, depression and
duration)
anxiety—Yes/No
• Leisure activities and hobbies III. Present psychiatric history
• Fantasy life „ Reason for starting the first drink
„ Amount of time spent in day dreaming „ First experience with alcohol
„ Content of the day dreams „ Amount of alcohol commenced initially
• Reaction pattern to stress „ Brand of alcohol started
„ Tolerate frustrations or sudden disappointments, and „ History of tolerance
situations causing anger, anxiety or depression: Yes/ „ History of craving
No „ History in regard with loss of control
„ Use coping mechanism or defense mechanism: Yes/ „ Presence of withdrawal symptoms
No „ Social and occupational impairment due to alcohol
552 Textbook of Psychiatric Nursing for BSc Nursing Students

„ Reason for increasing the amount of alcohol V. Family history

„ Brand of alcohol preferred „ Type of family
„ History of black out „ Type of marriage (consanguineous/non-consanguin-
„ History of abstinence eous)
„ Money spent daily for alcohol „ Interpersonal relationship with family members
„ Usual time of drinking alcohol „ Family genogram
„ Preferred drinking pattern (Individual/group) „ Family history of mental illness
„ Level of motivation to quit alcohol VI. Personal history
„ Feel of guilt in regard with drinking alcohol „ Antenatal history
„ Medical problems due to alcohol „ Postnatal history
„ Psychiatric problems due to alcohol „ Milestones development
„ Previous admission and treatment undergone in de- „ Behavior at home
addiction center. „ Behavior at school
IV. Past psychiatric history „ Habits
   V. Medical and surgical history „ Special interests
VI. Family history „ Hobbies
„ Family history of alcoholism „ Intelligence level
„ Interpersonal relationship with family members • Performance in school or academics
„ Family genogram • Performing the self-care (toileting, eating, bathing,
„ Family history of mental illness dressing).
VII. Marital History
Bonding in marital relationship
„
APPENDIX 4
„ Extramarital relationship
„ Sexual dysfunction HISTORY COLLECTION FORMAT—GERIATRIC
VIII. Premorbid personality PSYCHIATRY

APPENDIX 3 I. Demographic data

„ Name
HISTORY COLLECTION FORMAT—CHILDREN „ Age
AND ADOLESCENT WITH PSYCHIATRIC „ Gender
DISORDERS „ Education
„ Previous occupation
I. Demographic data
„ Pension
„ Name
„ Nationality
„ Age
„ Religion
„ Gender
„ Address
„ Education
„ Informant (name/relationship)
„ Universal Hospital Identity Number (UHID No.)
II. Chief complaints/presenting complaints (list with
„ Ward/OPD
duration)
„ Unit
III. Present and past psychiatric history
„ Nationality
„ Cognitive function
„ Religion
„ Current psychiatric problems
„ Date of admission and time
IV. Medical and surgical history (Medications are taken for
„ Diagnosis
the chronic illness)
„ Doctor’s In-charge V. Family history
„ Address „ Type of family
„ Informant (name/relationship) „ Number of members in the family
II. Chief complaints/presenting complaints (list with „ Monthly income of the family (socioeconomic status)
duration). „ Interpersonal relationship with family members
III. Present and past psychiatric history „ Family genogram
IV. Co-morbid illness „ Family history of mental illness
Appendices 553

VI. Personal history „ Unpleasable affect: Grief/mourning/depression

„ Educational history „ Other affects: Anxiety/fear/panic/free floating
„ Occupational history before retirement anxiety/apathy/aggression/moods swing/emotionally
„ Source of income labile.
„ Residence: Living alone/with spouse/old age home IV. Thought
„ Performing the self care (toileting, eating, bathing, „ Form of thought/formal thought disorder—not un-
dressing).
derstandable/Normal/Circumstantiality/tangential-
VII. 
Premorbid personality (social, occupational and
ity/neologism/Word Salad/Perseveration/ambiva-
biological functioning)
VIII. 
Psychological support by the family members or lence).
relatives or friends „ Stream of thought/flow of thought—Pressure of
IX. Attitude towards aging and death speech/flight of ideas/thought retardation/mutism/
aphonia/thought block/clang association.)
APPENDIX 5 „ Content of thought
◆ Delusions—Specify type and give example – Perse-
MENTAL STATUS EXAMINATION (MSE) FORMAT cutory/delusion of reference/delusion of influence
or passivity/hypochondriacal delusions/delusions
I. General appearance and behavior of grandeur/nihilistic delusion/derealization/de-
„ Facial expression (e.g. anxiety, pleasure, confidence, personalization/delusion of infidelity.
blunted, pleasant) ◆ Obsession
„ Posture (stooped, stiff, guarded, normal) ◆ Phobia
„ Mannerisms (stereotype, negativism tics, normal) ◆ Preoccupation
„ Eye to eye contact (maintained or not) ◆ Fantasy—Creative/day dreaming.
„ Rapport (built easily or not built or built with diffi- V. Disorders of perception
culty) „ Illusion
„ Consciousness (conscious or drowsy or unconscious) „ Hallucinations—(specify type and give example)—
„ Behavior (includes social behavior, e.g., over friendly, auditory/visual/olfactory/gustatory/tactile
disinherited, preoccupied, aggressive, normal) „ Others—hypnogogic/hypnopompic/lilliputian/
„ Dressing and grooming—Well-dressed/appropriate/ kinesthetic/macropsia/micropsia
inappropriate (to season and situation)/neat and tidy/ VI. Cognitive functions
dirty. „ Attention and Concentration:
„ Physical features: Look older/younger than his or her ◆ Digit span test: e.g., Repeat the numbers 1, 3, 7, 9
age/underweight/overweight/physical deformity. ◆ Digit forward test: e.g., Say the numbers 1 to 10
Psychomotor activity: (Increased/decreased/compulsive/ ◆ Digit backward test: e.g., Say the numbers
echopraxia/stereotyped/negativism/automatic obedience) 10 to 1
II. Speech: Write the sample of speech (verbatim in 2 or 3 ◆ Serial subtraction test: e.g., (100 – 7 = 93, then 93
sentences) – 7 = 86, 86 – 7 = 79)
„ Coherence—Coherent/incoherent „ Memory
„ Relevance (answer the questions appropriately)— ◆ Immediate: Recall the events happened
Relevant/irrelevant immediately
„ Volume (soft, loud or normal) ◆ Recent memory: Recall the events happened
„ Tone (high pitch, low pitch, or normal/monotonous) 24 hours before.
„ Manner—Excessive formal/relaxed/inappropriately ◆ Remote: Asking for date of birth or events which
familiar are occurred long back
„ Reaction time (time taken to answer the question) — ¾ Amnesia (memory loss)/Paramnesia (distorted
increased, decreased or normal. memory or confusion of facts or fantasy)/
III. Mood (subjective) and affect (objective) Retrograde amnesia (loss of memory to the
„ Appropriate/inappropriate (relevance to situation and events happened before the injury or onset of
thought congruent. illness)/Anterograde amnesia (loss of memory
„ Pleasurable affect—Euphoria/Elation/Exaltation/ec- to the events happened after the injury or onset
stasy. of illness).
554 Textbook of Psychiatric Nursing for BSc Nursing Students

¾ Confabulation (false filling of memory gaps) ◆ Test judgment (test the present situation and ask
¾ Déjà vu (familiar of unfamiliar things)/Jamais his/her response to the situation)
Vu (unfamiliar of familiar things) ¾ Rain test: Ask the client what he/she will do
¾ Hyperamnesia (excessive loss of memory) when rain comes?
„ Orientation ¾ Envelope test: Ask the client what he/she
◆ Ask the time approximately without looking at the will do when envelope remains in road with
watch, what time is it? stamp?
◆ Place—Where he/she is now? ¾ Fire test: Ask the client what he/she will do
◆ Person—Who has accompanied him or her? when there is a fire in his/her home?
„ Abstract thinking: Patient’s ability to answer the ¾ Child cry test: Ask the client what he/she will
exact meaning of the given proverb will identify the do when a child remains crying in a road?
presence of abstract thinking (e.g., all the glitters are „ Insight: (Aware of one’s own mental illness)
not gold)
Grade I : Complete refusal of illness
„ Intelligence of general information
Grade II : Slight aware of being ill
◆ Similarities and differences: E.g., Say the
Grade III : Awareness of being sick attribute toward
similarities and dissimilarities between pen and
external or physical factor
pencil?
Grade IV : Awareness of being sick, due to something
◆ General information: E.g., Who is the Prime
Minister of India? not known to oneself
„ Judgment Grade V : Intellectual insight (aware about the one’s
◆ Personal judgment (ask about the patients future own mental illness in detail)
plans) Grade VI :  True emotional insight—Aware of ones
◆ Social judgment (lobservation made by the own mental illness and how the family
examiner that how patient is being socialized with members suffer out of it due to patient’s
others) illness.

APPENDIX 6

MENTAL STATUS EXAMINATION OF UNCOOPERATIVE PATIENTS (KIRBY’S METHOD)

Aspects Description
General reaction and Spontaneous action performed
posture • Any show of activities occasionally—playfulness/assaultiveness/mischievousness
• Appearance of patient—neat/untidy
• Patient eats—voluntarily/needs assistance
• Patient dress himself/herself—voluntarily/needs assistance
• Patient voids or defecates—voluntarily/needs assistance
• Actions show slowness—initially/consistently throughout the day
Behavior toward the examiners: Resistant/irritable/apathy/complaining others/evasive, etc.
Voluntary postures: Comfortable/natural/awkward/constrained
(What does the patient do when placed in an awkward position?)
Whether the behavior remains constant or keeps on changing with time?
Facial movement and Facial expression: Being alert/smiling/mask like face/placid/anxious/perplexed/anger/distressed
expression Whether the facial expression remains constant or keeps changing?
Eyes and pupils • Eyes—Open/closed/resistance to open the client eyes by examiner
• Patient give attention to examiner and move the eyes with that of object—yes/no
• Gaze—Fixed/evasive
• Blinking or flickering of eye lids—yes/no
• Patient responds to examiner if sudden movement of hand has been performed by examiner near to
patient’s eyes—yes/no
• Corneal reflex—present/absent
Contd…
Appendices 555

Aspects Description
Reaction to examiners • Patient response to simple commands of the examiner
questions and tests • Presence of negativism—whether active or passive uncooperativeness exists
• Monitor for automatic obedience, echolalia and echopraxia
• Movements of limbs are slow or fast or being interrupted often
Muscular reactions • Assess for muscle tonicity—waxy flexibility/cogwheel rigidity, gegenhalten, mitmachen and mitgehen.
• Check out urinary or fecal incontinence
Speech • Whether patient speaks spontaneously?
• Whether patient is mute—Is it consistent or keep changing?
• Whether patient takes effort to create sounds or whisper?
Emotional responsiveness • Emotional response of patient when family members speak?
Š Response of patient toward the unexpected stimuli by examiner such as clapping hands or
switching on the light.
Writing Ask the patient to write one’s wishes on a plain paper
Vital signs Temperature, pulse, respiration and blood pressure
Inference:

APPENDIX 7 Sl. no. Components Score

16. (Show the patient the wrist watch and pen)
HINDI MENTAL STATUS EXAMINATION (HMSE) Can you tell me these objects? (If yes, items
17 and 18 apply) (If No, Item 17(a) apply)
For illiterate demention patients 17. Show him the wrist watch and say what is this? 1 0
Sl. no. Components Score (or)
17.(a). If necessary, identify the watch by touching
Correct Wrong what is this?
1. Is it morning (or) afternoon (or) 1 0 18. Show him the pen and say what is this? 1 0
evening? (or)
2. What day of the week is today? 1 0 18.(a). If necessary, identify the pen by touching what
is this?
3. What date is it today? 1 0
19. Now I am going to say a phrase, listen carefully 1 0
4. Which month is today? 1 0
and repeat it exactly as I say after I finish
5. What season of the year is this? 1 0 Phrase: ‘NEITHER THIS NOR THAT’
6. Under which post office does your 1 0 20. Now look at my face and do exactly what I do. 1 0
village come? Close your eyes?
7. Which district does your village fall 1 0 21. First you take the paper in your right hand, 1 2 3
under? then with your both hands, fold it into half
8. Which village are you from? 1 0 once and then give the paper back to me.
9. Which block (If village has only 1 0 22. Now say a line about your house?
blocks) or which numbered area 23. Copy the drawing exactly as shown in the 1 2 3
is this? space below.
10. Which place is this? 1 0

Sl. no. Components Score

11. (I went to Delhi and brought three things such 1 2 3
as chair, coin and mango) Can you say the
three things what I got from Delhi?
Score:
12. A. Can you say the name of the days starting 1 2 3 Must draw four sided figure = 1
from Sunday? 4 5 One figure should be mostly inside the
B. Now can you tell me names of the days other = 2
backwards? Orientation of the figures should be obviously
13–15 Can you name the three things what I got 1 2 3 appropriate = 3
from Delhi? Total Score = /31
Contd…
556 Textbook of Psychiatric Nursing for BSc Nursing Students

APPENDIX 8

MINI MENTAL STATUS EXAMINATION (OR) FOLSTEIN TEST FORMAT

Sl. no. Components Description Max. Score Total Score

1. Orientation Year, month, day, date, season 5
Country, state, town, place, floor 5
2. Registration Examiner names the three objects (example: pen, apple and table). Patient is 3
asked to repeat the objects, one score for each
3. Attention Subtract 7 from 100 then repeat from the result for five subtractions 5
4. Recall Ask the name of objects learned earlier 3
5. Language Name a pencil and watch 2
Repeat ‘No its and or buts’ 1
Give a three stage command. Score one for each stage. (For example, ‘Take this 3
piece of paper in your right hand, fold it in half and place it on the table’)
Ask patient to read and obey a written command on the piece of paper stating: 1
‘Close your eyes’
Ask patient to write a sentence. Score correct if it has a subject and verb. 1
6. Copying Ask the individual to copy the intersecting pentagons. Score if it overlaps and 1
has five sides
Total Score Cognitive impairment
24–30 No cognitive impairment
18–23 Mild cognitive impairment
0–17 Severe cognitive impairment

Grand Total = ________/30

APPENDIX 9 Glasgow Categories Scores Nurse’s

Coma responsibility in
NEUROLOGICAL ASSESSMENT Scale Documentation
of GCS
Level of consciousness: Alertness/lethargic/stuporous/ Motor • Obeys command 6 Record the
semicomatose/comatose response • Localizes pain 5 response
• Flexion withdrawal 4 in upper
Glasgow Categories Scores Nurse’s • Abnormal flexion 3 extremities
Coma responsibility in • Abnormal extension 2 (right/left) or
Scale Documentation • No response 1 lower extremities
of GCS or both
Eye • Spontaneous eye 4 Document ‘C’
Total GCS score 15
response opening 3 —Swollen eyes
• To verbal stimuli 2 due to injury/ Minimal GCS score 3
• To pain stimuli 1 infection Comatose patient <7
• No response
Verbal • Oriented to time, 5 VT – Patient in • Special cerebral function: Assess for agnosia, apraxia
response place and person 4 tracheostomy and aphasia
• Confused 3 • Cranial nerve assessment
• Inappropriate 2 VE – Patient is
„ Olfactory – Sense of smell: Present/absent
speech 1 in endotracheal
• Incomprehensive tube „ Optic
sounds ◆ Visual acuity test (Snellen’s chart)
• No response ◆ Assessment of visual fields (right and left eye)
Contd… ◆ Examine the fundus of eye with ophthalmoscope
Appendices 557

„ Oculomotor, trochlear and abducens • Assessment of cerebellar function

◆ Pupillary size—Equal/unequal • Finger to finger test
◆ Pupillary reaction to light—Reacting/not reacting • Finger to nose test
◆ Accommodation and visual field—Normal/ • Romberg test
abnormal • Tandom walking test
◆ Diplopia—Present/absent • Assessment of reflexes
◆ Nystagmus—Present/absent • Superficial (or) Cutaneous Reflexes—Corneal reflex
„ Trigeminal /Pharyngeal (or) Gag reflex/Abdominal reflex/
◆ Corneal reflex—Present/absent Cremasteric reflex/Anal reflex/Plantar reflex
◆ Mandibular strength—Normal/Hypotonia • Deep Tendon (or) Muscle-Stretch Reflexes—Biceps
◆ Facial sensory response (pain, temperature and reflex/Triceps reflex/Brachioradialis/Patellar reflex/
touch)—Present/absent. Achilles tendon reflex
„ Facial—Assess symmetry of face; ask the client to • Abnormal reflexes—Present/Absent
smile, frown, raise the eye brows, whistle, puff the • Special Tests
cheeks and show teeth • Stereognosis (or) Haptic perception (or) Tactile gnosis
„ Vestibulocochlear (or) acoustic nerve • Baragnosis
◆ Cochlear • Graphesthesia
¾ Hearing acuity test Summary
¾ Bone conduction and air conduction test—
Weber’s test and Rinne’s test APPENDIX 10
◆ Vestibular
¾ Romberg test PROCESS RECORDING FORMAT
¾ Caloric reflex test (oculovestibular reflex)
„ Glossopharyngeal and vagus Demographic Data
◆ Gag reflex—Present/absent • Name
• Age
◆ Movement of uvula and palate—Symmetrical/
• Gender
Deviation
• Education
◆ Sensation of taste—present/absent
• Occupation
„ Spinal accessory
• Monthly income
◆ Strength of Sternocleidomastoid muscle—Normal/
• Universal Hospital Identity Number (UHID No.)/In
Hypotonia
Patient Number (I.P.No.)/Out Patient Number (O.P.No.)
◆ Shoulder elevation—Adequate/Weak
• Ward/OPD
„ Hypoglossal
• Unit
• Tongue movement—Normal/Abnormal
• Marital Status
• Motor function assessment
• Nationality
„ Muscle size: Symmetrical/Nonsymmetrical/Atrophy/
• Religion
Hypertrophy
• Date of admission and Time:
„ Muscle tone: Hypotonicity/Hypertonicity/Rigid/
• Diagnosis:
spastic muscle.
• Doctor’s In-charge
„ Muscle strength: 0/5 to 5/5
• Address
„ Muscle Coordination: Present/Absent
• Languages known
„ Gait: Normal/Abnormal
• Summary of patient problem
„ Muscle movements (gross and fine motor movements)
• Assessment of Sensory Function Objectives (or) Purposes
• Sense of Touch—Hypoesthesia/Hyperesthesia/ Prerequisites (or) preparation of patient and environment:
Anesthesia Date, time and place of process recording:
• Sense of Pain—Hypoalgesia/Hyperalgesia/Analgesia Place of Interaction:
• Temperature sensation—Present/Absent Reason for selecting the patient:
• Vibration sensation—Present/Absent Context of interaction:
558 Textbook of Psychiatric Nursing for BSc Nursing Students

Participants in interaction Verbal communication Non-verbal communication Inference

Nurse: Use verbatim technique Include facial expression, posture, gesture, Write the interpretation of
Patient: mannerism, eye contact, tone of voice, pacing process recording (nurse-
and gait of patient during conversation. It patient interaction)
is important to include any such peculiar
behaviour such as biting the nail, periods of
silence, shouting or exhibiting aggression, etc.
Summary:

APPENDIX 11 „ Play history

„ Emotional problems during adolescence
NURSING CARE PLAN FORMAT „ Occupational history
„ Menstrual history
History Collection „ Sexual history
I. Demographic data „ Marital history
„ Name VIII. Premorbid personality
„ Age „ Attitude to others in social, family and sexual
„ Gender relationship
„ Education „ Attitudes to Self
„ Occupation „ Mood
„ Monthly income „ Leisure activities and hobbies
„ Universal Hospital Identity Number (UHID No.)/ „ Fantasy life
In Patient Number (I.P.No.)/Out Patient Number „ Reaction pattern to stress
(O.P.No.) „ Habits
„ Ward/OPD
„ Unit Physical Examination
„ Marital Status Head to toe assessment and focus assessment
„ Nationality
„ Religion Mental Status Examination
„ Date of admission and time:
• General appearance and behavior
„ Diagnosis:
• Psychomotor activity:
„ Doctor’s in-charge
• Speech:
„ Address
• Mood (subjective) and affect (objective):
„ Informant (name/relationship)
• Thought:
„ Reliability of informant
• Disorder of perception:
II. Chief complaints/presenting complaints (list with
• Cognitive functions:
duration)
• Attention and concentration:
„ According to patient:
• Memory:
„ According to informant:
• Orientation:
III. Present psychiatric history
• Abstract thinking:
IV. Past psychiatric history
• Intelligence:
V. Medical history
• Judgment:
Surgical history
• Insight:
Obstetrical history
Vi. Family history
Vii. Personal history NOTE
„ Birth History
„ Childhood history If the patient is uncooperative, write Kirby’s method of mental
status examination.
„ Schooling/Educational history
Appendices 559

Neurological Examination Investigation

• Level of consciousness Sl. no. Diagnostic tests Patient value Normal value
• Special cerebral function
• Cranial nerve assessment
• Motor function assessment Treatment
• Assessment of sensory function
• Assessment of cerebellar function Sl. Name of the Dosage Route Frequency Drug
no. medication action
• Assessment of reflexes
• Special tests
• Psychotherapy
• ECT

Nursing Process
Assessment Nursing diagnosis Goal Planning Implementation Rationale Evaluation
Subjective data

Objective data

Process Recording Compare the disease condition with book picture

• Introduction
Objectives (or) purposes:
• Definition
Prerequisites (or) preparation of patient and environment:
• Epidemiology
Date, time and place of process recording:
• Etiology
Place of interaction:
Reason for selecting the patient: Book picture Patient picture
Context of interaction:
Participants Verbal Non-verbal Inference
in communication communication • Psychopathology
interaction • Clinical manifestation
Nurse: . Book picture Patient picture
Patient:

Summary:
Psychoeducation • Investigations (or) Diagnostic studies
Conclusion Book picture Patient picture
Bibliography

APPENDIX 12 • Treatment
Book picture Patient picture
NURSING CARE STUDY/CLINICAL PRESENTATION
FORMAT

History collection Nursing process

Physical examination Process recording
Mental status examination (If the patient is uncooperative, Psychoeducation
write Kirby’s method of mental status examination) Conclusion
Neurological examination (If required) Bibliography
560 Textbook of Psychiatric Nursing for BSc Nursing Students

APPENDIX 13 Checklist Yes No Remarks

Nil per oral (NPO)
HEALTH EDUCATION FORMAT Premedications (If any)
Health teaching topic: Preoperative teaching
Group: Jewels removed
Date: Investigations
Time: • Routine blood test
Place: • Chest X-ray
• ECG
Duration of health teaching: • Echocardiography
Student name:
Signature of the staff nurse
Name of the clinical instructor:
Method of teaching: Table: Intra-ECT checklist
Av aids prepared: Name: Age: Sex: IP No.:
General objective: Procedure: Date/Time: Diagnosis: ECT Room No.:
Specific objective:
No. of ECT:
Sl. no. Specific objective Content A.V. aids Evaluation
Atropine/ Glycopyrrolate:
Thiopentone:

Conclusion Succinylcholine:
Bibliography Duration:
Frequency:
APPENDIX 14 Pulse width:
Charge (mc):
ASSESSMENT AND CHECKLIST USED FOR THE Seizure duration:
PATIENT UNDERGOING ELECTROCONVULSIVE
THERAPY (ECT) Blood pressure:
Pulse rate:
History collection Remarks:
Physical examination
Mental status examination Signature of the Doctor/Nurse practitioner
Assessment of patient and family member’s knowledge of Table: Post-ECT checklist
therapeutic effects
Name: Age: Sex: IP No.:
Table: Pre-ECT checklist Procedure: Date/Time: Diagnosis: ECT Room No.:
Name: Age: Sex: Diagnosis: IP No.: Checklist Yes No Remarks
Procedure: Date: Time: Ward: Assessment of memory
Orientation to patient
Checklist Yes No Remarks
Written informed consent NPO at least 2 hours after ECT
(If psychotic – Consent from care givers IV fluids infusion
If neurotic – Both from patient and care Pulse rate checked`
givers)
Blood Pressure checked
Skin preparation
Any significant complaints elicited
Hair wash done (Headache, Nausea/Vomiting, Confusion)
Hair combed Able to tolerate oral fluids after 2 hours
Dentures removed of ECT
Nails paired Soft diet after 3 hours of ECT
Nail Polish removed Signature of the nurse
Contd…
Appendices 561

Informed Consent to Electroconvulsive Therapy (ECT) APPENDIX 16

I. (Patient name with hospital identification number) with
the diagnosis of ________________ and ICD-10 code GROUP PSYCHOTHERAPY FORMAT
____________ hereby understand the following aspects
„ Nurse has explained my diagnosis for which ECT is History collection
proposed Findings of mental status examination
„ Nurse has explained how ECT will benefit me Size of the group
„ I understands that ECT is given under general Duration of the session
anesthesia with muscle relaxant Norms of the group therapy
„ Nurse has explained risks or side effects of ECT, Type of group therapy
general anaesthesia and muscle relaxant Purposes of group therapy
„ I have cleared my queries from the doctor regarding Topic addressed in the group therapy
the ECT Indications for group psychotherapy
„ I understand all the information given by the nurse in Problems encountered from the group
regard with ECT Techniques used in group therapy
„ I understand that results of ECT are not guaranteed Plan for the next session
„ Any changes in my ECT treatment will be intimated Summary
to me and the informed consent will be obtained in
regard to the changes APPENDIX 17
„ I had enough time to take decision in regard to my
ECT treatment
FAMILY THERAPY FORMAT
„ I know that, I can withdraw my ECT at any time, even History collection
the course of ECT has started. Findings of the mental status examination
I hereby agree to have specified Electroconvulsive Therapy Goals of the family therapy
(ECT), general anaesthesia and muscle relaxant. Indications for family therapy
Signature of the person giving informed consent: Type of the family therapy
Name of the person giving informed consent: Problems identified among the family members
Date and time: Description about the family therapy
Witness signature: • Session no.
Witness name: • Venue
• Date and time:
APPENDIX 15 • Name and relationship of the family members participated
in the session:
INDIVIDUAL PSYCHOTHERAPY FORMAT • Communication pattern of the family members
• Techniques used by the family therapist
History collection
• Outcome of the session
Findings of the mental status examination
• Homework given to the patient
Indications for psychotherapy
• Plan for next session
Problems identified from the patient
Summary
Description of the psychotherapy
• Session no.
APPENDIX 18
• Venue
• Date and time CLOZAPINE SIDE EFFECT CHART
• Type of psychotherapy
• Techniques used by the psychotherapist Patient name:
• Outcome of the session Age:
• Homework given to the patient Gender:
• Plan for next session UHID No. (or) I.P. No. (or) O.P. No.
Summary Diagnosis:
562 Textbook of Psychiatric Nursing for BSc Nursing Students

Date Sl. Components Yes No Not

Dosage no. applicable

Weight 8. Blood samples obtained

(specify)
Body mass index (BMI)
9. Plan for any investigations
Chest pain (e.g., CT scan, MRI – Specify)
Breathlessness 10. Vital signs monitored
Blood pressure 11. Had Breakfast (specify the diet)
Pulse 12. Taken the prescribed
Fever medications (morning,
afternoon and night)
Sore throat
13. Performed Exercises
Palpitation
14. Participated in Yoga or
Sedation
Meditation sessions
Hypersalivation (or)
15. Performed in occupational
sialorrhea (or) ptyalism
therapy sessions
Constipation
16. Had lunch (specify the diet)
Incontinence
17. Had short nap in afternoon
Skin rashes (mention the number of hours)
Jerks 18. Involved in recreational
Chest pain activities
Total count (white blood 19. Attended psychotherapy
cells) 20. Taken adequate oral fluids
Absolute neutrophil 21. Presence of suicidal risk
count (ANC)
22. Presence of aggressive
behavior
APPENDIX 19 23. Use of restraints
24. Any psychotropic drugs given
PSYCHIATRIC NURSING CARE DAILY CHECKLIST as oral orders

Name: 25. Health teaching provided to

the care givers
Age:
Gender: 26. Had dinner (specify the diet)
IP No. 27. Sleep window (duration of time
patient lies in the bed with the
Diagnosis:
intent to sleep and the number
Chief complaints: of hours patients slept)
Sl. Components Yes No Not
28. Any peculiar behaviour
no. applicable
observed (specify)
1. Oral care
29. Plan for ECT
2. Shave off the beard
30. Presence of Extrapyramidal
3. Hair care symptoms (specify)
4. Nail care 31. Any other nursing care given
5. Voided urine (specify)
6. Stool passed 32. Any other sentinel events
(specify)
7. Taken Bath
33. Any other (specify)
Contd…
Appendices 563

APPENDIX 20 APPENDIX 21

DISULFIRAM CONSENT FORM OCCUPATIONAL THERAPY FORMAT

Disulfiram is an antabuse medication which is used to prevent History collection
the relapse to alcohol. The body is unable to process the alcohol Findings of mental status examination
while taking disulfiram. This includes even a small dose that Goal (or) objectives of occupational therapy
may be absorbed from hand sanitizer, perfume, alcoholic Problems identified from the patient
beverages or food (vinegars, marinades, sauces, extracts, etc.). Assessment of patient’s interest
It is vital to check the labels of items that will be either consumed Description of the occupational therapy
or used on the surface of the body. Disulfiram should NOT be • Session no.
taken if you drank alcohol within 12 hours, because it leads • Venue
to Disulfiram-Ethanol Reaction (DER). Disulfiram-alcohol • Date and time
reaction may last up to 2 weeks after stopping the Disulfiram.
• Description of the activities with its therapeutic value
Disulfiram-Ethanol Reaction (DER) includes trouble in
• Difficulties faced by the patient during the occupational
breathing, nausea, vomiting, throbbing pain in head and neck,
therapy
sweating, increased thirst, dizziness, palpitations, blurred
• Area or part where the assistance is required for the
vision, confusion and weakness. Severe DER includes the
patient during the therapy
unconsciousness, cardiac failure, respiratory failure, seizures
• Outcome of the session
and death. Allergic reactions due to disulfiram includes chest
• Plan for next session
pain, skin rashes, trouble in breathing or wheezing, fainting,
Summary
dizziness, swelling of eyes, tongue, mouth or face. The most
common side effect of disulfiram is drowsiness. The adverse
reactions may occur in some patients having health problems APPENDIX 22
like, psychosis, liver failure, neuropathy, skin rash, acne,
impotence and optic neuritis. RECREATIONAL (OR) PLAY THERAPY FORMAT
Disulfiram can affect your liver so blood test should
History collection
be done before and after the treatment to ensure that liver is
Findings of mental status examination
healthy. Approach the doctor or seek emergency treatment if
Goal (or) objectives of recreational therapy
you develop any of these symptoms such as yellow discoloration
Problems identified from the patient
of the skin or eyes, dark urine, diarrhea, white stool, unusual
Assessment of patient’s interest
tiredness, abdominal pain and loss of appetite.
Description of the recreational therapy
Some medications which should not be taken with
• Session no.
disulfiram are metronidazole, phenytoin, dronabinol, some
• Venue
cough syrups, etc. Don’t change your medications without
• Date and time
consulting with the doctor. Store the disulfiram at room
• Indications of recreational therapy
temperature and in a light-resistant container. All your
• Description of the activities with its therapeutic value
family members and friends should be aware that you are
on disulfiram and the risk associated with it can be relapse. I • Advantages of the recreational therapy
hereby agree to have Disulfiram Therapy. • Outcome of the session
• Plan for next session
Signature of the person giving informed consent: Summary
_________________________________________________
Name of the person giving informed consent:
APPENDIX 23
_________________________________________________
Date and Time: CHECKLIST FOR ADMISSION PROCEDURE
___________________.
Witness Signature: .......................................................................... Name:
Witness Name: ................................................................................ Age:
564 Textbook of Psychiatric Nursing for BSc Nursing Students

Gender: Date and Type of Discharge:

IP No. Sl. no. Components Yes No Remarks
Diagnosis: 1. Check the discharge order of the
Address: treating doctor
Education: 2. Hand over the patient’s
Occupation: valuables which has been taken
Income: at the time of admission
Chief complaints: 3. Give discharge summary
Date of Admission: 4. Give the prescription of
Type of Admission: medications
Sl. no. Components Yes No Remarks 5. Provide information about the
follow-up visits
1. Preparation of patient unit
6. Explain the importance of drug
2. Introduce the health team adherence
members
7. Arrange transportation for the
3. Tie the identification band in patient and family members to
patient’s hand reach home
4. Orient the hospital routines or 8. Payment of the hospital bill is
policies or regulations of the done
ward such as visiting hours, diet
timings, etc. 9. Discharge teaching is done

5. Prepare the patient record 10. Remove the patient’s

Identification band
6. Obtain the admission consent
from the patient or relative 11. Allow the patient and family
members to clarify the doubts
7. Collect history from informant
12. Document the discharge
8. Perform physical assessment and
procedure in Nurses Notes.
mental status assessment
13. Monitored the vital signs at the
9. Monitor vital signs
time of discharge
10. Obtain the necessary
investigations done Name and Signature of Nursing Officer
11. Administer the medications as
per the order
APPENDIX 25
12. Write the admission notes in the
patient record
FORMAT FOR WRITING OBSERVATIONAL VISIT
Name and Signature of Nursing Officer REPORT

APPENDIX 24 Name of the organization:

Date of visit:
CHECKLIST FOR DISCHARGE PROCEDURE Location of the organization (or) institution (or) center:
Philosophy of the organization:
Name:
Objectives:
Age:
Gender: Various departments exist in the organization:
IP No. Various services rendered in the organization:
Diagnosis: Organizational pattern (or) organogram:
Address: Staffing pattern:
Education:
Physical layout:
Occupation:
Income: Admission and discharge procedure:
Chief complaints: Daily schedules (or) routines:
Date of admission: Learning experiences gained from the observational visit:
Appendices 565

APPENDIX 26 Month Date Event/Day

10th World Mental Health Day and World
PSYCHOMETRIC ASSESSMENT REPORT Homeless Day
11th World Obesity Day
Patient Identification Data
November 25th International Day for Elimination of
Name:
Violence Against Women
Age:
December 3rd World Disability Day (or) International Day
Gender:
for Disabled Persons
IP No.
Diagnosis:
Address: APPENDIX 28
Education:
PROPONENTS IN PSYCHIATRY
Occupation:
Income:
Therapies in psychiatry Proponent
Chief complaints:
Psychometric Assessment Alcoholic anonymous Dr Bob and Bill Wilson
Name of the psychological test: Aversion therapy L V Kantorovich
Date and venue of the psychometric test done: Cognitive therapy Aaron Beck
Indications and purposes of the psychometric assessment: Client centered psychotherapy Carl Rogers
Preparation of the patient and equipment (rating scales/cards): Family therapy Nathan Ackerman
Description about the psychometric test: Group therapy Joseph Pratt
Score interpretation:
Gestalt therapy Frederick Peris
Hypnosis James Braid
APPENDIX 27
Interpersonal psychotherapy Klerman
IMPORTANT DAYS RELATED TO MENTAL HEALTH Psychodrama Jacob Moreno
Psychotherapy Walter Cooper Danny
Month Date Event/Day Psychosurgery A Egas Moniz (Won Nobel
March 11th No Smoking Day Prize)
20th International Day for Happiness Rational emotive therapy Albert Ellis
30 th
World Bipolar Day Sexual counseling William H masters and
Virginia E Johnson
April 7th
World Health Day
Therapeutic community Maxwell Jones
11th World Parkinson’s Day
Transactional analysis Eric Berne
May 1st World Maternal Mental Health Day
Token economy Ayllon and Azrin
12th International Nurses Day
24th World Schizophrenia Day
Medications in psychiatry Proponent
31st Anti-tobacco Day (or) World No Tobacco
Day Chlorpromazine Jean Delay and Pierre Deniker
June 26th International Day against Drug abuse and Clozapine Bern
Illegal Trafficking Fluoxetine Lilly
September 10th World Suicide Prevention Day Haloperidol Paul Janssen
21st World Alzheimer’s Day Imipramine Ronald Kuhn
October 1st World Elderly Day (or) International Day Lithium John Cade
for Elderly (or) International Day for Older
Olanzapine Elli Lilly
Persons
Sertraline Roerig
2nd National Anti-drug Addiction Day and
International Day of Non-violence Tranquilizers Yonkman
Contd…
566 Textbook of Psychiatric Nursing for BSc Nursing Students

Mental illness/psychiatric symptoms Proponent APPENDIX 29

Agoraphobia Westphal
Akathisia Haskovec THERAPEUTIC SERUM LEVELS OF
PSYCHOTROPIC MEDICATIONS
Alcoholic delirium Thomas Salton
Bulimia nervosa Gerald Russell Name of the drugs Reference value
Catatonia, cyclothymia and verbigeration KL Kahlbaum Amitriptyline plus Nortriptyline 95–250 ng/mL
Dementia precox Emil Kraepelin Clozapine 200–700 ng/mL
Hysteria Jean Martin Charcot Carbamazepine 4–12 mg/mL
Neurosis William Cullen Chlorpromazine 50–300 mcg/ml
Pica Ambroise Pare Lithium 0.6 to 1–8 mEq/L
Postpartum psychosis Robert Gooch Lamotrigine 2.5–15 μg/mL
Psychosis for LSD Hoffman Desipramine 150–300 ng/mL
Sadism, masochism and sexual bondage Richard Von Krafft- Imipramine 200–250 ng/mL
Ebing
Desipramine plus imipramine 150–300 ng/mL
Schizophrenia Eugen Bleuler
Nortriptyline 50–150 ng/mL
Stress Hans Selye
Haloperidol 8–18 ng/mL
Trichotillomania Francois Hallopeau
Valproic acid (or) sodium valproate 50–125 mg/ml
Kleptomania Charles Henri Marc
and Jean Etienne
APPENDIX 30
Assessment in psychiatry Proponent
Intellectual development Jean Piaget IMBALANCE OF NEUROTRASMITTERS IN
Mental status assessment for Kirby VARIOUS PSYCHIATRIC DISORDERS
uncooperative patients
Minnesota multiphasic personality S.R. Hathaway and J.C. Psychiatric Neurotransmitters
inventory (MMPI) McKinley disorders
Increased Decreased
Mini-mental status examination Folstein Schizophrenia Dopamine, Gamma-Amino
Inkblot test Hermann Rorschach Epinephrine and Butyric Acid (GABA)
norepinephrine
IQ development Jean Piaget
Mania Dopamine, —
Thematic apperception test Henry A Murray
Epinephrine and
Theories or Miscellaneous concepts Proponent Norepinephrine
related to Psychiatry Depression Acetylcholine Epinephrine,
Behaviorism J. Watson Norepinephrine and
Biopsychosocial model George Engel and Histamine
Iohn Romano Parkinson’s disease — Dopamine
Interpersonal theory Harrystack Sullivan Anxiety disorder Serotonin Gamma-Amino
Classical conditioning Pavlov Butyric Acid (GABA),
Epinephrine and
Operant conditioning B.F. Skinner
Norepinephrine
Term psychiatry coined Johann Reil
Aggression, Suicide — Serotonin
Founder of modern psychiatry J.E.D. Esquirol and Impulsivity
Father of psychobiology Adolf Meyer Huntington’s Somatostatin —
Father of suicidology Edward Shneidman disease
Theory of humor to describe emotions Galen Alzheimer’s disease — Somatostatin
and mood
Eating disorder and Gamma-Amino —
Seat of mind is present in brain Hippocrates Sleep disorder Butyric Acid
Object relations theory Melanie Klein (GABA)
Appendices 567

APPENDIX 31 ICD-11 DSM-5 Classification of mental disorders

Tic disorders
ICD-11 AND DSM-5 CLASSIFICATION OF MENTAL 8A05.00 307.23 Tourette’s disorder
DISORDERS
— 307.22 Persistent (chronic) motor or vocal tic
disorder
ICD-11 DSM-5 Classification of mental disorders
— 307.21 Provisional tic disorder
Neurodevelopmental disorders
— 307.20 Other specified tic disorder
Intellectual disability (intellectual developmental disorder)
— 307.19 Unspecified tic disorder
6A00.0 — Mild intellectual disability
Other neurodevelopmental disorders
6A00.1 — Moderate intellectual disability
6A0Y 315.8 Other specified neurodevelopmental
6A00.2 — Severe intellectual disability disorder
6A00.3 — Profound intellectual disability 6A0Z 315.9 Unspecified neurodevelopmental
6A00.4 Provisional intellectual disability disorder
— 315 Global developmental delay Schizophrenia spectrum and other psychotic disorders
6A00.Z 319 Unspecified intellectual disability 6A20 295.90 Schizophrenia
(intellectual developmental disorder) 6A21 — Schizoaffective disorder
Communication disorders 6A22 301.22 Schizotypal (personality) disorder
6A01 315.39 Language disorder 6A23 — Acute and transient psychotic disorder
6A01.0 315.39 Speech sound disorder 6A24 297.1 Delusional disorder
— 315.35 Childhood-onset fluency disorder — 298.8 Brief psychotic disorder
(stuttering)
— 295.40 Schizophreniform disorder
— 307.0 Adult-onset fluency disorder
— 295.70 Schizoaffective disorder (bipolar type)
6A01.22 315.39 Social (pragmatic) communication
— 295.70 Schizoaffective disorder (depressive
disorder
type)
6A01.Z 307.9 Unspecified communication disorder
— 293.81 Psychotic disorder due to another
Autism spectrum disorder medical condition (with delusions)
6A02 299.00 Autism spectrum disorder — 293.82 Psychotic disorder due to another
— 293.89 Autism spectrum disorder with medical condition (with hallucinations)
catatonia 6A40 293.89 Catatonia associated with another
Attention-deficit/hyperactivity disorder mental disorder (catatonia specifier)
6A05.0 314.00 Predominantly inattentive — 293.89 Catatonic disorder due to another
presentation medical condition
6A05.1 314.01 Predominantly hyperactive/impulsive 6A41 — Catatonia induced by psychoactive
presentation substances, including medications
6A05.2 314.01 Combined presentation 6A4Z 293.89 Unspecified catatonia
6A05.Y 314.01 Other specified attention-deficit/ — 298.8 Other specified schizophrenia
hyperactivity disorder spectrum and other psychotic disorder
6A05.Z 314.01 Unspecified attention-deficit/ — 298.9 Unspecified schizophrenia spectrum
hyperactivity disorder and other psychotic disorder
Specific learning disorder Bipolar and related disorders
6A03.0 315.00 With impairment in reading Bipolar I disorder
6A03.1 315.2 With impairment in written expression — 296.41 Current or most recent episode manic
(mild)
6A03.2 315.1 With impairment in mathematics
— 296.42 Current or most recent episode manic
Motor disorders (moderate)
— 315.4 Developmental coordination disorder — 296.43 Current or most recent episode manic
6A06 307.3 Stereotypic movement disorder (severe)
Contd… Contd…
568 Textbook of Psychiatric Nursing for BSc Nursing Students

ICD-11 DSM-5 Classification of mental disorders ICD-11 DSM-5 Classification of mental disorders
6A60.5 296.44 Current or most recent episode manic 6A71.4 — Recurrent episode depression (severe
(with psychotic features) with psychotic features)
6A60.B 296.45 Current or most recent episode manic — 296.34 Recurrent episode depression (with
(in partial remission) psychotic features)
6A60.F 296.46 Current or most recent episode manic 6A71.6 296.35 Recurrent episode depression (in
(in full remission) partial remission)
6A60.E 296.40 Current or most recent episode manic 6A71.7 296.36 Recurrent episode depression (in full
(unspecified) remission)
Bipolar II disorder 6A71.Y 296.30 Recurrent episode depression
6A61 296.89 Bipolar II disorder (unspecified)

6A62 301.13 Cyclothymic disorder 6A7Z 300.4 Persistent depressive disorder

(dysthymia)
6A6Y 296.89 Other specified bipolar and related
— 625.4 Premenstrual dysphoric disorder
disorder
— 293.83 Depressive disorder due to another
6A6Z 296.80 Unspecified bipolar and related
medical condition
disorder
Anxiety disorders
Depressive disorders
6B00 300.02 Generalized anxiety disorder
— 296.99 Disruptive mood dysregulation
6B01 300.01 Panic disorder
disorder
6B02 300.22 Agoraphobia
6A70.0 296.21 Single episode depression (mild)
6B03 300.29 Specific phobia
— 296.22 Single episode depression (moderate)
6B04 300.23 Social anxiety disorder (social phobia)
6A71.1 — Single episode depression (moderate
without psychotic features) 6B05 309.21 Separation anxiety disorder
6A71.2 — Single episode depression (moderate 6B06 312.23 Selective mutism
with psychotic features) — 293.84 Anxiety disorder due to another
6A71.3 — Single episode depression (severe medical condition
without psychotic features) 6B0Y 300.09 Other specified anxiety disorder
6A71.4 — Single episode depression (severe with 6B0Z 300.00 Unspecified anxiety disorder
psychotic features)
Obsessive-compulsive and its related disorder
— 296.23 Single episode depression (severe)
6B20 300.3 Obsessive-compulsive disorder
— 296.24 Single episode depression (with
— 300.7 Body dysmorphic disorder
psychotic features)
6B24 300.3 Hoarding disorder
6A70.6 296.25 Single episode depression (in partial
remission) 6B25.0 312.39 Trichotillomania (hair-pulling disorder)
6A70.7 296.26 Single episode depression (in full 6B25.1 698.4 Excoriation (skin-picking) disorder
remission) — 294.8 Obsessive-compulsive and related
6A70.Z 296.20 Single episode depression disorder due to another medical
(unspecified) condition
6A71.0 296.31 Recurrent episode depression (mild) — 300.3 Other specified obsessive-compulsive
and related disorder
— 296.32 Recurrent episode depression
(moderate) 6B20.Z 300.3 Unspecified obsessive-compulsive and
related disorder
6A71.1 — Recurrent episode depression
(moderate without psychotic features) Trauma- and stressor-related disorders
6A71.2 — Recurrent episode depression 6B44 313.89 Reactive attachment disorder
(moderate with psychotic features) 6B45 313.89 Disinhibited social engagement
— 296.33 Recurrent episode depression (severe) disorder
6A71.3 — Recurrent episode depression (severe 6B40 309.81 Post-traumatic stress disorder
without psychotic features) — 308.3 Acute stress disorder
Contd… Contd…
Appendices 569

ICD-11 DSM-5 Classification of mental disorders ICD-11 DSM-5 Classification of mental disorders
6B43 — Adjustment disorders 6B82 307.51 Binge eating disorder
— 309.0 Adjustment disorders (with depressed 6B83 307.59 Avoidant/Restrictive food intake
mood) disorder
— 309.24 Adjustment disorders (with anxiety) 6B84 307.52 Pica
— 309.28 Adjustment disorders (with mixed 6B85 307.53 Rumination disorder
anxiety and depressed mood) 6B8Y 307.59 Other specified feeding or eating
— 309.3 Adjustment disorders (with disorder
disturbance of conduct) 6B8Z 307.50 Unspecified feeding or eating disorder
— 309.4 Adjustment disorders (with mixed
disturbance of emotions and conduct) Elimination disorders

— 309.9 Adjustment disorders (unspecified) 6C00 307.6 Enuresis

6B4Y 309.89 Other specified trauma- and stressor- 6C01 307.7 Encopresis
related disorder — 788.39 Other specified elimination disorder
6B4Z 309.9 Unspecified trauma- and stressor- (with urinary symptoms)
related disorder — 787.60 Other specified elimination disorder
Dissociative disorders (with fecal symptoms)

6B60 — Dissociative neurological symptom 6C00.Z 788.30 Unspecified elimination disorder (with
disorder urinary symptoms)

6B61 300.12 Dissociative amnesia 6C01.Z 787.60 Unspecified elimination disorder (with
fecal symptoms)
— 300.13 Dissociative amnesia (with dissociative
fugue) Sexual dysfunctions
6B62 — Trance disorder HA00 302.71 Hypoactive sexual desire disorder
6B63 — Possession trance disorder HA01.0 302.72 Female sexual interest/arousal
disorder
6B64 300.14 Dissociative identity disorder
HA01.1 302.72 Erectile disorder
6B65 — Partial dissociative identity disorder
HA02 302.73 Female orgasmic disorder
6B66 300.6 Depersonalization-derealization
disorder HA03.0 302.75 Premature (early) ejaculation
6B6Y 300.15 Other specified dissociative disorder HA03.1 302.74 Delayed ejaculation
6B6Z 300.15 Unspecified dissociative disorder — 302.76 Genito-pelvic pain/penetration
disorder
Somatic symptom and related disorders
HA03.Y 302.79 Other specified sexual dysfunction
— 300.82 Somatic symptom disorder
Gender dysphoria
— 300.7 Illness anxiety disorder
— 302.6 Gender dysphoria in children
— 300.11 Conversion disorder (functional
neurological symptom disorder) — 302.85 Gender dysphoria in adolescents and
adults
— 316 Psychological factors affecting other
medical conditions — 302.6 Other specified gender dysphoria
— 300.19 Factitious disorder — 302.6 Unspecified gender dysphoria
— 300.89 Other specified somatic symptom and Disruptive, impulse-control and conduct disorders
related disorder 6C90 313.81 Oppositional defiant disorder
— 300.82 Unspecified somatic symptom and 6C73 312.34 Intermittent explosive disorder
related disorder
6C91.0 312.81 Conduct disorder (childhood-onset
Feeding and eating disorders type)
6B80 307.1 Anorexia nervosa 6C91.1 312.82 Conduct disorder (adolescent-onset
6B80.10 — Restricting type type)
6B80.11 — Binge eating/purging type 6C91.Z 312.83 Conduct disorder (unspecified onset)
6B81 307.51 Bulimia nervosa — 301.7 Antisocial personality disorder
Contd… Contd…
570 Textbook of Psychiatric Nursing for BSc Nursing Students

ICD-11 DSM-5 Classification of mental disorders ICD-11 DSM-5 Classification of mental disorders
6C70 312.33 Pyromania Other personality disorders
6C71 312.32 Kleptomania 310.1 Personality change due to another
6C7Y 312.89 Other specified disruptive, impulse- medical condition
control, and conduct disorder 301.89 Other specified personality disorder
6C7Z 312.9 Unspecified disruptive, impulse- Medication-induced movement disorders and other
control, and conduct disorder adverse effects of medication
Personality disorders — 332.1 Neuroleptic-induced parkinsonism
6D10 — Personality disorders — 333.92 Neuroleptic malignant syndrome
6D10.0 — Personality disorders, mild — 333.72 Medication-induced acute dystonia
6D10.1 — Personality disorders, moderate — 333.99 Medication-induced acute akathisia
6D10.2 — Personality disorders, severe — 333.85 Tardive dyskinesia
6D10.Z — Personality disorders, unspecified — 333.72 Tardive dystonia
severity
— 333.99 Tardive akathisia
6D11 — Predominant personality traits
— 333.1 Medication-induced postural tremor
6D11.0 — Negative affectivity in personality
disorder — 333.99 Other medication-induced movement
disorder
6D11.1 — Detachment in personality disorder
Gender dysphoria (DSM-5) and gender incongruence (ICD-11)
6D11.2 — Dissociality in personality disorder
6D11.3 — Disinhibition in personality disorder HA60 302.85 Gender dysphoria in adolescents and
adults
6D11.4 — Anankastic personality disorder
HA61 302.6 Gender dysphoria in children
6D11.5 — Borderline pattern personality disorder
HA8Y 302.6 Other specified gender dysphoria
Cluster A personality disorders
HA6Z 302.6 Unspecified gender dysphoria
— 301.0 Paranoid personality disorder
Paraphilic disorders
— 301.20 Schizoid personality disorder
6D30 302.4 Exhibitionistic disorder
— 301.22 Schizotypal personality disorder
6D31 302.82 Voyeuristic disorder
Cluster B personality disorders
6D32 302.2 Pedophilic disorder
— 301.7 Antisocial personality disorder
6D33 302.84 Sexual sadism disorder
— 301.83 Borderline personality disorder
6D34 302.89 Frotteuristic disorder
— 301.50 Histrionic personality disorder
— 302.83 Sexual masochism disorder
— 301.81 Narcissistic personality disorder
F65.0 302.81 Fetishistic disorder
Cluster C personality disorders
— 302.3 Transvestic disorder
— 301.4 Obsessive-compulsive personality
disorder 6D35 and 302.89 Other specified paraphilic disorder
6D36
— 301.82 Avoidant personality disorder
— 301.6 Dependent personality disorder 6D3Z 302.9 Unspecified paraphilic disorder

Contd…
Clinical Case Scenarios

CASE 1 PATIENT WITH MANIA

Mr M, 52-year-old male, married, completed Secondary School Leaving Certificate (SSLC) and is currently unemployed. Mr M talks too
much, often sings songs, over grooming, uses abusive language, has reduced need for sleep, has sudden shift of one idea to other, being
authoritative, cleaning often and raised psychomotor activities. Mr M has no significant history of depressive ideation, repeated intrusive
thoughts, images, impulses or acts, substance abuse, head injury, infections and convulsions. Mr M has nonconsanguineous marriage
and belongs to low socioeconomic background. He has similar episodes of mania in the past and discontinued the medication twice.
He is married but he is separated from his wife. He is a shy personality even before the onset of illness. His vital signs are stable. In regard to
blood values, total count, Erythrocyte Sedimentation Rate (ESR) and platelets are increased. The current medications are trihexyphenidyl,
lithium, risperidone, chlorpromazine and paracetamol.

History Collection History of Present Illness

His illness is of insidious onset and episodic course of illness.
Demographic Profile
He was apparently normal three months before he developed
Mr M, 52-year-old male, married, completed SSLC and symptoms like elated mood with excessive speech and flight
currently unemployed. He is diagnosed with mania with of ideas. He also picked things outside the house and did
psychotic symptoms. The information gathered from patient excessive activities, and was over involved in religious rituals,
and mother was adequate, reliable and relevant. said that he had the power of God and he can help the poor
people. He was involved in cleaning and over grooming, sang
Chief Complaints for Seeking Admission
songs often religious songs, sometimes he demands money
• Over talkativeness from mother and if it is not given, he is abusive and assaultive.
• Shifting of one idea to other He also had decreased need for sleep and poor appetite. He is
• Increased activities not on regular treatment. No history of physical illnesses.
• Collecting things
• Over religiosity Negative History
• Singing songs for three months No history of depressive ideation, repeated intrusive thoughts,
• Cleaning images, impulses or acts, substance abuse, organic causes like
• Over grooming head injury, infections and convulsions.
• Authoritative and demanding
• Abusive and assaultive Current Treatment History
• Decreased need for sleep • Tab. Trihexyphenidyl (THP), 4 mg, BD
572 Textbook of Psychiatric Nursing for BSc Nursing Students

• Tab. Risperidone (RSPN), 6 mg, HS Past History

• Tab. Lithium, 300 mg, 1-0-3 Similar episodes in the past.
• Tab. Chlorpromazine (CPZ), 100 mg, HS
• Tab. Paracetamol, 500 mg, BD

Family History He was shy type and did not involve in any play activities.
Nonconsanguineous marriage, he is from low socioeconomic He was closely attached with family members. He was
emotionally controlled and calm and quiet.
status. Family history of mental illnesses in maternal uncle and
• Physical illnesses: No physical illness during childhood
Alcohol Dependence Syndrome (ADS) among 1st and 2nd
was reported.
degree relatives.
• Schooling: He started schooling at the age of four,
Genogram concentrated on his studies, few friends. Not good
in scholastic performances. He studied up to SSLC.
Occupation: No specific jobs held.
• Sexual and marital history: Married but her wife
separated, reason not known.
• Substance use: No significant history.

Premorbid Personality: Well Adjusted

• Social relationships: Fewer friends in school, closely
attached with his mother.
• Intellectual activities: Reading books. Not good in
academic activities.
Personal History
• Mood: Bright, calm and relaxed.
• Birth and early development: He was reported to be • Character: Attitude to work and responsibility, worried
born full term with normal vaginal delivery which was when responsibility comes, meticulous and methodical.
conducted at hospital. No complications were reported • Interpersonal relationships: Shy, few friends, no play in
during the periods of antenatal, intranatal and neonatal schools; perform household activities, concentrates on
periods. Birth weight was reported to be normal. Baby studies, emotionally controlled and quiet.
cried soon after delivery and breastfeeding was initiated • Energy and imitativeness: Sluggish in doing household
soon after delivery. Milestone development was reported activities: would always insist on studying.
to be normal. • Fantasy life: Not present
• Behavior during childhood: He was temperamentally an • Habits: Normal sleep and rest pattern. Regular bowel and
easy child; he possessed only few friends in his childhood. bladder habits.
Clinical Case Scenarios 573

Mental Status Examination 3 Excessive energies; hyperactive at times; restless (can be

calmed)
• General appearance and behavior: He looks irritable, 4 Motor excitement; continuous hyperactivity (cannot be
well kempt, groomed and restless, establishes eye to eye calmed)
contact, he is cooperative, and establishes rapport. 3. Sexual interest 3
• Psychomotor activity: Psychomotor activities observed 0 Normal; not increased
as increased. 1 Mildly or possibly increased
• Speech: Speech is spontaneous. Reaction time is decreased. 2 Definite subjective increases on questioning
Tone, tempo, and volume are normal. Speech is relevant 3 Spontaneous sexual content; elaborates on sexual
and coherent. Prosody was maintained throughout. matters; hypersexual by self-report
• Thought: Flight of ideas is present, possession normal; 4 Overt sexual acts (toward patients, staff, or interviewer)
no repeated thoughts reported. Delusion of grandiosity
4. Sleep 4
present “God has given power and to help the poor.”
0 Reports no decrease in sleep
• Mood
1 Sleeping less than normal amount by up to one hour
„ Subjectively: “I am very happy.”
2 Sleeping less than normal by more than one hour
„ Objectively: Elated. Range and reactivity increased,
3 Reports decreased need for sleep
congruent and appropriate, occasionally lability present.
4 Denies need for sleep
• Perception: Hearing voice of God and his brother. He
5. Irritability 6
may have auditory hallucination.
• Cognitive function: 0 Absent
„ Orientation: He is grossly oriented to time, place and 2 Subjectively increased
person. 4 Irritable at times during interview; recent episodes of
„ Attention and concentration: Attention is aroused anger or annoyance on ward
and concentration is not sustained. 6 Frequently irritable during interview; short, curt throughout
Digit span test: 8 Hostile, uncooperative; interview impossible
Digit forward test: 4 digits 6. Speech (rate and amount) 8
Digit backward test: 4 digits 0 No increase
Serial subtraction till 31 2 Feels talkative
„ Memory: Immediate, recent and remote intact. 4 Increased rate or amount at times, verbose at times
„ Intelligence General information, Comprehension, 6 Push; consistently increased rate and amount; difficult
Arithmetic ability, Abstraction intact. to interrupt
„ Judgment: Personal, social and test judgment are 8 Pressured; uninterruptible, continuous speech
impaired. 7. Language-thought disorder 3
• Insight: It is absent; as he completely denies that he is ill 0 Absent
and requires treatment. 1 Circumstantial; mild distractibility; quick thoughts
2 Distractible, loses goal of thought; changes topics
Psychometric Assessment frequently; racing thoughts
3 Flight of ideas; tangentiality; difficult to follow; rhyming,
The Young Mania Rating Scale (YMRS) echolalia
1. Elevated mood 3 4 Incoherent; communication impossible
0 Absent 8. Content 8
1 Mildly or possibly increased on questioning 0 Normal
2 Definite subjective elevation; optimistic, self-confident; 2 Questionable plans, new interests
cheerful; appropriate to content 4 Special project(s); hyper-religious
3 Elevated; inappropriate to content; humorous 6 Grandiose or paranoid ideas; ideas of reference
4 Euphoric; inappropriate laughter; singing 8 Delusions; hallucinations
2. Increased motor activity-energy 4 9. Disruptive-aggressive behavior 8
0 Absent 0 Absent, cooperative
1 Subjectively increased 2 Sarcastic; loud at times, guarded
2 Animated; gestures increased 4 Demanding; threats on ward
574 Textbook of Psychiatric Nursing for BSc Nursing Students

6 Threatens interviewer; shouting; interview difficult Nasal flaring is present, frontal and maxillary sinuses non
8 Assaultive; destructive; interview impossible tender.
10. Appearance 1 • Ears: Both ears are equally placed. Pinna is soft and
0 Appropriate dress and grooming flexible. Auditory canal patent, no discharges observed.
1 Minimally unkempt • Mouth and throat: Lips are dry and patchy. Buccal
2 Poorly groomed; moderately dishevelled; overdressed mucosa pink and moist; teeth normally aligned; no
3 Dishevelled; partly clothed; garish make-up missing teeth. Gum is pink and moist; uvular elevation
4 Completely unkempt; decorated; bizarre garb normal and midline. Gag reflux present. Tongue midline
11. Insight 4 and movements normal. Throat congestion is present. He
0 Present; admits illness; agrees with need for treatment is having hoarseness of voice.
1 Possibly ill • Neck: Trachea is in midline, nontender. Range of motion
2 Admits behavior change, but denies illness (ROM) is of full range, strong. No palpable tender lymph
3 Admits possible change in behavior, but denies illness nodes or masses. Thyroid is palpable; smooth and not
4 Denies any behavior change enlarged. Carotid pulses present.
Patient’s Score = 50 (Severe mania) N <20 • Thorax
„ Anterior thorax: Breathing movements bilaterally
General Physical Examination equal. No visible pulsations. Apical impulses are
palpable. No tender lymph nodes to palpate. Heart
• General appearance: He is thin-built, conscious, good sounds S1 and S2 heard; rate 86 beats/min; regular
hygiene. rate and rhythm. No murmurs, rubs or clicks.
„ Height: 166 cm „ Posterior thorax: Anterioposterior diameter is less
„ Weight: 49 kg than Transverse diameter; muscular development
„ Body mass index (BMI): 17 normal. No spinal abnormalities noticed; no increase
• Vital signs: Stable in tactile fremitus. Lungs are resonant and clear
„ Temperature : 98.6°F throughout.
„ Pulse : 86 beats/min • Abdomen: No visible gastric pulsations. Rounded; bowel
„ Respiration : 20 breaths/min sounds present no tenderness or palpable mass, liver and
„ Blood pressure : 120/80 mm Hg spleen; non palpable, nontender. Femoral pulses feeble.
• Head and scalp: Size and shape of the head is normal. Inguinal- femoral nodes tender as reported.
Hair distribution is even, no palpable mass or tenderness; • Upper and lower extremities: Well developed; no muscle
small wound on lower lip on mucosal surface is noted. wasting. No edema, injuries noted, ROM; full strength
• Eyes: No pallor present, Symmetrical in size and shape. and possible in all directions. Pedal and radial pulses
Pupils equal in round and reacting to light. No infections palpable equal bilaterally.
or color changes observed. • Genitals and rectum: Normal as reported; no examination
• Nose: Nostrils patent; though labored breathing persists. done.

Investigations

Sl. no. Date Investigation Patient’s value Normal value Remarks

1. • Hemoglobin • 13.9% • 12–16 g/dL • Normal
• Total count (TC) • 12,800 cells/mm3 • 4–9000 cells/mm3 • Elevated
• Platelet • 4.92 lakhs/ mm3 • 2.5–4.5 lakhs/ mm3 • Elevated
• Erythrocyte sedimentation • 33 mm/hr • 5–15 mm/hr • Elevated
rate (ESR)
2. Sr. Lithium 0.8 mg/dL 0.5–1.5 mg/dL Normal
Clinical Case Scenarios 575

Medication

Name of the Dose/ Action Side effects Nurses’ responsibility

drug frequency
Tab. Trihexy- 4 mg Trihexyphenidyl blocks • Cardiovascular: Tachycardia • Give Intra-muscular injections deep
phenidyl 1-1-0 efferent impulses in • Central nervous system: into muscle.
parasympathetically Confusion, agitation, euphoria, • Do not administer subcutaneously;
innervated structures drowsiness, headache, as tissue necrosis may occur.
like smooth muscles dizziness, nervousness, • Do not administer intra-arterially;
(spasmolytic activity), delusions, hallucinations, arteriospasm and gangrene of the
salivary glands and eyes paranoia. limb may result.
(mydriasis). • Dermatologic: Dry skin, • Reduce dosage of barbiturates given
increased sensitivity to light, concurrently with promethazine
rash. by at least half; arrange for dosage
• Gastrointestinal: Constipation, reduction of opioid analgesics given
xerostomia, dry throat, ileus, concomitantly by one-fourth to
nausea, vomiting, parotitis. one-half.
• Genitourinary: urinary retention
Neuromuscular and skeletal
weakness
• Ocular: Blurred vision,
mydriasis, increase in
intraocular pressure, glaucoma,
blindness (long-term use in
narrow-angle glaucoma).
• Respiratory: Dry nose
• Miscellaneous: Diaphoresis
(decreased)
Tab. Risperi- 4 mg It blocks postsynaptic • Altered cardiac conduction, • Monitor addiction-prone patients
done 0-0-11/2 mesolimbic arrhythmias. carefully because of their
dopaminergic D1 and D2 • Anticholinergic effects: predisposition to habituation and
receptors in the brain; (constipation, xerostomia, drug dependence.
depresses the release blurred vision, urinary • Monitor liver function and blood
of hypothalamic and retention); use with caution counts periodically in patients on
hypophyseal hormones; in patients with decreased long-term therapy.
believed to depress gastrointestinal motility,
the reticular activating paralytic ileus, urinary retention,
system, thus affecting Benign prostatic Hypertrophy
basal metabolism, (BPH), xerostomia, or visual
body temperature, problems.
wakefulness, vasomotor • Blood dyscrasias:
tone, and emesis. Extrapyramidal symptoms
including pseudo parkinsonism,
acute dystonic reactions,
akathisia, and tardive
dyskinesia.
• Hepatic effects: Hepatitis,
hyperprolactinemia
• Hypotension: Neuroleptic
malignant syndrome
• Orthostatic hypotension:
Sedation
Contd…
576 Textbook of Psychiatric Nursing for BSc Nursing Students

Name of the Dose/ Action Side effects Nurses’ responsibility

drug frequency
Tab. Lithium 300 mg Alters sodium transport • CNS: Lethargy, slurred speech, • Regular monitoring of serum lithium
1-0-3 in nerve and muscle muscle weakness, fine hand levels to patients with renal or
cells; inhibits release tremor. cardiovascular disease, debilitation,
of nor epinephrine • GI: Nausea, vomiting, diarrhea, or dehydration or life-threatening
and dopamine from thirst. psychiatric disorders.
stimulated neurons; • GU: Polyuria • Give drug with food or milk or after
slightly increases • 1.5–2 mEq/L (mild to moderate meals.
intra neuronal stores toxic reactions) • Monitor for therapeutic serum
of catecholamines; • CNS: Coarse hand tremor, levels of 0.6–1.2 mEq/L.
decreases intra neuronal mental confusion, • Advise patient that this drug may
content of second hyperirritability of muscles, cause serious fetal harm and cannot
messengers and may drowsiness, incoordination. be used during pregnancy; urge use
thereby selectively • CV: ECG changes of barrier contraceptives.
modulate the • GI: Persistent GI upset, • Decrease dosage after the acute
responsiveness of gastritis, salivary gland manic episode is controlled
hyperactive neurons that swelling, abdominal pain, • Ensure that patient maintains
might contribute to the excessive salivation, flatulence, adequate intake of salt and
manic state. indigestion. adequate intake of fluid
• 2–2.5 mEq/L (moderate to (2,500–3,000 mL/day).
severe toxic reactions)
• CNS: Ataxia, giddiness,
fasciculation, tinnitus, blurred
vision, clonic movements,
seizures, stupor, coma.
• CV: Serious ECG changes,
severe hypotension with cardiac
arrhythmias.
• GU: Large output of dilute urine.
• Respiratory: Fatalities
secondary to pulmonary
complications.
• 2.5 mEq/L (life-threatening
toxicity)
• General: Complex involvement
of multiple organ systems,
including seizures, arrhythmias,
CV collapse, stupor, coma.
• Reactions unrelated to serum
levels
• CNS: Headache, worsening of
organic brain syndromes, fever,
reversible short-term memory
impairment, dyspraxia.
• CV: ECG changes; hyperkalemia
associated with ECG changes;
syncope; tachycardia-
bradycardia syndrome; rarely,
arrhythmias, CHF, diffuse
myocarditis, death.
• Dermatologic: Pruritus with or
without rash; maculopapular,
acneiform, and follicular
eruptions; cutaneous ulcers;
edema of ankles or wrists.
• Endocrine: Diffuse nontoxic
goiter; hypothyroidism;
hypercalcemia associated with
Contd…
Clinical Case Scenarios 577

Name of the Dose/ Action Side effects Nurses’ responsibility

drug frequency
hyperparathyroidism; transient
hyperglycemia; irreversible
nephrogenic diabetes insipidus,
which improves with diuretic
therapy; impotence or sexual
dysfunction.
• GI: Dysgeusia (taste distortion),
salty taste; swollen lips; dental
caries.
• Other: Weight gain (5–10 kg);
chest tightness; swollen or
painful joints, eye irritation,
worsening of cataracts,
disturbance of visual
accommodation, leukocytosis.
Tab. Chlor- 100 mg Interference with central • Tardive dyskinesia, • Do not administer intra-arterially;
promazine 0-0-1 dopaminergic pathways extrapyramidal symptoms, arteriospasm or gangrene may
in the mesolimbic anxiety, drowsiness, depression, result.
and medullary hallucinations, anorexia. • Give IM injections of undiluted drug
chemoreceptor trigger • Transient tachycardia, its effects deep into muscle mass, monitor
zone areas of the brain, on the ECG include prolongation injection sites.
respectively. It is a of the PR and QT intervals, • Do not use solutions that are
dopamine blocker. blunting of the T wave and discolored or contain a precipitate.
depression of the S-T segment, • Protect drug from light, and
postural hypotension. refrigerate oral solution.
• Agranulocytosis, leukopenia,
granulocytopenia, eosinophilia,
thrombocytopenia, anemia,
aplastic anemia, pancytopenia.
• Lowered seizure threshold.
• Increased prolactin secretion;
gynecomastia, galactorrhea,
mastalgia, altered libido,
menstrual irregularities, weight
gain, alterations in glucose
tolerance and false positive
pregnancy tests have occurred.
Tab. Paraceta- 500 mg Antipyretic: Reduces • CNS: Headache • Do not exceed the recommended
mol 1-0-1 fever by acting directly • CV: Chest pain, dyspnea, dosage.
on the hypothalamic myocardial damage when doses • Avoid using multiple preparations
heat-regulating center to of 5–8 g/day are ingested daily containing acetaminophen.
cause vasodilatation and for several weeks or when doses • Carefully check all over the counter
sweating, which helps of 4 g/day are ingested for (OTC) products.
dissipate heat. 1 year. • Give drug with food if GI upset
• GI: Hepatic toxicity and failure, occurs.
jaundice. • Discontinue drug if hypersensitivity
• GU: Acute kidney failure, renal reactions occur.
tubular necrosis. • Treatment of overdose:
• Hematologic: Monitor serum levels regularly,
Methemoglobinemia— N-acetylcysteine should be available
cyanosis; hemolytic anemia— as a specific antidote; basic life
hematuria, anuria; neutropenia, support measures may be necessary.
leukopenia, pancytopenia,
thrombocytopenia,
hypoglycemia.
• Hypersensitivity: Rash, fever
578 Textbook of Psychiatric Nursing for BSc Nursing Students

Nursing Management Nursing Diagnosis

Client Assessment • Disturbed thought process related to inability to think

and process information and evaluate reality as evidenced
Elated mood with excessive speech, flight of ideas, picks things
by delusion of grandiosity and exaggerated responses.
outside the house and excessive involvement in religious
• Risk for violence, self-directed or toward others related
rituals. He says that he had the power of God and he can help
to lack of impulse control, self-destructive strategies as
the poor people, involved in cleaning and over grooming,
evidenced by grandiose ideas and increased psychomotor
sings songs often religious songs, sometimes he demands
money from mother and if it is not given, he becomes abusive activities.
and assaultive, he also has decreased need for sleep and poor • Imbalanced Nutrition: Less than body requirements
appetite, unemployed, separated from his wife. related to decreased intake of nutrients sufficient to meet
metabolic needs.
Diagnostic Studies • Ineffective therapeutic regimen management pattern of
Complete blood count reveals elevated white blood cell count regulating and integrating into daily living: A program
and erythrocyte sedimentation rate (ESR) and normal Sr. for treatment of illness and the sequelae of illness that is
Lithium. unsatisfactory for meeting specific health goals.
• Knowledge deficit related to the management of the
Nursing Priorities symptoms and about the hallucinations.
• Protect client/others from the consequences of hyperactive • Interrupted family processes, situational crises (illness,
behavior. economic, change in roles).
• Provide for client’s basic needs. • Disturbed sleep pattern related to biochemical changes in
• Support client/family participation in follow-up the brain and hyperactivity and increased environmental
care/community treatment. stimuli as evidenced by decreased sleep.

Nursing Care Plan

Assessment Nursing Objectives Nursing intervention Implementation Evaluation

diagnosis
Subjective Data: Altered thought The client • Do not make promises • Not made any Client
Patient says, “I process related will be able that you cannot keep. promises to the patient demonstrated
have the power to inability to to free from • Encourage the client to • Encouraged the normal thought
of God, I can think and process delusions or talk with you, but do not client to talk with his process as
help the poor.” information and demonstrate try only for information. thoughts. evidenced by
Objective data: evaluate reality the ability • Explain procedures, • Explained the the participation
• Nonreality- as evidenced to function and try to be sure the procedures in activities for
based by delusion of without client understands the (medication reduction in
thinking grandiosity and responding procedures before administration) to the delusions.
• Labile affect exaggerated to persistent doing it. patient.
• Impaired responses. delusional • Recognize the client’s • Did not make any
judgment thoughts. delusions as the client’s argument to the
• Distractibility perception of the patient
environment. • Interaction made with
• Do not argue with the the client on the basis
client or try to convince of real things.
the client that the • Engaged the client in
delusions are false or one-to-one activities
unreal. (cleaning).
• Interact with the client • Showed empathy
on the basis of real regarding the client’s
things; do not dwell on feelings; reassured the
the delusional material. client.

Contd…
Clinical Case Scenarios 579

Assessment Nursing Objectives Nursing intervention Implementation Evaluation

diagnosis
• Engage the client in one-
to-one activities at first,
then activities in small
groups, and gradually
activities in larger groups
• Show empathy regarding
the client’s feelings;
reassure the client of
your presence and
acceptance.
Objective data: Risk for violence, The client • The client has one-to- • The client had one-to- Client was
• Lack of self-directed or will not harm one contact with a staff one contact with a staff prevented from
impulse toward others himself or member at all times member at all times. self and other’s
control related to lack of others and • Assess the client’s suicidal • He is not having harm as evidenced
• Wounds in impulse control, identify potential, and evaluate suicidal ideas and the by reduction in
lips self-destructive alternative the level of suicide environment is safe. abusive behavior
• Abusive and strategies as ways of precautions at least daily. • Not involved in any and help the ward
assaultive evidenced by dealing with • Do not argue with the argument with patients people.
• Feelings of grandiose ideas stress and client. by the staff and family
anger or and increased emotional • Ask the client if he or she members.
hostility psychomotor problems. has a plan for suicide. • He was kept near the
activities. • The client’s room should nurse station and free
be near the nurse station from other patients.
and within view of the • The room and the
staff. surroundings were free
• Be especially alert to of dangerous objects.
sharp objects and other • Involved the client in
potentially dangerous planning his or her
items. own treatment.
• Involve the client as • Paid more attention to
much as possible in his conversations.
planning his or her own • His mood changes
treatment. and behavior were
• Be alert to the client’s recorded periodically.
behaviors, especially
excessive communication,
flight of ideas, etc.
• Observe, record, and
report any changes in the
client’s mood.
Objective data: Knowledge deficit The client will • Teach the client and • Taught the client and Client got
• Inappropriate related to the be able to family or significant family or significant adequate
behavior management of understand others about manic others about manic knowledge about
related to the symptoms about the behavior, bipolar behavior. the disease
self-care and about the illness, its disorder, and other • Taught the client about process and the
• Inadequate hallucinations. chronic problems as indicated signs of relapse, such side effects of
retention of nature, • Teach the client and as insomnia, decreased medications.
information treatment, family or significant nutrition, and poor
presented and safe others about signs personal hygiene.
• Inadequate use of of relapse, such as
under- medications. insomnia, decreased
standing of nutrition, and poor
information personal hygiene.
presented
Contd…
580 Textbook of Psychiatric Nursing for BSc Nursing Students

Assessment Nursing Objectives Nursing intervention Implementation Evaluation

diagnosis
• Inform the client and • Informed the client
family or significant about medications:
others about dosage, need to take
psychotropic drugs, the medication only as
dosage, need to take prescribed, the toxic
the medication only as symptoms, the need
prescribed, the toxic to monitor sr. lithium
symptoms, the need to levels, and other
monitor blood levels, and considerations.
other considerations. • Stressed to the client
• Reinforce teaching with that medications must
written material as be taken regularly
indicated. and continually to be
effective; medications
should not be
discontinued just
because the client’s
mood is has shown an
improvement.
Objective data: Imbalanced The client • Give positive support and • Positive support and The client
• Lack of Nutrition: Less will be able attention when the client attention was given maintained normal
appetite than body to establish eats; withdraw your to him, when he ate nutritional status
• Weight loss- requirements adequate attention when he or she the food; withdrew as evidenced by
49 kg. related to nutrition. refuses to eat. the attention when he weight gain.
• Refusal to eat decreased intake of • Encourage the client to refuses to eat.
• Delusions nutrients sufficient eat at appropriate meal • Encouraged the client
and other to meet metabolic and snack times; allow to eat at appropriate
psychotic needs. food only at those times. meal and snack times;
symptoms • Make culturally or allow food only at
ethnically appropriate those times.
foods available to the • Provided finger foods
client and plenty of oral
• Try to accommodate fluids according to his
the client’s normal or likes
previous eating habits as • Instructed the
much as possible family members to
• Gradually decrease the feed the client, by
frequency of suggestions, accompanying him,
and allow the client to or sit with the client
take responsibility for through meal time.
eating.
• It may be necessary for
you to feed the client,
accompany the client
to get food, or sit with
the client through meal
time. Nasogastric tube
feedings or intravenous
therapy also may be
necessary.
• Administer intravenous
(IV) fluids as per order.
Clinical Case Scenarios 581

Psychoeducation

Name of the Patient: Mr M Venue: Male Psy. Ward

Topic: Compliance to treatment Date: _____________
Name of student teachers: Time:_____________
Language: English

Objectives
• General objective: At the end of the health education, the participants will be able to understand compliance to treatment.
• Specific objectives: At the end of the health education, the participants will be able to:
„ Define compliance.
„ List the outcomes of noncompliance.
„ Measures to promote compliance.
Specific objectives Time Contents Teaching and Audio Evaluation
learning activities visual aids
At the end of the 2 minutes Introduction Discussion Charts Can you outline
health education, Not taking medicine properly can the basics of
the participants will be dangerous!!! Noncompliance to compliance?
be able to: medicine is the number one cause of
increasing disability in chronic mental
illnesses.
Define compliance 2 minutes Definiton Lecture Roller What is compliance?
Compliance is defined as, “The extent board
to which a person’s behavior—taking
medication, following a diet, and/or
executing lifestyle changes, corresponds
with agreed recommendations from a
health care provider.”
List the outcomes of 10 minutes Outcomes of Noncompliance Discussion Handouts List the outcomes of
noncompliance • 5–20% mental illness patients relapse noncompliance
every year
• 20–30% patients do not have
adequate recovery on treatment.
• Maximum loss of ability to work
• Not able to take care of oneself
• If not treated earlier with appropriate
doses for sufficient time, the illness
becomes chronic
• Frequent and longer admissions to
hospital are needed
• Illness can become more resistant to
treatment
• Increased risk of self-harm and
homelessness
• Loss of self-esteem
• Social relations wither and vocational
progress is lost
• Increased burden on families,
caregivers.
Contd…
582 Textbook of Psychiatric Nursing for BSc Nursing Students

Specific objectives Time Contents Teaching and Audio Evaluation

learning activities visual aids
Describe the 10 minutes Measures To Promote Compliance Lecture cum Flannel What are the
measures to • Understand mental illness is chronic discussion board ways to promote
promote compliance • Patient has to continue medication compliance?
for longer duration
• If patient develops side effects, notify
to the doctor
• Never stop medication abruptly
• Medication is given under supervision
• If patient refuses oral medication,
injectables or implants are available
• Provide counseling to the patient
regarding its benefits
• Effectively manage oneself in case of
crisis
• Encourage regular follow-up
Conclusion
I hope that you understand the
importance of compliance to medication,
this will help you to prevent relapse.

Recording and Reporting

Date Time Nursing care/activities Name with signature

8:00 am Assessment of the patient Ms X
8:50 am Patient has taken breakfast (2 pieces of bread) and 1 cup tea Ms X
9:00 am • Administration of Oral Medication Ms X
▪ Tab. Trihexyphenidyl 4 mg
▪ Tab. Lithium, 300 mg.
▪ Tab. Paracetamol, 500 mg.
• He has taken the medications and tolerated well.
9:15 am He participated in exercise program Ms X
10:00 am He participated in garden activities Ms X
10:35 am Health education given to family members on “Compliance to treatment” Ms X
Clinical Case Scenarios 583

CASE 2 PATIENT WITH DEPRESSIVE DISORDER

Mr K, 63-year-old male, unmarried, he is a carpenter, completed Higher Secondary Certificate (HSC). Mr K has a pervasive low mood, poor
appetite, decreased sleep, fearfulness, lack of interest in activities, decreased self-care and social withdrawal. He attempted suicide twice,
he was involved in alcohol consumption, not going to work and has fearfulness toward others. He occasionally expresses the death wishes.
Beck’s depression inventory reveals severe depression. Vital signs are stable. His complete blood count (CBC) is normal, sodium value is
decreased and liver enzymes are increased. He has similar episodes of depression in the past. He is on tricyclic antidepressants.

History Collection lethality. From 1976, he was treated with adequate dosage of
three antidepressants (TCA) and two selective serotonin re-
Demographic Profile uptake inhibitors (SSRIs). He reported of no improvement
Mr K, 63-year-old male, unmarried, he is a carpenter, in depressive ideations. He has developed severe depressive
completed HSC. He was diagnosed with chronic depression mood for two months, no interest in activities, decreased
with super imposed dysthymia. Information was given by sleep, not interested in taking food, always sits alone and
patient and his mother, the information given was adequate, passes the days, involved in alcohol consumption, not going
reliable and relevant. to work, fearfulness toward others, no interaction with others.
Occasionally expresses death wishes. No history of physical
Chief Complaints For Seeking Admission: illnesses. He is on regular follow-up.
• Pervasive low mood Negative History
• Poor appetite
• Decreased sleep No history of elevated mood, grandiosity, repeated intrusive
• Fearfulness for two months thoughts, images, impulses or acts, suicidal attempts, organic
• Lack of interest in activities causes like head injury, infections convulsions.
• Decreased self-care
Current Treatment History
• Social withdrawal
Tab. Chlorpromazine 200 mg, HS (one tablet before bed time
History of Present Illness at night)
His illness is of insidious onset and continuous course of Tab. Amitriptyline 150 mg, HS (one tablet before bed time at
illness. He was apparently normal 44 years back, with repeated night)
episodes of depression, super imposed of being depressed Past History
always from 1974 onwards. From 1982 to 1992, he was
reported of two suicidal attempts of high intentionality and Similar episodes in the past.

Family History
Nonconsanguineous marriage, he is from low socioeconomic status. Positive family history of mental illnesses and elder sister
died by suicide, father died at early age, mother got second marriage, stepfather is cruel to him, bitter early childhood experiences,
alcohol dependence syndrome (ADS) among 1st and 2nd degree relatives.
584 Textbook of Psychiatric Nursing for BSc Nursing Students

Genogram

Personal History • Mood: Dull, anxious and worried.

• Birth and early development: He was reported to be • Character: Attitude to work and responsibility; worried
born full term with normal vaginal delivery which was by responsibility, meticulous and methodical.
conducted at hospital. No complications were reported • Interpersonal relationships: Shy, few friends, no play in
during the periods of antenatal, intranatal and neonatal schools; perform household activities, concentrates on
periods. Birth weight was reported to be normal. Baby studies, emotionally controlled and quiet.
cried soon after delivery and breastfeeding was initiated • Energy and imitativeness: Sluggish in doing household
soon after delivery. Milestone development was reported activities: would always insist on studying.
to be normal. • Fantasy life: Not present
• Behavior during childhood: He was temperamentally • Habits: Normal sleep and rest pattern. He has regular
an easy child; he possessed only a few friends in his bowel and bladder habits.
childhood. He was shy type and did not involve in any play
activities. He was closely attached with family members. Mental Status Examination
He was emotionally intolerant, fearful, calm and quiet.
• General appearance and behavior: He looks ill-kempt,
groomed, fearful, and appears to be restless, establishes
Significant Stressors
eye to eye contact, he is cooperative and establishes
• Physical illnesses: No physical illness during childhood rapport.
was reported. • Psychomotor activity: Psychomotor activities observed
• Schooling: He started schooling at the age of five, as retarded.
concentrated on his studies and had few friends. Not • Speech: Speech is on prompting. Reaction time is
good in scholastic performances. He studied up to HSC. increased. Tone, tempo, and volume are decreased.
• Occupation: Carpenter. Speech is relevant and coherent. Prosody was maintained
• Sexual and marital history: He is unmarried throughout.
• Substance use: Nicotine and alcohol dependence • Thought: No formal thought ideas, no flight of ideas is
syndrome substance abuse. present, possession of thought is normal and no repeated
thoughts. No delusion present. He is having depressive
Premorbid Personality cognition, sense of worthlessness, hopelessness and
Anxious avoidant personality traits and dependent person uselessness. No death wishes.
• Social relationships: Fewer friends in schools, closely • Mood:
attached with his mother. „ Subjectively: “I am sad”
• Intellectual activities: Reading books. Not good in „ Objectively: Depressed mood. Range and reactivity
academic activities. decreased, congruent and appropriate.
Clinical Case Scenarios 585

• Perception: No illusion or hallucination present Sl. Score Items Patient

• Cognitive Function no. score
„ Orientation: Grossly oriented to time, place and 3 I am dissatisfied or bored with
person. everything
„ Attention and concentration: Attention can be 5. 0 I do not feel particularly guilty
aroused but concentration is not sustained. 1 I feel guilty a good part of the time
Digit span test: 2 I feel quite guilty most of the time √
Digit forward test: 5 digits
3 I feel guilty all of the time
Digit backward test: 4 digits
6. 0 I do not feel I am being punished
Serial subtraction till 42
• Memory: Immediate, recent and remote intact. 1 I feel I may be punished
• Intelligence: General information, comprehension, 2 I expect to be punished √
arithmetic ability, abstraction intact and proverb test was 3 I feel I am being punished
done well by the patient.
7. 0 I do not feel disappointed in myself
• Judgment: Personal and social are impaired and test
1 I am disappointed in myself √
judgment is normal.
• Insight: Insight is present 2 I am disgusted with myself
3 I hate myself
Psychometric Assessment 8. 0 I do not feel I am any worse than
anybody else
Beck’s Depression Inventory 1 I am critical of myself for my
weaknesses or mistakes
This depression inventory can be self-scored. The scoring scale
is at the end of the questionnaire. 2 I blame myself all the time for my
faults
Sl. Score Items Patient
3 I blame myself for everything bad that √
no. score
happens
1. 0 I do not feel sad
9. 0 I do not have any thoughts of killing
1 I feel sad myself
2 I am sad all the time and I cannot snap √ 1 I have thoughts of killing myself, but I
out of it would not carry them out
3 I am so sad and unhappy that I cannot
2 I would like to kill myself √
stand it
3 I would kill myself if I had the chance
2. 0 I am not particularly discouraged about
the future 10. 0 I do not cry any more than usual
1 I feel discouraged about the future √ 1 I cry more now than I used to
2 I feel I have nothing to look forward to 2 I cry all the time now √
3 I feel the future is hopeless and that 3 I used to be able to cry, but now I
things cannot improve cannot cry even though I want to
3. 0 I do not feel like a failure 11. 0 I am no more irritated by things than I
ever was
1 I feel I have failed more than the
average person 1 I am slightly more irritated now than
usual
2 As I look back on my life, all I can see is √
a lot of failures 2 I am quite annoyed or irritated a good √
deal of the time
3 I feel I am a complete failure as a
person 3 I feel irritated all the time
4. 0 I get as much satisfaction out of things 12. 0 I have not lost interest in other people
as I used to 1 I am less interested in other people √
1 I do not enjoy things the way I used to than I used to be
2 I do not get real satisfaction out of √ 2 I have lost most of my interest in other
anything anymore people
Contd… Contd…
586 Textbook of Psychiatric Nursing for BSc Nursing Students

Sl. Score Items Patient Sl. Score Items Patient

no. score no. score
3 I have lost all of my interest in other 1 I am worried about physical problems √
people like aches, pains, upset stomach, or
13. 0 I make decisions about as well as I ever constipation
could 2 I am very worried about physical
1 I put off making decisions more than I √ problems and it is hard to think of much
used to else

2 I have greater difficulty in making 3 I am so worried about my physical

decisions more than I used to problems that I cannot think of
anything else
3 I cannot make decisions at all anymore
21. 0 I have not noticed any recent change in
14. 0 I do not feel that I look any worse than my interest in sex
I used to
1 I am less interested in sex than I used √
1 I am worried that I am looking old or to be
unattractive
2 I have almost no interest in sex
2 I feel there are permanent changes √
in my appearance that make me look 3 I have lost interest in sex completely
unattractive
3 I believe that I look ugly Interpreting the Beck Depression Inventory
15. 0 I can work about as well as before • 1–10 These ups and downs are considered normal
1 It takes an extra effort to get started at • 11–16 Mild mood disturbance
doing something • 17–20 Borderline clinical depression
2 I have to push myself very hard to do √ • 21–30 Moderate depression
anything • 31–40 Severe depression
3 I cannot do any work at all • Over 40 Extreme depression
16. 0 I can sleep as well as usual • Total score is 35
1 I do not sleep as well as I used to • Mr K is having Severe Depression.
2 I wake up 1–2 hours earlier than usual √
and find it hard to get back to sleep General Physical Examination
3 I wake up several hours earlier than I
• General appearance: He is moderately built, conscious,
used to and cannot get back to sleep.
poor hygiene.
17. 0 I do not get more tired than usual
„ Height: 156 cm
1 I get tired more easily than I used to
„ Weight: 60 kg
2 I get tired from doing almost anything √ „ Body mass index (BMI): 21
3 I am too tired to do anything
• Vital signs: Stable
18. 0 My appetite is no worse than usual „ Temperature : 98.6°F
1 My appetite is not as good as it used √ „ Pulse : 80 beats/min
to be
„ Respiration : 22 breaths/min
2 My appetite is much worse now „ Blood pressure : 120/70 mm Hg
3 I have no appetite at all anymore
• Head and scalp: Size and shape of the head is normal.
19. 0 I have not lost much weight, if any, Baldness present, hair distribution is even, no palpable
lately
mass or tenderness; no scar or injuries present.
1 I have lost more than five pounds √
• Eyes: No pallor present, symmetrical in size and shape.
2 I have lost more than ten pounds Pupils equal, round and react to light. No infections or
3 I have lost more than fifteen pounds color changes observed.
20. 0 I am no more worried about my health • Nose: Nostrils patent; though labored breathing persists.
than usual Nasal flaring is present, frontal and maxillary sinuses
Contd… nontender.
Clinical Case Scenarios 587

• Ears: Bilaterally equally placed. Pinna is soft and flexible. S2 heard; rate 70 beats/min; regular rate and rhythm. No
Auditory canal patent, no discharges observed. murmurs, rubs or clicks.
• Mouth and throat: Lips are dry and patchy. Buccal • Posterior thorax: AP is less than transverse diameter;
mucosa pink and moist; teeth normally aligned; no muscular development normal. No spinal abnormalities
missing teeth. Gum is pink and moist; uvular elevation noticed; no increase in tactile fremitus. Lungs are resonant
normal and midline. Gag reflux present. Tongue midline
and clear throughout.
and movements normal. Throat congestion is present. He
• Abdomen: No visible gastric pulsations. Rounded; bowel
is having hoarseness of voice.
sounds present no tenderness or palpable mass, liver and
• Neck: Trachea is in midline, nontender. ROM is of full
spleen; nonpalpable, nontender. Femoral pulses feeble.
range, strong. No palpable tender lymph nodes or masses.
Thyroid is palpable; smooth and not enlarged. Carotid Inguinal; femoral nodes tender as reported.
pulses present. • Upper and lower extremities: Well developed; no muscle
• Anterior thorax: Breathing movements bilaterally equal. wasting. No edema injuries noted, ROM; full strength and
No visible pulsations. Apical impulses are palpable. No possible in all directions. Pedal and radial pulses palpable
tender lymph nodes to palpate. 80 heart sounds S1 and equal bilaterally. Clubbing present.

Investigations

Sl. no. Date Investigation Patient’s value Normal value Remarks

1. • Hemoglobin (Hb) • 14% • 12–16 g/dL • Normal
• Total count (TC) • 9000 cells/mm3 • 4–9000 cells/mm3 • Normal
• Platelet • 3 lakhs/mm3 • 2.5–4.5 lakhs/ mm3 • Normal
• Neutrophils • 48% • 45–75% • Normal
• Lymphocyte • 35% • 20–40% • Normal
• Basophil • 02% • 0.5–1% • Normal
• Monocyte • 05% • 2–8% • Normal
• Eosinophil • 10% • 0–6% • Normal
2. • Glucose • 65 mg/dL • 60–100 mg/dL • Normal
• Urea • 19 mg/dL • 17–43 mg/dL • Normal
• Creatinine • 1.2 mg/dL • 0.6–1.4 mg/dL • Normal
• Total bilirubin • 0.2 mg/dL • 0.3–1.2 mg/dL • Normal
• Alkaline phosphatase • 45 IU/mL • 40–129 IU/mL • Normal
• Serum glutamic-oxaloacetic • 27 IU/mL • 8–40 IU/mL • Elevated
transaminase (SGOT) • 17 IU/mL • 6–40 IU/mL • Normal
• Serum glutamic pyruvic • 134 mEq/L • 135–145 mEq/L • Decreased
transaminase (SGPT) • 4.1 mEq/L • 3.5–5.4 mEq/L • Normal
• Sodium • 104 mEq/L • 95–106 mEq/L • Normal
• Potassium
• Chloride

Medications

Name of the Dose/ Action Side effects Nurses’ responsibility

drug frequency
Tab. Amitrip- 150 mg/HS Tricyclic antidepressants • CNS: Disturbed concentration, • Restrict drug access
tyline (TCAs) inhibit the reuptake sedation and anticholinergic, for depressed and
of the neurotransmitters confusion, hallucinations, potentially suicidal
norepinephrine and serotonin, disorientation tinnitus, altered patients.
leading to an increase in their electroencephalogram (EEG) • Give intramuscular
effects; anticholinergics at • CV: Orthostatic hypotension, injection only when oral
central nervous system (CNS) hypertension, syncope, tachycardia, therapy is impossible.
and peripheral receptors; chronic heart failure (CHF), • Do not administer
sedative. cereberovascular accident (CVA) intravenous injection.
• Endocrine: Elevated or depressed
blood sugar, elevated prolactin levels
Contd…
588 Textbook of Psychiatric Nursing for BSc Nursing Students

Name of the Dose/ Action Side effects Nurses’ responsibility

drug frequency
• GI: Dry mouth, constipation, paralytic • Administer major
ileus. portion of dose at
• GU: Urinary retention, gynecomastia, bedtime if drowsiness,
testicular swelling; breast severe anticholinergics
enlargement, menstrual irregularity effects occur.
and galactorrhea; increased or • Reduce dosage if minor
decreased libido; impotence. side effects develop;
• Hematologic: Bone marrow discontinue if serious
depression, including agranulocytosis; side effects occur.
eosinophilia, purpura, • Arrange for CBC if
thrombocytopenia, leukopenia. patient develops fever,
Hypersensitivity sore throat, or other
• Withdrawal: Symptoms sign of infection.
• Other: Nasal congestion, excessive
appetite.
Tab. Chlor- 200 mg/HS Phenothiazines are thought • Tardive dyskinesia, extrapyramidal • Do not administer intra-
promazine to elicit their antipsychotic symptoms, anxiety, drowsiness, arterially; arteriospasm
and antiemetic effects via depression, hallucinations, anorexia. or gangrene may result.
interference with central • Transient tachycardia, its effects on • Give IM injections of
dopaminergic pathways in the the ECG include prolongation of the undiluted drug deep
mesolimbic and medullary PR and QT intervals, blunting of the into muscle mass,
chemoreceptor trigger zone T wave and depression of the S-T monitor injection sites.
areas of the brain, respectively. segment and postural hypotension. • Do not use solutions
Although often termed • Agranulocytosis, leukopenia, that are discolored or
dopamine blockers, the exact granulocytopenia, eosinophilia, contain a precipitate.
mechanism of dopaminergic thrombocytopenia, anemia, aplastic Protect drug from light,
interference responsible for the anemia, pancytopenia. and refrigerate oral
drugs antipsychotic activity has • Lowered seizure threshold. solution.
not been determined. • Increased prolactin secretion;
gynecomastia, galactorrhea,
mastalgia, altered libido, menstrual
irregularities, weight gain, alterations
in glucose tolerance and false positive
pregnancy tests have occurred.

Nursing Management • Support client/family participation in follow-up

care/community treatment.
Client Assessment • Provide information about condition, prognosis, and
Pervasive low mood, poor appetite, decreased sleep, fearfulness, treatment needs.
lack of interest in activities, decreased self-care and socially
Nursing Diagnosis
withdrawn, he is involved in alcohol consumption, not going
to work, occasionally expresses death wishes for 2 months. • Risk for violence, self-directed, related to depressed
mood, feelings of worthlessness and hopelessness.
Diagnostic Studies • Anxiety moderately related to disturbed thought
processes, related to unconscious conflict about essential
CBC is normal, elevated liver enzymes and decreased Sr. Sodium.
values/goals of life, and threat to self-concept.
• Social isolation related to preoccupation with thoughts as
Nursing Priorities
evidenced by withdrawn and less interaction with others.
• Promote physical safety with special focus on suicide • Knowledge deficit related to the electroconvulsive therapy
prevention. (ECT).
• Provide for client’s basic needs, promoting highest • Deficient self-care related to disinterest or unconcern;
possible level of independent functioning. lack of energy/inertia; psychomotor retardation.
• Provide experience/interactions that enhance self-esteem, • Disturbed sleep pattern related to biochemical alterations
sense of personal power. (decreased serotonin), unresolved fears and anxieties.
Clinical Case Scenarios 589

Nursing Care Plan

Assessment Nursing Objectives Nursing intervention Implementation Evaluation

diagnosis
Subjective data: Risk for Client verbalizes • Identify degree of risk/ • Helped in expressing He
• Patient says violence, self- a decrease/ potential for suicide feeling of hopelessness verbalized
“I am not directed related absence of through direct questions and worthlessness absence of
interested in to depressed suicidal ideas. • Re-evaluate potential for • Maintained one to one self-harm,
anything.” mood, State two suicide periodically at key observation and kept him showed
• Previous feelings of reasons for not times. near the nurses’ station interest in
history of worthlessness harming self. • Implement suicide • Communicated suicide activities as
self-harm and precautions precautions and provided evidenced
severe in hopelessness. • Create a time-specific sense of protection. by the calm
intentionality contract with client on what • Written contract is and relaxed
and lethality. client and nurse will do to made that he won’t hurt look.
provide for client’s safety himself.
• Provide close observation • His mother and father
(1:1 or random checks every stayed with him
10–15 minutes for most alternatively and nurses
acute risk). visited him one in every
• Check all items brought half an hour.
in to or by the client as • Harmful objects have
indicated. been removed from the
• Maintain special care patient’s room
in administration of • Oral medications are
medications. administered and
• Administer medications as confirmed the intake of
indicated, e.g., Selective medicines by the patient.
serotonin reuptake • Tab. AMN, 150 mg, HS
inhibitors. administered
• Prepare for/assist with ECT • Patient had taken 1 ECT
as indicated.
Subjective data: Anxiety Verbalize • Evaluate/re-evaluate level • He is having moderate He
Patient says, “I moderate awareness of anxiety. level of anxiety. understood
am having fear related to of feelings of • Recognize and deal with • Maintained the emotion his feelings
and anxiety, disturbed anxiety, changes own feelings in response to diary. and thinking
I don’t know thought in thinking/ client’s anxiety. • Spent time while and involved
how it occurs processes, behavior. Identify • Listen nonjudgmentally to interacting with him, in relaxation
to me I fear for related to ways to deal client’s expressions; convey listening to his problems activities.
everybody.” unconscious effectively with empathy; acknowledge or and concerns.
Objective data: conflict about decision-making. label feelings for client. • Provided appropriate
He looks fearful, essential • Use short, concrete explanations directly as
not interacting values/goals of communication. Assume required.
with others. life, and threat calm, “in-control-of-things” • Stayed in a separate
to self-concept. manner. room and visitors were
• Decrease environmental restricted.
stimulation; remove to • Maintained a calm and
quiet area away from other gentle approach.
clients. Suggest activity that • Provided large motor
may be relaxing. exercises for discharging
• Maintain a calm attitude pent-up tensions.
and use physical touch, if • He is actively participating
acceptable to client. in group therapy and
• Assist client to learn indoor games.
relaxation/imagery
exercises.
• Encourage participation in
regular exercise program.
Contd…
590 Textbook of Psychiatric Nursing for BSc Nursing Students

Assessment Nursing Objectives Nursing intervention Implementation Evaluation

diagnosis
• Involve in group settings, Attention given to his
encouraging and reinforcing physical problems.
appropriate participation.
Redirect into activities.
• Deal with physical
complaints in matter-of-fact
style.
Objective data: Knowledge The client will • Teach the client and family • Taught the client and Client got
• Not willing for deficit related be able to or significant others about family or significant adequate
ECT to ECT. understand symptoms of depression. others about symptoms knowledge
• Repeatedly about ECT. • Teach the client and of depression. about the
asks doubts family about treatment of • Taught them about the ECT.
regarding ECT depression. treatment for depression.
• Inform the client and • Informed the client and
family about ECT, types and family about ECT, Types
indications of ECT. and Indication of ECT.
• Teach client and family • Taught the client and
about preparation to be family about preparation
done before ECT. to be done before ECT.
• Inform them about the • Informed them about
procedure involved in ECT. the procedure involved
• Teach the client and in ECT.
family members about • Taught the client and
the post ECT care and its family members about
complications. the post ECT care and its
• Teach the client and family complications.
about medications must be
taken regularly along with
ECT.
• Reinforce teaching with
written material as
indicated.

Psychoeducation

Name of the patient: Mr K Venue: Male Psy. Ward

Topic: Care of patient undergoing ECT Date: _____________
Name of student teachers: Time: _____________
Language: English

Objectives
• General objective: At the end of the health education, the participants will be able to understand ECT.
• Specific objectives: At the end of the health education, the participants will be able to:
„ Define ECT
„ Mention the types of ECT
„ Explain the duration of ECT
„ List the side effects of ECT
„ Discuss the pre ECT care
„ Explain the care during ECT
„ Describe the post ECT care
Clinical Case Scenarios 591

Specific Time Contents Teaching and Audio visual Evaluation

objectives learning activities aids
At the end of the 1 minute Introduction: Electroconvulsive therapy Discussion Charts What is ECT?
health education, (ECT), or electroshock, is the most effective
the participants will modern treatment for those with severe and
be able to persistent emotional disorders.
Define ECT 1 minute Definition: Electroconvulsive therapy Lecture Power-point
(ECT), also known as electroshock, is a presentation
well-established, psychiatric treatment in
which seizures are electrically induced in
anesthetized patients for therapeutic effect.
Mention the types 2 minutes Types of ECT Lecture Power-point List the side
of ECT • Direct ECT presentation effects of ECT
• Modified ECT
Explain the 1 minute Duration: Treatments are usually given three Lecture Power-point
duration of ECT times a week for 2–7 weeks. For a sustained presentation
recovery, weekly or biweekly continuation
treatments are administered for several
months. The duration of the treatment
is similar to that of the psychotropic
medications frequently used for the same
conditions.
List the side effects 1 minute Risks/Side effects: Transient confusion, Lecture Power-point
of ECT headache, nausea, myalgia, retrograde and presentation
anterograde amnesia.
Discuss the pre ECT 2 minutes Pre ECT care Lecture Charts
care • Educate the patient concerning the
procedure and explain the patient about
the necessary tasks associated with ECT.
• Patient will not eat or drink anything after
midnight the night before scheduled ECT.
• Do not smoke in the morning of ECT.
• Carefully follow doctor’s instructions
about which medications you should take,
or not take, before treatments.
Explain the care 3 minutes During ECT Demonstration Model
during ECT • Nurse will place a needle into a vein in
your arm (IV).
• Place sensors called electrodes on head
• Wrap a blood pressure cuff around your
arm, so that they can monitor your blood
pressure during the procedure.
• Give you oxygen through a mask or a tube
• Doctor or nurse will inject you with a
medication (such as methohexital or
propofol) that will make you go to sleep
for 5–10 minutes. When you are asleep,
you will get another injection, of a muscle
relaxant (succinylcholine).
• Doctor will administer the ECT treatment.
Contd…
592 Textbook of Psychiatric Nursing for BSc Nursing Students

Specific Time Contents Teaching and Audio visual Evaluation

objectives learning activities aids
Describe the post 2 minutes After ECT care Discussion cum Model Mention the
ECT Care • Patient will be transferred to recovery unit demonstration post ECT care
• Doctor and nurses will check vital signs,
oxygen saturation and ECG
• They will check and maintain the airway.
• Administer fluids per order
• Position patient to maintain airway
patency and comfort; groom as needed.
• Maintain quiet environment, privacy, and
side rails up.
• Orient patient to person and place.
• Administer supplemental oxygen per order
and patient’s oxygen saturation (SPO2)
levels. Document oxygen flow rate and
SPO2 levels.
• Observe for and report cyanosis, perfuse
dieresis, nausea/vomiting, delirium,
psychomotor agitation, seizure activity, or
other unexpected activity.
Conclusion
I hope, you have understood about the ECT
and its care and will use these techniques
effectively while caring your beloved ones.

Recording and Reporting

Date Time Nursing care/activities Name with

signature
8:00 am Assessment of the patient Ms X
8:50 am Patient has taken breakfast (2 rotis with vegetable curry) and 1 cup tea Ms X
9:00 am Administration of Oral Medication Ms X
Tab. Chlorpromazine 200 mg, HS (one tablet before bed time at night)
Tab. Amitriptyline 150 mg, HS (one tablet before bed time at night)
He has taken the medications and tolerated well.
9:15 am He participated in exercise Ms X
10:00 am He participated in group therapy, and interacted with the group members Ms X
10:35 am Health education given to family members on “Care of patient undergoing ECT” Ms X
Clinical Case Scenarios 593

CASE 3 PATIENT WITH BIPOLAR AFFECTIVE DISORDER (Depression with Psychotic Symptoms)
Mrs S, 24-year-old female, married, housewife, she completed higher secondary education, she is from middle socioeconomic status,
got admitted in psychiatric emergency ward with the complaints of irrelevant talk, smiling to self, with crying spells, talking to self and
hearing voices for two months. She also attempted to commit suicide by hanging herself. It is of high intentionality and lethality. She has
significant neglect of self-care and decreased appetite and sleep. The symptoms are insidious onset and continuous course of illness.
She was a known case of bipolar affective disorder (BPAD) past 7 years. Significant family history of mental illnesses in paternal uncle
committed suicide and BPAD in second degree relatives. Normal birth and early development, she was temperamentally an easy child;
she possessed only a few friends in his childhood. She was shy type and did not involve in any play activities. She started schooling at
the age of four, not good in scholastic performances. No specific jobs held. Attained menarche at the age of 13 years, irregular and no
reactions reported, arranged marriage with cordial relationship. Her premorbid personality shows that she was shy, anxious, would seek
reassurance, sensitive to criticism, responsible, anxious avoidant personality, and fewer friends in school, closely attached with her mother.
Mental Status Examination revealed that attention could be aroused, but difficult to sustain, tone, tempo of speech was decreased,
depressed mood and range restricted. She hears voices which were derogating and criticized, she hears multiple voices, both genders,
known people from objective space, all the times, second person auditory hallucination. Grossly oriented to time, place and person,
judgment is impaired and insight is absent. On physical examination, inguino-femoral nodes tenderness reported and mild edema over
the right wrist. Investigation shows elevated Triglycerides (511 mg/dL), Sr. Cholesterol (222 mg/dL) and very low density lipoprotein
(102 mg/dL), Alk. Phosphatase (680 U/L), serum glutamic-oxaloacetic transaminase (41U/L), serum glutamic pyruvic transaminase
(42U/L) chloride (109 mEq/L) and Thyroid test normal and normal blood sugar levels. She is on Tab. Flumod, OD, Tab. Nexipride 50 mg, BD,
Tab. Topinol 100 mg, HS, Tab. Clopam, HS and Tab. Sebelium 5 mg, OD.

History Collection In 2015, after 2–3 months of childbirth, she tried to harm the
baby and herself by cutting her throat; high intentionality and
Demographic Profile lethality, since then she has behavior of smiling to self, talking
Mrs S, 24-year-old female, married, she is housewife and to self, irritability, periods of increased speech, increased level
completed Pre-University Course (PUC). She got admitted of energy, excessive grooming, decreased sleep and increased
in Female psychiatric ward. She was diagnosed with bipolar appetite, irritable mood, lasting for 7–10 days and periods
affective disorder-depression with psychotic symptoms. of crying spells, talking, smiling to self, decreased speech,
The information was collected from patient’s brother and decreased self-care, decreased sleep and appetite, lasting for
about 15–20 days. Mood is irritable, Deliberate self-harm
husband given was adequate, reliable and relevant.
(DSH) attempt about 3–4 months back. Her self-care is not
Chief Complaints for Seeking Admission adequate, has to be prompted. Sleep is decreased and appetite
is increased. She also tends to wash her hands repeatedly,
Smiling to self several times after touching anything, increases when periods
Crying 2 months of sad mood. She also hears abusive voices and threatening
2 months
Talking to self discussions about her among themselves. No history of
physical illnesses.
Hearing voices
Negative History
History of Present Illness
No thought alienation phenomenon, no history of grandiose
Her illness was insidious onset and has continuous course of ideas, substance abuse, organic causes like head injury,
illness. She was apparently normal 7 years back then she had infections, convulsions.
an episode characterized by smiling to self, irrelevant talking,
crying, decreased self-care, decreased need for sleep, excessive Current Treatment History
grooming, disorganized behavior like putting nails on head. • Tab. feno fibrate, 100 mg, OD
She also attempted to commit suicide by hanging herself. • Tab. quetiapine, 100 mg, HS
This is of high in intentionality and lethality. Her treatment • Tab. lamotrigine, 50 mg, BD
was started 3 months back, later she gradually improved in • Tab. levosulpride, 50 mg, BD
3–4 months. According to brother, there was 90% improvement. • Tab. clonazepam, 1 mg, HS
594 Textbook of Psychiatric Nursing for BSc Nursing Students

Past History
Similar episode in the past. Seven years before information not available.

Family History
She is the first-born child, nonconsanguineous marriage, from middle socioeconomic status. Family history of mental illnesses
in paternal uncle who died by committing suicide and presence of bipolar affective disorder (BPAD) in second degree relatives.

Genogram

Personal History • Sexual and marital history: Age at menarche was

13 years, irregular and no reactions reported. Married in
• Birth and early development: She was reported to
2004, arrange marriage with cordial relationship.
be born full term normal vaginal delivery which was
• Substance use: No substance abuse.
conducted at hospital. No complications were reported
during the periods of antenatal, intranatal and neonatal
Premorbid Personality: Well Adjusted
periods. Birth weight was reported to be normal. Baby
cried soon after delivery and breastfeeding was initiated • Social relationships: Shy type, anxious, would seek
soon after delivery. Milestone development was reported reassurance, sensitive to criticism, responsible, anxious,
avoidant personality, and fewer friends in college, closely
to be normal.
attached with her mother.
• Behavior during childhood: She was temperamentally
• Intellectual activities: Reading books. Not good in
an easy child; she possessed only a few friends in her
academic activities.
childhood. She was shy type and did not involve in any
• Mood: Bright, calm and relaxed.
play activities. She was closely attached with family
• Character: Attitude to work and responsibility; worried
members. She was emotionally controlled and calm and by responsibility, meticulous and methodical.
quiet. • Interpersonal relationships: Shy, few friends, no play in
• Physical illnesses: No physical illness during childhood schools; performs household activities, concentrates on
was reported. studies, emotionally controlled and quiet.
• Schooling: She started schooling at the age of four, • Energy and imitativeness: Sluggish in doing household
concentrated on her studies, few friends. Not good in activities: would always insist on studying.
scholastic performances. She studied up to Pre-University • Fantasy life: Not significant.
Course. • Habits: Normal sleep and rest pattern and having regular
• Occupation: No specific jobs held. bowel and bladder habits.
Clinical Case Scenarios 595

Mental Status Examination • Vital signs: Stable

„ Temperature : 98.2°F
• General appearance and behavior: She is ill kempt and „ Pulse : 90 beats/min
not clean, establishes eye to eye contact, attention can be „ Respiration : 18 breaths/min
aroused, but difficult to sustain, establishes rapport, no „ Blood pressure : 110/70 mm Hg
tics and mannerism noted, no catatonic symptoms.
• Head and scalp: Size and shape of the head is normal.
• Psychomotor activity: Psychomotor activities are
Hair distribution is even, no palpable mass or tenderness,
observed as normal.
• Speech: She was replying to the questions alone. Reaction no surgical scars or injuries noted.
time is normal. Tone, tempo decreased, volume and • Eyes: Severe pallor present, symmetrical in size and shape.
reaction time are normal. Speech is relevant and coherent. Pupils are equal, round and react to light. No infections or
Prosody was maintained throughout. color changes observed.
• Thought: No formal thought disorders elicited. She is • Nose: Nostrils patent; though labored breathing persists.
having normal stream of thoughts. No flight of ideas, Nasal flaring present, frontal and maxillary sinuses
retardation in thinking, circumstantialities, or thought nontender.
block. No thought interpolation. • Ears: Ears bilaterally equally placed. Pinna soft and
• Mood: Subjectively: Patient says, “Sometimes good and flexible. Auditory canal patent, no discharges observed.
sometimes bad.” Objectively: Looks depressed, congruent • Mouth: Lips are dry and patchy. Buccal mucosa pink and
to thought process, reaction present, range restricted. moist; teeth normally aligned; no missing teeth. Gum;
• Perception: Hears voices which were derogating and pink and moist; uvular elevation normal and midline. Gag
criticized. Patient also at times commands her. Multiple reflux present. Tongue midline and movements normal.
voices, both gender, known people from objective space, • Neck: Trachea; midline, nontender. Range of Motion
all the times; second person auditory hallucination. (ROM) full range, strong. No palpable tender lymph
nodes or masses. Thyroid palpable; smooth and not
Cognitive Function enlarged. Carotid pulses present.
• Thorax:
• Orientation: Grossly oriented to time, place and person.
„ Anterior thorax: Breathing movements bilaterally
• Attention and concentration: Attention can be aroused
equal. No visible pulsations. Apical impulses are
but concentration is not sustained.
palpable. No tender lymph nodes to palpate. Heart
Digit span test:
sounds S1 and S2 heard; rate 82 beats/min; regular rate
Digit forward test: 5 digits and rhythm. No murmurs, rubs or clicks.
Digit backward test: 3 digits „ Posterior thorax: Anteroposterior <transverse
Serial subtraction till 43 diameter; muscular development normal. No spinal
abnormalities noticed; no increase in tactile fremitus.
• Memory: Immediate, recent and remote intact.
• Intelligence: Average, General information, Comprehension, Lungs resonant and clear throughout.
Arithmetic ability, proverb and similarities concrete. • Abdomen: No visible gastric pulsations. Rounded; bowel
• Judgment: Impaired sounds (+) no tenderness or palpable mass, liver and
• Insight: Insight is absent spleen; nonpalpable, nontender. Femoral pulses feeble.
Inguino-femoral nodes tender as reported.
General Physical Examination • Upper and lower extremities: Well developed; no
muscle wasting. Contusions over the left upper arm near
• General appearance: She is moderately built, conscious, the elbow joint. Mild edema over the right wrist, range
poor hygiene. of motion: full strength and possible in all directions.
„ Height: 153 cm Pedal and radial pulses palpable equal bilaterally.
„ Weight: 44 kg • Genitals and rectum: Normal as reported; no examination
„ Body mass index (BMI): 23 done.
596 Textbook of Psychiatric Nursing for BSc Nursing Students

Investigations

Sl. no. Date Investigation Patient’s value Normal value Remarks

1. • Fasting blood glucose • 77 mg/dL • 60–100 mg/dL • Normal
• Post prandial blood glucose • 105 mg/dL • 100–160 mg/dL • Normal
2. • Triiodothyronine (T3) • 130 ng/dL • 60–200 ng/dL • Normal
• Thyroxine (T4) • 6.54 μg/dL • 4.5–12 μg/dL • Normal
• Thyroid Stimulating Hormone (TSH) • 0.86 μ IU/mL • 0.30–5.5 • Normal
3. • Glucose • 81 g/dL • 60–100 g/dL • Normal
• Urea • 22 mg/dL • 14–40 mg/dL • Normal
• Creatinine • 0.7 mg/dL • 0.6–1.4 mg/dL • Normal
• Triglycerides • 511 mg/dL • 50–150 mg/dL • Elevated
• Cholesterol • 222 mg/dL • 110–220 mg/dL • Elevated
• High-density lipoprotein (HDL) • 42 mg/dL • 40–60 mg/dL • Normal
• Low-density lipoprotein (LDL) • 79 mg/dL • 60–130 mg/dL • Normal
• Very low density lipoprotein (VLDL) • 102 mg/dL • 10–40 mg/dL • Elevated
• Total bilirubin • 0.2 mg/dL • 0.3–1.2 mg/dL • Normal
• Alk. phosphatase • 680 U/L • 40–129 U/L • Elevated
• Serum glutamic-oxaloacetic • 41 U/L • 31 U/L • Elevated
transaminase (SGOT) • 42 U/L • 39 U/L • Elevated
• Serum glutamic pyruvic • 138 mEq/L • 135–145 mEq/L • Normal
transaminase (SGPT) • 4.5 mEq/L • 3.5–5.2 mEq/L • Normal
• Sodium • 109 mEq/L • 95–106 mEq/L • Elevated
• Potassium
• Chloride

Medications

Name of the Dose/ Action Side effects Nurses’ responsibility

drug frequency
Tab. fenofibrate 100 mg Inhibits triglyceride • CV: Angina, arrhythmias, • Administer drug with meals.
1-0-0 synthesis in the swelling, phlebitis, • Monitor patient carefully.
liver resulting in a thrombophlebitis. • Ensure that patient continues strict
reduction in very-low- • Dermatologic: Rash, alopecia, dietary restrictions and exercise
density lipoprotein dry skin, dry and brittle hair, program.
(VLDL) released pruritus, urticaria. • Arrange for regular follow-up
into circulation; • GI: Nausea, vomiting, diarrhea, including blood tests for lipids, liver
may also stimulate dyspepsia, flatulence, function, and CBC during long-term
the breakdown of bloating, stomatitis, gastritis, therapy.
triglyceride-rich pancreatitis, peptic ulcer, GI • Give frequent skin care to deal with
lipoproteins. hemorrhage. rashes and dryness.
• GU: Impotence, decreased • Monitor patient for muscle
libido, dysuria, hematuria, weakness, aches, especially if
proteinuria, decreased urine patient takes Tricor in combination
output. with other cholesterol lowering
• Hematologic: Leukopenia, drugs.
anemia, eosinophilia, increased
alanine transaminase (ALT)
and aspartate transaminase
(AST), increased creatine
phosphokinase (CPK).
• Other: Myalgia, flulike
syndromes, arthralgia, weight
gain, polyphagia, increased
perspiration, systemic lupus
erythematosus, blurred vision,
gynecomastia.
Contd…
Clinical Case Scenarios 597

Name of the Dose/ Action Side effects Nurses’ responsibility

drug frequency
Tab. quetiapine. 100 mg Blocks dopamine and • Autonomic: Dry mouth, • Administer small quantity to any
0-0-3 serotonin receptors in salivation, nasal congestion, patient with suicidal ideation.
the brain; also acts as nausea, vomiting, anorexia, • Monitor elderly patients for
a receptor antagonist fever, pallor, flushed faces, dehydration and institute remedial
at histamine and sweating, constipation. measures promptly; sedation and
adrenergic receptor • CNS: Drowsiness, insomnia, decreased sensation of thirst related
sites. vertigo, headache, weakness, to central nervous system (CNS)
tremor, tardive dyskinesia, effects of drug can lead to severe
Neuroleptic malignant dehydration.
syndrome. • Monitor patient closely in any
• CV: Hypotension, orthostatic setting that would promote
hypotension, syncope. overheating.
• Hematologic: Increased • Regularly monitor patient for signs
alanine transaminase and symptoms of diabetes mellitus.
(ALT), total cholesterol and • Consult physician about dosage
triglycerides. reduction and use of Anticholinergic
• Other: Risk of development of antiparkinsonians (controversial) if
diabetes mellitus. extrapyramidal effects occur.
Tab. lamotrigine 25 mg It acts on sodium Skin reactions, including Stevens- • Assess for the side effects
2-0-4 channels, inhibits Johnson Syndrome and Toxic • Watch for skin rashes
voltage-sensitive Epidermal Necrolysis. Headaches, • Re-orient the patient
sodium channels, dizziness and insomnia, acne and • Provide oral care
thereby stabilizing skin irritation, vivid dreams or • Encourage to take nutritious diet.
neuronal membranes nightmares, night sweats, body • Monitor weight regularly
and consequently aches and cramps, muscle aches,
modulating presynaptic dry mouth, mouth ulcers, damage
transmitter release of to tooth enamel, fatigue, memory
excitatory amino acids and cognitive problems, irritability,
(for glutamate and weight changes, hair loss, changes
aspartate). in libido, frequent urination,
nausea, appetite changes.
Tab. levosulpride 50 mg Antidopaminergic • Amenorrhea, gynecomastia, • Regularly monitor patient for signs
1-0-1 (Selective dopamine galactorrhea, changes in libido. and symptoms of Neuroleptic
D2 receptors) activity • Neuroleptic malignant symptoms.
on both central and syndrome. • Consult physician about dosage
peripheral levels. It is reduction and use of Anticholinergic
an atypical Neuroleptic antiparkinsonians (controversial) if
and a prokinetic agent. extra pyramidal effects occur.
• Reassurance about changes in the
breast.
• Monitor for side effects.
Tab. clonazepam 1 mg Benzodiazepines • CNS: Sedation, depression, • Monitor addiction-prone patients
benzodiazepine 0-0-1 potentiate the lethargy, apathy, fatigue, light- carefully because of their
effects of Gamma- headedness, disorientation, predisposition to habituation and
aminobutyric acid anger, hostility, episodes drug dependence.
(GABA), an inhibitory of mania and hypomania,
neurotransmitter. restlessness, delirium,
headache, slurred speech,
dysarthria, stupor, rigidity,
tremor, dystonia, vertigo,
euphoria, nervousness,
difficulty in concentration,
vivid dreams, psychomotor
retardation, extrapyramidal
symptoms; mild paradoxical
excitatory reactions during first
2 weeks of treatment.
Contd…
598 Textbook of Psychiatric Nursing for BSc Nursing Students

Name of the Dose/ Action Side effects Nurses’ responsibility

drug frequency
• CV: Bradycardia, tachycardia, • Monitor liver function and blood
CV collapse, hypertension and counts periodically in patients on
hypotension, palpitations, long-term therapy.
edema. • Taper dosage gradually after long-
• EENT: Visual and auditory term therapy, especially in patients
disturbances, diplopia, with epilepsy; substitute another
nystagmus. antiepileptic.
• GI: Constipation, diarrhea, • Monitor patient for therapeutic
dry mouth, salivation, hepatic drug levels: 20–80 ng/mL.
dysfunction. • If the patient has epilepsy, arrange
• GU: Incontinence, urinary for patient to wear medical alert
retention, changes in libido, identification indicating the patient
menstrual irregularities. has epilepsy and is receiving drug
• Hematologic: Elevations therapy.
of blood enzymes—lactate
dehydrogenase (LDH), alkaline
phosphatase, aspartate
transaminase (AST); blood
dyscrasias: agranulocytosis,
Leukopenia.
• Other: Hiccups, fever.

Nursing Management

Client Assessment
Mrs S, 24-year-old female, married, a housewife and completed Pre-University Course. Her illness was insidious onset and has
continuous course of illness. She had an episode characterized by smiling to self, irrelevant talk, crying, decreased self-care,
decreased need for sleep, excessive grooming, disorganized behavior like putting nails on head. She also attempted to commit
suicide by hanging herself. It is of high in intentionality and lethality. She also hears voices abusive and threatening discussing
about her among them. She was a known case of bipolar affective disorder for 7 years.

Diagnostic Studies
Elevated blood cholesterol levels and elevated liver enzymes.

Nursing Priorities
• Promote physical safety with special focus on suicide prevention.
• Provide for client’s basic needs, promoting highest possible level of independent functioning.
• Support client/family participation in follow-up care/community treatment.

Nursign Diagnosis
• Altered thought process related to inability to think and process information.
• Risk for violence, self-directed related to lack of impulse control, self-destructive strategies as evidenced by severe depression
and loss of interest to live.
• Social isolation related to preoccupation with thoughts as evidenced by withdrawn and less interaction with others.
• Ineffective therapeutic regimen management pattern of regulating and integrating into a daily living program for treatment
of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals.
Clinical Case Scenarios 599

Nursing Care Plan

Assessment Nursing Objectives Nursing intervention Implementation Evaluation

diagnosis
Objective data: Altered thought The client will be • Do not make promises • Did not make any She maintained
• Nonreality- process related able to maintain that you cannot keep. promises to the normal thought
based thinking to inability to normal thought • Encourage the client patient. process as
• Laughing to self think and process process to talk with you, but • Encouraged the evidenced by
• Talking to self information do not try only for client to talk with her decreased hearing
• Hearing voices information. thoughts. voices improved
• Poor self-care • Explain procedures, • Explained the self-care.
and try to be sure the procedures to the
client understands patient before doing
the procedures before it.
doing it. • Recognized the
• Recognize the client’s client’s delusions
delusions as the as the client’s
client’s perception of perception of the
the environment. environment.
• Do not argue with • Did not make any
the client or try to argument to the
encourage nonverbal patient.
communication. • Interaction made
• Interact with the client with the client on
on the basis of real the basis of real
things; do not dwell things.
on the delusional • Engaged the client in
material. one-to-one activities
• Engage the client in at first, then
one-to-one activities activities in groups
at first, then activities slowly.
in small groups, and • Showed empathy
gradually activities in regarding the client’s
larger groups. feelings; reassured
• Show empathy the client.
regarding the client’s
feelings; reassure the
client of your presence
and acceptance.
Subjective data: Risk for violence, The client • The client has one- • Client was observed She was prevented
patient says “I self-directed will not harm to-one contact with frequently every from deliberate
don’t want to related to lack of herself or others a staff member at all 15–20 minutes. self-harm (DSH)
live.” impulse control, and identify times • Client is not and violence.
Objective data: self-destructive alternative • Assess the client’s verbalizing about
• Self-destructive strategies as ways of dealing suicidal potential, and suicidal thoughts.
tendencies evidenced by with stress evaluate the level of • Accepted her and
• Feelings of severe depression and emotional suicide precautions at not involved in any
anger or and loss of problems. least daily. arguments by staff
hostility interest to live. • Do not argue with the and family members.
client. • She is staying near to
• Ask the client if he the nurse station.
or she has a plan for • Sharp objects, drugs
suicide. and long clothes
• The client’s room removed.
should be near the • She was provided
nurse station and care based on her
within view of the preference.
staff.
Contd…
600 Textbook of Psychiatric Nursing for BSc Nursing Students

Assessment Nursing Objectives Nursing intervention Implementation Evaluation

diagnosis
• Be especially alert • She communicated
to sharp objects and with her parents and
other potentially staff.
dangerous items. • Daily and shift wise
• Involve the client as record maintained
much as possible in regarding her mood.
planning his or her
own treatment.
• Be alert to the
client’s behaviors,
especially decreased
communication,
conversations about
death or the futility
of life.
• Observe, record, and
report any changes in
the client’s mood.
Subjective Data: Social isolation The client will • Provide attention in • Provided attention to Client is able to
patient says “My related to be able to a sincere, interested the client and spent mingle with the
mother doesn’t preoccupation demonstrate manner. more time with the other patients and
want me and I am with thoughts appropriate • Support any successes patient. to me by increased
alone.” as evidenced by; emotional or responsibilities • Positive speaking and active
Objective data: withdrawn and responses fulfilled, projects, reinforcement participation in
• Inappropriate less interaction interactions with staff given if she talks to games.
or inadequate with others. members and other others and performs
emotional clients, and so forth. activities of daily
responses • Avoid trying to living
• Poor convince the client • Taught the client
interpersonal verbally of his own social skills and
relationships worth. demonstrated
• Feeling • Teach the client social specific skills, such
threatened skills and demonstrate as eye contact,
in social specific skills, such as attentive listening,
situations eye contact, attentive and so forth.
• Difficulty listening, and so forth. • Helped the client in
with verbal • Help the client improve grooming, she takes
communication his grooming; assist, bath on prompting.
• No responses when necessary, in Kept her bed clean
to stimuli bathing, doing laundry, and tidy
and so forth. • She accepts
• Help the client accept responsibilities
as much responsibility in taking food,
for personal grooming medication and self-
as she can (do not do care.
something for the client
that she can do alone).
Subjective data: • Ineffective The client will • Tell the client that the • Encouraged the Patient understood
patient says “I Therapeutic be able to take medications are a part patient and family the importance
don’t think I Regimen medications of the treatment plan members to of taking the
need to take the Management as given and and you expect him continue treatment. medications and
medications.” establish an or her to take them Medications were agreed to take it
adequate as prescribed. Check given on observation regularly.
balance of the client’s mouth if
rest, sleep, and necessary, after giving
activity. oral medications
Contd…
Clinical Case Scenarios 601

Assessment Nursing Objectives Nursing intervention Implementation Evaluation

diagnosis
Objective data: • Pattern of • Be straightforward • Information were
• Reluctance or regulating and with the client when given about the
refusal to take integrating into giving information medications,
medications a daily living about the medications, including the name
• Inability to program for including the name and desired effects
carry out treatment of desired effects • She takes regular
responsibilities illness and the • Observe the client’s meals but in smaller
at work, home, sequelae of eating, drinking, and quantity, frequently
and so forth illness that is elimination patterns, drinks fluids and
• Inadequate unsatisfactory and assist the client as have regular
attention for meeting necessary elimination.
to need for specific health • Monitor the client’s • She sleeps 6 hours at
nutrition, rest, goals. sleep patterns, and night and 1 hour in
or sleep prepare him or the daytime.
• Inability to her for bedtime by
carry out decreasing stimuli
activities of and administering
daily living comfort measures or
medications
• Assess and record the
client’s caffeine intake
and limit it if necessary

Psychoeducation
Name of the Patient: Mrs S Venue: Female Psy. Ward
Topic: Suicide prevention Date: _______________
Name of student teachers: Ms X Time: _______________
Language: English

Objectives
• General objective: At the end of the health education, the participants will be able to understand suicide prevention and
help to protect the patients from committing suicide.
• Specific objectives: At the end of the health education, the participants will be able to:
„ Define suicide.
„ List the causes of suicide.
„ Describe the preventions of suicide.
Specific Time Contents Teaching and Audio visual Evaluation
objectives learning activities aids
At the end 2 minutes Introduction: Suicide is a major public health Discussion Charts Can you outline
of the health concern. Suicide is a leading cause of death in the basics of
education, the India. Among 15–24-year-old 12.0 per 100,000 suicide?
participants for females and 14.2 per 100,000 for males
will be able to. commit suicide. Suicide is complicated and
tragic, but it is often preventable. Knowing the
warning signs for suicide and how to get help
can help save lives.
Define suicide. 1 minute Definiton: Suicide can be defined as the Lecture Roller board Explain the
intentional taking of one’s own life in a meaning of
culturally nonendorsed manner suicide?
Contd…
602 Textbook of Psychiatric Nursing for BSc Nursing Students

Specific Time Contents Teaching and Audio visual Evaluation

objectives learning activities aids
List the causes 5 minutes Cause: Genetic factors (18% in monozygotic Lecture Handouts What are
of suicide. twins); Biochemical factors (low levels of the causes of
5-HIAA); Physical factors (Patients with suicide?
incurable or painful physical disorders, like
cancer and AIDS); Social factors (a divorced
male, who has no children and who lives
alone); Psychological factors (failures in
examination, failure in love, dowry difficulties,
marital difficulties, illegitimate pregnancy,
family dispute, loss of a loved object by death
or others means, occupational and financial
difficulties and social isolation).
Describe the 10 minutes Prevention Discussion Power-point How to prevent
preventions of Risk identification (Talking about wanting presentation suicide?
suicide. to die, feeling empty, hopeless, or having no
reason to live, withdrawing from family and
friends, making a plan or looking for a way
to kill themselves, such as searching online,
stockpiling pills, or buying a gun).
Five step action:
1. Ask: “Are you thinking about killing yourself?”
2. Keep them safe: Reducing a suicidal person’s
access to highly lethal items or places is an
important part of suicide prevention.
3. Be there: Listen carefully and learn what the
individual is thinking and feeling. Findings
suggest acknowledging and talking about
suicide
4. Help them connect: Save the National
Suicide Prevention Lifeline’s number in your
phone so it’s there when you need it: 1-800-
8255 (TALK).
5. Stay Connected: Staying in touch after a
crisis or after being discharged from care
can make a difference.
Conclusion: People who want to kill
themselves are only suicidal for a limited time,
most suicides occur within about 3 months
after the beginning of “improvement,” hence, it
is important to prevent suicide.

Recording and Reporting

Date Time Nursing care/activities Name with signature

8:00 am Assessment of the patient Ms X
8:50 am Patient has taken breakfast (2 dosas with sambar) and 1 cup tea Ms X
9:00 am • Administration of Oral Medication Ms X
▪ Tab. Fenofibrate, 100 mg
▪ Tab. Lamotrigine, 50 mg
▪ Tab. Levosulpride, 50 mg
• She has taken the medications and tolerated well.
9:15 am She went to occupation training unit Ms X
10:00 am She participated in group therapy, she responded very minimally Ms X
10:35 am Health education given to family members on “Prevention of Suicide” Ms X
Clinical Case Scenarios 603

CASE 4 PATIENT WITH MULTIPLE SUBSTANCE USE DISORDER

Mr C, 19-year-old male, unmarried, residing in Bengaluru, working as a construction worker, studied up to 7th standard. Mr C is dependent
to alcohol, nicotine and cannabis. He has symptoms of fearfulness, suspiciousness, fearfulness, reduced socialization, decreased sleep and
appetite, attempted suicide, hearing voices of people saying that he will be killed when he goes out of the jail, for past 3.5 months. He has
two similar episodes in the past. He is on Tab. Risperidone, Tab. Trihexyphenidyl (THP) and Cap. Fluoxetine.

History Collection for 3 months, sleeplessness, decreased appetite, voices of

people telling that he will be killed when he goes out of
Demographic profile: Mr C, 19-year-old male, unmarried, the jail, when he see the prisoners talking he thinks they
residing in Bengaluru, working as a construction worker, are talking about him, he made a suicidal attempt two days
studied up to 7th standard, admitted in male psychiatric ward back, had two episodes in the past, one in 2015 in the prison
with the diagnosis of multiple substance abuse disorders (sadness, death wishes and decreased sleep) another episode
(Alcohol, cannabis and nicotine dependence syndrome). one year back with increased talkativeness, irritable and
Source of information from patient, the information given was thinking high about him. He had socio-occupational
inadequate, not reliable. dysfunctioning and substance abuse disorders. He had legal
issues for attempt to theft.
Chief Complaints for Seeking Admission:
Negative History
• Fearfulness
• Suspiciousness No history of repeated intrusive thoughts, images, impulses or
• Decreased socialization acts, organic causes like head injury, infections convulsions.
• Decreased sleep and appetite For 3.5 months Current Treatment History
• Attempted suicide
• Sadness • Tab. Risperidone 8 mg HS
• Hearing voices • Tab. Trihexyphenidyl 2 mg BD
• Cap. Fluoxetine 40 mg HS
History of Present Illness
Past History
His illness is of insidious onset and episodic course of illness.
He was apparently normal 4 months back before he was Similar episodes in the past. Nicotine dependence
brought to the prison, then he developed pervasive sadness, syndrome for 6–7 years and cannabis dependence syndrome
lack of interest in all activities, lack of energy, hearing voices 3–4 years.

Family History
Nonconsanguineous marriage, he is from low socioeconomic status and family history of alcohol dependence syndrome (ADS)
among 1st-degree relatives.
604 Textbook of Psychiatric Nursing for BSc Nursing Students

Genogram

Personal History • Fantasy life: Not present.

• Habits: Normal sleep and rest pattern. He is having
• Birth and early development: He was reported to be born
regular bowel and bladder elimination habits.
full term normal vaginal delivery which was conducted
at hospital. No complications were reported during the
Mental Status Examination
periods of antenatal, intranatal and neonatal periods. Birth
weight was reported to be normal. Baby cried soon after • General appearance and behavior: He appears to be
delivery and breastfeeding was initiated soon after delivery. irritable, poorly kempt and poor hygiene. Not able to
Mile stone development was reported to be normal. establish eye to eye contact, rapport not established.
• Behavior during childhood: He was temperamentally • Psychomotor activity: Psychomotor activities observed
an easy child; he possessed only a few friends in his as retarded.
childhood. He was shy type and did not involve in any play • Speech: Speech is not spontaneous. Reaction time is
activities. He was closely attached with family members. increased. Tone, tempo, and volume are decreased.
He was emotionally controlled and calm and quiet. Speech is relevant and coherent. Prosody was maintained
• Physical illnesses: No physical illness during childhood throughout.
was reported. • Thought: Possession of thought is normal; no repeated
• Schooling: He started schooling at the age of five, thoughts reported. Delusion of persecution presents—
concentrated on his studies, few friends. Not good in single, nonelaborative, nonsystematized—“people are
scholastic performances. He studied up to 7th standard. planning to kill me once I am released from jail”. Delusion
No specific jobs held. of references—“people are talking about me”. He is having
• Sexual and marital history: Married but her wife depressive ideation, such as feeling of worthlessness,
separated reason not known. hopelessness and suicidal ideation present.
• Substance use: He is a chronic alcoholic and smoker and • Mood:
occasionally uses cannabis. „ Subjectively: “I am sad”.
„ Objectively: He looks depressed. Range restricted
Premorbid Personality—Dissocial and reactivity absent, not congruent.
• Social relationships: Fewer friends in school, quarrelled „ Perception: He hears voices of people discussing
with friends, not attached with parents. about him and they are threatening. Auditory
• Intellectual activities: Reading books. Not good in hallucination presents.
academic activities. • Cognitive functions:
• Mood: Dull, irritable and troubling. „ Orientation: He is not oriented to time, place and
• Character: Attitude to work and responsibility—worried person.
by responsibility, meticulous and methodical. „ Attention and concentration: Poor attention and
• Interpersonal relationships: Shy, few friends, no play in concentration.
schools; perform household activities, not concentrates Digit span test:
on studies, emotionally uncontrolled and dissocial. Digit forward test: 3 digits
• Energy and imitativeness: Sluggish in doing household Digit backward test: 2 digits
activities. Serial subtraction for 50–3, completed till 31.
Clinical Case Scenarios 605

„ Memory: Immediate, recent and remote intact. (1) Less than monthly
„ Intelligence: General information, comprehension, (2) Monthly
arithmetic ability and abstraction were intact. (3) Weekly √
„ Judgment: Personal, social and test judgment are (4) Daily or almost daily
impaired. 7. How often during the last year have you needed an
„ Insight: Awareness of being sick, insight is absent. alcoholic drink first thing in the morning to get
yourself going after a night of heavy drinking?
Psychometric Assessment (0) Never
(1) Less than monthly
The Alcohol Use Disorders Identification Test (2) Monthly
(AUDIT) (3) Weekly √
(4) Daily or almost daily
1. How often do you have a drink containing alcohol? 8. How often during the last year have you had a feeling
(0) Never of guilt or remorse after drinking?
(1) Monthly or less (0) Never
(2) 2–4 times a month (1) Less than monthly
(3) 2–3 times a week √ (2) Monthly
(4) 4 or more times a week (3) Weekly √
2. How many drinks containing alcohol do you have on (4) Daily or almost daily
a typical day when you are drinking? 9. Have you or someone else been injured as a result of
(0) 1 or 2 your drinking?
(1) 3 or 4 √ (0) No √
(2) 5 or 6 (2) Yes, but not in the last year
(3) 7, 8, or 9 (4) Yes, during the last year
(4) 10 or more
10. Has a relative, friend, doctor, or another health
3. How often do you have six or more drinks on one professional expressed concern about your drinking
occasion? or suggested you cut down?
(0) Never (0) No
(1) Less than monthly (2) Yes, but not in the last year
(2) Monthly √ (4) Yes, during the last year √
(3) Weekly
(4) Daily or almost daily Scoring
4. How often during the last year have you found that • A total score of less than 8: No harmful drinking behavior
you were not able to stop drinking once you had or alcohol dependence.
started?
• A total score of 8 or more: Harmful drinking behavior.
(0) Never
• A score of 13 or more in women: Alcohol dependence.
(1) Less than monthly
• A score of 15 or more in men: Alcohol dependence.
(2) Monthly √
(3) Weekly Mr C scored: 23 (Alcohol dependence)
(4) Daily or almost daily
5. How often during the last year have you failed to do General Physical Examination
what was normally expected from you because of
drinking? • General appearance: He is thin built, conscious, poor
(0) Never nutritional status, poor hygiene.
(1) Less than monthly „ Height: 168 cm
(2) Monthly √ „ Weight: 52 kg
(3) Weekly „ Body mass index (BMI): 18
(4) Daily or almost daily • Vital signs: His BP is low.
6. How often during the last year have you been unable „ Temperature : 98.2°F
to remember what happened the night before because „ Pulse : 70 beats/min
you had been drinking? „ Respiration : 20 breaths/min
(0) Never „ Blood pressure : 90/70 mm Hg
606 Textbook of Psychiatric Nursing for BSc Nursing Students

• Head and scalp: Size and shape of the head is normal. • Thorax:
Hair distribution is even, no palpable mass or tenderness; „ Anterior thorax: Breathing movements bilaterally
numerous wound scars seen. equal. No visible pulsations. Apical impulses are
• Eyes: No pallor present, symmetrical in size and shape. palpable. No tender lymph nodes to palpate. Heart
Pupils equal in round and reacting to light. No infections sounds S1 and S2 heard; rate 64 beats/min; regular rate
or color changes observed. Conjunctivitis is present. and rhythm. No murmurs, rubs or clicks.
• Nose: Nostrils patent; though labored breathing persists. „ Posterior thorax: Anteroposterior diameter is less than
Nasal flaring is present, frontal and maxillary sinuses— transverse diameter; muscular development normal.
nontender. No spinal abnormalities noticed; no increase in tactile
• Ears: Ears are bilaterally equally placed. Pinna is soft and fremitus. Lungs are resonant and clear throughout.
flexible. Auditory canal patent, no discharges observed. • Abdomen: No visible gastric pulsations, bowel sounds
• Mouth and throat: Lips are dry and patchy. Buccal mucosa present, no tenderness or palpable mass, liver and spleen
pink and moist; teeth normally aligned; no missing are nonpalpable, nontender. Femoral pulses are normal.
teeth. Gum is pink and moist; uvular elevation normal No tenderness of inguinal and femoral nodes is reported.
and midline. Gag reflux is present. Tongue midline and • Upper and lower extremities: No muscle wasting,
movements normal. Throat congestion is present. He is numerous wound scars present in the anterior aspect of
having hoarseness of voice. forearms, no edema, injuries noted, range of motion; full
• Neck: Trachea is in midline, nontender. Range of motion strength and possible in all directions. Pedal and radial
is of full range, strong. No palpable tender lymph nodes pulses are bilaterally palpable.
or masses. Thyroid is palpable; smooth and not enlarged. • Genitals and rectum: Normal as reported; no examination
Carotid pulses present. done.

Investigations

Sl. no. Date Investigation Patient’s value Normal value Remarks

1. Hemoglobin 15.4% 12–16 g/dL Normal
Red blood cells (RBC) 4.38 cells/mm 3
1.5–4.5 lakh cells/mm 3
Normal
Total count (TC) 7,700 cells/mm3 4–9,000 cells/mm3 Normal
Platelet 2.33 lakhs/mm 3
2.5–4.5 lakhs/mm 3
Normal
Neutrophils 70% 45–70% Normal
Lymphocytes 20% 20–40% Normal
Basophils 02% 0.5–1% Normal
Monocytes 05% 1–10% Normal
Eosinophils 10% 0–6% Elevated
Erythrocyte sedimentation rate (ESR) 10 mm/hr 0–20 mm/hr Normal
Postprandial blood glucose 110 mg/dL 80–140 mg/dL Normal
Glucose (random) 81 mg/dL 60–100 mg/dL Normal
2. Urea 13 mg/dL 17–43 mg/dL Normal
Creatinine 0.9 mg/dL 0.6–1.4 mg/dL Normal
Total bilirubin 1.1 mg/dL 0.3–1.2 mg/dL Normal
Alkaline phosphatase 84 IU/mL 40–129 IU/mL Normal
Serum glutamic-oxaloacetic transaminase (SGOT) 23 IU/mL 8–40 IU/mL Elevated
Serum glutamic pyruvic transaminase (SGPT) 78 IU/mL 6–40 IU/mL Normal
Sodium 130 mEq/L 135–145 mEq/L Decreased
Potassium 4.4 mEq/L 3.5–5.4 mEq/L Normal
Chloride 984 mEq/L 95–106 mEq/L Normal
Clinical Case Scenarios 607

Medication

Name of the drug Dose Action Side effects Nurses’ responsibility

Tab. Trihexyphenidyl 4 mg Trihexyphenidyl blocks efferent Tachycardia, confusion, agitation, • Give intramuscular
0-0-2 impulses in parasympathetically euphoria, drowsiness, headache, injections deep into
innervated structures like dizziness, delusions, hallucinations, muscle
smooth muscles (spasmolytics paranoia, dry skin, increased • Do not administer
activity), salivary glands and sensitivity to light, rash, constipation, subcutaneously; tissue
eyes (mydriasis). xerostomia, dry throat, ileus, nausea, necrosis may occur
vomiting, urinary retention, blurred • Do not administer intra-
vision, increase in intraocular arterially; arteriospasm
pressure. and gangrene of the limb
may result
• If patient develops side
effects, it should be
reported
• Take plenty of oral fluids
Tab. Risperidone 4 mg It blocks postsynaptic • Cardiac: arrhythmias • Monitor addiction,
0-0-2 mesolimbic dopaminergic D1 • Anticholinergic effects: habituation and
and D2 receptors in the brain; (constipation, xerostomia, blurred dependence
depresses the release of vision, urinary retention); use with • Monitor liver function
hypothalamic and hypophyseal caution in patients with decreased • Monitor blood counts
hormones; believed to gastrointestinal motility, paralytic periodically in patients on
depress the reticular activating ileus, urinary retention, BPH, long-term therapy
system, thus affecting basal xerostomia, or visual problems. • If serious effects,
metabolism, body temperature, • Blood dyscrasias the drugs should be
wakefulness, vasomotor tone, • Extrapyramidal symptoms: discontinued
and emesis. pseudoparkinsonism, acute • Monitor temperature
dystonic reactions, akathisia, and • Regular follow-up
tardive dyskinesia.
• Hepatic effects: hepatitis
• Hyperprolactinemia
• Hypotension
• Neuroleptic malignant syndrome
• Orthostatic hypotension
• Sedation
Cap. Fluoxetine 20 mg Selective serotonin reuptake Changes in sex drive or ability; coma • Restrict drug access for
0-0-2 inhibitors (SSRIs). Preventing (loss of consciousness for a period of depressed and potentially
the reuptake of one time); confusion; difficulty breathing suicidal patients
neurotransmitter, serotonin, or swallowing; dizziness; drowsiness; • Give intramuscular only
by nerve cells after it has been dry mouth; excessive sweating; when oral therapy is
released. fainting; fever; hives; joint pain; loss impossible
of appetite; nausea; nervousness; • Do not administer
rapid, irregular, or pounding intravenous injection
heartbeat; rash; seeing things or • Administer major portion
hearing voices that do not exist of dose at bedtime
(hallucinating); seizures; sore throat; if drowsiness, severe
weakness; weight loss. anticholinergic effects
occur.
• Reduce dosage if minor
side effects develop;
discontinue if serious side
effects occur.
• Arrange for complete
blood count (CBC) if
patient develops fever,
sore throat, or other sign
of infection.
608 Textbook of Psychiatric Nursing for BSc Nursing Students

Nursing Management Nursing Diagnosis

Client Assessment • Ineffective denial related to weak, underdeveloped ego

evidenced by “I don’t have a problem with (substance).
He is having pervasive sadness, lack of interest in all activities, I can quit any time I want to.”
lack of energy, hearing voices for 3 months, sleeplessness, • Ineffective coping related to inadequate coping skills
decreased appetite, history of suicidal attempt two days back. and weak ego evidenced by use of substances as a coping
He is separated from his wife. He has socio-occupational mechanism.
dysfunctioning and substance abuse disorders. He has legal • Altered thought process related to inability to think
issues for attempt theft. and process information and evaluate reality as
evidenced by delusion of grandiosity and exaggerated
Diagnostic Studies
responses.
Complete blood count and differential count are normal, renal • Deficient knowledge (effects of substance abuse on the
function test found to be normal and elevated liver enzymes body) related to denial of problems with substances
and decreased Sr. sodium are seen. evidenced by abuse of substances.
• Anxiety moderate related to unconscious conflict about
Nursing Priorities essential values/goals of life, unmet needs and threat to
• Provide support for decision to stop substance use/harm self-concept.
reduction. • Disturbed sensory perception—auditory related to
• Strengthen individual coping skills. change in the amount or patterning of incoming stimuli
• Facilitate learning of new ways to reduce anxiety. accompanied by an exaggerated, distorted, or impaired
• Promote family involvement in rehabilitation program. response to such stimuli.
• Facilitate family growth/development. • Risk for violence, self-directed related to lack of impulse
• Provide information about condition, prognosis, and control, self-destructive strategies as evidenced by severe
treatment needs. depression and loss of interest to live.

Nursing Care Plan

Assessment Nursing Nursing Nursing interventions Implementation Evaluation

diagnosis objectives
Subjective Ineffective denial The client will • Develop trust. • Developed trusting Client
data: related to weak, be able to • Convey an attitude of relationship with the demonstrated
Patient says, “Iunderdeveloped accept that acceptance. patient. acceptance of
can stop taking ego evidenced substance taking • Ensure that client • Accepted the patient as substance use
substance as by “I don’t have behavior is a understands it is not the he is. as maladaptive
my will, it is a problem with maladaptive and person but the behavior • Made him aware that behavior as
not a problem (substance). decided to quit. that is unacceptable. everyone like him but evidenced by
for me.” I can quit any • Correct any not his substance taking he voluntarily
Objective data: time I want to”. misconceptions, such as behavior. participates in
Dependence “I don’t have a drinking • Explained about facts activities to quit
to substance is problem. I can quit any about substance abuse. substance use.
clear time I want to”. • Given care in a
He is having • Be matter-of-fact, nonjudgmental manner.
physical nonjudgmental manner. • Discussed the laboratory
problems of • Identify recent maladaptive report with him
substance use behaviors or situations and related that the
Impaired that have occurred in the abnormal finding is due
judgment and client’s life, and discuss to substance use.
insight were how use of substances may • Discouraged rationalizing
absent. be a contributing factor. behavior such as
• Do not allow client to blaming others for his
rationalize or blame others maladaptive behaviors
for behaviors associated associated with
with substance use. substance use.
Contd…
Clinical Case Scenarios 609

Assessment Nursing Nursing Nursing interventions Implementation Evaluation

diagnosis objectives
Objective data: Knowledge The client will • Teach the client and family • Taught the client and Client gained
Believe that deficit related to be able to about substance use family about meaning, adequate
substance use the management understand disorder (SUD). causes, psychopathology knowledge
is a normal of the substance about the • Teach the client and family and clinical presentation about the
behavior use disorder illness, its about signs of relapse, of SUD. disease process,
Inadequate (SUD) and chronic nature, such as substance taking • Taught the client about medications
retention and impact of impact of behavior, insomnia, signs of relapse, such and impact of
understanding substance use. substance decreased nutrition, and as insomnia, decreased SUD.
of information uses on health poor personal hygiene. nutrition, and poor
presented. treatment, • Inform the client personal hygiene.
and safe use of and family about • Informed the client
medications. psychopharmacology. and family about
• Inform about the impact of psychopharmacology;
substance abuse on health. dosage, need to take
• Reinforce teaching with the medication only as
written material as prescribed, the toxic
indicated. symptoms, the need to
monitor blood levels, and
regular intake.
• Explanation given on
the impact of SUD
on physical health,
psychological health,
vocational and legal
issues.
Subjective Ineffective Client will be • Set limits on manipulative • Identified manipulative Client
data: coping related able to develop behavior. behavior and advised his developed
Patient says to inadequate effective coping • Administer consequences parent not to listen such effective coping
“I have lots coping skills skills an able to when limits are violated. behaviors. skills and kept
of family and weak ego use to solve the • Obtain routine drug • Outing and watching TV him away from
problems and evidenced daily stressors screening for identifying was restricted for not substance use.
not getting any by use of in life. substances. crossing the limits.
job”. substances • Explore options available • Explored options
Objective data: as a coping to assist with stress rather available to assist with
He quarrels mechanism. than resorting to substance stress.
with parents use. • Taught about the steps in
and abusive • Teach problem solving problem solving.
and assaultive. techniques. • Positive reinforcement
• Give positive schedule was followed.
reinforcement for ability • Involved him in Yoga,
to delay gratification and listening to music
respond to stress with and participated in
adaptive coping strategies. badminton.
• Teach about relaxation
techniques.

Psychoeducation

Name of the patient: Mr C Venue: Male psychiatric ward

Topic: Ill effects of Alcoholism Date: __________________
Name of student teachers: Time: __________________
Language: English
610 Textbook of Psychiatric Nursing for BSc Nursing Students

Objectives
• General objective: At the end of the health education, the participants will be able to understand the ill effects of alcoholism.
• Specific objectives: At the end of the health education, the participants will be able to:
„ Define alcoholism.
„ List the causes of alcoholism.
„ Describe the various effects of alcoholism.
„ Explain the treatment for alcoholism.
Specific objectives Time Contents Teaching and Audiovisual Evaluation
learning activities aids
At the end of the Introduction: Alcohol exerts a depressant Discussion Charts Can you give
health education, effect on the central nervous system, an outline
the participants will resulting in behavioral and mood changes. about
be able to: An individual is legally intoxicated with alcoholism?
a blood alcohol level of 0.08–0.10%.
Long-term and uncontrollable harmful
consumption can cause alcohol-related
disorders. It is estimated that about 62.5
million alcohol users.
Define alcoholism. 2 minutes Definition: Alcoholism is defined as alcohol Lecture Roller chart What is
seeking and consumption behavior that is alcoholism?
harmful.
List the causes of 10 minutes Causes: Behavioral related to the internal Lecture cum Handout Mention the
alcoholism. feedback: Shame or hangover; external discussion list of causes
feedback: Reprimands, criticism, or of alcoholism.
encouragement. Other external factors:
peer pressure, acceptance in a peer group.
Specific moods (easygoing, relaxed, calm,
sociable) that are related to the formation
of intimate relationships.
• Environmental factors: Severe childhood
trauma, lack of peer and family support.
• Biological factors: Repeated use of
alcohol can impair the brain levels
of a “pleasure” neurotransmitter
called dopamine. Norepinephrine
modulates reward dependence or the
resistance to extinction of previously
rewarded behavior. A high testosterone
concentration during pregnancy may be
a risk factor for the alcohol dependence
syndrome in future.
• Genetic factors: Alcoholism recognized
to be run in the family. Sevenfold risk
of alcoholism in first-degree relatives
of alcohol-dependent individuals
predominantly among males.
Contd…
Clinical Case Scenarios 611

Specific objectives Time Contents Teaching and Audiovisual Evaluation

learning activities aids
Describe the various 10 minutes Effects of Alcohol: Discussion cum Flannel board Describe the
effects of alcoholism. • Peripheral neuropathy brainstorming effects of
• Alcoholic myopathy sessions alcoholism.
• Wernicke’s encephalopathy
• Korsakoff’s psychosis
• Alcoholic cardiomyopathy
• Esophagitis
• Gastritis
• Pancreatitis
• Alcoholic hepatitis
• Cirrhosis of the liver
• Leukopenia
• Thrombocytopenia
• Sexual dysfunction
• Alcohol intoxication
• Socio-occupational dysfunction
• Legal issues
Explain the treatment 8 minutes Treatment of Alcoholism: Lecture PowerPoint What is the
for alcoholism. Medication: Alcohol-sensitizing drugs Presentation treatment for
(Disulfiram 125–500 mg) alcoholism?
Cognitive and behavior therapies:
• Relapse prevention
• Social skills and assertiveness training
• Contingency management
• Deep muscle relaxation
• Self-control training
• Cognitive restructuring
• Motivational Enhancement Therapy
(MET)
Teach more adaptive coping strategies
alter to the conditions that precipitate and
reinforce drinking
• Self-help groups
Conclusion
I hope that you all understood alcoholism
as a disorder, its causes and its effects, this
discussion helps you to quit alcohol.

Recording and Reporting

Date Time Nursing care/activities Name with

signature
8:00 am Assessment of the patient Mr X
8:50 am Patient has taken breakfast (2 pooris with sambar) and 1 cup tea Mr X
9:00 am Administration of oral medication, Tab. Trihexyphenidyl 2 mg BD, he has taken the Mr X
medications and tolerated well
9:15 am He involved in playing badminton Mr X
10:00 am He participated in group therapy, and actively participated Mr X
10:35 am Health education given to patient and family members on “Impact of Alcoholism” Mr X
612 Textbook of Psychiatric Nursing for BSc Nursing Students

CASE 5 PATIENT WITH UNDIFFERENTIATED SCHIZOPHRENIA

Ms K, 37-year-old female, unmarried, completed 9th standard, got admitted in female psychiatric ward with the complaints of muttering to
self, laughing to self, irritability, crying spells with fearfulness, abusive toward neighbors and family members and tear newspaper, throw
articles, says that bad smell from her body, complaints of obstruction in the throat, she is irritable at that time. She says that some people
are trying to harm her. She hears voices abusive and threatening discussing about her among them. Her illness was insidious in onset and
continuous course of illness. She was a known case of schizophrenia past 14 years. She is from low socioeconomic status and no significant
family history of mental illnesses, normal birth and early development; she possessed only a few friends in her childhood. She did not
involve in any play and group activities, not well in scholastic performances. Premorbid well adjusted. MSE reveals that she is irritable,
moderately kempt not groomed, she is having blunted affect; range restricted, decreased reactivity, inappropriate and noncongruent
mood, denies of any delusion, she has auditory and visual hallucination. Personal and social judgment was impaired and lacks insight.
On physical examination, it was found that she had severe pallor and no other significant findings. Investigations done are Hemoglobin
(8 g/dL), white blood cells (7,400 cells/mm3) and platelet (2.88 lakh cells/mm3). She is on medications such as Tab. Chlorpromazine 100 mg HS,
Tab. Clozapine 25 mg OD, Tab. Trihexyphenidyl 2 mg OD and Inj. Fluphenazine 25 mg IM fortnightly.

History Collection she occasionally expresses fearfulness without any cause, she
is withdrawn, sit alone not interacting to the people previously
Demographic profile: Ms K, 37-year-old female, unmarried, she was over talkative, not performing the household activities,
unemployed, completed 9th standard, diagnosed as 1 week before she went away from home but brought back.
undifferentiated schizophrenia. The information given by Not sleep at night, again she tried to escape from home
patient and mother, it was adequate, reliable and relevant. stopped food intake 3 days back, wake up at 2 am, puts all
lights and take bath in the night. Tear newspaper, throw
Chief Complaints for Seeking Admission articles, says that bad smell from her body, complaints of
• Muttering to self obstruction in the throat, she is irritable at that time. She says
• Laughing to self that some people are trying to harm her. Hears voices abusive
• Irritability and threatening discussing about her among them. Currently
she is having disorganized behavior. No history of physical
• Crying spells
For 2 months illnesses.
• Abusive
• Fearfulness Negative History
• Delusion of persecution
No history of grandiose ideas, over spending, elevated mood,
• Third person hallucination
increased activity, over religiosity, depression, repeated
• Visual hallucination
intrusive thoughts, images, impulses or acts, substance abuse,
organic causes like head injury, infections, convulsions.
History of Present Illness
Her illness is of insidious onset and continuous course of Current Treatment History
illness. She was apparently normal 14 years back, then she • Tab. Clozapine 125 mg 0-0-1
developed muttering to self and laughing to self, she was • Tab. Trihexyphenidyl 2 mg 1-0-0
irritable and abusive toward neighbors and family members, • Inj. Fluphenazine 25 mg IM fortnightly
Clinical Case Scenarios 613

Past History
Similar episodes in the past.
Year Signs and symptoms Diagnosis Treatment Side effects/compliance
2005 Muttering to self, laughing to Psychosis NOS T. CPZ (Chlorpromazine) 60% improvement
self, irritability, crying spells, ↓ 400 mg + Inj. FFZ Gastritis/poor. Developed
abusive, fearfulness, delusion Paranoid schizophrenia (Fluphenazine) 25 mg increased weight gain and
of persecution, third person ↓ increased appetite/poor
hallucination, visual hallucination. Tab. Risperidone 2 mg Similar complaints of
↓ symptoms masked face,
Tab. Olanzapine 10 mg constipation, tremor,
↓ slowness/poor.
Tab. Chlorpromazine 100 mg +
Inj. Fluphenazine 25 mg
↓
Inj. Fluphenazine increased to
50 mg + Tab. Chlorpromazine
300 mg for disorganized
behavior
Tab. Chlorpromazine 600 mg
2015 Similar complaints 6 months later Schizophrenia with Tab. Clozapine 200 mg + Hypersalivation, drowsiness
developed amotivation, apathy, negative symptoms Inj. FFZ 25 mg withdrawn/poor
anhedonia, affect flattening. ↓ Dysphagia.
Stopped T. Clozapine
T. Trihexyphenidyl 4 mg +
Inj. Fluphenazine
(Fluphenazine) 25 mg

Family History • Behavior during childhood: She was temperamentally

She is the second born child, nonconsanguineous marriage, an easy child; she possessed only a few friends in her
from low socioeconomic status. No family history of mental childhood. She was shy type and did not involve in any play
illnesses. activities. She was closely attached with family members.
She was emotionally controlled, calm and quiet.
Genogram • Physical illnesses: No physical illness during childhood
was reported.
• Schooling: She started schooling at the age of four,
concentrated on her studies, few friends. Not good in
scholastic performances. She studied up to 9th standard.
Occupation: No specific jobs held.
• Sexual and marital history: Age at menarche was 13 years,
regular and no reactions reported. She is unmarried.
• Substance use: No substance abuse.

Premorbid Personality—Well Adjusted

Personal History • Social relationships: She had fewer friends in college,
• Birth and early development: She was reported to closely with her mother.
be born full term normal vaginal delivery which was • Intellectual activities: She spent times in reading books.
conducted at hospital. No complications were reported Not good in academic activities.
during the periods of antenatal, intranatal and neonatal • Mood: She was bright, calm and relaxed.
periods. Birth weight was reported to be normal. Baby • Character: She is worried of responsibility, meticulous
cried soon after delivery and breastfeeding was initiated and methodical.
soon after delivery. Milestone development was reported • Interpersonal relationships: She is shy, has few friends,
to be normal. she is emotionally controlled and quiet.
614 Textbook of Psychiatric Nursing for BSc Nursing Students

• Energy and imitativeness: Sluggish in doing household • Interpersonal activities (social relationships): Include
activities. initiating and maintaining interactions with others in
• Fantasy life: Wants to become IAS officer. contextual and socially appropriate manner.
• Habits: She is having normal sleep and rest pattern. She is • Communication and understanding: Include commu-
having regular bowel and bladder habits. nication and conversation with others by producing and
comprehending spoken/written/nonverbal messages.
Mental Status Examination • Work: Three areas are Employment/Housework/
Education. Measures on any aspect.
• General appearance and behavior: She looks irritable, 1. Performing in work/job: Performing in work/
moderately kempt, not groomed. Not able to establish eye employment (paid) employment/self-employment/
to eye contact, she is cooperative, rapport established. family concern or otherwise. Measures ability
• Psychomotor activity: Psychomotor activities observed to perform tasks at employment completely and
as normal. efficiently and in proper time includes seeking
• Speech: She only responds to the questions. Reaction employment.
time is normal. Tone, tempo, and volume are normal. 2. Performing in housework: Maintaining household
Speech is relevant and coherent. Prosody was maintained including cooking, caring for other people at home,
throughout. taking care of belongings, etc. Measures ability to
• Thought: No formal thought disorders elicited. No take responsibility for and perform household tasks
flight of ideas, retardation in thinking, circumstantiality, completely and efficiently and in proper time.
or thought block. Possession normal; no repeated 3. Performing in school/college: Measures performance
thoughts reported. Denies delusion predominantly education-related tasks.
occupied by thoughts of obstruction in throat. No thought
interpolation and no obsession. Scores for Each Item
• Mood: Subjectively: “I am OK”. Objectively: Blunted
affect; range restricted, decreased reactivity, inappropriate Items 0 1 2 3 4
and congruent. No Mild Moderate Severe Profound
disability disability disability disability disability
• Perception: Patient denies hallucination? Olfactory
hallucination. Self-care √
• Cognitive functions: Inter- √
personal
„ Orientation: Grossly oriented to time, place and person. activities
„ Attention and concentration: Attention can be
Communi- √
aroused, but concentration is not sustained. cation and
„ Digit span test: under-
„ Digit forward test: 4 digits standing

„ Digit backward test: 4 digits Work √

„ Serial subtraction till 31.
„ Memory: Immediate, recent and remote intact. • 0: No disability (none, absent, negligible Scores for Each
„ Intelligence: General information, comprehension, Item
arithmetic ability, and abstraction were intact. • 1: Mild disability (slight, low)
„ Judgment: Personal, social and test judgment are • 2: Moderate disability (medium, fair)
normal. • 3: Severe disability (high, extreme)
„ Insight: Insight is absent. • 4: Profound disability (total, cannot do)
Total score: 12
Psychometric Assessment Add scores of the four items and obtain a total score.
Weightage for duration of illness (DOI): 15 years of illness
Indian Disability Evaluation and Assessment • <2 years : score to be added is 1
Scale (IDEAS) • 2–5 years : add 2
Items: • 6–10 years : add 3
• Self-care: Includes taking care of body hygiene, grooming, • >10 years : add 4
health including bathing, toileting, and dressing, eating, Global disability: Total disability score + Duration of illness
and taking care of one’s health. (DOI): score = Global disability score percentages: 12 + 4 = 16
Clinical Case Scenarios 615

• 0 : No disability = 0% • Mouth: Lips are dry and patchy. Buccal mucosa pink and
• 1–6 : Mild disability = <40% moist; teeth normally aligned; no missing teeth. Gum
• 7–13 : Moderate disability = 40–70% appears to be pink and moist; uvular elevation normal
• 14–19 : Severe disability = 71–99% and midline. Gag reflux is present. Tongue midline and
• 20 : Profound disability = 100% movements normal.
Inference: Ms K is having severe disability • Neck: Trachea is in midline, nontender. Range of motion
is in full range, no palpable tender lymph nodes or masses.
General Physical Examination Thyroid gland is not palpable, carotid pulse is felt.
• Thorax:
• General appearance: She is moderately built, conscious, „ Anterior thorax: Breathing movements bilaterally
poor hygiene. equal. No visible pulsations. Apical impulses are
„ Height : 146 cm palpable. No tender lymph nodes to palpate. Heart
„ Weight : 50 kg sounds S1 and S2 heard; rate 86 beats/min; regular rate
„ Body mass index (BMI): 23 and rhythm. No murmurs, rubs or clicks.
• Vital signs: It is stable „ Posterior thorax: Anteroposterior < transverse
„ Temperature : 99°F diameter; muscular development normal. No spinal
„ Pulse : 86 beats/min abnormalities noticed; no increase in tactile fremitus.
„ Respiration : 20 breaths/min Lungs are resonant and clear throughout.
„ Blood pressure : 120/80 mm Hg • Abdomen: No visible gastric pulsations, bowel sounds
• Head and scalp: Size and shape of the head is normal. heard, no tenderness or palpable mass, liver and spleen
Hair distribution is even, no palpable mass or tenderness, are not palpable and nontender.
no surgical scars or injuries noted. • Upper and lower extremities: Well, developed; no
• Eyes: Symmetrical in size and shape. Pupils equal in muscle wasting. Mild swelling was present over the right
round and reacting to light. No infections, no pallor, or wrist, Range of motion is on full strength and possible in
color changes observed. all directions. Pedal and radial pulses on both sides were
• Nose: Nostrils patent; though labored breathing persists. palpable.
Nasal flaring is present, frontal and maxillary sinuses— • Genitals and rectum: Normal as reported; no examination
nontender. done.
• Ears: Ears bilaterally equally placed. Pinna is soft and
flexible. Auditory canal patent, no discharges observed.

Investigation

Sl. no. Date Investigation Patient’s value Normal value Remarks

1. Hemoglobin 14% 12–16 g/dL Normal
Total count 7,400 cells/mm3 4–9,000 cells/mm3 Normal
Platelet 2.88 lakhs/mm3 2.5–4.5 lakhs/mm3 Normal

Medication

Name of the Dose Action Side effects Nurses’ responsibility

drug
Tab. 125 mg It blocks receptors in the brain Agranulocytosis, infections, seizures, • Assess for any allergy, CNS
clozapine 0-0-1 for several neurotransmitters, dizziness, orthostatic hypotension, depression and CV disease
including dopamine type drowsiness. Increased heart rate, • Monitor
4 receptors, serotonin type increased salivation, headache, Electrocardiogram, Blood
2 receptors, norepinephrine tremor, low blood pressure, and fever. pressure, renal function
receptors, acetylcholine Blurred vision and difficulty urinating, and liver function.
receptors, and histamine constipation, paralytic ileus • Regularly check WBCs
receptors. count and temperature
• Report lethargy, fever,
sore throat, oral ulcer, etc.
Contd…
616 Textbook of Psychiatric Nursing for BSc Nursing Students

Name of the Dose Action Side effects Nurses’ responsibility

drug
Inj. 50 mg It blocks postsynaptic • Altered cardiac conduction, • Monitor and report
fluphenazine 1-0-0 mesolimbic dopaminergic D1 arrhythmias; neuroleptic malignant
and D2 receptors in the brain; • Anticholinergic effects: (constipation, syndrome
depresses the release of xerostomia, blurred vision, urinary • Monitor signs of
hypothalamic and hypophyseal retention); use with caution agranulocytosis
hormones; believed to in patients with decreased • Assess motor function and
depress the reticular activating gastrointestinal motility, paralytic check for extra-pyramidal
system, thus affecting basal ileus, urinary retention, BPH, symptoms
metabolism, body temperature, xerostomia, or visual problems. • Monitor allergic reactions
wakefulness, vasomotor tone, • Blood dyscrasias • Check blood pressure for
and emesis. • Esophageal dysmotility/aspiration hypotension
use with caution in patients at risk of • Assess heart rate and
pneumonia (i.e., Alzheimer’s disease). electrocardiogram
• Frequently check for
weight gain
• Protect against fall and
trauma.
• Extrapyramidal symptoms: Including
pseudoparkinsonism, acute dystonic
reactions, akathisia, and tardive
dyskinesia.
• Hepatic effects: Hepatitis
• Hyperprolactinemia
• Neuroleptic malignant syndrome
(NMS): Mental status changes, fever,
muscle rigidity, and/or autonomic
instability.
• Ocular effects: May cause pigmentary
retinopathy, and lenticular and
corneal deposits.
• Orthostatic hypotension
• Sedation: Impaired core body
temperature regulation.
Tab. 2 mg The exact mechanism of action • Frequency not defined. • Assess for contraindication
trihexyphenidyl 1-0-0 in parkinsonian syndromes is • Cardiovascular: Tachycardia; central • Perform thorough physical
not precisely understood, but it nervous system: confusion, agitation, examination.
is known that trihexyphenidyl euphoria, drowsiness, headache, • Monitor
blocks efferent impulses in dizziness, nervousness, delusions, Electrocardiogram and
parasympathetically innervated hallucinations, paranoia. renal functions
structures like smooth muscles • Dermatologic: Dry skin, increased • Administer drug along
(spasmolytic activity), salivary sensitivity to light, rash. with meals.
glands and eyes (mydriasis). • Gastrointestinal: Constipation, • Provide safety measures
xerostomia, dry throat, ileus, nausea, to prevent injuries.
vomiting, parotitis.
• Genitourinary: Urinary retention
• Neuromuscular and skeletal:
Weakness
• Ocular: Blurred vision, mydriasis,
increase in intraocular pressure,
glaucoma, blindness (long-term use in
narrow-angle glaucoma).
• Respiratory: Dry nose
• Miscellaneous: Diaphoresis
(decreased).
Clinical Case Scenarios 617

Nursing Management • Support client/family participation in follow-up care/

community treatment.
Client Assessment • Provide information about condition, prognosis, and
She is having muttering to self and laughing to self, she treatment needs.
was irritable and abusive toward neighbors and family
Nursing Diagnosis
members; she is withdrawn, and having wandering behavior.
Lack of sleep at night, hears voices abusive and threatening • Disturbed thought processes related to disruption in
discussing about her among them. She is having disorganized cognitive operations and activities.
behavior. • Disturbed sensory perception—auditory related to
change in the amount or patterning of incoming stimuli
Diagnostic Studies accompanied by an exaggerated, distorted, or impaired
response to such stimuli.
Blood test values are within normal range.
• Impaired social interaction related to aloneness
experienced by the individual and perceived as imposed
Nursing Priorities
by others and as a negative or threatening state.
• Provide for client’s basic needs, promoting highest • Deficient knowledge related to deficiency of cognitive
possible level of independent functioning. information related to a specific topic.

Nursing Care Plan

Assessment Nursing Nursing Nursing interventions Implementation Evaluation

diagnosis objectives
Subjective data: Disturbed Client will • Be sincere and honest • Maintained honest She maintained
Client says thought be able to when communicating communication with normal thought
“Some people process related maintain with the client. Avoid her and talked with process as
near to her tries to disruption normal thought vague or evasive remarks. purpose. evidenced by
to kill her”. in cognitive process. • Be consistent in setting • Consistency was reduction in fear
Objective data: operations and expectations, enforcing maintained in ward and crying spells.
She is abusive activities. rules, and so forth. routine, rules and
toward her • Do not make promises regulation.
neighbors, looks that you cannot keep. • Not given false
fearful and • Encourage the client to assurance.
having crying talk with you, but do not • Collection information
spells. pry for information. about her abnormal
• Explain procedures, thoughts only once and
and try to be sure the never discussed about
client understands it later.
the procedures before • Explanation was given
carrying them out. during medication
• Give positive feedback administration.
for the client’s successes. • Positive reinforcement
• Recognize the client’s given as she was
delusions as the client’s involved in self-care.
perception of the • Informed that delusions
environment. were her own, not
• Initially, do not argue really it exists.
with the client or try to • Not involved in
convince the client that arguments regarding
the delusions are false or her delusional thinking.
unreal. • Involved in interactions
• Interact with the client with her other that
on the basis of real about her delusions.
things; do not dwell on
the delusional material.
Contd…
618 Textbook of Psychiatric Nursing for BSc Nursing Students

Assessment Nursing Nursing Nursing interventions Implementation Evaluation

diagnosis objectives
• Engage the client in one- • She was involved in
to-one activities at first, indoor games and group
then activities in small therapy.
groups, and gradually • Conveyed acceptance of
activities in larger groups. the clients.
• Show empathy regarding • She is on Tab. clozapine
the client’s feelings; 125 mg HS and Inj.
reassure the client of fluphenazine 25 mg IM
your presence and fortnightly.
acceptance.
• Never convey to the
client that you accept the
delusions as reality
• Administer antipsychotics
as prescribed.
Subjective data: Disturbed Client will • Be aware of all • Made her aware about She demonstrated
Client says “She sensory be able to surrounding stimuli, her environment. normal perceptual
hears voices perception— demonstrate including sounds from • She is placed in functioning and she
that are abusive auditory decreased other rooms (such as separate room and interact well with
and threatening related to hallucinations television or stereo in visitors are limited. others.
her”. neurochemical Interact with adjacent areas). • Client was informed
Objective data: imbalances others in • Try to decrease stimuli that only she hears the
Hallucinatory in brain the external or move the client to voices and others were
behavior like accompanied environment. another area. not hearing such voices.
talking to self by an • Avoid conveying to • Details about the
and gesturing exaggerated, the client the belief hallucination were
Listening distorted, that hallucinations are collected only during
intently to no or impaired real. Do not converse the initial assessment.
apparent stimuli response to with the “voices” or • Interacted with the
Feelings of such stimuli. otherwise reinforce client on purpose.
insecurity and the client’s belief in the • Spoken to her in simple
confusion. hallucinations as reality. and in local language.
• Explore the content of • Positive reinforcement
the client’s hallucinations given when she speaks
during the initial about herself and
assessment to determine family.
what kind of stimuli the • Involved her in watching
client is receiving, but TV.
do not reinforce the • She was involved in
hallucinations as real. You painting.
might say, “I don’t hear
any voices-what are you
hearing?”
• Use concrete, specific
verbal communication
with the client.
• Avoid gestures, abstract
ideas, avoid asking the
client to make choices.
Don’t ask “Would you
like to talk or be alone?”
Rather, suggest that the
client talk with you.
• Respond verbally and
reinforce the client’s
conversation when he or
she refers to reality.
Contd…
Clinical Case Scenarios 619

Assessment Nursing Nursing Nursing interventions Implementation Evaluation

diagnosis objectives
• If the client appears to
be hallucinating, attempt
to engage the client’s
in conversation or a
concrete activity.
• Provide simple activities
that the client can
realistically accomplish
(such as uncomplicated
craft projects).
Objective data: Impaired social Client will be • Provide attention in • Actively listen to her She developed
Poor interaction able to report a sincere, interested problems and helped sense of self-
interpersonal related to increased manner. her in fulfilling her daily concept and
relationships, aloneness feelings of self- • Support any successes or needs. interacts with
sits alone, and experienced by worth, identify responsibilities fulfilled, • Appreciated her for a others.
has difficulty the individual strengths and projects, interactions small conversation with
with verbal and perceived assets with staff members and family member, staffs
communication. as imposed by Engage in social other clients, and so and other patients.
others and as interaction. forth. • Demonstrated
a negative or • Avoid trying to convince her about the
threatening the client verbally of her communication skills.
state. own worth. • Client was actively
• Teach the client about participating in social
communication skills. skills training program.
• Teach the client social • Client was encouraged
skills. Describe and to have a one to
demonstrate specific interaction.
skills, such as eye • Client was instructed
contact, attentive to do daily bathing,
listening, and so forth. grooming and wear
Discuss the types clean clothes.
of topics that are
appropriate for casual
social conversation, such
as the weather, local
events, and so forth.
• Help the client improve
his or her grooming;
assist when necessary, in
bathing, doing laundry,
and so forth.

Psychoeducation

Name of the patient: Ms K Venue: Female psychiatric ward

Topic: Prevention of side effects of antipsychotics Date: ____________________
Name of student teachers: Time: ____________________
Language: English

Objectives
• General objective: At the end of the health education, the participants will be able to understand the prevention of side
effects of antipsychotics.
• Specific objectives: At the end of the health education, the participants will be able to:
„ Define antipsychotics.
620 Textbook of Psychiatric Nursing for BSc Nursing Students

„ List the common antipsychotics.

„ Describe the side effects and its prevention.

Specific Time Contents Teaching Audiovisual Evaluation

objectives and learning aids
activities
At the end of the 2 minutes Introduction: An antipsychotic (or neuroleptic) Discussion Charts Can you outline
health education, is a psychiatric medication primarily used the basics of
the participants to manage psychosis (e.g., delusions or anti-psychotics?
will be able to: hallucinations), particularly in schizophrenia and
bipolar disorder.
Define 2 minutes Definition: All antipsychotic drugs tend to block Lecture Roller board What is
antipsychotics. D2 receptors in the dopamine pathways of the antipsychotics?
brain. It is the blockade of dopamine receptors in
this pathway that is thought to control psychotic
experiences.
List the common 6 minutes List of common antipsychotics: Discussion Handout List two
antipsychotics. • Chlorpromazine (Largactil, Thorazine) antipsychotics.
• Trifluoperazine (Stelazine)
• Haloperidol (Haldol, Serenace)
• Fluphenazine (Prolixin)
• Clozapine (Clozaril)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
Describe the side 20 minutes Prevention of side effects: Lecture Flannel How to prevent
effects and its Side effects Preventive measures board dystonic
prevention. reactions?
Dystonic reac- Administer medications as
tions ordered for effectiveness,
reassure client if frightened.
Tardive dyski- Notify physician
nesia
Neuroleptic Stop medication and notify
malignant physician.
syndrome
(NMS)
Akathisia Administer medication
as ordered, assess for
effectiveness.
Extrapyrami- Administer medication
dal syndrome as ordered, assess for
effectiveness.
Seizures Stop medication, notify
physician, protect client form
injury during seizure, provide
reassurance and privacy.
Sedation Caution about activities
requiring client to be fully
alert such as driving a car.
Photosensi- Caution client to avoid sun
tivity exposure, advise client when
in the sun, to wear protective
clothing and sun-blocking
lotion.
Weight gain Encourage balanced diet,
regular exercise.

Contd…
Clinical Case Scenarios 621

Specific Time Contents Teaching Audiovisual Evaluation

objectives and learning aids
activities

Side effects Preventive measures Brainstorming Charts What immediate

session measures to be
Dry mouth Use ice chips or hard candy taken if patient
for relief. develop NMS?
Blurred vision Assess side effect, which
should improve with time,
report to physician if no
improvement.
Constipation Increase fluid and dietary
fiber intake, client may need
a stool softener if unrelieved.
Urinary reten- Report any frequency or
tion burning with urination,
report to physician.
Orthostatic Instruct client to rise slowly
hypotension from sitting or lying position,
wait to ambulate until no
longer dizzy or lightheaded.

Conclusion: I hope that all of you have Lecture PowerPoint How to prevent
understood the prevention of side effects of Presentation weight gain?
antipsychotics; it will help you to identify at
the earliest and prevent it. This will help for
mediation compliance and thereby prevent the
relapse of the illness.

Recording and Reporting

Date Time Nursing care/activities Name with

signature
8:00 am Assessment of the patient Ms X
8:50 am Patient has taken breakfast (2 rotis with vegetable curry) and 1 cup tea Ms X
9:00 am Oral medication given, Tab. THP 2 mg, she has taken the medications and tolerated well Ms X
9:15 am She participated in vocational training activities Ms X
10:00 am She participated in painting activities, and interacted well during the session Ms X
10:35 am Health education given to patient and family members on “Prevention of Side Effects of Ms X
Antipsychotics”.
622 Textbook of Psychiatric Nursing for BSc Nursing Students

CASE 6 BIPOLAR AFFECTIVE DISORDER—MANIA WITH PSYCHOTIC SYMPTOMS

Mr X, a 19-year-old single male, admitted in male psychiatric ward. He is undergoing his graduation and domiciled in Chennai from
middle socioeconomic status. His mother complains that he was normal 1 month before then he developed wandering out behavior,
suspiciousness toward his mother that he has immoral affair with the neighbor, over talkative and over familiarity and decreased interest to
sleep and personal care neglect. Past history of bipolar affective disorder for about 3 years with three previous episodes of manic features;
3 years ago, met with a road traffic accident. Maternal uncle committed suicide at the age of 25. No significant personal history.
Mental Status Examination finding reveals that he is well hygienic and wears colorful dresses. Not able to establish eye contact,
increased psychomotor activities, pressured speech, patient says “I love staying here rather going home that I hate my mother who is not
good,” paranoid delusion present. He says, “I am very happy and feel great energy today,” appears to be euphoric. Poor attention and
concentration, he says that he is admitted to treat his eye problem. Laboratory investigation shows Hb—11.8 g/dL, WBCs—7,000 cells/mm3,
Sr. lithium is 1.2 mEq/L, and he is on Tab. Lithium 1050 mg TDS and Tab. chlorpromazine 200 mg BD.

CASE 7 MULTIPLE SUBSTANCE ABUSE DISORDER—ADS, CDS, NDS

Mr C, 28-year-old male, married, and from low socioeconomic background got admitted in psychiatric emergency ward with the complaints
of attempt suicide, pervasive sadness and fearfulness, suspiciousness, hearing voices, decreased socialization, lack of interest in all
activities, lack of energy and decreased sleep and appetite for 3.5 months. His illness is of insidious onset and episodic course of illness.
On MSE, he looks sad, irritable and poorly kempt not involving in any activities, psychomotor activities observed as retarded, Speech is
not spontaneous, reaction time is increased. Tone, tempo, and volume are decreased. He had delusion of persecution nonelaborative,
nonsystematized—“people are planning to kill me once I am released from jail”, delusion of references— “people are talking about me”.
He had depressive ideation such as feeling of worthlessness, hopelessness and suicidal ideation present, personal, social and test judgment
are impaired. Insight is absent. He had two episodes of mood disorders in the past. He had a history of multiple substance abuse such as
alcohol, cannabis and tobacco. He was imprisoned for attempted theft. His father is a chronic alcoholic. Normal birth and development,
he was temperamentally easy child; he possessed only a few friends in his childhood. He was shy type and did not involve in any play
activities. He was closely attached with family members. Not good in scholastic performances. No specific jobs held. His wife was
separated; the reason is not known. Physical examination revealed that he is thin body built, and malnourished (BMI–17). He underwent
investigations Hb (15.4%), blood urea (52 mg/dL), SGOT (231 IU/mL), Sr. sodium (137 mEq/L). He is on Tab. risperidone 4 mg HS,
Tab. trihexyphenidyl, 2 mg BD, and Cap. fluoxetine 20 mg HS.

CASE 8 MAJOR DEPRESSIVE DISORDER

Mr K, 53-year-old male, unmarried, completed SSLC, got admitted in male psychiatric ward with the complaints of pervasive low mood,
fearfulness, socially withdrawn, lack of interest in any activities, poor self-care associated with poor appetite, and decreased sleep for
2 months. His illness is of insidious onset and episodic course of illness. He is known case of depressive disorder past 4 years with past
history of suicidal attempt with high intentionality and severely lethal. He is from low socioeconomic status. His elder sister died by
committing suicide, father died at early age, mother got second marriage, step father is cruel to him, bitter early childhood experiences,
ADS among 1st- and 2nd-degree relatives. Normal birth and early development, he was temperamentally an easy child; he possessed only
few friends, he was introvert and did not involve in any play activities. He was closely attached with family members; he had emotional
intolerance and fearful. He had significant stressors during his childhood. He is a chronic smoker and chronic alcoholic. He has anxious
avoidant personality traits and dependent person. MSE revealed that he was ill kempt, fearful, restless, psychomotor activities were
observed as retarded. He speaks on prompting. Reaction time is increased. Tone, tempo, and volume are decreased. He has depressed
mood, range and reactivity decreased. He is grossly oriented to time, place and person. He has good insight about his illness. On physical
examination, he has clubbing. He underwent following investigation: Hb (13%), WBCs (8,900 cells/mm3), platelet (2.16 lakh cells/mm3),
SGOT (52 IU/L), Sr. sodium (130 mEq/L) and blood urea and creatinine are normal. He was on Tab. Chlorpromazine 100 mg and
Tab. Amitriptyline 75 mg OD and underwent six episodes of ECT and psychotherapy.
Clinical Case Scenarios 623

CASE 9 MENTAL RETARDATION

Mr J, 21-year-old male, educated up to 6th standard, belongs to joint family. He got admitted in male psychiatric ward with the complaints
of wandering behavior, self-injury, he cuts his upper limb with no intention to die, he tried to burn himself and he harms people around
him, associated with lack of sleep. History of delayed milestones, not cried soon after his birth, he started sitting and walked with support
at the age of 1.5-year-old. At the age of 4 years, he played with toys but could not play with children around him. He started his schooling
at the age of 7-year-old in Government school and continued till Class 5th. In primary school, he did not find interest in studies and left
school after 6th standard, had low grades in subjects. He left school and worked in a shop; he left the job after some time. Then he got
unemployed and used to stay at home. He is a chronic smoker. No significant family history. On physical examination, he was found
malnourished (BMI–17), burn scars present over his both arms and cut injury present inner aspect of left inner arm. MSE reveals that he
is ill kempt, irritable, not interested and responsive and highly distractive in nature. The eye contact was not maintained and sustained.
His emotional expression is labile. He responds to questions, speech is loud, tempo is decreased, and flow of speech is decreased and not
clear. Patient is not fully oriented to time, place and person. Attention was not sustained. Immediate memory is impaired, intelligence
is below average, abstraction is poor, personal, social and test judgment are poor. Insight is partially absent. Investigation reported are
WBCs (7,000 cells/mm3), neutrophils (32%), eosinophils (15%), monocytes (1%), normal blood sugar, blood urea (22 mg/dL) and creatinine
(1 mg/dL), and urinalysis reported normal findings.
He is taking medications such as Tab. Risperidone 2 mg HS, Tab Amisulpride 100 mg OD, Tab. Trihexyphenidyl 2 mg OD, Tab. Quetiapine
40 mg BD and Tab. Haldol 15 mg OD.

CASE 10 OBSESSIVE-COMPULSIVE DISORDER

Mrs K, 47-year-old female, married, belongs to a middle-class family. The patient got admitted to the female psychiatry ward with the
complaints of repetitive thoughts of temple-related objects such as murti, bell entering through her urinary tract which were repeated,
intrusive and distressing causing anxiety and restlessness, her symptoms worsened and started affecting her activities of daily living,
decreased appetite and sleep in the past 2 months. The onset is insidious and progressive. No significant family history of mental illnesses,
she is well adjustable, actively involved in household activities, maintains good relationship with family members, her mood is cheerful
and optimistic. MSE reveals that she is well kempt, dresses properly, but she looks restless and worried, depressed mood, anxious and is
congruent. She responds to the questions, volume is normal, rhythm and expressive intonation are clear and flow of speech is normal.
Speech is understandable and clear. There is no evidence though disturbances such as of flight of ideas, word salad, clang association,
neologism and circumstantiality. No suicidal thoughts, intent, or plan. No evidence of auditory and visual hallucination, and also there
is no illusion, depersonalization and derealization present in the patient. She is conscious, alert and responsive, she is oriented to time,
place and person. The attention can be aroused but sometimes cannot be sustained. Concentration was good. The immediate, recent
memory is intact and remote partially intact. Intelligence is good and average, abstraction is intact, personal, social and test judgment
are intact, fully aware about her illness, and participates in her treatment. No significant finding on physical examination. She underwent
following investigations such as Hb (10 g/dL), WBCs (4,000 cells/mm3), RBCs (3.38 lakh cells/mm3), normal differential count and platelet
(1.3 lakh cells/mm3). She is on Tab. Sertraline 50 mg BD, Tab. Lorazepam 2 mg HS and Tab. B-complex OD; she is participating in cognitive
behavioral therapy.
Notes
Glossary

A Acute and transient psychotic disorders (or) brief

psychotic disorder: Short-lasting psychotic symptoms
Abasia: It is inability to walk due to lack of motor coordination.
which are abrupt and acute with positive symptoms such as
Abdominal reflex: In this reflex, abdominal muscle contracts
delusion, hallucination, disorganized thoughts and abnormal
and umbilicus move toward the stimulated side while stroking
psychomotor movements. It may or may not be due to acute
of the skin in the abdominal quadrant
stressors.
Abnormal Behavior: It’s a kind of behavior which is not
Acute depression: It’s a sudden abrupt onset of depression.
socially acceptable.
Acute Mania: It’s an intensified manic symptom which
Abreaction: It is the release and expression of emotional
requires hospitalization. It is characterized by euphoria (or)
tension associated with the repressed ideas by bringing those
elation, frequent mood variation, thinking may have psychotic
ideas into conscious mind.
features, raised sexual interest with poor control of impulse,
Abstract thinking: It is the ability to think about things which high energy level and may deny grooming.
are not actually present. Individuals who think in an abstract
Acute Stress Reaction: It’s an immediate and clear relation
way look at the broader significance of ideas and information
exists between the stressor (e.g., Accident, sudden job loss,
rather than the concrete details.
disaster) and the onset of symptoms such as anger, depression,
Abulia (or) aboulia (or) blocq’s disease: It’s an absence of
etc.
initiative or act to take decisions independently which is
Adjustment disorder: Presence of significant behavioral or
seen in Disorder of Diminished Motivation (DDM). Abulia
emotional symptoms in response to the psychosocial stressors
might be seen in Depression, Progressive supranuclear palsy,
is called adjustment disorder.
Parkinson’s disease, Huntington’s disease, Normal pressure
hydrocephalus, Schizophrenia, Frontotemporal dementia, Affect: It’s an outward expression of emotions in a given time.
Pick’s disease, Traumatic brain injury and Stroke. Affect illusion: A type of illusion in which the misperception
Acetylcholine: It is biological amine (cholinergics) category remains present with heighten emotions or with the changes
of neurotransmitter which mediates cognitive functioning of mood, e.g., in night time, the shadow has been perceived as
directly or by modulating another neurotransmitter indirectly; ghost.
contributes to sleep-wake cycles. It is increased in depression Aggression: It is an expression of anger by physical or
and decreased in Alzheimer’s disease. psychological or verbal means, in a socially inappropriate
Achilles Tendon Reflex: It’s plantar flexion of foot while manner which may or may not cause significant harm to self
tapping of Achilles tendon. or others.
Acupuncture: It is an ancient traditional Chinese medicine Agitated depression: It’s a kind of depression with
that works on the principle of stimulating the points in body Psychomotor agitation.
in order to correct the imbalances in energy flow (Qi) through Agitation: Presence of severe motor restlessness arises out of
the channels known as meridians. individual’s anxiety or frustration is called agitation.
626 Textbook of Psychiatric Nursing for BSc Nursing Students

Agnosia: It’s the inability to recognize the sounds or objects or Ambivalence: It’s a coexistence of two opposing impulses to a
shapes or persons or smells where there is no defect in specific single person at the same time put the person inability to take
sense or no memory loss. It is associated with the neurological decision.
problems or brain injury. American Law Institute (ALI) Test: Person is not responsible
AIDS Dementia Complex: HIV stands for Human for criminal activity if he/she has done it as the result of
Immunodeficiency Virus. It is a retrovirus which crosses ‘mental disease/defect’. The term ‘mental disease/defect’ does
Blood Brain Barrier (BBB) as HIV infected macrophages not include the criminal activity or antisocial conduct.
and lymphocytes will lead to decreased cognition, motor, Amnesia: Loss of memory.
behavioral and neurological functions.
Amphetamine: It is a stimulant of central nervous system.
Al-anon: It’s a mutual support group for families and friends Its primary action is to release Norepinephrine along with
who has been affected by someone else drinking dopamine and serotonin.
Alateen: It’s a subgroup of Al-anon. It’s a mutual support group Anergia: It’s a complete lack of energy seen in depression.
for individuals, especially teenagers who have been affected by
Anger: It is a normal human emotion which is mishandled
someone else drinking.
and expressed assertively may solve the problem and show a
Alcohol: Natural substance formed with the reaction of productive change.
fermented sugar and yeast spores. It’s classified as food because
Anhedonia: It’s a kind of depression in which the patient
it gives calories but no nutritive value in it.
becomes unable to enjoy the pleasurable things which seem to
Alcoholic hallucinosis: Hallucinations present even in be enjoyed before the onset of depression.
abstinence after the regular alcohol intake. It commonly occurs
Anorexia nervosa: It is an eating disorder with the symptoms
with clear consciousness.
of having less than 85% of expected weight, fear of increase in
Alcoholic Pellagra: The main cause is Niacin deficiency due
body weight, complete denial about the morphology of body
to alcoholism.
when said by others and amenorrhea (3 cycles of menses after
Alcoholics anonymous: Recovered alcoholics help the new menarche). It has 2 types: Restricted and Binge eating/purging.
alcoholics to join the group in order to achieve sobriety.
Anterograde amnesia: It’s an inability to create new memories
Alcohol withdrawal seizures (or) rum fits: It occurs within due to brain damage.
6-48 hours of last intake of alcohol. It is usually Grand mal
Antianxiety agents: These are drugs to treat anxiety disorders.
seizures type. Around 3-15% of untreated alcohol withdrawal
Antidepressants: These are drugs to treat depression.
clients might develop seizure. Less than 3% of patients will get
status epilepticus. Antimanic drugs: These are drugs to treat mania.
Alexithymia: It’s an inability to describe the one’s feelings Antipsychotics: These are drugs to treat psychosis
verbally. (Schizophrenia). Antipsychotics are also called Major
Alice in Wonderland syndrome (or) Todd’s Syndrome (or) tranquilizers.
Lilliputian hallucination (or) Dysmetropsia: Disorienting Antisocial personality disorder: It’s a type of personality
neurological dysfunction which affects the perception disorder with the diagnostic criteria. The patient violates
(Subcategories are Micropsia (or) Lilliputian, Macropsia, rules/regulations/social norms, fails to maintain relationship,
Pelopsia and Teleopsia). impulsive action, low frustration tolerance, absence of guilt,
Alogia: It is an inability to speak or reduction in the amount manipulation in activities to get self-gratification, unconcerned
of speech due to mental defect, mental confusion or aphasia. with safety of others, not able to learn from punishment, blame
It is seen in patients with dementia and negative symptoms of others for one’s own antisocial activities and deceitfulness
schizophrenia. This is also called Poverty of Speech. (Frequent lying or cheating others to gain profit as well as
Alternative medicine: It is a non-main stream practices used pleasure).
instead of conventional medicine. Anxiety: It is defined as ‘feelings of uncertainty, apprehension,
Alzheimer’s dementia: Neuropathological changes was uneasiness or tensed that individual’s response to any situation.’
explained by Alois Alzheimer. Deposits of β amyloid will lead to Apathy: Absence of emotional expression. It exhibits the lack
Plaque formation outside the neuron. Hyperphosphorylation of interest or concern or enthusiasm. This is a sign of seen in
of tau protein will cause Neurofibrillary Tangles (NFT) inside depression.
the neuron. Aphasia: Absence in the production of speech.
Glossary 627

Aphonia: Absence of sound that produces speech due to intellectual impairment is not prominent). ICD-10 denotes
laryngeal nerve damage or secondary to thyroidectomy and this disorder as pervasive developmental disorder.
also due to underlying psychological problems. Autistic thinking: Thinking which is preoccupied with the
Apraxia: Inability to perform learned motor activities. inner experience. It differs from dereistic thinking by having
Aromatherapy: It is the use of plant oil for the therapeutic disconnection with the reality.
purposes such as antimicrobial, analgesics and psychological Automatic obedience: Exaggerated co-operation of the
effects. examiner’s request in obeying the commands which is seen in
Art therapy: It is defined as ‘a form of psychotherapy which patients with Schizophrenia.
uses the art media as a primary mode of expression and Autoscopy (or) phantom mirror image: Misperception as
communication’. seeing oneself.
Asociality: Social withdrawal seen in negative symptoms of Aversion therapy (or) antabuse: Treatment to arouse the
Schizophrenia unlikeness or feel likely to be hated of substance usage or any
Asperger’s syndrome: It is also called ‘High functioning behavior.
Autism’ (i.e., capable to perform functioning in daily life). It Avoidant personality disorder: Type of personality disorder
is usually diagnosed from 3–9 years of age. Children who are with the diagnostic criteria such as avoidance of activities
diagnosed might have normal to advanced intelligence, normal which needs to be done with interpersonal relationship,
to advanced verbalization skills or language development but continuous tension and apprehension, fear of criticism/
severely impaired social skills. rejection, feel inferior than others, not willing to involve with
Assertiveness training: It is provided to stand up for one’s others and preoccupied with criticism/rejection by others.
own rights by expressing the one’s feelings, thoughts, ideas in Avolition: Inability to take initiative in performing the
an honest and direct manner. goal directed activity which is seen in negative symptoms of
Associative loosening: Rapid shift of ideas without having any Schizophrenia.
central theme or concept is termed associative loosening. Ayurveda: The word, ‘Ayurveda’ is a Sanskrit word which
Astasia-Abasia: The term ‘Astasia’ refers to inability to stand means, ‘science of life and longevity’. Ayurvedic medicine has a
normally and ‘Abasia’ refers to inability to walk due to lack of belief that life force called ‘prana’ moves through chakras. Chakras
motor coordination. are considered a center of energy in the body.
Ataxic gait: Unsteady, uncoordinated staggering gait
happened due to damage of cerebellum (part of brain controls B
the muscle coordination) Baragnosis: It denotes the loss of ability to estimate the
Attention Deficit Hyperactivity Disorder (ADHD): It is differences in weight or pressure.
child psychiatric disorder with three main features such as Behavior therapy: It is defined as ‘form of psychotherapy in
inattention, hyperactivity and impulsivity. which the maladaptive behavior is aimed to change as adaptive
Atypical depression: A subtype of major depression or behavior’.
dysthymia characterized by increased appetite, excessive Biceps reflex: Flexion of forearm occurs when arm is gently
sleepiness, feeling that arms are heavy and interpersonal flexed at elbow, tap the biceps brachii tendon.
rejection, sensitiveness.
Binge eating: It is an eating disorder with the symptoms of
Auditory hallucination: Commonest type of hallucination increased food intake within short period with increased
in psychiatric disorders, in which the voice or sounds are rate, feel of guilt within short duration, unable to control the
heard by the patient without any external stimuli. Sounds behavior, food intake still the feel of discomfort increases, feel
heard are termed simple or elementary auditory hallucination. disgust or guilt and doesn’t use any compensatory behavior
Voice heard is termed complex auditory hallucination. Voice (purging/non-purging)
speaking to him/her addressing ‘you’ is termed second person
Binswanger’s disease (or) Subcortical leukoencephalopathy:
hallucination. Voice speaking to him/her addressing ‘he’ or
Small vessel vascular dementia occurs due to damage of white
‘she’ is termed third person hallucination. Individual hearing
matter.
one’s own thoughts speaking aloud is termed thought echo.
Bioelectromagnetic therapy: It is the usage of electromagnetic
Autism spectrum disorder: It consists of Autism and
fields (usage of magnets and electric currents) in the body for
Asperger’s syndrome or Asperger’s disorder (Language or
a therapeutic purpose.
628 Textbook of Psychiatric Nursing for BSc Nursing Students

Biofeedback: It is defined as, ‘psychophysiological therapy Cannabis: It is derived from ‘hemp plant’, Cannabis Sativa. It
in which the individual is able to monitor the physiological produces more than 400 chemicals in which 50 are cannabinoids
changes in the body due to the psychological stressors’. (active ingredient of 9-tetrahydrocannabinol).
Bipolar disorder: Either of two poles consists of mania or Capgra syndrome: It is defined as delusion of doubles or
hypomania in one pole and depression in opposite pole. delusional misidentification syndrome in which patient
Black out (or) alcohol-induced amnesia: Transient short- strongly believes that the other person is not real and he/she
term memory loss may be complete or partial in relation with is doubles of self.
intoxication state and does not indicate dementia. Catalepsy: Individual maintains the body posture in the
Blunt/shallow affect: Lack of affect is more severe than position which has been placed. The end result of waxy
constricted or restricted affect and less severe than flat affect. flexibility leads to catalepsy.
Body Language: Type of nonverbal communication which Cataplexy: It’s an abrupt loss of muscle tone without the loss of
means the mixture of gesture, posture and expressions. consciousness which is seen in Narcolepsy.
Borderline personality disorder: A type of personality Catatonic excitement: It is type of Catatonic Schizophrenia, in
disorder with the diagnostic criteria such as impulsivity, which the patient has increased psychomotor activity.
chronic feel of emptiness, unstable affect (intense anxiety/
Catatonic schizophrenia: Type of Schizophrenia in which the
irritable within few hours), unstable relationships, unstable
motor symptoms are predominantly present. Types include:
self-image, self-mutilation (threats of self-harm), unable to
stuporous, excited and periodic.
control anger, transient dissociative symptoms during stress,
paranoid ideas and tendency to act of out impulsivity without Catatonic stupor: It is a clinical syndrome or type of Catatonic
considering the consequences (e.g., Driving very fast, binge Schizophrenia, with the combination of akinesis (absence of
eating). movements) and mutism (absence of speech).
Bouffee delirante: It is a French term for short-lived psychosis. Catharsis: Emotional ventilation will help the individual to
It is mainly characterized by hallucination, delusion, confused come out of stress.
state and amnesia after attack and paranoia, aggression and Cautious gait (or) senile gait: Excess degree of age-related
psychomotor excitement. It is a culture bound syndrome changes in walking (slow and wide based abducted arm) and
of west Africa. Remission takes place within 3 months even having a fear of fall.
without any treatment. It occurs mainly due to consequence of Child abuse (or) child battered syndrome: It is defined as
urbanization and westernization. physical, psychological or sexual maltreatment of child or
Boundary violations: A kind of therapeutic impasses neglecting the child by care givers.
in which a nurse or patient crosses over the limits in the Choreiform gait (or) hyperkinetic gait: Jerky irregular and
therapeutic relationship. The categories of boundary violations
involuntary movements in both the extremities. It is seen in
are role, time, space, place, money, gifts, clothing, language,
Huntington’s Disease, Chorea, Athetosis and dystonia.
self-disclosure, post discharge social boundaries and physical
contact boundaries. Circumstantiality: Speech of the individual reaches the
goal or center point toward the question raised only after the
Brachioradialis reflex: Flexion of elbow/hand/fingers and
unwanted speech.
supination of forearm occurs when tapping of styloid process
of radius about 1–2 inches above the wrist. Clang association: It is rhyming of words seen in patients with
schizophrenia.
Bulimia nervosa: It is an eating disorder with the symptoms of
binge eating within short duration of time, having no control Cluttering: Disorder of speech characterized by erratic,
over eating, immediate compensatory behavior is present. dysrhythmic speech pattern and fast jerky spurts of words
There is self-evaluation of raised body weight or appearance. (e.g.: ‘Machine-gun’ speech with irregular rate).
It has two types: Purging and nonpurging. Cocaine: It is alkaloid derived from coca bush, erythroxylum
coca.
C Cognitive therapy: It is a form of psychotherapy in which the
Caloric Reflex Test (Oculovestibular reflex): This test is distorted cognitions are modified into positive cognitions.
performed to assess the coordination of eye and ear muscles. Cog wheel rigidity: It is a ratchet-like start-and stop passive
Pouring of cold water in the ear will move the opposite eye balls movements while performing the physical assessment mainly
and the warm water in ear will move the same side of eye balls. seen in patients with Parkinson’s disease.
Glossary 629

Communication: It is defined as ‘interaction process between Crisis: It is a sudden event in one’s life which disturbs
the sender and receiver in which the receiver receives the homeostasis during which the usual coping mechanism can’t
message exactly what the sender intended to say as such, i.e., resolve the problem.
both the sender and receiver have a common understanding Crisis resolution: These are the steps or measures taken to
of a message’. solve the crisis situation.
Community Mental Health Centers Act (1963): It is initiated Cross-gender homosexuality (or) Pseudo-transsexualism:
by 35th United States President, John F. Kennedy which Male or Female homosexuals sometimes need a sex change
brought a change of shifting the mental healthcare from and wear the dress of opposite gender.
hospitals to the community. Cue exposure therapy: Expose the alcoholics with craving
Community mental health nursing: It is defined as, inducing cue and guide the patient how to prevent the use of
‘decentralized pattern of rendering mental health services/ alcohol.
care to the needy in the community, further it focuses on Cyclothymia: Mood swing is present between the short
prevention of mental illness, promotion of mental health periods of mild depression and hypomania or an elevated
and rehabilitation of patients with mental disorder in the mood.
community’.
Complementary medicine: It is a nonmainstream practice D
used along with conventional medicine.
Dance therapy: It is defined as, ‘psychotherapeutic use of
Completion illusion: Illusion is mainly due to lack of
movement as process which promotes physical, emotional and
attention.
cognitive integration of the individual’.
Compulsion: Repetitive actions performed are followed by
Deep brain stimulation: It is defined as, ‘implanting the
obsession in order to avoid the marked distress even though
electrodes in certain parts of brain, the electrodes produce
the client knows that behavior is unrealistic, senseless and
the impulses to regulate the abnormal impulses. The amount
irrational.
of stimulation has been controlled with the pacemaker like
Conduct disorder: A repeated and pervasive pattern of device which is kept under the skin of the chest’.
age-inappropriate behavior that violates the basic rights of
Defence mechanism: It is an unconscious psychological
others.
mechanism that reduces anxiety which arises from
Confabulation: False filling of memory gaps. unacceptable or potential harmful stimuli.
Constricted or restricted affect: Reduction in the individual’s Deinstitutionalization: Bringing the mental health patients
emotional response. out of the hospital and shifting the care to community.
Coolidge effect: Married couples do not feel each other as Déjà entendu: It’s a false feel or sense of familiarity with the
excited during the sexual intercourse. unfamiliar words heard newly.
Coprophilia: Sexual pleasure with feces. Déjà vu: It’s a false feeling or sense of familiarity with the
Corneal reflex: Blinking of eyes while touching the cornea unfamiliar scenes or circumstances.
with wisp of cotton. Deliberate self harm (or) Nonsuicidal self injury disorder:
Counseling: It is an interaction process between the counselor It is defined as ‘deliberate, self-inflicted destruction of the body
and counselee. Counselor is the person who provides help and tissue without having the suicidal intent and for purposes not
counselee is the person who seeks help. socially sanctioned, includes the behaviors such as cutting,
Counter transference: Nurse is emotionally dependent on biting, burning and scratching skin’.
patient. There are three types of counter transference reactions Delirious mania: Severe clouding of consciousness with
of intense love or caring, reactions of intense disgust or confusion, disorientation and may be stupor, extreme
hostility and reactions of intense anxiety, especially in response liable mood, delusion with grandiosity, religiosity and/or
to resistance by the patient. persecution, auditory and/or visual hallucinations, increased
Covert sensitization: Patient will be advised to imagine the psychomotor activity has risk for harming to self and to others,
unpleasant symptoms whenever required to stop the stimulus even death may occur if left untreated.
of undesirable behavior by self. Delirium: An acute confusional state with disturbances in
Cremasteric reflex: Elevation of ipsilateral testicle while level of consciousness and reduced ability to focus, sustain, or
stroking the inner thigh of patient. shift attention is called delirium.
630 Textbook of Psychiatric Nursing for BSc Nursing Students

Delirium Tremens: It is the alcohol-withdrawal syndrome Dependent personality disorder: It’s a type of Personality
that occurs within 48–72 hours of stopping alcohol. Clinical Disorder with the diagnostic criteria such as to depend on
features are clouding of consciousness, disorientation, visual others more for psychological support, inability to take
hallucination, illusion, poor attention span, insomnia, decision, allow others to take important decisions in life,
autonomic disturbances, dehydration and electrolytes difficult to express unwillingness due to fear, not willing to
imbalance. make reasonable demands on others, low self-esteem, feel
Delusion: False fixed unshakable belief irrespective of their helpless by being alone and lack of self-confidence.
socio-cultural background is called delusion. Depersonalization: Alteration in the perception of self as
• Nihilistic delusion: Strong unshakable belief that the unreal one.
world is not existing is referred to nihilistic delusion. Depersonalization disorder (or) Depersonalization-
Delusion of control: It’s a strong unshakable belief that one’s Derealization syndrome: Alteration in the perception or
own thoughts or action are controlled from outside. experience of self and alteration in the perception or experience
Delusion of guilt (or) delusion of sin: It’s a strong unshakable of others seems to be unreal.
belief that the individual feels more guilt to an extent which is Depression: It is a mood disorder characterized by anhedonia,
unreal. feel of guilt, anergia, insomnia, psychomotor retardation,
Delusion of infidelity (or) delusion of jealousy (or) othello decreased concentration, lack of interest, crying spells, avoid
syndrome: Strong unshakable belief that his/her spouse has socialization, diurnal variation (worsening of symptoms
extra-marital relationship with other is called delusion of in morning), suicidal ideation and feel of hopelessness/
infidelity (or) delusion of jealousy (or) Othello syndrome. helplessness/worthlessness.
Delusion of influence or passivity: Strong unshakable Derealization: Alteration in the perception of external
belief that active movements are considered passive which is environment as unreal one.
imposed by someone from outside. Dexamethasone suppression test: Cortisol level usually
Delusion of love (or) erotomanic delusion: It’s a strong decreases with dexamethasone but it will not reduce in patients
unshakable belief that some famous personality is having love with depressive disorder.
desire on oneself. Dhat syndrome: Belief that there will be a presence of semen
Delusion of persecution: Having a strong suspicious belief in urine. There may be sexual dysfunction, depression, anxiety,
that other individual will cause harm is delusion of persecution. multiple somatic complaints and Asthenia (Physical/Mental
Delusion of poverty: It’s a strong unshakable belief that he/she Exhaustion).
will be deprived of material possessions. DiGeorge syndrome (or) Velocardiofacial syndrome (or)
Delusion of reference: Strong unshakable belief that the Shprintzen syndrome (or) Conotruncal anomaly face
other person is referring oneself with a neutral event in the syndrome (or) Takao syndrome (or) Sedlackova syndrome
environment is called delusion of reference. (or) Cayler cardiofacial syndrome (or) 22q 11.2 deletion
Delusion of thought broadcasting: It’s a strong unshakable syndrome: It is defined as deletion of 30–40 genes in middle
belief that one’s own thoughts have been projected/displayed of chromosome 22.
in mass media such as television, newspaper, internet, etc. Disorientation: Lack of orientation to time, place and person.
Delusions of grandeur: Strong unshakable belief that he/she Dissociative amnesia: Amnesia is purely psychogenic due to
is an important famous personality or superior knowledge or intrapsychic conflicts.
ideation or power is termed delusions of grandeur. Dissociative disorder: It is defined as lack of integration of
Dementia: It is a group of heterogeneous and neurodegenerative consciousness, memory and identity.
disorder with presence of significant decline in Memory, District Mental Health Program, 1996: Government of India
Cognitive abilities (Planning, organizing, executing, thinking, funded to launch this District Mental Health program as per
judgment, etc.), emotional control (lability, apathy, irritability) the guidelines of National Mental Health Program. In 1996,
and social behavior. It is a chronic memory impairment DMHP was launched in 4 districts under 9th five-year plan
with clear consciousness. The progressive deterioration of and it extended to 123 districts in 12th five-year plan. In 1997,
intelligence, behavior and personality is due to consequences District Mental Health program (DMHP) was launched in
of impairment in the brain hemispheres. The cerebral cortex Trichy and it has been extended to Ramanathapuram, Madurai
and hippocampus are affected to higher extent. in 2003 and it has been further extended into 13 districts.
Glossary 631

Disulfiram ethanol reaction (DER): When client takes Emotional lability (or) emotional incontinence (or)
disulfiram along with alcohol it might lead to disulfiram pseudobulbar affect: Uncontrolled expression of emotions
ethanol reaction. such as laughing or crying out suddenly.
Disulfiram therapy (or) deterrent therapy (or) chemical Encopresis: It is defined as repeated passage of feces in
aversion: Administration of Disulfiram will inhibit the inappropriate place or time after the bowel control is possible
Alcohol Dehydrogenase enzyme thereby it promotes the physiologically and not due to organic cause. It is also called
aversion to alcoholism. fecal incontinence.
Double depression: Major depressive disorder and Persistent Endogenous depression: Depression is due to hereditary or
depressive disorder occurs at the same time (Dysthymia is a biochemical imbalance.
chronic low-level depression at least of 2 years and add on to Enuresis: It means urinary incontinence (involuntary passing
that major depressive symptoms) of urine).
Down syndrome: Patients have 47 chromosomes with an Epileptic furor: Attacks of anger seen in patients with epilepsy
additional chromosome 21. in certain occasions without disturbances of consciousness.
Dual role transvestism: Wearing opposite gender dress to Ethanol challenge test: It is performed to create cognitive
enjoy the experience of opposite sex on temporary basis and awareness of Disulfiram Ethanol Reaction (DER). Patient has
not having a desire to change the anatomical sex organs as like to be on 250 mg of disulfiram as initial dose for 5 days. Alcohol
transsexualism and also sexual excitement is absent with cross has to be administered approximately 40 mL (15 mL for every
dressing which is present in fetishistic transvestism. 15 minutes) or maximum of 90 mL can be given.
Durham’s rule/Product rule: In 1954, Durham test was Euphoria: Mild elevation of mood seen in hypomania.
framed on the basis of decision in District of Columbia. Happiness is present but not related to ongoing events.
Accused is not liable as criminal for his/her action due to
Euthymia: Normal mood
product of mental disease.
Exaltation: Severe elevation of mood is seen in severe mania.
Dyslexia (or) specific reading disorder: A disorder of children
Intense elation along with the delusion of grandeur is present.
who fails to attain the language skills of reading, writing and
Excessive sexual desire disorder: Excess sexual desire in
spelling commensurate with their intellectual abilities.
male is termed ‘Satyriasis’ and excess sexual desire in female is
Dysmorphophobia: Excess dislike of one’s own body.
termed ‘Nymphomania’.
Dysthymia: It is a persistent depressive disorder in which the
Exhibitionism: Showing of sex organs to stranger.
mild depressive symptoms persist for at least 2 years (1 year in
Exogenous depression: Depression caused by external factors
case of children).
such as unemployment, divorce, sudden death of loved ones,
etc.
E
Extinction: A technique of behavior therapy, in which the
Eating disorders: It is characterized by severe form of gradual reduction in the frequency or the disappearance of the
disturbances in eating pattern/behavior which leads the life- responses occurs when the positive reinforcement has been
threatening condition. withheld.
Echolalia: Repetition of words spoken by others as mimicking Extracampine hallucination: Misperception outside the
the words or phrases. limits of sensory field (e.g., I hear voices from USA when I am
Echopraxia: Repetition or mimicking of actions performed by in India).
others, seen in patients with schizophrenia.
Ecstasy: Very severe elevation of mood seen in stuporous or F
delirious mania.
Factitious disorders (or) munchausen syndrome by proxy:
Elation: Moderate elevation of mood in which the individual Falsification of physical or psychological symptoms which
feels confident with increased psychomotor activity. project the individual as an ill person. The deception is evident
Elective mutism: Complete absence of speech in social even in the absence of obvious external reward. It may happen
situations. as a single episode or in a recurrent episode.
Electroconvulsive therapy: Convulsions are induced by Family therapy: It is defined as, ‘a form of psychotherapy
passing a brief pulse of electric current through brain via in which the issues or problems or conflicts exist among the
electrodes for a therapeutic purpose. family members are addressed and the solution is identified.
632 Textbook of Psychiatric Nursing for BSc Nursing Students

Female orgasmic disorder or female anorgasmia: Females Functional hallucination: Misperception within the same
feel difficult to have orgasm during the coitus. This may be sensory field, e.g., Patient verbalizes that, ‘I am hearing voices
due to biological (drug induced or endocrine disorders like when I hear the birds sound’. (Sensory field is auditory).
hypothyroidism) and psychological factor.
Female sexual arousal disorder: Vaginal dryness due to G
absence of lubrication. This may be due to biological or
Gag reflex (or) pharyngeal reflex: It is a reflex contraction
(postmenopausal) psychological.
of the back of the throat, evoked by touching the root of the
Fetal alcohol syndrome: Pregnant women who drink alcohol month, the back of the tongue, area around tonsils or back of
might affect the fetus and cause microcephaly or mental the throat.
retardation in children.
Gait: Manner of walk, it is a rare genetic disorder that affects
Fetishism: Sexual pleasure with objects. on individual’s ability to metabolize galactose properly.
Fetishistic transvestism: Sexual pleasure with clothes of Galactosemia: Infant unable to metabolize Galactose (It is
opposite sex. simple sugar along with glucose it forms lactose), which might
Flat affect: No emotional expression. accumulate in brain and lead to mental retardation.
Flight of ideas: Rapid shift of one idea to other idea with the Gegenhalten: It is an involuntary resistance to the passive
presence of central theme as seen in mania, schizophrenia and movement, which is seen in cerebral cortical disorders.
in some patients with ADHD. Gesture: Movement of body part, especially head or hand to
Flooding (or) implosive therapy: It is used to desensitize convey the ideas.
the persons to phobic stimuli. It differs from systemic Glasgow coma scale: It is the scale used to measure the level
desensitization that instead of working out in hierarchy of of consciousness.
anxiety provoking stimuli, the person will be ‘flooded’ with
Graphesthesia: Ability to recognize the writing in skin.
the continuous presentation of phobic stimuli until the anxiety
comes down. Grief: It is defined as physical, somatic, spiritual, emotional
and intellectual responses to the nature of loss.
Folie a deux: Delusions are shared between two closely related
or connected individuals. (When it happens among three Group homes: These are small, residential facilities present in
individuals, it is termed folie a trio. When it happens among the community, which are allotted to take care of the children
four individuals, it is termed folie a quatre). and adults with chronic disabilities.
Forensic psychiatry: It is a branch of medicine which deals Group therapy: It is defined as, ‘psychosocial treatment where
with mental disorders with its related legal aspects. The core the patients meet regularly to talk, interact and discuss the
aspects are criminal responsibility, crime due to psychiatric problems with each other along with the therapist’.
disorder, civil responsibility, laws related to psychiatric Guided imagery (or) guided affective imagery (or)
disorder, admission and discharge procedure in psychiatric Katathym: Imaginative psychotherapy—It is defined as, ‘a
hospital. form of relaxation therapy in which the therapist helps the
Formication: Type of tactile hallucination in which the participants in relaxation by evoking the mental images which
individual feels that the insects are crawling underneath stimulate or recreate the sensory perception of sound, sights,
the skin which may be associated with the prolonged use of taste, movement, smell and touch.
cocaine. Gustatory hallucination: Perception of taste without an
Foster homes: It is the place where the children are taken care, external stimulus.
when the parents are unable to take care of their children due
to a variety of reasons. Foster care may be the informal one or H
arranged by the courts or by a social service agency. Half way homes (or) sober house (or) recovery house: It is an
Fragile X syndrome: Fragile site in band q27–28 on institution in which the patients with physical emotional and
X chromosome mental disabilities or individuals with criminal backgrounds
Frotteurism: Sexual pleasure with rubbing others learn or relearn the required skills to re-integrate into society
Fugue: It is a loss of awareness in regard with one’s identity, for the needed support and care.
often coupled with flight from one’s usual environment, which Hallucinogens: Substances which alter the individual’s
is seen in dissociation disorder and epilepsy. sensory perception of reality and induce hallucinations.
Glossary 633

Hebephrenic (or) disorganized schizophrenia: Behavior Hypnogogic hallucination: Misperception happens when the
is aimless and not goal-directed one, in hebephrenic individual is getting into sleep.
schizophrenia. Hallucinations and delusions are not Hypnopompic hallucination: Misperception happens when
prominent. Inappropriate and incongruent affects are seen. the individual is awakening from sleep.
Speech is incoherent. Early and insidious onset is associated Hypnosis: Individual is directed into state of subconsciousness,
with poor premorbid personality. assisted through suggestions in order to recall the events which
Herbal therapy: Treating the diseases with the use of herbs he/she was unable to recall at conscious time.
is herbal therapy. The commonly used herbs to treat the Hypoactive sexual desire disorder: Decreased sexual desire
psychiatric disorders are St. John’s wort, Rosemary, Kava Kava, in sexual activity.
Ginkgo biloba, Valerian, SAMe (S-adenosylmethionine),
Hypokinetic gait (or) magnetic gait: Inability to lift the feet
Passion flower, Guarana and 5-Hydroxytryptophan (5-HTP).
from the floor results in decreased mobility. It is a cardinal sign
Hindu Adoptions and Maintenance Act (1956): It states that, of Normal Pressure Hydrocephalus.
Section 7 – Hindu male, who is major and sound minded can
Hypomania: Manic symptoms which are not severe to cause
adopt a child with consent of wife unless the wife is of unsound
significant impairment in social or occupational functioning.
mind. Section 8 - Hindu female, who is major and sound
Psychotic features are absent.
minded can adopt a child with consent of husband unless the
husband is of unsound mind. Person giving in adoption also
I
has to be with sound mind.
Hindu having an Marriage Act (1955): Among the couples, Illness anxiety disorder (hypochondriasis/health phobia/
any other who is unsound mind is considered null as per law. health anxiety disorder): Excessive health concern and
Party can file for divorce if spouses’ mental illness continues preoccupation with having or acquiring a specific illness.
for the period of 2 years. If divorce has been filed for more than Somatic symptoms are absent usually, mild symptoms may be
3 years, then divorce can be granted with the condition that, seen sometimes.
party need to pay maintenance charges. Illusion: False perception with an external stimulus.
Histrionic personality disorder: Type of Personality Disorder Imperative hallucination: Voices give instructions to the
with the diagnostic criteria’s such as self-dramatization, patient who may or may not feel obliged to carry out.
attention-seeking behavior, labile effect, exaggerated way Indian Contract Act (1872): Contract is an agreement
of expressing emotions, more concern in regard to physical enforced by law. Section 11 states, every individual can
attractiveness, emotional blackmail/suicide attempts, crave for perform contract, provided he/she is major and having sound
excitement, impulsive behavior and discomfort with situations mind. Section 12 states that person with unsound mind and
where the other person is being a guest and he/she is easily occasionally with sound mind (lucid interval) can make
influenced by others. contract. However, person who is in sound mind usually and
Homeopathy: It means to ‘treat like with like’ i.e., substance occasional in unsound mind, should not make contact when
which causes symptoms of disease in healthy individual may he/she is in unsound mind state.
in smaller doses is also used to cure the similar symptoms Indian Evidence Act (1872): As per this Act, mentally ill is
resulting from the disease. It helps to augment the individual’s not competent to give evidence, provided the evidence can be
own immune system. considered if given in lucid interval.
Homosexuality (or) egodystonic sexual orientation Indian Lunacy Act (1912): It consists of 4 Parts, 8 Chapters
disorder: Individual wishes to change the sexual orientation and 100 Sections. Objectives of this act are improvement of
because it is causing significant distress (ego-dystonic: asylums and care of lunatics in asylums.
Opposite to that of ego). Indian Mental Health Act (1987): It is initiated by Parliament
Huntington’s Chorea: A genetically dominant disease due to 4 in 1987 and came into effect in all states of India in 1993.
defects in chromosome. Enactment of this act revised the Indian Lunacy Act (1912).
Hyperesthesia: Individual perceives highest intensity of It has 10 chapters with 98 sections.
sensations seen in hypochondriasis, anxiety personality Insight: Aware of one’s own mental illness.
disorder and in intense emotions. (e.g., Sounds are heard Insight psychotherapy (or) uncovering: This therapy or
louder, colors are seen brighter, pain is perceived with high technique is helpful to bring the patient’s repressed conflict
intensity, etc.) and traumatic experience on the surface level in order to gain
Hypermnesia: Excessive loss of memory. the insight.
634 Textbook of Psychiatric Nursing for BSc Nursing Students

International Classification of Diseases (ICD-10): It is the L

10th revision and a medical classification is done by the World
Health Organization (WHO). It contains codes for diseases, Labile affect (or) pseudobulbar affect-PBA (or) involuntary
emotional expression disorder (IEED): Emotional
signs and symptoms, abnormal findings, complaints, social
Incontinence, i.e., immediate urge in expression of emotions.
circumstances, and external causes of injury or diseases.
Lacunar amnesia: Partial loss of memory (or) memory loss of
Intersexuality: Presence of both anatomical and psychological
specific events.
aspect of other sex. They are seen in Pseudo-Hermaphroditism,
Ovatestes, True Hermaphrodite, Congenital Adrenal Lacunar state/lacunar syndrome/status lacunaris: It is
Hypoplasia, Testicular Feminization Syndrome, Temporal defined as more minute infarcts called lacunae that are seen in
Lobe Disorder, Turner’s Syndrome and Klinefelter’s Syndrome. vascular dementia and in severe hypertension.
Irresistible Impulse Act: As per the rule, person might know Late paraphrenia: Type of Schizophrenia with the late onset,
that the action is illegal still is unable to control the action due delusion of persecution with bizarre/fantasy are present.
Visual, auditory, olfactory, gustatory and tactile hallucination
to presence of mental illness.
are seen.
Lesch-nyhan syndrome: It is also called juvenile gout
J
caused due to deficiency of hypoxanthine-guanine
Jacobson progressive muscle relaxation (JPMR): It is defined phosphoribosyltransferase (HGPRT).
as relaxation therapy in which the series of guided steps about Lewy body dementia: A type of dementia having decline in
tension and relaxation of the different parts of body helps in cognition with three more features such as fluctuations in
relaxation. alertness, recurrent vivid visual hallucinations at early stages
Johari window of IPR: Joseph Luft and Hary Ingham (1950) of disease and features of Parkinson’s disease such as muscle
described the model of interpersonal relationship. Other rigidity, loss of spontaneous movement, Mask-like face,
names are Disclosure or Feedback Model of Self Awareness Bradykinesia, etc. Other features include syncope, autonomic
and Information Processing Tool. Components are known symptoms, REM Sleep behavior disorder and Severe
to self, known to others, not known to self and not known to neuroleptic sensitivity.
others. Light therapy: Use of light with the specified intensity for
Judgment: The ability to make logical decisions. therapeutic purpose.
Juvenile delinquency: An individual below 18 years of age Lithium: It is a mood stabilizer.
involved in antisocial activities is called Juvenile Delinquent. Lunatics: Individuals with unsound mind (or) mentally ill
individuals.
K
Kinesthetic hallucination: Hallucination involves the sense of M
body movements. M’Naghten Rule: Daniel M’Naghten murdered Edward
Klismaphilia: Sexual pleasure obtained by the use of enema. Drummond, secretary of Sir Robert Peel, Prime Minister in
Kluver-bucy syndrome: This syndrome includes insertion his insane mind. But he was not punished under law
of inappropriate things in mouth (hyperorality), high sexual because the gun shot happened due to the delusion of
desire (hypersexuality) and poor response to emotional stimuli persecution.
(placidity). It is due to the lesions present in medial temporal Macropsia: Objects appear larger than the original size
lobe. It is commonly seen in Pick’s disease. Maladaptive behavior: Abnormal behavior persists for the
Korsakoff syndrome: It is the complication of alcoholism longer duration.
characterized by gross memory disturbances (Severe Male erectile disorder: Lack of ability to sustain the penile
retrograde and anterograde amnesia) with preserved long- erection in males.
term memory, cognition and social skills. Other symptoms Male orgasmic disorder or male anorgasmia: Males feel
are confabulation (False filling of memory gaps), confusion, difficult to have orgasm during the coitus. This may be due
disorientation, poor attention span, easily distractible in to biological (drug induced or after prostate surgery) or
nature and client may be unaware of illness. psychological, cause/causes.
Glossary 635

Malingering: It is a psychiatric disorder in which the patient Mental illness: A clinically significant behavioral or
plays a similar sick role to get secondary gain (avoiding work, psychological syndrome or pattern that occurs in an individual
escape from the criminal cases, unwilling to pay the amount, which is associated with present distress or disability.
etc.). Mental retardation (or) intellectual disability (or) mentally
Mania: It is a mood disorder, a state of abnormally elevated challenged individuals: It is defined as, ‘sub-average
arousal, energy level and affect. intellectual functioning that results in or is associated with
Marchiafava-bignami disease: It is a neurological disease concurrent impairment in adaptive behavior and is manifested
of alcoholism which occurs due to demyelination of corpus during the development”
callosum, optic tract and cerebellar peduncles. Symptoms Micropsia (or) lilliputian: Objects appear smaller than the
include ataxia, disorientation, epilepsy, dysarthria and original size
hallucinations. Mild cognitive impairment (MCI): It is an intermediate state
Masked depression: Most clients complaint of somatic between normal ageing and dementia.
symptoms such as body ache, lack of energy, pain in the body Milieu therapy: The scientific structuring of the environment
with less or no psychological symptoms. in order to elicit the behavioral changes and to enhance the
Masochism: Sexual pleasure by humiliating others or being psychological health and functioning of the individual.
humiliated Mini mental status examination (or) folstein test: It was
Massage therapy: Body tissues, superficial and deeper layer introduced by Folstein in 1975. It is 30-point questionnaire
of muscle/connective tissues are manipulated to enhance the used to assess the cognitive impairment apparently.
wellness in massage therapy. Mitgehen (or) Angle-Poise Effect (or) Angle Poise Lamp
Meditation: It is defined as ‘an experience of relaxing the body, Sign: Severe form of Mitmachen in which even the slight
mind and spirit’. pressure will move the particular body part. So, it is also called
Melancholic (or) involutional melancholia: Severe form of angle-poise effect (or) angle poise lamp sign.
major depression occurs above 40 years of age, i.e. at the time Mitmachen: It is a sign in which the patient’s body can be put
of menopause or andropause. in any posture even though it has been instructed to resist.
Mental health: State of well-being in which every person Modeling: It is a technique of behavior therapy in which,
realizes one’s own potential, able to cope with the normal learning out new behavior takes place by imitating the behavior
stresses of life, able to work productively or fruitfully, and is of the others.
able to make a valuable contribution to the community. Mood: It is a sustained and persistent emotional feeling.
Mental Health Care Act (2017): It superseded the previous Motivational enhancement therapy (or) brief intervention:
Mental Health Act (1987). In India, Mental Health Care Act A client-centered approach to improve the readiness to change
commenced in 7.4.17 and came into force on 7.7.18. It has 16 by helping the client in solving ambivalence.
chapters.
Mourning: Act of exhibiting great sadness.
Mental health nurse (or) psychiatric nurse: An expert in
Music therapy: It is defined as, ‘utilization of music in
performing mental status assessment, crisis intervention,
treatment, training, education and the rehabilitation of patient
administering psychotropics, therapies and providing the
with mental disorder’.
patient assistance. Psychiatric nurses work with patients to
help them in order to manage their psychiatric illness and live Mutism: Complete absence of speech seen in patients with
a productive fulfilling life. depression, negative symptoms of schizophrenia and catatonic
stupor.
Mental health nursing: Mental health nursing is defined as
‘branch of nursing which deals with the study of measures in
order to prevent the mental illness, promote mental health and N
restore of the patient with mental illnesses’. Narcissistic personality disorder: Type of Personality
Mental health team: Members include Psychiatrist, Disorder with the diagnostic criteria such as attention
Psychiatric Nurse, Clinical Psychologist, Psychiatric Social seeking, arrogance, strong belief that, he/she is special, feel
Worker, Occupational Therapist, Counsellor, Pharmacist to have relation with high status people, envious of others but
and Psychiatric Paraprofessionals or Technical Staff such as verbalizes that others are envious to self, no empathy, difficulty
Psychiatric Nursing Aid, ECT technician, Dietician, Clergy to face criticism of others, preoccupied with fantasy world of
Men/Chaplain and Speech Therapist. success/beauty and power.
636 Textbook of Psychiatric Nursing for BSc Nursing Students

Narcolepsy: It is a sleep disorder characterized by excessive Non-organic dyspareunia: Male or Female might have pain in
daytime sleepiness, sleep paralysis, hallucinations and genital area during coitus.
cataplexy. Non-organic vaginismus: Spasm of lower part of vagina
Nasolabial folds: Lines on the either side of mouth extend interferes the coitus.
from the edge of nose to outer corner of mouth might suggest Normal behavior: Behavior performed as per the socially
depression. acceptable norms.
National Mental Health Policy: Policy formulated in 1982, Nursing ethics: It is a branch of philosophy which deals with
consists of the plan of action that is required for promoting the study of values and moral standards related to nursing
mental health. profession.
National Mental Health Program: It was initiated in 1982.
Aims taken into account were prevention/treatment of mental O
and neurological disorders, use of mental health technology Obesity: Excessive accumulation of body fat is termed obesity.
to improve general health services and application of mental In general, Obesity was assessed by Body Mass Index (or)
health principles in total national development to improve Queenlet’s Index = Weight (Kg)/Height (m2)
quality of life.
Obsession: To control one’s thoughts by a continuous,
Naturopathy: It is the way of life in which body innately knows powerful idea or feeling or the ides of feeling itself. These
to maintain the health and heal oneself. are repetitive thoughts, images and doubts (that one feels it’s
Necrophilia: Sexual pleasure with dead bodies. absolutely senseless and irrational, individual tries to resist
Negativism: It is defined as apparently motiveless resistance to but unable to do so because that restriction might increase the
all instructions which is seen in catatonic stupor. level of anxiety.)
Neologism: Coining of new words. Obsessive-compulsive personality disorder: Type of
Neurasthenia: Individual will have a persistent and distressing Personality Disorder with the diagnostic criteria such as
complaints of body weakness and feel exhausted even after a preoccupied with perfectionism, thinking of orderliness
minimal effort. always, excessive doubtfulness, rigid and stubborn,
preoccupied with rules, list, details, schedules, etc. which
Neuroleptic malignant syndrome: It is an extrapyramidal
interfere the daily routines and tendency to hoard/unable to
symptom/hypermetabolic reaction to the dopamine
throw the useless object even it may not have any sentimental
antagonists especially with typical antipsychotics.
value.
Neurolinguistic programming: It is item from the concept
Occupational therapy: It is defined as, ‘therapeutic use of
of Milton Hyland Erickson. Effective communication exists at
work, play activities and self-care to enhance the development
the state of hypnosis or by alteration in the individual’s state of
and to prevent disability. It might also include the task
consciousness.
adaptation to obtain the maximum level of independence and
Neurotransmission: It is the fundamental process that to improve the quality of life’.
transfers information between neurons. Olfactory hallucination: Type of Hallucination in which
Neurotransmitters: They are the endogenous chemicals the individual smells the odors without any external stimuli.
which enable the neurotransmission. Commonly felt unpleasant odors are vomit, rotten flesh,
Nicotine: It is addictive substance seen in tobacco products. smoke, feces, urine, etc.
Night eating syndrome: Overeating in night time with sleep Omega sign: Furrowed brow due to sustained contraction of
problems. corrugator muscle, which is seen in depression.
Nightmares: Children may wake up after the frightening Oneiroid schizophrenia: Type of Schizophrenia with acute
or unpleasant dreams. The themes of dreams are threat to onset, brief episodic dream-like state. Symptoms include
survival or self-esteem. Dreams are recalled but they are vivid clouding of consciousness, perceptual disturbances and
in nature and also cause marked distress. It occurs in second disorientation.
half of night time sleep (REM Sleep). Opioids: It is the exudate from dried seeds of Papaver
Night terrors (or) sleep terrors: Child gets up from the sleep somniferum. The street name is smack and brown sugar.
with panic screaming and high-level anxiety. It occurs in the Oral communication: Communication by speaking/talking
deepest stage of Nonrapid Eye Movement (NREM) sleep. to others.
Glossary 637

Organic brain disorder: A neuropsychiatric disorder which Perseveration: Persistent repetition of words beyond the point
has a strong biological basis or a significant brain dysfunction. of relevance.
This is classified as delirium, dementia, amnesia and other Persistent delusional disorders: Delusions are well-
disorders such as organic hallucinosis, organic delusional systematized and nonbizarre type which is stable and chronic
disorder, organic mood disorder, organic personality disorder, in nature.
organic dissociative disorder and organic emotionally labile
Personality: Personality is defined as the characteristic set of
disorder.
behaviors, cognitions, and emotional patterns that evolve from
Othello syndrome (or) morbid jealousy: Delusion that life biological and environmental factors.
partner is not faithful (i.e. suspiciousness that life partner is
Personality disorder: It is defined as, “enduring pattern of
having extramarital relationship). If it persists, it might lead to
inner experience and behavior which has marked deviation
domestic violence.
from the expectation of individual’s culture”
Otto veraguth’s folds: Upward inward folds of upper eyelids,
Pervasive developmental disorder: It denotes the group of
which are seen in depression
disorders characterized by abnormalities in social interaction
Overt sensitization: It is a kind of aversion therapy in which
and communication skills.
introduction of unpleasant consequences for the undesirable
behavior can be observed. Pfropf schizophrenia: Schizophrenia occurs with the
presence of mental retardation. Behavior disturbance is more
prominent than thought disorder. It differs from schizophrenia
P
due to unsystematized delusions and poverty of ideation.
Panic anxiety (or) panic attacks: Anxiety with high level of Phenylketonuria: Simple autosomal recessive traits which
physiological response such as raised blood pressure, heart have deficiency of liver enzyme, ‘phenylalanine hydroxylase’
rate, etc.
leads to lack of ability to metabolize phenylalanine.
Paranoid personality disorder: Type of Personality Disorder
Pica: It is defined as eating the non-edible items.
with the diagnostic criteria such as suspiciousness/mistrust,
Pickwickian syndrome (or) obesity hypoventilation
excess sensitive to criticism, doubts the loyalty of friends,
syndrome: Individual with obesity will fail to breathe deeply
suspicious of sexual partner fidelity, interpret remarks as
threatening and holding “grudges” (Unable to forget/forgive). which results in decreased oxygen supply to blood.
Paranoid Schizophrenia: It is commonest type of Pick’s disease (or) frontotemporal dementia: Frontal lobe is
Schizophrenia in which patient has hallucination, delusion prominently involved (Frontal signs are inhibited). Atrophy,
and thought disorder. Examples of hallucinatory themes Neuronal loss, Gliosis and Intraneural bodies (Pick bodies)
are commenting, arguing, threatening, body sensations/ seen in Frontal or temporal lobe.
movements. Examples of thought disorders are irrelevant, Plantar reflex: Contraction of toes while touching the foot’s
incoherent and neologisms in speech. Examples of delusional outer plantar surface, from heel toward toes.
themes are persecution, grandiose, jealousy and reference. Play therapy: It is a form of psychotherapy in which the
Pareidolic illusion: Illusion which is seen over the other therapist utilizes the child’s fantasies and uses the symbolic
illusion. meaning as a medium of play to have a communication or
Parkinson’s disease: It is a neurodegenerative disease understanding about the children. It also gives a chance to the
caused by degeneration of neurons in brain, particularly in child to express feelings and experiences.
nigrastriatal pathway of the basal ganglia. Postschizophrenic depression: Depressive episode develops
Partial Hospitalization (or) Day care Hospital/Centers (or) after the resolution of schizophrenic symptoms. Patient might
Day Treatment Program: It is an outpatient facility where be in high suicidal risk.
clients undergo the assessment, treatment and rehabilitation Post-Traumatic Stress Disorder (PTSD): It is an anxiety
during day time and then patient can return to home at later disorder, in which the individual might develop after witnessing
times. or experiencing an extreme, overwhelming traumatic event
Patellar reflex: Extension of leg while tapping of quadriceps during which the individual has intense fear or helplessness.
femoris tendon (present below patella). Postpartum depression: Episode of depression occurs after
Pedophilia: Sexual pleasure with children. the delivery. If the depression episode is present during
Pelopsia: People/objects/things appear closer than the original pregnancy and within one year after the delivery it is termed
place. perinatal depression.
638 Textbook of Psychiatric Nursing for BSc Nursing Students

Postpartum depression: Major depression appearing within 4 Pseudoneurotic schizophrenia: A type of Schizophrenia
weeks of delivery/postpartum which has classical triad features such as pan-anxiety, pan-
Postpartum psychosis (or) puerperal psychosis: It is a serious neurosis and pan-sexuality. Pan-anxiety denotes free floating
mental illness in which the episode of depression occurs anxiety which will not subside easily. Pan-neurosis includes
after the delivery. Here, there will be presence of depressive the predominant neurotic symptoms. Pan-sexuality is
symptoms and psychotic features. preoccupied with sexual desires.
Poverty of ideation: Speech delivered is adequate but the Psychiatric nursing: It is the branch of nursing which deals
content of speech is inadequate. with the study of nursing care required for the mentally ill
Poverty of speech: Decreased production of speech. patients.
Prader-Willi syndrome: This disorder is caused by a deletion Psychiatry: It is a branch of medicine with deals with the study
in the paternal chromosome 15. It is a complex genetic of prevention, diagnosis and treatment of patient with mental
condition in children, characterized by poor muscle tone illness.
(hypotonia), feeding difficulties, poor growth, and delayed Psychoanalytical psychotherapy: It is defined as form of
development. insight therapy which aims to overcome the unconscious
Premack principle: This technique has been named after its conflict and it also aims to identify the relationship between
originator. The frequently occurring response (R1) might act the unconscious motivation and the abnormal behavior.
as a positive reinforcement for the response (R2) which is Psychodrama: It is a form of psychotherapy (group therapy),
occurring less frequently. in which the dramatization or dramatic presentation of self
Premature ejaculation: Ejaculation of sperm occurs before the helps to gain self–insight.
satisfactory sexual activity. This may be due to biological (not Psychological pillow: A characteristic feature of Catatonic
common) or psychological (Performance anxiety) pressure. Schizophrenia in which the patient hold his/her head few
Premenstrual syndrome: It is combination of physical, centimeters above the bed for long hours.
emotional, mood and behavioral disturbances present in Psychosurgery (or) psychiatric neurosurgery: It is functional
women before few days of menstrual flow due to the interaction neurological surgery for treatment of mental disorders. It is
between the neurochemicals in brain and the sex hormones. done when there is presence of strong treatment resistance
Pressure of speech: Rapid speech with an urgent quality. It is with psychotropic agents and ECT.
often noted in patients with mania. Psychotherapy: It is defined as, ‘way to help the people with
Preventive psychiatry: It is defined as, ‘services rendered variety of mental illnesses and emotional difficulties and it also
in the community in order to prevent the mental illness and helps to control or remove the symptoms which troubles the
promote the mental health’. person, function in a better way, increase the sense of well-
being and promote healing’.
Prion disease: Replicative protein mutates and causes a
variety of spongiform diseases. It can transmit through use Puerperal blues (or) postpartum blues (or) baby blues: It is a
of contaminated duramater, Corneal graft and ingesting meat less severe form of postpartum depression, in which the onset
from infected cattle (Bovine Spongiform Encephalopathy). of depressive episode is present within few days and ends up
within one or two weeks.
Process recording: It is a method of recording the nurse-
patient interaction, which has been done by the nurses in
psychiatric setup. Q
Propulsive gait (or) Parkinsonian’s gait: A stiff and stooped Quarterway homes: It provides lower-level supervision than
posture with head/neck forward. It is seen in Parkinson’s the half way homes. Here, mostly patients have to take care of
disease, carbon monoxide poisoning and manganese toxicity. themselves.
Prosopagnosia (or) face blindness (or) facial agnosia:
A neurological disorder characterized by the inability to R
recognize faces. Reality therapy: It is a psychotherapeutic technique focused
Proximity: Nearness in time, space and relationship. on the present behavior and the present coping ability of the
Pseudohallucination: It is an involuntary sensory experience patient against the stressors. The active relationship between
vivid enough to be regarded as hallucination, but recognized the therapist and patient might promote the realistic behavior
by the patient not as a result of external stimuli. which is focused on the present.
Glossary 639

Recreational therapy: It is a systematic process which utilizes Romberg test: It is performed to assess the balance or
the recreation and other activity-based interventions based equilibrium of body. Ask the patient to stand straight with the
on the needs of individual with illness or disabling conditions eyes closed. Nurse has to be cautions while performing this
which means psychological/physical health recovery and well- test, since patient has a risk of fall.
being. Russel sign: Callus knuckles due to self-induced vomiting,
Recurrent depression: Two or more episodes of depression. seen in eating disorders.
Reflex hallucination: Stimulus in one sensory field produces
hallucination in another in other sensory field. (For example, S
patient says that, ‘I feel pain when I am hearing the sneeze
Sadism: Sexual pleasure by humiliating others.
sound’. One sensory field is tactile i.e., feel of pain and other
Sadomasochism: Sexual pleasure by humiliating others and
sensory fields are auditory i.e., hearing sneezing sound, in the
getting or being humiliated.
given example).
Schizoaffective disorders: It has both symptoms of
Rehabilitation: It is defined as the restoration of the person’s
schizophrenia and mood disorders which are prominently
health to his/her former capacity.
seen in same episode.
Reiki technique: The term, Reiki is a Japanese word which
Schizoid personality disorder: Type of Personality Disorder
means, ‘Universal life force’. The purpose of Reiki is to direct
with the diagnostic criteria such as having emotional coldness,
access to universal, transcendental, radiant and light energies
blunted or flat affect, humorless, preferably solitary activities,
at various levels on energy spectrum.
introspective, indifference with praise or criticism, inability to
Relaxation therapy: It is a component of body-mind
express both positive and negative feelings, lack of desire to
intervention in which the therapist helps the participants at
enjoy relationships and being aloof (loneliness).
the higher extent of mind relaxation.
Schizophrenia: It is a psychotic disorder (disorder in which
Residual schizophrenia: Progression from early stage
client believes that he/she will not have a base of reality,
(Hallucination and delusions are predominant) to late
characterized by abnormalities in emotions, thinking and
stage (Hallucination and delusions are minimal). Negative
cognition.
symptoms are present.
Schizophreniform disorder: Presence of symptoms of
Resistance: It is a kind of therapeutic impasses. Patient is
schizophrenia for up to 6 months.
not willing to communicate the troubling aspect of oneself
and is not willing to change when the change is expected. Schizotypal personality disorder: Type of Personality
Primary resistance (e.g., Inappropriate role model). Secondary Disorder with the diagnostic criteria such as odd/eccentric
resistance (e.g., financial problem, unpleasant situation, behavior, social withdrawal, no close relation with others,
attention seeking and Social pressure). inappropriate/constricted affect, magical thinking, paranoid
ideation, ruminations with violence and sexual themes, vague/
Restraints: Restricting the violent behavior of patient either
circumstantial speech, depersonalization and prefer to have
by physical or chemical (use of drugs) modality.
social distance even to his/her own family members.
Retrograde amnesia: Inability to recall before the onset of
School refusal (or) school phobia: Children refuse to go to
amnesia.
school because of fear.
Rett’s syndrome: Syndrome due to autosomal dominant
Scissor gait: It happens due to the contractures of all spastic
mutation. Girls are more affected. The main symptoms are
muscles (hypertonia of leg muscles), increased adduction of
hypotonia, muscle spasm, loss of speech in 1–2 years, abnormal
leg. It is seen in spastic cerebral palsy and upper motor neuron
gait, mixed receptive and expressive language development
lesion.
in 1–4 years of age, severe psychomotor retardation, apraxia,
hand flapping, presence of microcephaly, Toe walking, lack of Seasonal affective depression: Depressive symptoms in
eye contact, scoliosis and peripheral motor disturbances. winter season.
Rinne’s test: Keep the tuning fork in mastoid bone and also Secondary depression: Depression is due to organic causes.
near to patient’s ear after striking it. When air conduction Sedatives: Drugs that promote sleep.
is more than bone conduction, it is normal. If the bone Sensory gait (or) stomping gait: It happens when the patient
conduction is more than air conduction it denotes conductive lacks proprioceptive information to the brain when the foot
hearing loss. touches the ground. But it lacks in patient with peripheral
640 Textbook of Psychiatric Nursing for BSc Nursing Students

neuropathy (due to the complications of alcohol, complications Stuttering/stammering/childhood onset fluency disorder:
of diabetes and disorders of dorsal columns). Normal flow of speech interrupted by the pause or by repeating
Separation anxiety disorder: An excessive display of fear and the fragments of the word.
distress when faced with situation of separation from home or Substance abuse: Maladaptive pattern of substance use
any specific attachment figure. leading to clinically significant distress or impairment with
Serotonin syndrome: It is defined as, ‘over activation of recurrent substance use results in failure to perform well in
serotonergic receptors which leads to increased serotonin. home, school or at work, recurrent substance use in situation
Sexual aversion disorder (or) lack of sexual enjoyment: which is physically hazardous (e.g., While driving), recurrent
Avoidance of sexual activity with life partner or sexual partner. substance related legal problems and continued substance use
Thoughts of sexual activities provoke anxiety and negative might lead to recurrent or continuous social/interpersonal
feelings. problems.
Sheltered workshop: It is an environment or organization Substance codependency: Behavior of one family member
which employs the persons with disabilities separately from affects the other because of the substance abuse.
the other individuals. Substance cross tolerance: Effect of one drug produces
Shuffling gait: Individual drags his/her feet to walk (Seen in tolerance of another drug; usually it happens between the two
disorders associated with dementia, Parkinsonism,  etc.) drugs with same functions.
Sibling rivalry disorder: It refers to significant competition or Substance dependence: Compulsive and repeated use
animosity among the siblings for the love and affection from of substance which results in tolerance toward the substance
parents associated with unusual negative feelings (e.g., elder and also leads to withdrawal symptoms when commenced to
son will think that, only my parents are showing love and quit or decrease the dosage of the substance.
affection to the younger ones only). Substance detoxification: It is the process of eliminating or
Simple schizophrenia: Prominent negative symptoms of neutralizing the toxins from the human body.
Schizophrenia such as amotivation, apathy, social withdrawal, Substance harmful use: A pattern of psychoactive substance
flat or blunt affect and poverty of speech. Positive symptoms use which harms the physical health (liver cirrhosis due to
are absent. Social functioning is reduced. Onset is early and alcohol use) or psychological health (depression due to alcohol
insidious. Course is progressive. Prognosis is worst. use)
Social skills training: A form of behavior therapy which Substance intoxication: Substance-related syndrome occurs
focuses to enhance the social skills among patients. due to the strong exposure to the substance.
Somatic delusion: Strong unshakable belief in regard to the Substance withdrawal: Symptoms occur when blood level of
one’s bodily function or appearance is grossly abnormal. abused drug gets decreased and symptoms cease when that
Somatic hallucination: False sensation of movement occurs substance has been taken by the individual.
inside the body usually which is visceral in origin. Suicide: It is defined as, ‘intentional way of killing oneself ’ (or)
Somatic symptom disorder: Presence of one or more somatic ‘Self-inflicted cessation of life ends with a fatal outcome’.
symptoms which cause significant personal distress in patient. Sundowning syndrome: Worsening of symptoms in evening
Somatoform disorder: It is a mental illness in which multiple (Diurnal variation). Symptoms of sun downing syndrome
bodily signs and symptoms are elicited but the medical such as wandering, mood swings, disorientation, insomnia,
evaluation does not reveal abnormalities. resistance, confusion and hallucination are present.

Somnambulism: It refers to walking during the sleep. Supportive psychotherapy: It is defined as psychotherapeutic
approach which integrates the various components such
Steppage gait (or) neuropathic gait (or) equine gait:
as cognitive-behavioral, psychodynamic and interpersonal
Abnormal gait characterized by foot drop due to absence or
techniques of psychotherapy.
dorsiflexion of foot.
Systemic desensitization: It is the technique of behavior
Stereognosis (or) haptic perception (or) tactile gnosis:
therapy developed by Joseph Wolpe. It has three steps such as
Ability to perceive and recognize the object using tactile sense.
Relaxation training (Relaxation gives the physiological effects
Stereotype behavior: Repetitive strange behavior which is opposite to the anxiety), Hierarchy Construction
Stereotypical movements: Repetitive movements which are (Arrange the conditions in the order of increasing the anxiety)
irregular, purposeless and jerky. and Desensitization of stimulus (Gradual exposure of the
Stereotypical speech: Meaningless repetitive speech individual from least to most anxiety provoking state).
Glossary 641

T Thought retardation: It is decreased idea identified by

decreased content of speech which is seen in patients with
Tactile hallucination: Type of Hallucination in which the depression, dementia, nervousness, memory impairment and
individual feels that someone is touching without any external
schizophrenia.
stimuli. It may be superficial (touching the skin), kinesthetic
Thought withdrawal: Thoughts have been removed by an
(movement of the body parts) or visceral (pain felt due to the
external source.
separation or twisting of internal organs).
Tai-chi’ technique: The term, ‘Tai-chi’ denotes ‘moving Tics: It is defined as sudden, nonrhythmic, involuntary, jerky
meditation’ which consists of a series of continuous slow motor (or) vocal activity.
movements performed along with the mental and breath co- Token economy: It is a kind of contingency contracting
ordination. in which the contract can be either made orally or signed.
Tandem walking test: Patient is asked to walk over the heel Here, tokens will be issued to the patient for performing the
in straight line. Assess for unsteadiness or staggering or desirable behavior.
imbalance gait. Tolerance: Increase in the amount of substance use in order to
Tangentiality: Speech of the individual does not reach the goal get the same desired effect.
or center point. Tourette syndrome: Classical Tic disorder named after Gilles
Tay-Sachs disease: A rare fatal inherited disorder occurs de la Tourette, a French Physician was first person to describe
due to absence of an important enzyme hexosaminidase-A this disorder. Tourette Syndrome is chronic, combined motor
(Hex-A) leads to the destruction of nerve cells in brain and and vocal tics. Usually, motor tics precede the vocal tics in
spinal cord. Tourette syndrome.
Teleopsia: People/objects/things appear far away from the Transactional analysis: The term ‘Transactional Analysis’
original place. was first used by Dr Eric Berne (1964). Dr Eric Berne suggests
Telephone (or) mail scotologia: Sexual pleasure attained by that there are three ego states that exist in individual. Parent—
sending sexual pictures. Focus on rules/regulations/values. Adult—Approach based on
Testamentary capacity: It is a legal term used to explain the previous observations. Child—Focus on emotions and desires.
person’s legal and mental ability to make (or) alter a valid will. Transference: Transfer of client’s feeling toward the nurse.
Therapeutic communication: Communication maintained Negative or hostile transference denotes feel of anger or
between nurse and patient for therapeutic purpose. enmity that the client has expressed toward the nurse. Positive
Therapeutic community: Psychiatric nurse structures, give or dependent transference denotes the client is emotionally
and maintain the therapeutic environment. It is done in dependent on nurse.
collaboration with the patient and other health team workers. Transient epileptic amnesia: Memory loss due to epilepsy
Therapeutic impasses: Barriers in therapeutic communication either during the ictal or post-ictal period.
or relationship. Transient global amnesia: Sudden temporary episode of
Therapeutic relationship: Relationship maintained between memory loss.
nurse and patient for therapeutic purpose. Transsexualism: Anatomical sex is normal. Feeling of
Thought alienation phenomenon: Thought insertion, discomfort with one’s own anatomical sex organs. Individual
thought broadcasting and thought withdrawal. will have preoccupied ideas that to feel better to have opposite
Thought block: It is a sudden interruption of thoughts sex organs and have marked significant distress. There will be a
exhibited by silence for few seconds to minutes which is presence of social and occupational dysfunction.
commonly seen in patients with schizophrenia. Transvestism (or) fetishistic transvestism: Wearing the dress
Thought broadcasting: It is a symptom of schizophrenia. The of opposite gender for purpose of sexual excitement; mostly
patient believes that his/her thoughts have been shared with seen in males (Transsexuals wear dress of opposite gender
other people without the patient’s willingness, through an because they feel they are a part of that gender and not because
unknown or known medium (Here, the known medium is of sexual excitement).
mass media such as television, newspaper, radio, etc.) Triceps reflex: Extension of forearm while tapping of triceps
Thought echo: Voices are speaking thoughts aloud brachii tendon in elbow.
Thought insertion: Thoughts have been inserted by an Truancy: Children leave the school and go somewhere else
external source without the knowledge of parents.
642 Textbook of Psychiatric Nursing for BSc Nursing Students

U W
Undifferentiated schizophrenia: Schizophrenia not Waddling gait (or) myopathic gait: Individual walks
conforming any subtypes comes under the category of like a duck due to the weakness present in the proximal
undifferentiated schizophrenia. muscles of pelvic girdle. This gait is seen in congenital hip
dysplasia, pregnancy, spinal muscular atrophy and muscular
Unipolar depression: Presence of depressive episode; patient
dystrophies.
will not experience mania or hypomania.
Waxy flexibility: Body parts placed in the fixed position
Urophilia: Sexual pleasure with urine.
are maintained for a long duration even if the position is
uncomfortable.
V
Weber’s test: It is a test a lateralization. Tap the tuning fork
Van Gogh syndrome: Self-mutilation (or) Self-injurious strongly on your palm and then press the butt of the instrument
behavior in this type of Schizophrenia. Van Gogh was a famous on the top of the patient’s head in the midline, and ask the
painter. He cut his ear in acute illness state and hence this term patient where he/she hears the sound normally, the sound is
is named after this incident after his name. heard in the center of the head or equally in both ears. If there
Vascular dementia (or) Multi-infarct dementia (MID): is a conductive hearing loss present, vibrations will be louder
Presence of occlusive plaque or thromboembolism or on one side (lateralization).
hemorrhage in blood vessels. Multiple small cortical infarcts Wernicke’s encephalopathy: It is the complication of
are present in vascular dementia. Alcoholism characterized by cerebellar ataxia, mental
Verbal communication: It’s a type of communication through confusion, palsy of 6th cranial nerve, hypothermia, cardiac
oral, written and visual means. problems, vestibular dysfunction and peripheral neuropathy.
Verbigeration: It’s a senseless repetition of words or phrases. Widower’s syndrome: Widowed male feels pressure to
perform sexual intercourse when he has completed the
Vibrational medicine (or) sound therapy: It’s an ancient
grieving process of his wife.
technique in which the sounds of objects such as bell rings,
Word salad: It refers to mixture of words.
tuning forks, gongs, chants, drum beats are used to promote
vibrations in the body which further promote the healing
process. Vibrations of the human voices are also used. Y
Visual communication: It refers to communication to others Yoga: It means union, i.e., joining of the individual
by symbols. consciousness with the consciousness in the universe.
Visual hallucination: A type of hallucination in which the
individual visualizes or sees the things without any external Z
stimuli. It may be elementary (flashes of light), partially Zone therapy: It is also called Reflexology. It consists of
organized pattern (blurred images) or fully organized pattern massaging the specific areas of hands or feet in order to reduce
(people, animal or objects). stress, pain and illness in the corresponding related areas in
Voyeurism/scopophilia: A kind of sexual pleasure by the body.
observing the sexual activity of opposite sex/watching naked, Zoophilia (Bestiality): It relates to sexual pleasure with
etc. (Visualizing Pornography is not included in this category). animal.
Index

Refer ‘f ’ for figure, ‘fc’ for flowchart and ‘t’ for table, respectively.

A Affective disorders 205, 215 Alternative

African mental health research initiative and complementary medicine 165, 183
A’s of schizophrenia 191f (AMARI) 431 medicine 626
Aaron beck 125, 130 Alzheimer’s
Aggression 18, 625
Abasia 625 dementia 352, 626
Agitated depression 625
Abdominal disease 16, 18, 350, 356, 361, 625
Agitation 625
reflex 625 Amantadine 119, 278
behavior 625 Agnosia 18, 78, 626
Agranulocytosis 109 Ambivalence 626, 17
Aboulia 625 and conflict 460
Abreaction 625 Agraphia 18, 343
Agreeableness 33 Ambulatory schizophrenia 297
therapy 125 American
Abstinence 17 Aguilera model of crisis 384
association of mental deficiency (AAMD) 312t
Abstract thinking Ahimsa 160
law institute (ALI) test 626
and concrete thinking 465 AIDS dementia complex 626
psychiatric association (APA) 21
thinking 625 Aims of Amisulpride 107, 199
Abulia 625 music therapy 149 Amitriptyline 243, 583, 587
Acamprosate 452 occupational therapy 170 Amnesia 76, 270, 339, 346, 347, 486, 626
Acceptance-commitment therapy 132 Akathisia 18, 109, 110, 182 Amnestic disorders 16, 61
Acetylcholine 44, 625 Alanine aminotransferase (ALT) 265 Amobarbital 117
Acetylcholinesterase inhibitors 361 Al-anon 626 Amotivational syndrome 443
Achilles tendon 625 Alarm reaction 393f Amoxapine 441
reflex 625 Alateen 626 Ampakines 121
Acquired immunodeficiency syndrome (AIDS) 354 Albert Ellis 53 Amphetamine/s 121, 276, 442, 456, 626
Action potential 42 Alcohol 29, 118, 263, 626 Amygdala 41
Acupuncture 166, 625 absorption 263 Amytal 86
Acute dependence syndrome (ADS) 583 Anaclitic depression 441
and transient psychotic disorder/s 194, 625 -induced amnesia 628 Anafranil 243
depression 625 -related disorders 62 Anatomy of brain 212
dystonia 19, 109, 110, 182 use disorders identification test 266, 605 Anergia 626
intoxication effects of withdrawal Anesthetics 173
amphetamine 276 Anger 397, 626
seizures 626
cocaine 277 Angle
syndromes 269
opioids 275 -poise effect 635
Alcoholic/s
mania 207, 625 poise lamp sign 635
stress anonymous (AA) 270
Anhedonia 18, 626
disorder 246 anonymous 626
Anna freud 34
reaction 256, 625 blackout 17 Anorexia nervosa 16, 299, 301, 304, 626
Adaptive behavior 379 hallucinosis 269, 626 and bulimia nervosa 464
Adjustment disorder/s 243, 256, 625 pellagra 269, 626 Antabuse therapy 130
and post-traumatic stress disorder 465 Alexia 18 Antacids 118
Administrative plan of Alexithymia 18, 626 Anterior cingulate cortex (ACC) 230
district mental health program 423fc Alice in wonderland syndrome 443, 626 Anterograde amnesia 41, 76, 347, 626
Admission procedure 489 Aliphatics 107 Antianxiety agents 117, 626
Adrenocorticotropic hormone (ACTH) 393 Allergic side effects 109 Anticholinergic
Affect 16 Alogia 626 agents 115
illusion 625 Alprazolam 117, 240, 441, 451 drugs 379
644 Textbook of Psychiatric Nursing for BSc Nursing Students

Anticipatory grief 17 Atypical Biceps reflex 627

Anticonvulsants 212 antipsychotics 107 Binge eating 299, 627
Antidepressants 112, 237, 240, 298, 355, 626 depression 303, 627 syndrome 303
Antidiabetic agents 268 Auditory hallucination/s 344, 627 Binswanger’s disease 355, 627
Antihistamine 119 Authenticity 52 Biochemical factors 37
Antihypertensive agents 268 Autism 16 Bioelectromagnetic therapy 169, 627
Antimanic drugs 626 spectrum disorder 21, 308, 318, 436, 627 Biofeedback 628
Antimicrobial agents 268 Autistic Biological
Antimuscarinic side effects 110 savant 443 effects of electroconvulsive therapy 174t
Antiparkinson agents 119 thinking 627 factors for anxiety disorders 255
Antipsychotics 106, 182, 240, 298, 346, 355, 626 Automatic obedience 627 risk factors of violence 397
Antisocial personality disorder 296, 626 Autonomic Biopsychosocial
Antiviral agents 268 nervous system (ANS) 41 etiology of mental illness 37
Anuloma-viloma 162 side effects 108 model 209f
Anxiety 56, 73, 231, 626 Autonomy 96 Biperiden 119
disorder/s 23, 64, 229 Aventyl 243 Bipolar
in DSM-5 255 Aversion therapy 56, 288, 627 affective disorder 594, 622
interview schedule (ADIS) 243 Avoidant disorder 207, 628
related to physical illness 250t personality disorder 475, 627 II disorder 23
Anxiolytic/s 115, 117 -restrictive food intake disorder 299 mood disorder 121
-related disorders 29 Avolition 18, 627 -virtual sign identification 507
Anxious personality disorder 475 Axon 42 type I disorder 210
Aparigraha 160 Ayurveda 166, 627 Blackout 17
Apathy 18, 73, 626 Bloch 137
Aphasia 18, 78, 626 Blocq’s disease 625
Aphonia 74, 627 B Blood
Apocalyptic anxiety schizophrenia 189 Babungo integrated mental health care 432 alcohol
Appearance schemas inventory (ASI) 301 Baby blues 638 concentration 264t
Apraxia 18, 78, 627 Balderdash syndrome 443 level 265
Ardha chakrasana 162 Bandura’s social learning -brain barrier (BBB) 354
Ardhakatichakrasana 162 model 31f tests 84
Areas of rehabilitation 428fc, 438 theory 31 Blunt
Aripiprazole 199 Baragnosis 627 facial expression 72
Aromatherapy 167, 627 Barbiturates 115, 117, 377 /shallow affect 628
Arrangement of equipment 487 Baresthesia 82 Blunted affect 18
Art therapy 627 Barognosis 82 Body
Articles required for Barriers of communication 96fc, 97 dysmorphic disorder 16, 255
electroconvulsive therapy 176t Basal ganglia 40 exposure in sexual activity questionnaire 301
Asanas 160, 162 Basic image
Asociality 627 assumptions of behavior theory 55 assessment (BIA) 301
Aspects of concepts of automatic thoughts questionnaire 301
mental health 1 POCSO Act, 2012 402t Borderline
music therapy 150 psychoanalytical psychotherapy 124f defenses 34
suicidal risk 368t dimensions of human existence 52f personality disorder 297, 628
warning clues of suicide 368t forms of dementia 350fc Bouffee delirante 203, 628
Asperger’s syndrome 336, 443, 627 tenets of psychoanalytic model 53 Bounce model of stress 395fc
Aspirin 120, 355 Battering 18 Boundary violations 97t, 103, 628
Assault cycle 372f Beck depression inventory 220 Boxer’s syndrome 443
Assertiveness training 627 Behavior therapy 627 Brachioradialis reflex 628
Assessment 46 for mentally retarded children 312fc Brahmacharya 160
and checklist used for the patient 560 -positive reinforcement 485 Brain 38
of Behavioral psychological symptoms anatomy 215
biceps reflex 83f in dementia (BPSD) 352 atrophy 356
brachioradialis 83f Bellary model 423 -derived neurotrophic factor (BDNF) 212
eating disorders 301 Benefits of imaging tests 86
reflexes and responses 83t dance therapy 151, 152t stem 39
triceps reflex 83f meditation 162 structures, location, functions
Assessment 46 psychodrama 148 and psychiatric implications 40t
Associative loosening 627 recreational therapy 152 waves 164
Assumptions of existential model 51f relaxation therapy 157f Breathing 164
Astanga yoga 160 smoking cessation 280f meditation 163
Astasia-abasia 627 Benzisothiazole 107 Brief
Asteya 160 Benzisoxazole 107 intervention 635
Ataxic gait 81, 627 Benzodiazepines 85, 212, 346, 355, 377 psychiatric rating scale (BPRS) 191
Atomoxetine 328 Benzphetamine 276 psychotic disorder 625
Attention Benztropine 119, 379 Briquet’s syndrome 255
and concentration 466 Bestiality 304, 642 Bromocriptine 115, 119, 277, 278, 377
deficit Beta Buccal mucosa 587, 606
hyperactive disorders 436 blockers 117, 268 Bulimarexia 16
hyperactivity disorder 73, 308, 627 -lactams 268 Bulimia nervosa 16, 299, 301, 304, 628
as per ICD-11 and DSM-5 325t Bhakti yoga 160 Bulimic inventory test 301
 Index 645

Bulletin boards 136 psychological tests 86 Clinical

Bupropion 114 therapeutic communication 98 features of
hydrochloride 279 Chemical aversion 631 agoraphobia 233
Buspirone 117, 240 Chemoreceptor trigger zone (CTZ) 275 body dysmorphic disorder 239
Butyrophenones 107 Child dissociative disorder 248t
abuse 334 excoriation (skin-picking) disorder 240
battered syndrome 443, 628 generalized anxiety disorder 232
C post-traumatic stress reaction index 243 hoarding disorder 239
Caffeine 29, 280 psychiatry deals 336 selective mutism 236
intoxication 280 PTSD symptom scale 243 separation anxiety disorder 236
-related disorders 62 Childhood social anxiety disorder 236
Cage questionnaire 265t disintegrative disorder 336 trichotillomania 240
and psychological test 495 onset fluency disorder 640 nurse specialist (CNS) 8
Calcium channel blockers 212 schizophrenia 441 pathway 17
Callus knuckles 639 Children’s impact of traumatic triad of abnormalities
Caloric events scale-revised (CITES-R) 243 in serotonin syndrome 378fc
test 79 Chloral hydrate 117 Clinician-administered PTSD scale 243
reflex test 628 Chloramphenicol 268 Clomipramine 117, 240, 243, 449
Cannabis sativa 273 Chlordiazepoxide 117, 267, 269 Clonazepam 117, 212, 240, 597
Cannabis 29, 85, 273, 628 Chlorpromazine 107, 273, 445, 572, 577, 583, 588 Clonidine 115, 243, 276
-related disorders 62 Chlorpropamide 268 Cloninger’s classification based on
Capgra syndrome 443, 628 Chlorprothixene 107 genetics and environmental factors 265t
Caplen’s phases of crisis 383f Cholestatic jaundice 109 Clorazepate 117
Carbamates 117 Choreiform gait 81, 628 Clozapine 107, 109, 199, 441, 452, 615
Carbamazepine 85, 120, 211, 243, 298, 442 Chronic side effect chart 561
effects of cocaine 277 Clumsy child syndrome 443
Cardiac side effects 110
fatigue syndrome (CFS) 254 Cluttering 315, 628
Cardiovascular diseases 216
obstructive pulmonary disease 164 Cocaine 277, 628
Carisoprodol 117
stressors 216 -related disorders 62
Catalepsy 628
traumatic encephalopathy 443 Codependence 17
Cataplexy 18, 628
Cimetidine 115, 118, 120 Cog wheel rigidity 628
Catastrophic reaction 352
Cingulate gyrus 41
Catatonia 86, 197 Cognition 16
Circadian rhythm 216
Catatonic Cognitive
Circumstantiality 628
excitement 628 behavioral
and tangentiality 460
schizophrenia 202, 628 family therapy 139
Clang association 628
stupor 375, 628 therapy 19, 130
Classical triad of
Categories of errors 130
mania 208f
alcohol withdrawal 266t functions 74
pseudoneurotic schizophrenia 203f
eating disorders 301 of brain 346t
wernicke’s encephalopathy 269f
intelligence 309f stimulation 352
Classification of
lithium level in blood 212t alcoholism 265 therapy 125, 126f, 131, 182, 628
medication 177t barbiturates 272t triad 130
mini mental status examination 350t child psychiatry of depression 209f
weight in body mass index 303t (ICD-10) 335 Collaboration 47
Category-wise signs of anger 372t (ICD-11 and DSM-5) 308t Collegiality 47
Catharsis 148, 628 depressive disorders 217 Common
Caudate 40 dissociative disorders 247 alcoholic beverages 264t
Causes of autism 318 electroconvulsive therapy 172, 173fc personality disorders in females, male 292f
Cautious gait 81, 628 major and mild neurocognitive disorders 349t preparations of cannabis 274t
Cayler cardiofacial syndrome 189, 443, 630 male penile erection disorder 289fc screening instruments of mental
Cefamandole 268 mental retardation 313t
Cefoperazone 268 disorders 20fc types of enuresis in females, male
Cefotetan 268 retardation 309t and older children 331f
Central neurotransmitters 44fc Communication 91, 629
nervous system 38, 229 occupational therapy 171 disorders 21, 61
infections 550 organic brain disorder 339, 340fc process 96fc
side effects 109 personality disorders 292, 293t Communis 91
theme of delusions 196t prevention of mental retardation 314fc Community
Cephalosporin 268 psychiatric emergency 365fc mental health
Cerebellum 39 psychological tests 87fc centers act (1963) 415, 424, 438, 629
Cerebral hemispheres 38 psychotherapy 123fc nursing 415, 438, 629
Cerebrum 38 recreational therapy 153fc rehabilitation facilities 427t
Chakra meditation 163t reflexes 82fc Comorbid illness with mood disorders 207fc
Chakrasana 162 sedatives, hypnotics and Comparison of
Chandra bhedana 162 antianxiety agents 272fc anorexia nervosa and bulimia nervosa 300t
Chandranuloma-viloma 162 sexual disorders 286fc conduct disorder 321t
Chapters and sections of pocso act, 2012 403t somatic symptom and related disorders 249 hypomania and mania 208t
Characteristics of substance abuse based ICD-11 and DSM-5 293t
a mentally healthy person 3, 13 on psychological effects 261 postpartum blues and
cognitive behavioral therapy 130 tics 328, 329fc postpartum depression 435t
milieu therapy 135 trauma- and stressor-related disorders 240, 241t Complementary medicine 629
646 Textbook of Psychiatric Nursing for BSc Nursing Students

Completion Contraindications of in relation with origin 33

illusion 629 antianxiety drugs 119 used in various age groups 33t
test 487 antidepressants 115fc Deinstitutionalization 19, 438, 629
Complex post-traumatic stress disorder 243 antipsychotics 108fc Déjà entendu 629
Complicated grief 17 psychotherapy 122 Deliberate self harm 593, 629
Complications of Conversion disorder 16, 247, 466 Delirious mania 208, 629
cannabis abuse 274fc Convulsions 172, 183 Delirium 16, 107, 339, 360, 438, 629
eating disorders 300t Coolidge effect 629 and dementia 461
opioids dependence 275fc Cope 17 tremens 269, 630
pregnancy 310 Coping versus dementia 345t
substance abuse 263 mechanism 396fc Delusion/s 18, 74, 193, 630
Components of styles as per Nash and Roger 396t and overvalued idea 460
group therapy 141 Coprophagia 302 of
mental health 3fc, 13 Coprophilia 304, 629 control 630
supportive psychotherapy 137 Core psychodrama techniques and grandeur 630
therapeutic community 133t description 147t guilt 630
Compulsion 18, 256, 629 Corneal reflex 629 infidelity 630
Computed tomography 86 Corpse syndrome 443 influence or passivity 630
Concept/s Cortical and subcortical dementia 462 jealousy 630
map of Cortico-striatal-thalamo-cortical 230 love 630
adjustment disorder 245fc Corticotropin releasing hormone (CRH) 393 persecution 630
understand induced Cotard poverty 630
delusional disorder 203f delusion 443 reference 630
of syndrome 443 sin 630
cognitive therapy 221f Counseling 47, 390, 629 thought broadcasting 630
conduct disorder develops into for behavior modification 480 Delusional
antisocial personality disorder 296fc Countertransference 17, 97, 103, 629 disorder 195, 196t, 211
cue exposure therapy 268f Couple therapy 139 parasitosis 443
deinstitutionalization and Covert sensitization 629 perception 193
reinstitutionalization 424f C-reactive protein (CRP) 85, 89 Dementia 16, 61, 107, 339, 360, 630
dependence and abuse 260fc Creatine phosphokinase (CPK) 89 and pseudodementia (depression) 462
light therapy 216f Cremasteric reflex 629 pugilistica 443
mood and affect 206t Crisis 17, 629 Dendrites 42
normal and abnormal behavior 12f, 14 intervention 17 Denial 190, 264, 381
behavioral model 13 resolution 387fc, 629 Dependent personality disorder 483, 630
continuum model 13 Depersonalization 18, 630
Criteria
medical model 12 and derealization 465
for
process model 13 -derealization
identification of types of
social model 13 disorder 248
personality disorder 475
statistical model 12 syndrome 630
mental health 3
subjective model 13 disorder 630
to use ECT 174t
utopian model 12 Depression 16, 206, 215, 630
Cross-gender homosexuality 629
panic anxiety 232f with psychotic symptoms 593
Cue exposure therapy 629
personality disorders 291fc Depressive disorders 23, 63, 505
Current trends and issues in
rehabilitative nursing 426fc Deprimere 215
care of mentally ill patients 9
secondary prevention in model Derealization 18, 630
Cushing disease 303
of preventive psychiatry 425fc syndrome 443
sibling rivalry versus happy family 330fc Cycle of violence 436, 437f Dermatological side effects 110
various responses in Cyclic ethers 117 Description of
anxiety situation 231fc Cycloplegia 108 immature defenses 35t
Conceptual models in psychiatric nursing 51 Cyclothymia 629 mature defenses 36t
Conduct Cyclothymic disorder 208, 211 neurotic defenses 35t
disorder 61, 320, 336, 629 Cyproterone acetate 288 pathological defenses 35t
and antisocial personality disorder 466 Desipramine 113, 243, 278
Confabulation 18, 629 Deterrent therapy 631
Confusion assessment method (CAM) 344
D Detoxification 17, 273
Conjoint family therapy 138 Daiva vyapashraya chikitsa 166 Development
Conner’s rating scale 327 Dance therapy 629 and evolution of mental health nursing 13
Conotruncal anomaly face syndrome 189, 443, 630 Dantrolene 377 of
Conscientiousness 33 Data interpretation 484 community mental
Constipation 108 De clerambault syndrome 443 health services 416t, 438
Constricted or restricted affect 629 Decision making 484 personality 31f
Consultation 47 Decline of psychiatric nursing in India 6t
and research in psychiatric cognition in dementia 351f Developmental
nursing practice (1946–1990) 6 memory in dementia 351f coordination disorder (DCD) 443
Content of thought 74 Decongestants 276 dyslexia 317
Continuum 232f Decorticate and decerebrate posture 467 Dexamethasone suppression test 86, 220, 630
from normal aging to dementia 358f Deep Dhanurasana 162
of brain stimulation 181, 629 Dharana 160
affect 206f dyslexia 317 Dhat syndrome 630
dissociation 249f Defense mechanism/s Dhouti 161
mental health 13 and coping mechanism 459 Dhyana 160
 Index 647

Diagnosis 46 Disorder/s criteria for

and management of histrionic of antisocial personality disorder 296
personality disorder 481 diminished motivation 625 illness anxiety disorder 257
of language 316, 336 diagnostic criteria
alcohol abuse 265 psychological development 315 for
anxiety disorder 236t sex preference/deviation 288t autism spectrum disorder 318
dementia 350 sexual borderline personality disorder 297
Diagnostic dysfunction 304 childhood onset fluency 315
criteria for maturity 304 conduct 321
aids dementia complex 354f preference 304 delirium 343
bipolar speech 315 disruptive mood dysregulation 218
I disorder 209 Disorganized schizophrenia 202, 633 eating 299
II disorder 210 Disorientation 18, 630 intellectual disability 311
cyclothymic disorder 211 Dissociative persistent depressive 219
depressive disorder 218 amnesia 16, 248, 347, 630 premenstrual dysphoric 220
research 57 disorder 246, 257, 630 separation anxiety 324
procedure 484 fugue 16, 248 single episode depression 218
statistical manual (DSM) 21, 65 neurological symptom disorder 247 specific learning 317
Dialectical behavior therapy (DBT) 132, 298 Distress 17, 392 of
Diazepam 115, 246, 249, 280, 379 District encopresis 333
Dibenzothiazepine 107 medical officer (DMO) 420 enuresis 331
Differences mental health program (DMHP) 419, 422, 630 tic 329
between Disulfiram 118, 267, 455 DSM-IV
alzheimer’s disease and consent form 563 and 5 criteria of delirium 343t
pick’s disease 356t ethanol reaction (DER) 130, 267, 268, 631 classification of
congruence and incongruence 32t therapy 631 alcoholism 264
cortical and subcortical dementia 351t Divalproex 120 somatoform disorders 255
dementia and pseudodementia 345t Do’s and don’ts in violence management 373t -tr classification system 61
endogenous and Domains of Dual role transvestism 631
atypical depression 221t alternative and complementary Dugdha neti 161
exogenous depression 221t medicine 166fc Durham’s rule 631
epileptic seizures and psychogenic psychiatric rehabilitation 429t Dynamics 101, 131
nonepileptic seizures 253t Donepezil 441, 453 Dys 316
expressive psychotherapy and Donna’s phases of crisis 384f Dysarthria 18, 344
supportive psychotherapy 137t Dopamine 44, 111, 442 Dyscalculia 492
general history collection and agonist 277
Dyslexia 316, 631
psychiatric history collection 70t hypothesis 189
Dysmetropsia 443, 626
immediate and delayed onset PTSD 242t pathways 190t
Dysmorphophobia 303, 631
intellectual disability and in brain 190f
Dyspareunia 18
mental illness 313t Dopaminergic
Dyspraxia 443
lewy body dementia and agonists 119
Dyssomnia 343
parkinson’s disease 357t pathways in the brain 111f
Dysthymia 16, 225, 631
medical and psychiatric disorders 251t Dose-response curve 111f
Dysthymic disorder 219
psychoanalytic and cognitive Double
behavioral therapy 124t bind communication 18
self-harm and suicide 367t depression 631 E
in personality based on the birth order 31t Down’s syndrome 310, 631
Differential Doxepin 243 Eating
diagnosis Drug/s attitude test (EAT) 301
for PTSD 256 identification 503 disorders 64, 298, 304, 631
of and food interactions 115 of infancy and childhood 302
adjustment disorder 256 of MAOI 116f habits questionnaire (EHQ) 301
anxiety disorders 255 inducing serotonin syndrome 378t Ebstein anomaly in fetus 442
dementia 352 interactions Echolalia 18, 193, 631
schizophrenia 192 of Echopraxia 18, 631
Digeorge syndrome 189, 443, 630 antipsychotics 107, 108f echolalia, perseveration and coprolalia 460
Digit benzodiazepines 118t Ecstasy 18, 631
backward test 74 SSRI 115 Education 47
forward test 74 with lithium 213t Effect/s
span test 74 levels in blood 85t of
Dihydroindolones 107 therapy of OCD 256 music therapy 149
Dimensions in the psychopathology used in anxiety disorders 255 stimulants on the body 121
of schizophrenia 194 DSM-5 Effort reward imbalance model of stress 394f
Diogenes syndrome 443 classification of Egodystonic sexual orientation disorder 633
Diphenhydramine 119 delirium 28t, 342 Eight
Diphenylbutylpiperidines 107 major and mild neurocognitive folds of yoga 160
Disadvantages of disorders (dementia) 28t, 349 limbs 160
group therapy 143 mental disorders 21 Ekbom syndrome 443
light therapy 156 personality disorders 292, 303 Elation 73, 631
milieu therapy 137 somatic symptom and related Elavil 243
Discharge procedure 493 disorders 249t Elective mutism 631
Disinhibited social engagement disorder 246 substance use disorders 29t, 261 Electrocardiogram (ECG) 164, 344
648 Textbook of Psychiatric Nursing for BSc Nursing Students

Electroconvulsive therapy 404, 441, 560, 588, 631 Exhibitionism 631 Forensic
Electrodermogram (EDG) 164 Existential nursing 17
Electroencephalogram (EEG) 312, 350 model 52 psychiatric nurse 9
Electrophysiological tests 85t psychology 51 psychiatry 407, 413
Elements of theory 51, 52 Formal thought disorders 74t
cognitive behavioral therapy 131 vacuum 53 Formication 632
psychodrama 147t Exocytosis 43 Forms of cognitive behavioral therapy 131
Elimination disorders 25, 61 Exogenous depression 631 Foster homes 632
Emotional Expressive aphasia 18 Founder of modern yoga 159f
brain 40 Extinction 127, 129, 631 Fragile X syndrome 310, 443, 632
center of the brain 41 Extracampine hallucination 631 Frederic S. pearls 53
incontinence 631 Extrapyramidal Frontal lobe 39, 356
lability 631 motor system 39 syndrome 39
nervous system 40 side effects (EPS) 108f, 109 Frontotemporal dementia 355, 625, 637
Empathy 17, 95, 96, 104 symptoms 19, 40, 110, 182 Frotteurism 304, 632
Encopresis 18, 332, 631 Extreme labile mood 208 Fugue 632
Endocrine Extroverts 33 Functional
disorder 216 and reflex hallucination 461
theory 216 hallucination 632
Endogenous F neurological
and Facial expression 72f surgeries 181
atypical depression 463 Factitious disorder/s 64, 16, 257, 631 symptom disorder 251
exogenous depression 463 Factors system disorder as per DSM-5 247
depression 631 affecting the level of practice 14 Functions of
Energy therapies 169 of psychiatric nurse 12 a family 139t
Enuresis 18, 330, 631 determining neurotransmission 43 brain 38
Epidemiology of anxiety disorders 230 influencing crisis 382fc psychiatric nurse in various settings 10, 14
Epileptic that determine the suicidal risk 368t child and adolescent psychiatry units 11
furor 379, 631 False reassurance 100 community mental health center 11
seizures and dissociative convulsions 469 Family day care centers 11
Epinephrine 44 psychoeducational therapies 139 ECT room nurse 10
Episodes of tic disorder 329f therapy 138, 183, 631 emergency department 11
Equine gait 81, 640 assessment 139 family therapy units 11
Erikson’s theory of psychosocial development 31 format 561 forensic psychiatry units 11
Erotomania 443 Father of modern light therapy 155f hospice care centers 11
Erotomanic delusion 630 Features of industrial medical centers 11
Erythromycin 120 intellectual disability in children 311t medical inpatient wards 11
Erythroxylum coca 628 mental illness 4 psychiatric
Escitalopram 243 parkinson’s disease 354 inpatient ward 10
Eskalith 211 suicidal levels 367t outpatient department 10
Essential elements of therapeutic relationship 95t Feeding and eating disorders 25 psychotherapy unit 10
Estrogen 86 Female the play therapy 146
Ethanol 117 anorgasmia 632 Fundamental concepts of lithium 212f
challenge test 269, 631 orgasmic disorder 632
Ethchlorvynol 117 sexual arousal disorder 632
Ethics 47, 101 Fenofibrate 596 G
Ethosuximide 120 Fetal alcohol syndrome 270, 443, 632 Gabapentin 212
Etiological factors of PTSD 256 Fetishism 304, 632 Gag reflex 632
Etiology of Fetishistic transvestism 304, 632, 641 Gait 81, 632
adjustment disorders 256 Finger to ataxia 269
eating disorder 298 finger test 82 Galactorrhea 109, 442
mood disorders 208 nose test 82 Galactosemia 310, 632
obesity 302 Fire accident 487 Gamma
organic brain disorder 341fc Flat affect 18, 632 aminobutyric acid (GABA) 212
personality disorders 292 Flight of ideas 18, 632 glutamyl transferase (GGT) 265
substance abuse 262f and loosening of association 460 Ganser syndrome 248, 443
suicide 365f Floating anxiety 73 Gastric lavage 213
violence 371, 397 Flooding 56, 128, 632 Gastrointestinal disorder 216
Eugeroics 121 Fluoxetine hydrochloride 454 Gateway drugs 17
Euphoria 18, 73, 232, 631 Fluoxetine 117, 120, 240, 243, 441, 607 Gazing meditation 163
Eustress 17, 392 Flupenthixol 107 Gegenhalten 632
and distress 466 decanoate 442 Gender
Euthymia 18, 631 Fluphenazine 107, 616 and schizophrenia 189t
Evaluation 47 decanoate 442 dysphoria 25, 286
Evolution of mental Flurazepam 117 of childhood 287
health services/psychiatry 4, 13 Fluvoxamine 117, 120, 240, 243 identity disorders 64, 304
Exaltation 73, 631 Fogging 129 incongruence (ICD-11) 26
Excessive sexual desire disorder 631 Folie à deux 203, 632 General
Excitatory 44 Folstein test 82, 89, 635 adaptation syndrome (GAS) 17
Excretion 110 format 556 assistance and volunteer organization 432
 Index 649

hospital psychiatric unit (GHPU) 419 Hamilton rating scale for Hysterical
physical examination 574 anxiety (HAM-A) 255 fits 253t, 469
Generalized anxiety disorder 504 depression 220 pseudodementia 248
Genetic Haptic perception 82, 640
factors 37 Hatha yoga 160 I
responsible for anxiety disorder 231t Health
Genitourinary disorder 216 anxiety disorder 633 Ibuprofen 120
Genogram symbols 71t education format 560 ICD-
Geophagia 302 phobia 633 10 classification
George eman vaillant 34f promotion and health maintenance 47 for bipolar affective disorder 225
Gerald caplan 438 Hebephrenic 202 of
Geriatric Hebephrenic 633 depression 225
considerations 298 Hemoglobin 84 mental disorders 57
depression scale 225 Herbal therapy 168t, 633 mood disorders 225
Geropsychiatric nurse 9 Hildegard peplau 7, 101 organic brain disorders 360
Gestalt therapy 53 personality disorders 303
Hindi mental status examination (HMSE) 555
Gesture 93, 632 schizophrenia 201
Hindu
Glasgow coma scale (GCS) 78t, 632 sexual disorders 303
adoptions and maintenance act (1956) 408, 633
substance abuse 283
Glibenclamide 268 having an marriage act (1955) 633
11 and DSM-5 466
Gliclazide 268 marriage act (1955) 407
classification of
Glipizide 268 Hippocampus 41
ADHD 326
Globus pallidus 40 Hippocrates coined 206
anxiety disorders 232t
Glutamate 354 Histamine 44
autism 318
Glutethimide 117 Historical
bipolar related disorders 207t
Glyburide 268 background of milieu therapy 134t
conduct disorder 321
Goals of development of play therapy 144t
depressive disorders 217t
cognitive therapy 125 History collection format 70, 549
dissociative disorders 247t
milieu therapy 134 —children and adolescent with
eating disorders 299
process recording 103f psychiatric disorders 552 encopresis 333
psychotherapy 122 demographic data 70 enuresis 331
recreational therapy 153 for patient with alcohol mental disorders 21t, 567
supportive psychotherapy 137 dependence syndrome 551 other psychotic disorders 194t
therapeutic communication 98 —geriatric psychiatry 552 sexual disorders 286
Grades of lithium toxicity 214t past psychiatric history 71 specific learning disorder 317
Graduate psychiatric Histrionic personality disorder 499, 633 tic disorders 328
nursing education (1936–1945) 5 Homeopathy 167, 633 code for separation anxiety disorder 324
Grandiosity 18 Homosexuality 633 11 classification of
Graphesthesia 82, 632 Human immunodeficiency virus (HIV) 354 amnestic disorder 27, 347
Gravare 387 Huntington’s delirium 342
Grief and depression 468 chorea 350, 356, 633 dementia 27, 348
Grief 17, 73, 387, 398, 632 disease 356, 625 mental disorders 20
-kubler-ross theory 389f Hyalophagia 302 personality disorders 292
Griseofulvin 268 Hydroxyzine 117 substance use disorders 28, 260
Group Hyperactive delirium 342 11 diagnostic criteria 244
homes 632 Hyperactivity in ADHD 326 for
format 561 Hypercalcemia 216 alcohol withdrawal 266
of special population 143t Hyperesthesia 633 amphetamine dependence 276
therapy 140, 632 Hyperkinetic gait 81, 628 autism spectrum disorder 319
Growth hormone releasing hormone 393 Hypermnesia 633 borderline pattern
Guanethidine 115 Hyperprolactinemia 442 personality disorder 297
Guanidine 115 Hypertelorism 189 cocaine dependence 278
Guided Hypertensive crisis 19 conduct disorder 322
affective imagery 632 Hypervigilance 19 delirium 344
imagery 632 Hypnogogic dementia 352
imagery types 158fc and hypnopompic hallucination 461 developmental learning disorder 317
therapy 158 hallucination 633 dissociative disorder 248
Gustatory hallucination 632 Hypnopompic hallucination 633 hallucinogens dependence 280
Hypnosis 125, 167, 633 intellectual disability 311
Hypoactive nicotine dependence 278
H delirium 342 opioids dependence 275
Halazepam 117 sexual desire disorder 633 persistent depressive disorder 219
Half way homes 632 Hypochondriasis 16, 255, 633 PTSD 256
Hallucination/s 18, 74, 194, 269, 270 Hypokinetic gait 81, 633 recurrent
and Hypomania and mania 463 depressive disorder 219
illusion 460 Hypomania 16, 206, 207, 633 episode depression 219
pseudohallucination 468 Hypothalamic-pituitary-adrenal 37, 216 separation anxiety disorder 324
Hallucinogen/s 279, 632 axis and cortisol 216f single episode depression 218
-related disorders 62 Hypothalamus 41 of
Haloperidol 107, 240, 273, 346, 379 Hypoxanthine-guanine encopresis 333
decanoate 442, 446 phosphoribosyltransferase 634 enuresis 332
650 Textbook of Psychiatric Nursing for BSc Nursing Students

Iceberg metaphor of mind 54f Intoxication 17 Levels of

Ideas of reference 19 effects of anxiety 255
Identification of cannabis 274fc prevention of suicide 369fc
abnormal test finding 484 hallucinogens 280 Levodopa 115
therapy 502 nicotine 278 Levosulpride 597
types of delusions 501 sedatives, hypnotics and Lewy body dementia 634
Identify the types of narcissistic personality 482 antianxiety agents 272fc and Parkinson’s disease dementia 462
Idiot savant 443 Intuition 16 Lexapro 243
Illness anxiety disorder 251, 633 Involuntary emotional expression disorder 634 Lexia 316
Illusion 633 Involutional melancholia 635 Librium 267
Imbalance Ionotropic receptor 118 Liebowitz social anxiety scale (LSAS) 255
of neurotrasmitters in Irresistible impulse act 634 Light therapy 154, 183, 634
various psychiatric disorders 566 Ishwarapranidhana 160 Lilliputian 626, 635
levels of neurotransmitters 38t Isoniazid 268 hallucination 443, 626
Imipramine 85, 278, 441, 448 Isoptin 212 Limbic system 40, 118
Immature defenses 34 Issues in mental health 14 and abnormal neurotransmission 38
Impact of event scale-revised (IES-R) 243 Lithium 85, 212, 441, 456, 572, 634
Imperative hallucination 633 carbonate 211, 243
Implosive therapy 632 J Lithobid 211
Importance of OSCE 471 Jacobson progressive muscle relaxation 634 Liver function test (LFT) 85, 89, 265
Important days related to mental health 565 Jala neti 161 Lobes 39
Impulsivity in ADHD 326 Jnana yoga 160 of brain 39f
Inappropriate affect 19 Johari window 17, 101 Logical therapy 166
Inattention in ADHD 326 of Logo
Incidence of dementia 348f interpersonal relationship 101, 102f of international yoga day 160f
Indian IPR 104, 634 therapy 53
contract act (1872) 407, 633 Judgment 634 Looseness of association 19
disability evaluation and Jung’s theory 31 Lopinavir 268
assessment scale 614 Juvenile 323 Lorazepam 117, 267, 273, 346, 379
evidence act (1872) 408, 633 delinquency 323, 336, 634 Loxapine 107
Lunacy act (1912) 399, 400, 409t, 413, 633 Ludiomil 243
and mental health act 469 Lunatics 634
mental health act (1987) 633 K Luvox 243
nursing council standards in
Kapalabhati 160
mental health nursing 47, 48t
Kaplan’s theory of crisis sequence 384f
penal code (1860) 407 M
Indications of Karma yoga 160
antianxiety drugs 117 Katathym 632 Macropsia 626, 634
music therapy 149 Ketaconazole 268 Magnetic
Indicators of mental health 2 Ketamine 281 gait 81, 633
Individual Key resonance imaging (MRI) 350
family therapy 138 concepts of resonance 86, 89
psychotherapy 182 milieu therapy 136 Mail scotologia 641
format 561 strategic family therapy 140t Maintenance of electroconvulsive therapy 180f
Indolic derivatives 107 elements of light therapy 155 Major
Ineffective coping skills 250t Kinesthetic hallucination 634 depression 183
Infantile autism 318 Kirby’s method 77t, 89, 554 depressive disorder 622
Infections 37 Kleffner syndrome 316 Maladaptation 17
Information education Klismaphilia 304, 634 Maladaptive
communication 419, 423 Kluver-bucy syndrome 355f, 443, 634 behavior 379, 634
Inhalants 29 Korsakoff syndrome 444, 634 behaviors in response to crisis 381f
Ink blot test 487 Kriyas 160 coping among children 380f
Insight psychotherapy 633 Kundalini meditation 163 Male
Insight 16, 633 anorgasmia 634
Institutionalization 438 erectile disorder 634
versus deinstitutionalization 423
L orgasmic disorder 634
Instructions for the simulated anxious 475 Labile affect 19, 634 Malingering 635
Integrated child development services 418, 422 Lacunae 355 Mania 73, 206, 506, 635
Intellectual Lacunar with psychotic symptoms 622
developmental disorder 311 amnesia 347, 634 Mantra meditation 163
disability 309, 311fc, 635 state 355, 634 Maprotiline 243
Intensive psychiatric rehabilitation 199 syndrome 355, 444, 634 Marchiafava bignami disease 270, 635
International Lamictal 212 Marijuana abuse 443
classification of diseases (ICD) 65, 634 Lamotrigine 120, 199, 212, 449, 597 Marital therapy 139
day to eliminate violence against women 436f Landau-kleffner syndrome 316 Masked depression 635
mental health research organization 432 Late paraphrenia 203, 634 Masochism 304, 635
network toward alternatives and recovery 432 Laws related to psychiatry 408t Massage therapy 635
Interpersonal model 56 Learning disorders 61 Maternal
of schizophrenia 189f Legal test 407 factors 37
theories 56 Lesch-nyhan syndrome 310, 444, 634 infections 310
Intersexuality 634 Lesions in the left frontal lobe of the brain 441 Mature defenses 34
 Index 651

Maudsley obsessive-compulsive inventory 255 Metta meditation 163 mental health

Mean corpuscular volume (MCV) 84, 89, 265 Michigan alcoholism screening test 266 association (2004) 4
Mechanism of Micropsia and macropsia 461 policy 636
action Micropsia 626, 635 program 419, 421, 438, 636
—disulfiram 267f Midstream urine (MSU) 350 social service (NSS) 418
for lithium 212f Mild cognitive impairment (MCI) 358, 635 Natural
of Milieu therapy 19, 47, 134, 183, 635 and synthetic opioid derivatives 274f
antianxiety drugs 118f Mindfulness meditation 163 hallucinogens 279
light therapy 156f Mini mental status examination 84t, 344, 556, 635 Naturopathy 167, 636
MAOI 114f Minnesota multiphasic personality inventory 191 Nauli 161
SSRI 113f Mirtazapine 114 Necrophilia 304, 636
tricyclic antidepressants 113f Miscellaneous griefs 388t Nefazodone 114
music therapy 149f Mitgehen 635 Negative
Medical Mitmachen 635 reinforcement 127
disorders 107 Mixed delirium 342 symptoms 19
emergency in psychiatry 376 Modafinil 121 of schizophrenia 627
officer of primary health center 422 Modalities of VAKT technique 318t Negativism 72, 636
Medications for Model of preventive psychiatry 425fc Neo-freudian approaches 31t
ADHD 328fc Modeling 129, 635 Neologism 193, 636
PTSD 256 Models of stress 392t, 398 Nerve cells 41
the treatment-resistant schizophrenia 199f Modified mann’s index of addiction 260f Nervous system 41
Medicolegal issues related to suicide 370 Molindone 107 Neti 161
Meditation 162, 635 Monitoring heart rate 164f Neurasthenia 254, 636
with self-inquiry 163 Monoamine Neurobiology 298
Medroxyprogesterone acetate 288 oxidase 112, 113 Neurochemical 215
Mefloquine 120 inhibitors 113, 115, 222, 441 Neurocognitive disorders 342t
Melancholia 215 Monozygotic twins 208 Neurodegenerative disease 357
Melancholic 215, 635 Mood 16, 205, 635 Neurodevelopmental disorders 21, 22
Melatonin 360 and affect 463 Neuroendocrine 231
Memory systems 346t congruent psychotic symptoms 217 tests 86t
Mental disorders 63 Neuroendocrinology 189
disorders 38 incongruent psychotic symptoms 217 Neuroexamination tray arrangement 80f
health 13, 635 stabilizers 120 Neurofibrillary tangles 626
act (1987) 400, 404, 410t, 413 Morbid jealousy 270, 637 Neuroleptic malignant syndrome 20, 109, 376,
care act (2017) 404, 411t, 413, 423, 635 Motivational enhancement therapy 635 444, 636
continuum 2f Neurolinguistic programming 92, 103, 636
Motor
nursing 15, 635 Neurological
disorders 22
problems in women 438 assessment 78, 89, 556
skills disorders 61
society ghana (MEHSOG) 432 effects on cranial nerves 78t
Mourning 17, 73, 635
team 635 Neurons 41
Moxalactam 268
illness 13, 635 in alzheimer’s disease 354f
Multiaxial system of DSM-IV-TR 60
retardation 61, 312, 309, 336, 623, 635 with action potential 42
Multi-infarct dementia (MID) 642
status Neuropathic gait 81, 640
Multiple
assessment 224t Neuropathological changes
family group therapy 139
examination 72, 89 in alzheimer’s dementia 353
substance abuse disorder 622
(MSE) format 553 Neuropeptides 44, 231
of uncooperative patients 77, 554 Munchausen syndrome 443, 631 Neuroplasticity 42
ventilation and catharsis 466 Muscle Neuroscience and play therapy 146
Mentalization-based therapy (MTP) 298 relaxant 173 Neurotic 215
Mentally challenged individuals 635 strength—strength’s score 81t and stress-related disorders 111
Multidisciplinary team 6 Musculoskeletal disorders 216 defenses 34
Meprobamate 117 Music therapy 635 disorder 229
Meridians 625 Mutism 74, 193, 635 Neuroticism 33
Mesocortical Myoclonus 269 Neurotransmission 42, 636
pathway 190 Myopathic gait 81, 642 Neurotransmitter/s 208, 231, 636
tract 111 and their functions 44t
Mesolimbic binding 43
pathway 190
N in mania 208f
tract 111 Nada yoga 163 packaging 43
Metabolism 110 Naloxone challenge test 275 release 43
Metabotropic receptor 118 Naltrexone 267 synthesis 43
Meta-cognitive therapy 132 Narcissistic personality disorder 635 Nicotine 278, 284, 636
Methaqualone 117 Narcolepsy 636 -related disorders 62
Method/s of Narcotic drugs and psychotropic Niels ryberg finsen 155f
committing suicide 366fc substance act (1985) 408, 413 Night
testing 74 Nasolabial folds 636 eating syndrome 636
Methohexital 117 National terrors 636
Methylenedioxymethamphetamine 281 aids control society (NACO) 438 Nightmares 636
Methylphenidate 276, 328 health policy (NHP) 420 Nigrostriatal pathway 190
Methylphenidine in children 442 institute of mental health and Nigrostriatal tract 111
Metrogyl 268 neurosciences (NIMHANS) 206, 418 Nihilism 19
652 Textbook of Psychiatric Nursing for BSc Nursing Students

Nihilistic delusion 630 Openness 33 Paxil fluoxetine 243

Nitrofurantoin 268 Opioid/s 29, 274, 636 Peculiar changes in brain 353f
Niyama 160 receptors with its significance 275t Pedophilia 304, 637
Nocturnal penile tumescence 86 -related disorders 62 Peer pressure 135
Nonamphetamines 276 Oppositional defiant disorder (ODD) 436 Pelopsia 626, 637
Nonbarbiturate and nonbenzodiazepine Oral and teleopsia 461
anxiolytic agents 117 communication 636 Pemoline 276
Non-organic movements in rabbit syndrome Penile doppler 86
dyspareunia 636 and tardive dyskinesia 470 Pentobarbital 117
vaginismus 636 Organic Performance appraisal 47
Nonsuicidal self injury disorder 629 brain disorder/s 339, 360, 637 Pericyazine 297
Nontherapeutic mental disorders 107 Perinatal causes 310
communication techniques 100 Organization of OSCE 472 Peripheral nervous system (PNS) 41
techniques of communication 100t Orofacial tremors 110 Perseveration 19, 637
techniques 100 Orthostatic hypotension 108 Persistent
Norepinephrine 44, 208 OSCE process 472 delusional disorders 637
-dopamine reuptake inhibitor 121 Othello syndrome 270, 443, 630, 637 somatoform pain disorder 255
reuptake inhibitor (NRI) 121 Otto Persona 30
Normal F Kernberg 34 Personality 30, 291, 304, 637
behavior 636 veraguth’s folds 637 disorders 26, 65, 291, 637
human sexual response cycle 288f Overdose of psychotropic agents 377 Perspectives
pressure hydrocephalus 625 Overt sensitization 130, 637 in personality theory 30f
Norpramin 243 Oxazepam 117 of mental health and mental health nursing 1
Nortriptyline 85, 243 Pervasive developmental disorder 336, 637
Nurse’s -dysgraphia 491
responsibility P
PFROPF schizophrenia 202, 637
after ECT procedure 179t Padahastasana 162 Phantom mirror image 627
before ECT procedure 178t Paddington alcohol test (PAT) 266 Pharmacodynamics 275
during ECT procedure 179t Padmasana 162 of
role to prevent suicide 397 Pagophagia 302 alcohol 263
Nursing Panic 19 antipsychotics 110
care anxiety 637 Pharmacokinetics 212
in attacks 637 of
acute episode 281 disorder severity scale (PDSS) 255 alcohol 263
withdrawal 281 Papaver somniferum 274, 636
plan format 558 antipsychotics 110
Papaverine test 86 Pharyngeal reflex 632
study/clinical presentation format 559 Paracetamol 277, 572, 577
ethics 636 Phases of
Parahippocampal gyrus 189
interventions for alcoholism 264
Paraldehyde 117
antisocial personality disorder 297 assault cycle 372t
Parameters in electroconvulsive therapy 174f
borderline personality disorder 298 biofeedback therapy 165t
Paramnesia 76
management of organic mental disorders 361 crisis 382
Paranoid
Nymphomania 631 grief 390t
personality disorder 637
normal human sexual response cycle 288t
schizophrenia 201, 637
Paraphilias 64 nurse-patient relationship 95f, 95t
O Paraphilic disorders 27, 288t play therapy 145f
Obesity hypoventilation syndrome 303, 637 Parasomnias 64 psychodrama 146f
Obesity 302, 636 Pareidolic illusion 637 schizophrenia 192f
Object Parietal lobe 39 Phencyclidine (PCP) 281
meditation 163 Parish nurse 9 Phendimetrazine 276
relations 55 Parkinson’s disease 72, 357, 361, 625, 637 Phenergan 453
Objective structured clinical evaluation 471 Parkinsonian’s gait 638 Phenobarbital 117, 120
Obsession 74, 238, 255, 636 Parkinsonism 19 Phenothiazines 107, 120
and thought insertion 465 Paroxetine 117, 243 Phentermine 276
Obsessive compulsive Parsvakonasana 162 Phenylketonuria 310, 637
disorder (OCD) 127, 441, 498, 623 Partial Phenytoin 115, 118, 120
personality disorder 636 hospitalization 637 Phobia/s 16, 74
Occipital lobe 39 prothrombin time (PPT) 265 and anxiety 465
Occupational Parts -diagnostic procedure 508
therapy 169, 636 involved in fear network 231f Phobic object 56
activities 170t of a neuron 42f Physical
format 563 of basal ganglia 40f examination 484
process 171 Patellar reflex 637 symptoms in depression 217f
Oculovestibular reflex 628 Pathological defenses 34 Physiology of hyperventilation syndrome 252fc
Olanzapine 107, 240, 346, 441, 451 Patient with Physostigmine 346
Olfactory hallucination 636 bipolar affective disorder 593 Pica 299, 304, 336, 500, 637
Oligophrenia 309 depressive disorder 583 Pick’s disease 355, 625, 637
Omega sign 636 mania 571 Pickwickian syndrome 303, 444, 637
Oneiroid 203 multiple substance use disorder 603 Pigmentary retinopathy 110
schizophrenia 203, 636 OCD personality disorder 480 Pimozide 240
Onset of anxiety disorders 230 undifferentiated schizophrenia 612 Pineal body 40
 Index 653

Pinna 587 Process test 312

Pioneers in psychiatry 188f followed for ECT 175fc therapies 122, 182
Piperazines 107 of trauma 240
Piperidinediones 117 light therapy 156 Psychometric assessment 487, 573, 585
Piperidines 107 occupational therapy 171f report 565
Pipothiazine decanoate 442 recreational therapy 154fc Psychomotor
Placidity 355 social learning 31 agitation 19
Planning 47 recording 17, 102, 104, 638 retardation 19
Plantar reflex 637 format 557 Psychopathology of
Play therapy 144, 145, 183, 637 Procyclidine 119 mental disorders 38
format 563 Product rule 631 schizophrenia 194fc
Polysubstance-related disorder 63 Prognosis of Psychosis 16
Positron emission tomography 231, 298, 350 anxiety disorder 238t and neurosis 459
Possession trance disorder 248 schizophrenia 198t Psychosocial interventions for schizophrenia 198t
Postnatal causes 310 Programs within the milieu therapy unit 136t Psychosomatic model of stress 395t
Postpartum Progressive Psychostimulants 355
blues 638 levels of responsibility 136f Psychosurgery 181, 638
depression 637, 638 nonfluent aphasia (PNFA) 356 Psychosynthesis 53
psychosis 638 Prolonged grief disorder 244 Psychotherapeutic process 122f
Postschizophrenic depression 202, 637 Proponents in psychiatry 565 Psychotherapy 47, 122, 182, 638
Postsynaptic Propranolol 117, 243 for
cell 43 Propulsive gait 81, 638 anxiety disorders 255
neuron 118 Prosopagnosia 347, 638 schizophrenia 199
Post-traumatic Protection of child from of OCD 256
diagnostic scale (PDS) 243 sexual offences (POCSO) act (2012) 402, 413 Psychotic
events 242t Proximity 93, 638 disorder 211
stress disorder (PTSD) 240, 256 Prozac 243 symptoms 195
Posture 93 Pseudobulbar affect-PBA 631, 634 PTSD symptom scale interview (PSS-I) 243
Poverty of Pseudohallucination 638 Puerperal
ideation 638 Pseudoneurotic schizophrenia 202, 297, 638 blues 638
Pseudo- psychosis 638
speech 638
parkinson’s disease 109, 110, 182 Punch-drunk syndrome 443
thought 19
transsexualism 629 Putamen 40
Prader-willi syndrome 310, 444, 638
Psychiatry 638
Pranayama 160, 162
consultation—liaison nurse 9
Pratyahara 160
Prazepam 117
disorder 254 Q
emergency 364, 397
Predisposing factors of delirium 360 Quarterway homes 638
history collection 69, 89
Predominant symptoms of PTSD 242f Quazepam 117
illness in children 438
Premack principle 638 Quetiapine 107, 346, 447, 597
neurosurgeries 181t
Premature ejaculation 638 Quinazolines 117
neurosurgery 638
Premenstrual syndrome 444, 638 Quit smoking 279fc
nurse 16, 635
Premorbid nursing 5, 638
personality 72 care daily checklist 562
assessment 479, 494 R
paraprofessionals 6, 7
Prenatal damage 37 patients 77 Rabbit syndrome 109, 110, 182
Pressure of speech 638 rehabilitation 438 Raja yoga 160
Presynaptic neuron 43 association (PRA) 438 Rapid eye movement (REM) 354
Prevalence of premenstrual Psycho 123 Rating scale in anxiety disorders 236t
dysphoric disorder (PMDD) 434 Psychoanalysis 123, 288 Rational emotive therapy 53, 131
Preventive psychiatry 438, 638 Psychoanalytic Reactive attachment disorder 245
Primary basis of defense mechanism 33 Reality therapy 53, 638
and secondary transsexualism 287t, 464 model 53 Reassurance and false assurance 465
dyslexia 317 theory 30 Receptive aphasia 18
health center (PHC) 419 Psychoanalytical 298 Recovery house 632
prevention interventions 425t counseling 477 Recreational
sleep disorders 64 model 216 activities for various
Principles of psychotherapy 123, 182, 638 psychiatric disorders 154t
cognitive therapy 125 theory 190 therapy 152, 154, 183, 639
dance therapy 150 Psychobiological interventions 47 Recreational 563
mental health 3 Psychodrama 146, 183, 638 Recurrent depression 639
milieu therapy 135 Psychodynamic Reflex hallucination 639
nurse-patient relationship 94 factors of dissociative disorder 247fc Reflexology 169
occupational therapy 170 family therapy 139 Rehabilitation 201, 438, 639
play therapy 145t theories 53 of patient with schizophrenia 201
psychiatric nursing 43 theory of obsessive-compulsive team 438
psychodrama 147 disorder 238fc Rehabilitative nursing 438
psychological tests 87 Psychoeducation 131, 301, 581, 590 Reiki 169
Prion disease 356, 638 Psychological technique 639
Private body talk questionnaire (PBTQ) 301 factors 38 Reinforcement 127
Procainamide 115 pillow 638 Reinforcing stimulus 127
654 Textbook of Psychiatric Nursing for BSc Nursing Students

Relaxation therapy 156, 183, 639 Schizophrenia Sibling rivalry 330

Renal function test (RFT) 84, 89 research foundation (SCARF) 418 disorder 640
Repression 34 spectrum and other psychotic disorders 22 Sibutramine 276
Reproductive child health (RCH) 430 spectrum 21 Side effects of
Research 47 Schizophrenia 18, 189, 344, 625, 639 antidepressants 114t
Residual Schizophrenic symptoms 202 benzodiazepines 119t
schizophrenia 202, 639 Schizophreniform disorder 196, 202, 211, 639 lithium 213f
symptoms 19 Schizotypal personality disorder 639 stimulants 122
Resistance 97, 103, 639 Schneider’s first-rank symptom 193 Sigmund freud’s psychoanalytical theory 30
reaction 394f School Significant features of personality disorders 292
Resource utilization 47 refusal 336 Simple schizophrenia 202, 640
Responses to grief and loss 389f versus truancy 333t Sinequan 243
Responsibilities of a nurse in Scissor gait 81, 639 Single-photon emission computerized
prevention of suicide 370t Scope of psychiatric nursing 8 tomography (SPECT) 350
Restating 98, 104 Scopophilia 642 Sitkarma kapala neti 161
Restraints 373, 639 Score interpretation of Situational inventory of body image dysphoria 301
Retrograde beck depression inventory (BDI) 220t Six branches of yoga 160
amnesia and anterograde amnesia 461 Seasonal affective Skill training program for
amnesia 41, 76, 347, 639 depression 639 children with conduct disorder 323fc
Rett’s syndrome 336, 444, 639 disorder (SAD) 216, 303 Sleep
Review of Secobarbital 117 disorders 64
personality development 30 Secondary in children 334, 336
structure of brain 38 depression 639 terrors 636
Rifampicin 120 dyslexia 317 Smith’s stress model 372, 397
Right/s gain 19 Smoking cessation 279fc
frontal lobe 441 Sedation 109 —6 d technique 279f
of Sedatives 639 Sober house 632
mentally ill 413 and hypnotics 468 Social
patients 405 -hypnotics 271 factors 38
Rinne’s test 639, 79, 80f Sedlackova syndrome 189, 443, 630 readjustment rating scale (SRRS) 392
Risk 222, 223, 436 Seizure 109 skills training 640
Risperidone 107, 323, 454, 575, 607 duration 183 Socioenvironmental model of stress 395fc
decanoate 442 threshold in electroconvulsive therapy 175t Sodium valproate 85, 120, 211, 442
Ritonavir 268 threshold 175f, 183 Soma 41
Robert plutchik 34 Selective Somatic
Roberto assagioli 53 norepinephrine reuptake inhibitors delusion 640
Rogers theory of personality 31 (SNRI) 117 hallucination 640
Role of serotonin reuptake inhibitors 112, 117, 222, 435 symptom
nurse in Semantic differential and related disorders 24, 249
managing the side effects feelings and mood scales 214 disorder 640
of antidepressants 116t Senile gait 81, 628 Somatization 19
psychological therapies 182 Senile squalor syndrome 443 disorder/s 255, 466
the psychiatric nurses 12, 5 Sense of touch and pain 82fc Somatoform 249
therapist in group psychotherapy 143 Sensory gait 81, 639 autonomic dysfunction 257
Romberg test 79, 82, 639 Separation anxiety disorder 324, 336, 640 disorder 256, 640
Ruesch’s theory 91, 103 Serial subtraction test 74 –therapeutic procedure 497
Rum fits 269, 626 Serotonin 44, 112 Somnambulism 334, 640
Rumination norepinephrine reuptake inhibitors Sound
disorder 304 (SNRI) 112, 113, 115 meditation 163
-regurgitation disorder 300 syndrome 20, 377, 444, 640 therapy 642
Russel sign 639 Sertaline 117, 240, 243, 450 South Africa federation association (2014) 4f
Serum Special tests in neurological assessment 82
creatine phosphokinase (CPK) 85 Specific
S glutamic developmental disorders of
Sadism 304, 639 oxaloacetic transaminase (SGOT) 265 scholastic skills 316
Sadomasochism 304, 639 pyruvic transaminase (SGPT) 265 speech and language 315
Samadhi 160 melatonin 86 learning disorder 22
Santhosha 160 prolactin test 86 reading disorder 631
Sarvangasana 162 testosterone 86 Specified neurotic disorders 254t
Sasankasana 162 Sessions in cognitive behavior therapy 131t Split mind 187
Satvavajaya chikitsa 166 Sexual Spotty amnesia 344
Satya 160 and gender identity disorders 64 Stages of
Saucha 160 aversion disorder 640 adolescent substance abuse 261, 262fc
Savant syndrome 443 disorder/s 286, 490 alcohol withdrawal 266f
Savasana 162 dysfunction 288 change model 271f
Scale for assessment of negative symptoms 191 Shankhaprakshalana kriya 161 craving 262f
Schema 131 Shared delusion 18 dance therapy 151f
focused therapy 131 Sheltered workshop 640 dementia 357fc
Schizoaffective disorder/s 196, 211, 639 Short-lived psychosis 203 grief 390t
Schizoid personality disorder 639 Shprintzen syndrome 189, 443, 630 group therapy 141, 142f
-virtual sign identification 510 Shuffling gait 81, 640 guided imagery 159f
 Index 655

mania 207 Sullivan 189 Therapeutic

personality development 32t Sundowner’s syndrome 19 approaches 56
psychotherapeutic process 122 Sundowning syndrome 640 communication 98, 641
therapeutic community 133f Supportive psychotherapy 137, 183, 640 techniques 98t
Stammering 640 Surya community 132, 183, 641
Standards of bhedana 162 impasses 97, 103, 641
administration 51 namaskar 161f procedure 484, 502, 503
education 51 Suryanuloma–viloma 162 relationship 641
evidence-based practice and research 51 Sutra neti 161 serum levels of psychotropic medications 566
practice 51 Swadhyaya 160 use of self-awareness 101
professional performance 47, 51 Sympathomimetic 115 window 111
psychiatric nursing 46 Symptoms of Therapies based on existential theory 53
Status lacunaris 355, 634 a schizophrenia spectrum 197, 198 Thiamine 348
Steppage gait 81, 640 acute stress disorder 246t Thienobenzodiazepine 107
Steps anxiety 232 Thiopentone sodium 117
in neurotransmission process 43f disorder 233t Thiopentone 249
intervention model to resolve the crisis 386fc catatonia 197t Thioridazine 107, 109, 110, 117
of digeorge syndrome 189f Third eye meditation 163
crisis intervention 397 disulfiram ethanol reaction (DER) 267 Thorax 615
effective crisis management 385f PTSD 241, 256 Thought
Stereognosis 82, 640 schizophrenia 193 alienation phenomenon 641
and barognosis 467 schizotypal disorder 195fc block 641
Stereotype behavior 640 sundown syndrome 343f blocking 19
Stereotypical Synaptic transmission 42 broadcasting 641
movements 640 Synonymous terms for echo 641
speech 640 delirium and dementia 341t insertion 641
Stimulant-related disorders 29 Synthetic retardation 641
Stomping gait 81, 639 cathinones 280 withdrawal 641
Strategic family therapy 139 hallucinogens 279 Thyroid
Strategies to Syrup lithium citrate 211 function test (TFT) 85, 89
manage violence 374t System 40 releasing hormone (TRH) 89
prevent assault 375t Systematic desensitization 56, 333 stimulation test 86
Stress 392 Systemic desensitization 128f, 640 stimulating hormone (TSH) 393
reaction 395f Thyrotropin releasing hormone (TRH) 393
responses in alarm reaction 393t Tic/s 328, 336, 641
Stressor 240, 392 T disorders 22, 61
Structural Tactile and tourette syndrome 466
damage to brain 37 gnosis 82, 640 Tobacco 29
family therapy 139 hallucination 641 Todd’s syndrome 443, 626
Structure of Tai-chi’ technique 641 Token
mind 31t Takao syndrome 189, 443, 630 economy 130, 641
personality 53 Tandem walking test 82, 641 system 56
Structured interview for PTSD 243 Tangentiality 19, 641 Tolazamide 268
Stuttering 640 Tantra yoga 160 Tolbutamide 120, 268
/stammering versus cluttering 315t Taoist emptiness meditation 163 Tolerance 641
Subcategories of dyslexia 316fc Tapas 160 Topamax 212
Subcortical leukoencephalopathy 627 Tardive dyskinesia 19, 109, 182 Topiramate 199, 212
Subdivision of pick’s disease 356f Tay-sachs disease 310, 641 Topography of mind 54
Substance Technical staff Total
abuse 640 psychiatric nursing aid 6 electrolytes panel (TEP) 85, 89
based on psychological effects 262fc speech therapist 7 leukocyte count (TLC) 84
codependency 640 Techniques of Tourette syndrome 444, 641
cross tolerance 640 cognitive Toxic epidermal necrosis (TEN) 121
dependence 640 behavioral therapy 131 Toxicology screening 85
detoxification 640 therapy 126 Trachea 587, 615
harmful use 640 counseling 391t Training in community living (TCL) 426
intoxication 377, 640 crisis intervention 386t Trance disorder 248
-related disorders 62 supportive psychotherapy 137 Transactional analysis 91, 103, 641
withdrawal 640 Teleopsia 626, 641 Transaction-based model 394fc
Substituted benzamides 107 Telephone 641 Transcendental meditation 163
Succinylcholine 118 Temazepam 117 Transference 17, 97, 103, 641
Suicidal Temperament 30 and counter transference 464
barometer model 367f Temporal lobe 39, 356 -focused psychotherapy (TFP) 298
ideation 476 Temporary seclusion 135 Transient 194
Suicide 365, 397, 640 Testamentary capacity 641 epileptic amnesia 347, 641
and homicide 466 Testosterone 442 global amnesia 347, 348, 641
intention model 367fc Thalamus 41 situational disturbances 375
prevention and stress helpline numbers 370t Theoretical foundations by sullivan 56 Transsexual 286
Suicidium 365 Theories of Transsexualism 286, 641
Sulfonamides 268 communication 91 Transvestism 641
Sulfonylureas 268 personality development 30 Trataka 161
656 Textbook of Psychiatric Nursing for BSc Nursing Students

Trauma 240 encopresis 332fc Violence 436

- and stressor-related disorders 24, 240 enuresis 331fc Violent behavior and selection
dyslexia 317 family therapy 138 of appropriate medicine 478
symptom checklist for grief 387, 388fc, 398 Viral and bacterial infections 216
children (TSCC) 243 group therapy 141, 142t Virtual sign identification 484
young children (TSCYC) 243 hallucination 75t Visual
Traumatic brain injury 625 homosexuality 287t communication 642
Trazadone 114, 278 illusion 75t hallucination/s 208, 642
Treatment language disorders 316 Vital signs examination tray arrangement 80f
for meditation 163 Volatile solvents 281
antisocial personality disorder 297 music therapy 149 Voyeurism 642
PTSD 256 obsessive-compulsive disorder 239fc, 256 Vyutkrama kapala neti 161
in children 256 personality disorders 293t
of phobias 255
adjustment disorders 256 pica 302 W
alcohol withdrawal 267 play therapy 145 Waddling gait 81, 642
anorexia nervosa 302 psychiatric emergencies 364f Warfarin 115, 268
bipolar disorder 214 psychological tests 87t Waxy flexibility 642
bulimia nervosa 301 PTSD 242fc, 256 Weber’s test 79, 80f, 642
dissociative disorders 257 relaxation therapy 157 and Rinne’s test 469
eating disorders 301 restraints 374fc Wechsler adult intelligence scale 191
-resistant schizophrenia 199 scale used for assessing Wernicke’s encephalopathy 642
Trends in mental health 14 separation anxiety disorder 325t Wernicke-korsakoff syndrome 269
Triazolam 117 schizophrenia 201 Widower’s syndrome 444, 642
Triceps reflex 641 simple phobia 233t William glasser 53
Tricophagia 302 suicide 366t, 397 Wilson’s disease 216
Tricyclic antidepressants 113, 118, 120, 441 Typical Withdrawal effects of
Triglycerides 85, 89 and atypical antipsychotics 467 amphetamine 276
Trihexiphenidyl 119, 273 antipsychotics 107 cocaine 277
Trihexyphenidyl 571, 575, 607, 616 hallucinogens 280
Trikonasana 162 nicotine 278
Truancy 641 U opioids 275
Tryptophan 112 sedatives, hypnotics and
Umbilical hernia 189
regulation concept 342fc antianxiety agents 273fc
Unconscious 34
Tuberoinfundibular 190 stimulants 122
Undifferentiated schizophrenia 202, 642
tract 111 Word salad 642
Unipolar
Twin studies in schizophrenia 188f
depression 642
Tybamate 117
disorder 205
Type/s X
I and type II schizophrenia 203t, 464 Urine analysis 344
Urophagia 302 Xylophagia 302
of
ADHD 326 Urophilia 304, 642
alcoholics anonymous meetings 270 Y
alzheimer’s dementia 353
V Yama 160
amnesia 347f, 361
antidepressants 112 Vaillant’s Yoga 159, 183, 642
antipsychotics 107 categorization of defense mechanisms 34 and exercise 468
anxiety disorders 230, 255 levels of defense mechanism 34f in mental health 162
biofeedback 164fc Vajrasana 162 mudras 162
bipolar Van gogh syndrome 202, 444, 642 sutras of patanjali 159
and related disorders 208 Vascular dementia 355, 642 Young mania rating scale 214, 573
disorder 207fc Velocardiofacial syndrome 189, 443, 630 Yuj 159
catatonic schizophrenia 202fc Venereal disease research laboratory 85, 89 Yuktivyapashraya chikitsa 166
communication 92fc, 92t Venlafaxine 117
coping 396t Ventral tegmental area (VTA) 263
counseling 390 Verapamil 212 Z
crises 383t Verbal communication 642 Zidovudine 120
delirium 343f Verbatim 102, 103 Ziprasidone 107, 447
delusion 75t recording technique 102 Zoloft 243
depression 226fc Verbigeration 642 Zone/s
dissociative Vibrational medicine 642 therapy 169, 642
amnesia 248 Views of psychologists about of
disorders 257 defense mechanism 34 space 94t
eating disorders 304 Viktor e frankl 53 touch 94t
ECT 591 Vilazodone 114 Zoophilia 304, 642