UNIT 3

BY
S. MATENGU
1
UNIT OBJECTIVES
• At the end of this unit, you should be able to:
Classify Psychiatric Disorders
Manage patients with neurotic disorders
Manage patient with psychotic disorders
Apply knowledge and skill of managing a
patient with Psychiatric disorders.

cheelo 2
CLASSIFICATION AND MANAGEMENT
OF PSYCHIATRIC DISORDERS
• There are 2 main classifications:
– Neurosis (Minor Disorders)
– Psychosis (Major Disorders)

Major Mental Disorders (Psychoses) are further

divided into:
Functional psychoses and
Organic psychoses.
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• Functional psychoses are major mental disorders
with no demonstrable physical cause.
• Organic psychoses are major mental disorders
with demonstrable physical cause.

Minor Mental Disorders (Neurotic Disorders) are

classified into:
– Anxiety Disorders
– Obsessive Compulsive Neurotic Disorders
– Hysterical Neurotic Disorders
– Hypochondriasis
– Reactive or Exogenous Depression 4
5
Neurosis (Minor Mental Disorders)
• These are a category of minor mental disorders
in which the symptoms are distressing to the
person, but reality testing is intact and
behaviour does not violet gross social norms
and with no apparent organic cause.
• Neurotic Disorders are classified into:
– Anxiety Disorders
– Obsessive Compulsive Neurotic Disorders
– Hysterical Neurotic Disorders
– Hypochondriasis
– Reactive or Exogenous Depression
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ANXIETY DISORDERS
• Anxiety is a state of apprehension and
impending doom.
• Anxiety Disorders are characterized by their
predominant symptoms of anxiety and
avoidant behaviour (depression).
• Causes of neurotic disorders like anxiety may
be linked to the following:
(i) Emotional conflict
(ii) Maladjustment to life situations
(iii) Some genetic and constitutional factors
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• Anxiety ranges from mild, moderate, severe
and Panic state.
• Panic state is the worst form of anxiety.
• An individual in a panic state is completely
frozen.
• Self awareness is completely absent. He/she
cannot perform and will need assistance to
function.
• Hallucinations can be experienced in a panic
state.

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Classifications of Anxiety Disorders
1. General anxiety disorder (GAD).
• This is when the patient feels apprehensive and
tense for no apparent reason, but usually due to
minor problems.
• The patient may present with the following signs
and symptoms such as : Muscle aches, nausea,
sleep problems.
2. Panic attacks
• These are unexpected attacks of anxiety, often
marked with physical signs and symptom such as
tremors, palpitations and dry mouth.
3. Obsessive compulsive disorders
• This is a condition characterized by repetitive
anxiety driven behaviour such as checking if the
door has been locked or not.
4. Post- traumatic stress disorder
• This is a condition where anxiety is followed by a
traumatic experience such as death of a family
member or being raped.
5. Phobic states
• Excessive and somewhat irrational fear of some
object/situation which is usually so disturbing that
it leads to avoidance of that object/ situation.
• Phobias are categorised into three types, namely
agoraphobia, social phobia and specific phobia.
• The commonest being Specific phobia (intense
fear of particular objects or situations, e.g.
snakes, heights)
• Social Phobia (intense fear of being scrutinized
in social or public, e.g. giving a speech, speaking
in class). An individual fear to be humiliated,
scrutinised, or embarrassed in public for
example, chocking while eating in front of
others, or stumbling while dancing in view of
others.
• Agoraphobia - fear of the market place, of
crowds, of travelling on public transport, and an
avoidance of social situations and a marked
tendency to stay at home, rarely, if ever,
venturing outside.
• Agoraphobia is also defined as fear of places in
which escape might be difficult

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Signs and Symptoms of Anxiety Disorders
• Diaphoresis (profuse sweating)
• Experiencing feelings of unreality about self or
environment.
• Fear of dying or going crazy
• Palpitations or tachycardia
• Shortness of breath and Choking
• Chest discomfort or pain
• Dizziness, unsteady feeling of fainting
• Nausea, abdominal distress or diarrhea
• Flushes or chills
• Trembling or shaking
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Medical Management of Anxiety Disorders
1. Sedatives / Anxiolytics / Hypnotics Drugs
• These are drugs used mainly for the treatment
of acute anxiety and sleep disorders
(insomnia).
• In general, these drugs will:
produce sleep when given in high doses at
night
provide sedation and reduce anxiety when
given in low divided doses during the day.
• Hypnotics should never be used in children,
except in night terrors and sleepwalking.
Examples of Anxiolytic/Hypnotic Drugs:
Benzodiazepines e.g. Diazepam, clonazepam,
alprazolam and Lorazepam
• Mechanism of Action: These drugs reduce
anxiety by stimulating the action of an inhibitory
neurotransmitter called gamma-aminobutyric
acid (GABA) improving symptoms of sleep
disturbances, anxiety, tremor and muscle
tension.
• Adverse Effects: Drowsiness and confusion,
Impaired alertness, Ataxia (poor coordination of
skeletal muscles), Memory difficulties and Hang
over
a.) DIAZEPAM (VALIUM)
• Dose:
• Adult: Anxiety: 2mg PO tds. Insomnia with
anxiety 5-15mg OD nocte. Severe acute anxiety or
panic attack 10mg IV/IM.
• Elderly or debilitated; half adult dose.
• Child: night terrors 1-5mg nocte. Status
epilepticus 1mg/kg IV or Rectally 5mg infants
6months -3yrs; 10mg above 3yrs.
2. Beta-Adrenoceptor blockers e.g. propranolol
• Propranolol is effective in alleviating the
autonomic symptoms of anxiety such as:
Tremor
Palpitations
Sweating
Diarrhoea
3. Antidepressants e.g. Amitriptyline & Buspirone
Amitriptyline Hydrochloride (Elavil)
• Presentation: tablet containing 10mg, 25mg and
50mg, Syrup containing 25mg/5ml. Injection
containing 10mg/ml
• Indication: Anxiety and in depression
• Dose: Adult: Anxiety 10-100mg dose range.
Depression 75mg Po OD. Injection 10-20mg qid.
• Not recommended in children under 16yrs.
BUSPIRONE
• Mechanism of Action- acts by inhibiting the
action of serotonin by binding to serotonin and
dopamine receptors, also increase
norepinephrine metabolism.
• Indications- In anxiety and panic state.
• Dose -Adult dose is 10-15 mg daily in 2 or 3
divided doses. The dose may be increased by 5
mg every 2 to 4 days until an effective dose is
found.
• The maximum adult dose is 60 mg daily, but
most patients respond to 15-30 mg daily in 2 or 3
divided doses.
Other Drugs
– Antidepresants e.g. Citalopram (celexa)
40mg
– Monoamine oxidase inhibitors are used in
clients with severe panic disorders. E.g.
Phelzine (nardil) 45mg

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Nursing Management
• Take full history of the illness including mental
assessment.
• Explore the stimuli that trigger anxiety attacks.
– E.g. have client identify and discuss sources
of frustration, anxiety, conflicts and unmet
needs.
• Teach client ways to inhibit the anxiety
response through the use of problem solving
and logical analysis.
– e.g. coming up with a list of possible
solutions and seeking feedback from others.
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• Specific Nursing management of
manifestations of Anxiety Disorders involves:
• Pharmacotherapy- where drugs of choice are
given as per prescription to relieve the signs
and symptoms following the 6 Rights of drug
administration.
• Cognitive behavioural therapy- involves use
of relaxation exercises and desensitization
combined with IEC aimed at helping the
patient understand that their panic attacks are
a result of misunderstanding their bodily
sensations.
• Exposure therapy can also be used .
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• E.g.:
•Palpitations or tarchycardia and Diaphoresis
(profuse sweating)
I will administer (according to prescription)
Beta-Adrenoceptor blockers e.g. propranolol
which is effective in alleviating the autonomic
symptoms of anxiety such as: Tremor,
Palpitations, Sweating and Diarrhoea.
I will also use cognitive behavioural therapy
which involves use of relaxation exercises and
desensitization combined with IEC aimed at
helping the patient understand that their panic
attacks are a result of misunderstanding their
bodily sensations. 23
If the patient’s panic episode is due
agoraphobia, I will use exposure therapy.
 Since the patient is also sweating profusely, I
will encourage the patient to take a bath,
assisted tab bath or take a cool drink.
• Experiencing feelings of unreality about self or
environment- I will use Cognitive behavioural
therapy to make patient what is going on and
lessen the panic attack.
• Fear of dying or going crazy- Cognitive
behavioural therapy can also be used.

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• Shortness of breath and Choking- I will insure
that the patient assumes a sit up position to
allow easy breathing.
• Dizziness, unsteady feeling of fainting- the
patient’s environment should be free from any
injurious objects and ensure good air circulation.
• I will also promote recognition of the self-limiting
aspect of panic attacks in order for the client to
begin to develop a sense of control over them.
• Instruct the client about relaxation techniques to
eliminate physical tensions that precede panic
attacks.
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• After client achieves control over symptoms,
explore with client the underlying conflicts.
• Encourage the clients to use the group for
support and reassurance.
• Educate family members about panic disorder
and how to work with the client.
• Have family develop effective communication
skills to decrease underlying conflict between
members.
• Promote honest, open expression and
discussion of feelings.
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OBSESSIVE-COMPULSIVE DISORDER
• Is an anxiety disorder characterised by
recurrent and persistent thoughts, ideas and
feelings of obsessions or compulsions
sufficiently severe to cause marked distress,
consume considerable time, or significantly
interfere with the patient’s occupational, social
or interpersonal functioning.
Etiology
Genetic factors- monozygotic twins shows a
higher incidence rate compared to dizygotic
twins 27
Brain injury or disorder- e.g. head trauma,
seizure disorders, Huntington’s disease
Abnormal serotonergic function
Excessive demands during and early intensive
toilet training
Obsession and compulsive criteria
Obsession
• Recurrent and persistent thoughts, impulses,
or images are experienced during the
disturbance as intrusive and inappropriate and
cause marked anxiety or distress.
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• The thoughts, impulses, or images are not
simply excessive worries about real-life
problems.
• The person attempts to ignore or suppress
such thoughts or impulses or to neutralise
them with some other thought or action.
• The person recognises that the obsessional
thought, impulses or images are a product of
one’s own mind.
• For instance, fear of dirt and germs, fear of
burglary or robbery.
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Compulsion
• The person feels driven to perform repetitive
behaviours or mental acts in response to an
obsession or according to rules that one
deems must be applied rigidly.
• The behaviours or mental acts are aimed at
preventing or reducing stress or prevent some
dreaded event or situation; however, these
behaviours or mental acts either are not
connected in a realistic way with what they
are designed to neutralise or prevent or are
clearly excessive.
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Examples
• Excessive hand washing
• Repeated checking of door and window locks.
• Excessive straightening, ordering or of
arranging things.
• Repeated words or prayers silently.

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 Management
Diagnosis
• To diagnose the obsessive compulsive
disorder, the following three features should
be present.
The patient realizes that the feeling, thought
or action is irrational, with a subjective feeling
of compulsion
He has tried to resist it
Resistance leads to an increase in tension or
anxiety
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Treatment
• Pharmacotherapy: anxiolytic drugs, tricyclic
antidepressants are effective in reducing
obsessional symptom.
Tricyclic Antidepressants (such as Amitriptyline,
Imipramine, Clomipramine),
Selective Serotonin(5HT) Re-uptake Inhibitor
(such as fluoxetine and fluvoxamine)
• Behaviour therapy: exposure to any
environmental cues that increase obsessional
rituals
• Psychotherapy:
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Family Therapy
• Because OCD often causes problems in family
life and social adjustment, family therapy is
often advised.
• Family therapy promotes understanding of the
disorder and can help reduce family conflicts.
• It can also motivate family members and teach
them how to help their loved one.
• The nurse educates family members about the
patient’s condition and explains that the patient
needs social support from them as part of
treatment. 34
• She further explains the roles of the family in
patient care as follows:
i) Viewing patient’s obsessive-compulsive
behaviours as symptoms, not character flaws.
The family should remember that their relative is
a person with a disorder, but who is healthy and
able in many other ways and they should focus on
the whole person.
ii) Not allowing OCD to take over family life. As
much as possible, they should keep stress levels
low and family life normal.

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iii) Not participating in patient’s rituals. In order
for people with OCD to make progress, family and
friends must resist helping with habitual
behaviours.
iv) Communicating positively, directly and clearly.
The family should state what they want to happen,
rather than criticizing their relative for past
behaviours.
v) Mixing humour with caring. People with OCD
know how absurd their fears are. They can often
see the funny side of their symptoms, as long as
the humour does not feel disrespectful. Humour
from family members can often help their relative
become more detached from symptoms. 36
Patient Support Groups Group Therapy
• Group therapy is another helpful obsessive-
compulsive disorder treatment.
• Through interaction with fellow OCD sufferers,
group therapy provides support and
encouragement and decreases feelings of
isolation.
• The nurse links the patient and family to any
OCD interest groups nearby to allow them share
experiences and challenges.

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Self-help for OCD
• The mental health nurse can teach patients with
OCD how to deal with obsessive thoughts and
compulsive behaviours in the following ways:
• Educating self: The client should learn everything
he/she can about OCD, read books on the
disorder and talk to your therapist and doctor in
order to better able you will be to manage your
symptoms.
• Practicing the skills learned in therapy. Using the
skills you’ve learned in therapy, actively work
toward eliminating your obsessions and
compulsive behaviours.
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• Staying connected to family and friends.
Obsessions and compulsions can consume
patient’s life to the point of social isolation. In
turn, social isolation can aggravate OCD. It’s
important to have a network of family and
friends whom the patient can turn to for help
and support. Involving others in his/her
treatment can help guard against setbacks and
keep him/her motivated.
• Joining an OCD support group. This reminds the
patient that he/she is not alone in his/her
struggle with OCD, and participating in a
support group is an effective reminder of that.
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• In a support group, he/she can share
experiences and learn from others who are
going through the same thing.
• Practicing relaxation techniques. Meditation,
deep breathing, and other stress relief
techniques may help reduce the symptoms of
anxiety brought on by OCD. Mindfulness
meditation may be particularly helpful to OCD
sufferers.
• ELECTROCONVULSIVE THERAPY (ECT)
• ECT has been found effective in severe and
refractory cases
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DISSOCIATIVE DISORDERS
• The patient behaves as if the brain is not
functioning properly
Dissociative amnesia
• Patients are unable to recall long periods of their
lives and sometime deny any knowledge of their
previous life or personality identity.
Dissociative fugue
• The patient not only looses their memory but also
wander away from their usual surroundings.
• When found, they usually deny all memory of their
whereabouts during the period of wondering and
may also deny knowledge of personal identity. 41
Dissociative stupor
• Patients show the characteristics features of
stupor as in schizophrenia. They are
motionless and mute and do not respond to
stimulation, but they are aware of their
surroundings.
Ganser syndrome
• The patient gives approximate answers to
questions designed to test intellectual
functions. Each answer is one greater than the
correct answer e.g. 2+2=5; 2+5=6
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• A client with dissociative disorder experiences
disturbance in the integrated functions of
memory, identity, consciousness or perception
of the environment.
• This alteration in mental functioning can occur
suddenly or gradually and can progress from a
transient to a chronic condition.
• If there is an alteration in memory, significant
personal events will not be remembered.
• When the disturbance is in the identity, the
person’s usual personality is temporarily
forgotten or a new one may be assumed.
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Nursing Interventions
• Orient client to the current surroundings if
necessary.
• Encourage the client to verbalize emotions.
• Work with the client to identify how the
anxiety is manifested.
• Encourage the client to discuss what is
remembered.
• Instruct the family about the disorder,
treatment and how to cope with the client's
memory.

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HYSTERIA
• Hysteria can be described as a type of
psychoneurosis (minor mental health problem)
causing emotional excitability, such as fear, panic or
disturbance of the sensory, motor and psychic
functions of human beings.
EPIDEMIOLOGY
• It is more common in females than males.
• It is now less seen than 70 years ago when it was
frequent in people.
• Evidence from clinical experience suggests that pain
and the simulation of bodily disease are the
predominant forms of hysteria now manifested by
45
patients.
AETIOLOGY
• Post traumatic conflict or experience.
• Undue stress
• History of past abuse
• Repression of sexual or aggressive behaviour.
Symptoms and Signs
• History may reveal the sudden onset of a
single debilitating sign or symptom that
prevents normal function of the affected body
part, such as paralysis of a leg.

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TYPES OF HYSTERIA
1. SINGLE/INDIVIDUAL/MONO HYSTERIA
• This is when the hysterical symptoms and
signs attack one person at a given time.
2. MASS HYSTERIA
• This is the attack that affects more than one
person at a given time.

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PHASES OF HYSTERIA
1. Conversional Or Physical Phase.
• This phase of hysteria must be distinguished
from psycho physiological disorders which are
mediated by the autonomic nervous system;
from malingering, which is done consciously
and from neurological lesions, which cause
anatomically circumscribed symptoms.
MANIFESTATION OF CONVERSIONAL PHASE
Nausea and vomiting and Abdominal pains,
Loss of libido and Impotence,
Partial paralysis, Temporal blindness,
48
Involuntary eye movements such as, rolling
the eyes inwards.

SPECIFIC FEMALE PHYSICAL SYMPTOMS

• Faintness and Nervousness
• Increased or reduced libido
• Fluid retention
• Heaviness on the abdomen & Poor appetite
• Shortness of breath and Insomnia
• Muscle spasms and Irritability
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2. DISSOCIATIVE OR MENTAL PHASE.
• This is the form of hysterical neurosis in which
alterations of patient’s state of consciousness
or identity to produce such symptoms.
• The primary manifestations are mental or
central nervous system involving in that the
sufferer depicts mental symptoms.
• The various forms of dissociative hysteria
begin and end abruptly.
• The patient rapidly goes into a somnambulistic
state or he suddenly becomes aware that he
has lost his memory for a period of time in the
immediate past.
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3. SOMNAMBULISM
• Here the patient exhibits altered state of
conscious awareness of the surroundings.
• The patient develops vivid hallucinatory
recollections of emotionally traumatic events
in the past of which he may not recall in his
normal awake state.
• This state may occur during sleeping or waking
up hours.
• This should not be confused with episodes of
sleepwalking seen in children.
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• In somnambulism, the patient is out of
contact with the environment in that he/she
looks preoccupied with a private world and
may stare into space or air if eyes are open.
• Patient seems upset, would speak words and
sentences that are frequently hard to
understand, or be involved in a pattern of
seemingly meaningful activities that is
repeated every time an episode occurs.
• This behaviour usually represents the external
manifestations of a hallucinatory re-
experiencing of a traumatic event whose
memories are normally repressed.
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4. AMNESIA
• In localized and general amnesia the patient
suddenly becomes aware he has lost a total
loss of memory for the events of a period of
time covering anything from a few hours
(localized form) to a whole lifetime of
experience (general form).
• The amnesic patient gives no indication that
there is anything wrong and seems entirely
alert both before and after the amnesia
occurs.

53
• In systematized amnesia, the patient loses
memory only for specific and related past
events.
• The patient with continuous amnesia forgets
each successive event as it occurs, though
clearly alert and aware of what is going on
around him.

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5. FUGUE
• Here the patient wanders away from home
and for days at a time.
• During this time, patient is completely
forgetful of his past life and associations, but,
unlike the patient with amnesia, he is unaware
that he has forgotten anything.
• When he comes back to his former self, he
recalls the time antedating the onset of the
fugue itself.

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• Unlike those in somnambulistic state, the
patient in fugue does not behave strangely,
nor does he give evidence of acting out any
specific memory of a traumatic event.
• On the contrary, he leads a quite, prosaic,
seclusive or solitary, works at simple
occupations, lives modestly and does nothing
to attract the attention or suspicion of the
neighbours or friends.

56
6. MULTIPLE PERSONALITY
• In this phase, the patient is dominated by one
of two or more distinct personalities, each of
which determines the nature of his behaviour
and attitudes during the period that it is upper
most in consciousness.
• The transition from one personality to another
is sudden and dramatic in occurrence.
• There is generally amnesia during each state
for the existence of the others and for the
events that took place when another
personality was in the ascendancy.
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• However, one personality state is not bound
by such amnesia and retains complete
awareness of the existence, qualities and
activities of the other personalities.
• The patient shows nothing unusual in his
mental status

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DIAGNOSIS OF HYSTERIA
• A physician should take a thorough history of
the symptoms causing concern to the patient
after which there would be a thorough
physical examination.
• Involve a psychiatrist or psychologist to
evaluate and assess the patient
• It should be borne in mind that it is important
to understand that the patient is disturbed
and wants the problem to go away even if
there are no abnormal findings and not
faking.
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MANAGEMENT
DRUGS
Dopamine, Serotonin, Noradrenaline
• It should be clear that drugs play very little
role in treating the hysterical patient.
However, if there are any features, then
attend to them accordingly.
• Antidepressants if there is depression
• Anxiolitic if there is anxiety.
• Analgesics if there is headache, backache or
body pains.
60
• Psychotherapy is most advisable in helping an
hysterical patient.
• Patient should be encouraged to go through
life daily with a positive attitude.
• In case of a sexual dysfunction in a female,
massage of the genitalia by the psychiatrist or
physician and then later on use of vibrators
and water sprays to cause orgasm can be
done.

61
PRECAUTIONS AGAINST FREQUENT HYSTERIA
ATTACKS
• Avoid extreme change in climate. Hysteria can
be aggravated when it rains too heavily or too
cold.
• Avoid disclosing very shocking news to the
patient.
• Give the patient love, care and attention
because they are always feeling neglected.
• Always keep cool and composed when dealing
with such a patient.
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• Never retaliate with a patient who has
hysterical attack because patient may be
violent.
• When the attack has cleared, try to comfort
the patient with soothing words.
• Physical touch is necessary and expected
because the parasympathetic system stabilizes
the patient.
• Give juices or plain water to regain
composure.
• Do not give coffee or tea because they
aggravate the attack further. 63
Treatment
• Psychotherapy
• Family therapy
• Relaxation therapy
• Behaviour therapy or
• Hypnosis
• Patient may describe a recent and severe
psychologically stressful event that preceded
the symptom.
• Physical examination findings are inconsistent
with the primary symptom e.g tendon reflexes
may be normal in a paralysed part of the body.
64
Nursing intervention
• Help the patient maintain integrity of the
affected system.
• Regularly exercise the paralyzed limbs to
prevent muscle wasting.
• Frequently change the bedridden patient’s
position to prevent pressure ulcers.
• Ensure adequate nutrition, even if the patient
is complaining if GI distress.
• Provide a supportive environment and
encourage the patient to discuss the stress
that provoked the conversion disorder
(hysteria). 65
• Don’t force the patient to talk, but convey a
caring attitude to help him/her share his/her
feelings.
• Don’t insist that the patient use the affected
system.
• This will only anger him/her and prevent a
therapeutic relationship.
• Include the patient’s family in all care.
• They may be part of the patient’s stress and
they are essential to support the patient and
help him regain normal function.
66
COMPLICATIONS
• Severe tear on the heart due to great level of
attacks.
• Stroke and heart attack due to attacks.
• Brain malfunction due to asphyxia
• Permanent paralysis may occur due to
hysterical attacks.

67
Epidemic hysteria
• Occasionally, conversion disorder spreads within a
group of people an epidemic
• This spread happens most often in closed groups of
young women, for example in girls school.
• Usually anxiety has been heightened among the
members of the group by some threat to the
community, such as the possibility of being involved
in an epidemic of actual and serious physical disease
present in the neighborhood.
• Typically the epidemic starts in one person and
spreads to others.
• Symptoms are variable, but fainting and dizziness
are common 68
Management
• Counseling
• Closing the institution for epidemic hysteria
• Carry out appropriate investigations to rule
out physical causes
• Do not neglect the patient
• Treat any form of anxiety

69
Conversion Disorder
• This disorder mimics the effects of physical
illness. The disorder is divided as follows:
With motor symptoms or deficits
• Symptoms include: psychogenic paralysis, gait
disorder, tremor, dysphonia and mutism, and
globus hystericus (feeling of lump in the
throat)
With sensory symptoms or deficits
• Symptoms include: aneasthesia, parasthesia,
hyperaesthesia, pain, deafness and blindness
70
With seizure and convulsions
• Psychogenic convulsions can be distinguished
from epilepsy in three ways;
• The patient does not become unconscious,
though he may inaccessible.
• The pattern of movements does not show a
regular and stereotyped form of seizure
• There is no incontinence, cyanosis, or injury
and tongue is not bitten.

71
EXOGENOUS (REACTIVE, NEUROTIC,
MINOR, SITUATIONAL) DEPRESSION
• This is a neurotic depression that comes about
due to external happenings that may gravely
affect the patient/client and one is aware that
something has gone wrong and so seeks remedy
to the problem.
• Examples of the external happenings are; loss of
a cherished property, loved one, loss of employ.

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AETIOLOGY
HEREDITARY – This is likely to run in family
with some genetically weakness.
PSYCHOLOGICAL FACTORS – Stressful
environments, death of a loved one or loss of
property.
SOCIAL FACTORS - Social isolation,

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SIGNS AND SYMPTOMS
• Feeling fatigued
• Lack of interest in oneself and or surrounding
• Withdrawal/solitariness and Social isolation
• Insomnia
• Lack of or changes in appetite with
corresponding weight loss or gain.
• Miserable mood and Irritability
• Self reproach or self blame
• Low or lack of self esteem & hopelessness
• Feeling of grief and Crying spells 74
• Management
– Psychotherapy. This is the treatment of
choice
– Observe patient closely in case patient has
suicidal ideation

75
MANAGEMENT
• NURSING CARE
• Welcome the patient and the relatives
• Offer them a seat
• Introduce your self
• Take vitals and record them.
• Orient the patient
• Put or nurse patient near the nurses or duty
room.

76
• Never cover the patient’s neck completely
when sleeping
• Patient should be nursed in an open bay for
easy observation even by fellow patients.
• Patient should be weighed every week
• The patient be given small appetizing meals
• Patient be encouraged to eat or be fed.
• Remove the cause of the depression where it
is identified.

77
PSYCHOLOGICAL CARE
• Encourage patient to verbalize
• Involve family members in coming up with
solutions
• Identify their weaknesses and then build them
from there.
• Be empathetic to the patient
• Offer all the techniques of psychotherapy.
• Offer behavioural therapy
• Cognitive therapy is now encouraged.

78
CHEMOTHERAPY
• Tab Imipramine (Tofranil) 25mg – 75mg –
100mg BD, TDS, QID is given.
• Tab Amitriptyline (tripizol) 25mg – 75mg –
100mg BD, TDS, QID
• Tab Thioridazine 25mg -75mg BD, TDS, QID
• Tab Fluoxetine 20mg – 60mg BD, TDS, QID.
• Where the depression is severe and resistant
to drugs then Eletro Convulsive therapy is
done.

79
COMPLICATIONS OF DEPRESSION
• Delirium
• Mental Retardation
• Coma
• Death

80
HYPOCHONDRIASIS
• DEFINITION: Hypochondriasis is an
overwhelming fear that one feels has a serious
disease, even though health care provider can
find no evidence of illness.
• In estimated 75 – 85% of people who have
hypochondriasis also have anxiety, depression or
another mental disorder?
• Hypochondriasis or hypochondria (sometimes
referred to as health phobia or health anxiety)
refers to preoccupancy or worry about having a
serious illness. 81
SIGNS AND SYMPTOMS
• Preoccupation with a serious illness for at least
six (6) months.
• Misinterpreting normal body symptoms.
• Persistent fear of illness despite reassurance of
health status by health care providers.
• Difficulties in maintaining a job, keeping
relationships, and performing daily activities.
• The person may suffer from anxiety, depression
and nervousness.

82
CAUSES
• Hereditary.
• Disturbance in perception such that normal
sensations are magnified.
• The belief that an illness may be deserved due
to some past real or imagined wrong doing.
• Having learned that apparent benefits of being
sick, such as receiving attention and sympathy.
• May be related to another psychiatric illness
such as anxiety or obsessive compulsive or
depression.
• History of physical or sexual abuse.
• A poor ability to express emotions. 83
WHO IS MOST AT RISK
• These factors increase the risk of developing
hypochondriasis:
• Family history of hypochondriasis
• Recent stressful event e.g. due to death of a
close friend or relative.
• Mental illnesses such as anxiety
TREATMENT
• In addition to regular visit with a health care
provider who will take physical symptoms
seriously, people with hypochondriasis may also
benefit from psychotherapy. 84
• People with hypochondriasis often have other
mental health conditions such as anxiety and
depression and treatment of the underlying
condition is important in treating symptoms of
hypochondriasis.
COMPLEMENTARY AND ALTERNATIVE THERAPIES
• Cognitive behavioral therapy and stress
management are the cornerstones of treatment
for hypochondriasis.
• Acupuncture has also been shown to help.
• Similarly, participating in mindfulness
techniques, such as meditation, may help
patients manage symptoms.
85
• Beyond that, few studies have been done on
complementary and alternative therapies for
hypochondriasis.
• Regular appointments with a health care
provider may help relieve health-related fears
because of the regularity of the visits, the
reassurance from a professional, and the focus
on wellness and healthy behaviors.
• Work with someone who is licensed and
reputable to develop a solid program of self-care
and health promotion.

86
DRUG TREATMENT
• Selective serotonin reuptake inhibitors such as
fluoxetine, fluvoxamine are sometimes
prescribed.
• L-theanine 200mg 0.d or .td.s daily for nervous
symptom support.
• Hydroxytrypton (5-HTP) 50MG 2-3 times daily
for mood stability.
• Melotonin 1-6mg at night for sleep.

87
COMPLICATIONS
• Depression
• Anxiety
• Excessive anger and frustration
• Substance abuse e.g. alcohol.
• Prostitutes in women

88
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90
Psychosis (Major Mental Disorders)
• Psychotic disorders are a collection of mental
disorders in which psychosis predominates the
symptom complex.
• Psychosis is general term referring to mental
disorders having marked impairment of
behaviour, perception, mood and/or
intellectual functions.
• Or psychosis is defined as gross impairment to
reality testing.
• The following are the types of psychotic
disorders: Schizophrenia, Schizophreniform
and Schizoaffective disorders. 91
Schizophrenia
• Disorder in which patients presents with
psychotic, social and/or occupational
dysfunction characterized by the presence of
communication, language, thought,
perception, affect and behaviour disturbances
that persist for at least 6 months.
• The cause is idiopathic, but there is clear
inheritable component (familial).
• However, it is believed to have a
neurobiological basis, in which Schizophrenia
is due to hyperactivity in the dopaminergic
pathways.
92
• The theory is consistence with the efficacy of
Antipsychotics (which block dopamine
receptors) and the ability of drugs such as
cocaine or amphetamines that stimulate
dopaminergic activity to induce psychosis.

Clinical Manifestations of Schizophrenia

• Schizophrenia is characterized by positive and
negative symptoms.
• The signs and symptoms persists for at least 6
months.
• The positive symptoms are characterized by
presence of unusual thoughts, perceptions, and
behaviours e.g. :
93
 – Hallucinations (Auditory, visual, olfactory and
tactile hallucinations)
– Thought insertion, withdrawal or broadcasting
– Delusions (gradiose, paranoid, persecutory,
religious, and ideas of reference)
– Bizarre behaviour (Agitation, aggression, odd
clothing, odd social behaviour and repetitive-
stereotyped behaviour)
• The negative symptoms are characterized by:
– Asociality (Social withdrawal or isolation)
– Affective flattening
– Lack of motivation and Alogia (lack of words)
– Poor hygiene
– Hoading (keeping rubbish)
94
PREDISPOSING/RISK FACTORS
• The actual cause of schizophrenia is not known
but there are risk factors associated with
schizophrenia such as;
1. Perinatal
• Perinatal exposure to infections, trauma,
malnutrition during pregnancy or a difference in
rhesus blood factor between the foetus and the
mother, increases the risk for developing
schizophrenia later in life.
2. Social
• Schizophrenia has been found to be associated
with living in an urban environment consistently.
95
• Social disadvantages found to be a risk factors
include poverty, migration related to social
adversity, racial discrimination, family
dysfunction, unemployment or poor housing
conditions.
• In addition, children who experience abuse have
also been found to develop schizophrenia later
in life.
• Unsupportive dysfunctional relationships may
contribute to an increased risk.

96
3. Substance use
• A number of drugs have been associated with
development of schizophrenia such as cannabis
cocaine, and amphetamines.
• Amphetamines trigger the release of dopamine
and excessive dopamine function is believed to
be responsible for many symptoms of
schizophrenia.
• Amphetamines may worsen schizophrenia
symptoms. Schizophrenia can be triggered by
heavy use of hallucinogenic or stimulant drugs
such as cannabis.
97
4. Hereditary
• Several genes interact to generate risk for
schizophrenia.
• Schizophrenia has shown a familial trend
• Genetic evidence has suggested a 28% chance of
one identical twin developing schizophrenia if
the other twin already has it.
5. Psychological factors
• Persons who are withdrawn and have few social
factors (Introverts or Schizoid personalities) are
more prone to develop schizophrenic illness.
98
6. Environment
• There is considerable evidence indicating that stress
may trigger episodes of schizophrenia.
• For example, emotionally turbulent families and
stressful life events conflicts in families,
bereavement, loss of job, divorce, end of
relationship have been shown to be risk factors for
relapses or triggers for episodes of schizophrenia.
• Other factors such as poverty and discrimination
may also be involved.
• This may explain why minority communities have
much higher rates of schizophrenia than when
members of the same ethnic groups are resident in
their home country.
99
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Subtypes of Schizophrenia
1. Simple schizophrenia
• Onset in adolescence ages between 5-19 years.
• The main characteristic here is the state of
fantasizing (called autistic thinking).
• The child withdraws from the rest of the family
member (social withdrawal), prefers remaining
and playing alone with dolls, insects or pets.
• The variety is easily missed by parents, teachers
and even psychiatrists.
101
• The child slowly becomes resistant to advise,
especially concerning bathing or eating.
• The become dirty, and apathetic
• Delusions and hallucinations are uncommon.
• Prognosis very poor.
• Since clear schizophrenic symptoms are
absent, simple schizophrenia is difficult to
identify reliably.
• This may go or drift to another level-
hebephrenia

102
2. Hebephrenic schizophrenia
• This variety begins slowly and as chronic phase
of simple schizophrenia
• Onset is around early 20s or 30s.
• Patients often appear silly and childish in their
behavior.
• It is sometimes referred to as cancer of the
brain (Praecox).
• Hebephrenia is characterized by disorders of
thinking (they usually think in bizarre or strange
manner), emotions (feelings) and behavior.
103
• Patient creates and uses codes and mixes words
or word salad, fails to construct sentences
properly and so talks nonsense which is called
incoherence.
• The distinction between himself/herself and
sister/brother is lost.
• Patient keeps or carries or wears more than
necessary and this is called hoarding.
• There is total personal hygiene negligence in
that patient can live for many years without
bathing at all.
104
• Patient tends to offer inappropriate responses and
this called loosening of association.
• This variety destroys a patient completely in that
he/she fails to function in a normal manner.
• The patients acts and functions far below normal.
• Affective symptoms (flattened affect and
incongruity) and thought disorder are prominent.
Delusion is common and not highly organized.
Hallucinations also are common, and are not
elaborate.
• Though onset is usually insidious, some cases begin
suddenly, with marked depression and anxiety.
• Prognosis is the worst. 105
3. Catatonic schizophrenia
• Onset is at any age, especially early 20s later
and is usually acute.
• Characterized by motor symptoms and by
changes in activity between excitement and
stupor.
• Patient may maintain postures, move very
slowly or no movement at all (stupor).
• Patient may be extremely restless, destructive
to property and violent.
• Patient appears scaring/fierceful.
106
Catatonic stupor or mutism: Patient does not
appreciably respond to the environment or to
the people in it. Despite appearances, these
patients are often thoroughly aware of what is
going on around them.
Catatonic negativism: Patient resists all
directions of physical attempts to move him or
her.
Catatonic rigidity: Patient is physically rigid.
Catatonic posturing: Patient assumes bizarre or
unusual postures.
Catatonic excitement: Patient is extremely
active and excited. 107
• No compromising mood.
• Hears voices that are threatening in nature.
• Personality is preserved; meaning patient
doesn’t deteriorate to a wasted state of mind.
• Can function normally as long as the motor
activity is not involved or disordered.
• The main characteristic is psychomotor
disturbance.
• Patient many have one (or a combination) of
several forms of the following catatonic
symptoms described below:-
108
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4. Paranoid schizophrenia
• Develops later (in the 40s-50s) than other forms
of schizophrenia.
• It is usually sudden onset.
• The cardinal feature in this variety is over or
extreme suspicious behavior.
• The patient may even suspect his/her own
children or the spouse that they want to kill
him/her.
• Auditory hallucinations are prominent of the
patient.
• Patient may hear voices.
• Patient feels controlled by strong forces.
• The most stable and common subtype. Paranoid
delusions are predominant. Patients are often
uncooperative and difficult to deal with and
may be aggressive, angry, or fearful.
• However patient remains in touch with reality
and personality is preserved, but Hallucinations
(auditory) are often present.
• But patient can function very well if he/she is
taking medication regularly.
113
5. Residual schizophrenia
• Patient had met criteria for schizophrenia, but
now resolved., and only remaining with residual
features.
• After many years and repeat episodes, the
active symptoms of schizophrenia ‘burn out’
and the patient displays symptoms of residual
phase (e.g. dullness, social withdrawal, flat or
inappropriate affect, eccentric behavior,
loosening of association, illogical thinking,
lacking in interest, volition or imagination).
114
• It is characterized by emotional blunting, social
withdrawal, eccentric behaviour, illogical
thinking and loosening of association. It is
diagnosed after at least one episode has
occurred.

6. Undifferentiated Schizophrenia
• Most common type
• Patient has hallucinations, disorganised speech,
catatonic behaviour, negative symptoms.
• Criteria for met for paranoid, catatonic or
disorganised.
115
Management of Schizophrenia
Diagnosis
• Schizophrenia is diagnosed clinically based on
the history and mental status examination.
• There are no specific laboratory examinations to
confirm schizophrenia but only to help
differentiate schizophrenia-like psychosis
resulting from medications, substance abuse or
medical conditions.

116
• To make a diagnosis, two or more of the
following criteria must be met:
Hallucinations, delusions, disorganised
speech, grossly disorganised or catatonic
behaviour, or negative symptoms.
• There must also be social and/or
occupational dysfunction.
• The patient must ill for at least 6 months.

117
Blood tests
• Urea and electrolytes to assess kidney
functions.
• Liver function tests to rule out liver diseases of
malfunction.
• RPR (Rapid Plasma Reagent) to rule out
syphilis as the cause of mental confusion.
Radiological tests
• CT (computed tomography) or MRI (magnetic
resonance imaging) to rule out neurological
abnormalities.
• EEG (electroencephalogram) in the history of
seizures.
118
Medical Management
1. Antipsychotic Drugs- Individuals with
Schizophrenia have an increased number of brain
dopamine receptors; hence these drugs block the
dopamine receptors.
• Two types of Antipsychotic drugs:
Typical Antipsychotic drugs (Neuroleptics)-e.g.
Chlorpromazine (Thorazine), Haloperidol
(Haldol), Trifluoperazine (Stelazine), Thiothixene
(Navane), Thioridazine (Mellaril), Perphenazine
(Trilafon), and Fluphenazine (Prolixin).
Atypical Antipsychotics-e.g. Clozapine (Clozaril),
Risperidone (Risperdal) & Olanzapine (Zyprexa).
119
Typical Antipsychotic drugs (Neuroleptics)
• M/A: These drugs are dopamine receptor
blockers (block both D2 and D4 receptors).
• These drugs have a high affinity on D2 than D4
receptors.
• Blockage of dopamine in the cortical and limbic
areas results in reduction in psychotic symptoms
• Whereas blockade of dopamine in the basal
ganglia produces extrapyramidal side effects
(movement disorders).

120
1. Chlorpromazine Hydrochloride (Largatil)
Indications: it is very sedative and used in
psychotic features in which patient is violent.
Also used in intractable hiccup, nausea and
vomiting.
Dose: Adult: in Psychotic features, 50-100mg tds
x 48 hrs or more.
• Acute excitement states, 50mg-100mg IM tds to
a max of 300mg in 24 hours.
• Anti-emetic, 25 to 50mg IM tds
• Side-effects: Sedation, apathy, constipation,
urine retention, hypotension, parkinsonism,
haemolytic anaemia, & cholestasis jaundice. 121
2. Haloperidol (Haldol or Serenace)
Indications: Schizophrenia; mania;
tranquillization and emergency control in
behavioral disturbances.
Dose: Adult; 3 to 20mg daily in divided doses, up
to 100mg daily may be given in clinically healthy
cases.
Side effects: high incidence of movement
disorders, muscle hypotonia, hypotension.
3. Fluphenazine Decanoate (Modecate)
Indications: Schizophrenia and related psychoses
Dose: 12.5mg to 25mg by deep IM injection
every 2 to 5 weeks
4. Trifluoperazine (Stelazine)
• Indications: Schizophrenia and related
psychoses, tranquillization in behavioral
disturbances, short-term adjunction treatment
of severe anxiety
• Dose: Adult; Psychoses, initially 5mg twice daily,
increased by 5mg after 1 week, then at intervals
of 3 days according to the response.
Atypical Antipsychotic drugs
• M/A: These drugs block both dopamine
receptor(block both D2 and D4 receptors) and
Serotonin 5HT2 receptors.
• Serotonin receptor blockade conveys some
protection against extrapyramidal side effects.
1. Clozapine (Clozaril), 150-600mg
2. Risperidone (Risperdal), 1-6mg

124
Nursing Management
• Hospitalization needed for both first episodes of
schizophrenia and acute relapses
• On admission, as the admitting nurse, welcome
the patient and those accompanying him or her,
and offer them where to sit.
• Greet, introduce yourself (name & title), describe
the length and duration of the interview,
• Explain what to expect, assure confidentiality and
explain reasons for note taking.
• All these are done in order to create a
therapeutic rapport with the client. 125
• Schizophrenic patients presents with a variety
of clinical manifestations ranging from positive
to negative signs and symptoms, so quickly
make a brief assessment of the patient’s
behavior so as to derive information used to
identify needs and problems of the patient.
• Also take a brief history either from the patient
or from relatives, and the Physical and Mental
status of the patient can help you come up with
a nursing diagnosis.
• Take vital signs and record them

126
• Do not challenge the content of disorganized
thoughts.
• Encourage client to discuss feelings associated
with disturbing thoughts.
– Discussion of feelings can help focus the
interaction on a reality-based situation.
• Be judicious about touching the client.
– Clients with schizophrenia are mistrustful of
closeness and physical touch can be
threatening.

127
Environment
Risk of Injury
• Reduce environmental stimuli by assigning a
private room possibly with soft lighting, low
noise level as patients respond to even the
slightest stimuli.
• Remove all sharp objects or weapons from
patient’s environment as client’s rationality is
impaired.
• Administer the prescribed drugs to reduce
symptoms and hence reduce chances of injury
128
Observations
• In mental health, Observations are cardinal to
ensure a safe environment for clients and staff alike.
• This is because many Schizophrenic patients lack
insight into their illness and may pose a danger to
themselves and others when measures are not put
in place to watch them carefully.
• Monitor the patient closely to reduce risk of injury
• Assess the physical condition as patient with mental
disorder are not able to tell you what is wrong with
them physically.
• Observations include general condition, mental
state examination, appearance, vital signs, fluid
balance.
129
• Patients with mental disorders like Schizophrenia can
be unpredictable, for example, violent, risk to self
and others, suicidal, destructive to property.
• If the patient is violent or suspicious, quickly sedate
him/her with Diazepam 5-10mg IV/IM stat or
Chlorpromazine 50-100mg IM.
• Offer patient a bed with clean linen and as the
patient is sedated:
 Monitor the vital signs including the side effects of
the drugs
 Give dextrose 5-10% to prevent hypoglycemia
 Bath the patient if dirty and refusing to bath on
his/her own
 Feed the patient if unable to eat on his/her own
130
Nutrition
• Offer small nutritious frequent meals.
• Give the patient food before medications.
• Encourage family to bring patient’s preferred
food and encourage them to eat with him/her.
• Administer drugs like multivitamins promote
appetite.
• Supervise the patient during meals to ensure that
they take adequate food.
• Give dextrose 5-10% to prevent hypoglycemia
• Feed the patient if unable to eat on his/her own
131
Impaired verbal communication.
• Simple adjustments that can help to improve
communication by using communication strategies
such as:
• Using clear short sentences that convey one idea at
a time
• I will use simple words and be patient when
explaining to her as she has decreased
concentration.
• Using a warm tone. I will encourage other health
care workers to keep the voice low and speak slowly
because high sounds will worsen her problem.
• Use of gestures, pictures and body language can
enhance the effectiveness of the message 132
• Explain to the person who you are, what you
want to do and why.
• I will focus and direct the patient’s attention to
concrete things in the environment.
• I will engage Lizzy in group therapy as a way of
establishing and maintaining friendships which
in turn help patient have good communications
and interpersonal relations.

133
• I will incorporate behavioural modification
therapy where abnormal behaviours can be
changed into good or acceptable behavior using
behavior modification skills and principles of
classical and operant conditioning and
modelling.
• I will also have one-one conversations with Lizzy
as this provides a way of examining and
modifying her own thoughts and behavior.
• I will give prescribed mood stabilizers and
antipsychotic drugs when the elevated mood is
coupled with psychosis
134
Medication
• Various Antipsychotic drugs can be used, the drugs
should given following the six rights of drug
administration.
• Patients who are violent or unwilling to comply with
treatment need to be sedated with chlorpromazine
or diazepam.
• Monitor the side effects of the drugs i.e. give
antiparkinsonian drugs (e.g. artane) if side effects of
antipsychotic drugs are troublesome.
• ECT is indicated mainly in catatonic stupor and
severe depressive symptoms.
• Also in patients whose symptoms have not
responded to adequate antipsychotic drug therapy.
135
Social Interaction
• Prepare client for building daily social relationships
by role playing and practicing new skills.
• When the patient begin to stabilize, start short and
long term rehabilitation therapies
• The rehabilitation therapies include:
 Short-term Social Skills such as grooming, wash
cloths, sweeping, holding conversations and
cooking
 Long-term Psychosocial treatments- by using
behavior modification skills and principles of
classical and operant conditioning and modelling.
136
Short-term Social Skills/Rehabilitation
• Schizophrenic patients, do not interact with
others because their social skills are poor, hence
when the patient begin to stabilize, start short
term rehabilitation by:
Holding conversations- this provides a way of
examining and modifying their own thoughts
and behavior.
Group therapy: Establishing and maintaining
friendships- as it will help patient have good
communications and interpersonal relations
Grooming, wash cloths, sweeping and cooking 137
Long-term Psychosocial treatments
• Such as engaging family support, social and
vocational skills training are important in
behavioral modification, and long-term
management of these patients.
• Behavior modification is to change behavior.
• These abnormal behaviours can be changed into
good or acceptable behavior using behavior
modification skills and principles of classical and
operant conditioning and modelling.
• For instance, when it is time to go out for a social
outing, explain to them that they cannot go out
because they are unpleasant to other people.
138
• They will only be able to go out when they stop
treating other people unkindly.
• When patients display good behaviour like
being helpful, being good to others, they can be
positively reinforced by giving them something
they like in the form of food, makeup, a social
outing and so on.
• And when you ignore and do not laugh at a
patient’s unkind jokes that targets vulnerable
patients, the unkind jesting will soon stop.

139
• Modeling: This is a form of learning that is done
by imitating what others are doing. This strategy
is also used to form new behaviour patterns as in
Schizophrenia, patient present with abnormal
behaviour.
• Social learning or modelling can be displayed by
nurses as they interact with patients in the ward
environment.
• As a nurse you can model behaviours like
greeting, politeness to say ‘thank you’.
• You can also model grooming, holding
conversation, and through involving themselves
in the activities of daily leaving in the unit.
140
IEC TO RELATIVES ON DISCHARGE
• Teach them about the illness. The more they
know about the disorder, the better equipped
they will be of help to the patient.
• Be understanding. The family should be there
for the patient to provide a sympathetic ear,
encouragement, or assistance with treatment.
• Be patient. Managing a mental illness is a
lifelong process and therefore the family should
not expect a quick recovery or a permanent cure
• Spend time with the person. Psychiatric
patients often feel isolated and discriminated and
so sharing your company can help them.
141
• Have careful conversation with patient. Since
patients are highly irritable, relative should not
argue or debate with a patient. They should avoid
intense conversation.
• Prepare easy-to-eat foods and drinks
• Avoid subjecting the person to a lot of activity
and stimulation.

142
 BY
S. MATENGU
143
Introduction
• Mood or Affective disorders are characterized by
a disturbance of mood associated with
alterations in behaviour, energy, appetite, sleep
and weight.
• Patients with mood or affective disorders range
from mania (intense excitement and elation) to
severe depressive states.
• In depression, a person becomes persistently
unhappy and sad, with thoughts of taking their
life.
• In general the prognosis is good. 144
Mono-amine theory of Depression
• The brain contains biogenic amines
Norepinephrine (NA) and/or Serotonin(5HT)
which are responsible for the mood and any
reduction in their activity lead to depression and
any elevation leads to mood elevation or mania.
Mechanism of Action of Antidepressants
• These drugs mainly act by elevating the brain
biogenic amines (NA and/or 5HT) by inhibiting
their re-uptake.
• Mood or Affective Disorders are determined by
the patterns of mood episodes.
• Mood disorders are classified in two categories.
These are:-
1. Unipolar Disorders- Major Depressive Disorders
2. Bipolar Disorders:
Bipolar I Disorders- most serious form and
diagnosed at least after one episode of mania.
Bipolar II Disorders- characterised by hypomania
and episodes of major depression.

146
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148
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TYPES OF MOOD DISORDERS

150
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With those illustrated pictures above;
1. What do you think is the problem?
2. What is depression?
3. What are the causes of depression?
4. What are the signs and symptoms of
depression?
5. How would you manage and treat a patient
with depression?
6. What are the complications that can come
about due to depression?

153
TYPES OF MOOD DISORDERS
1. UNIPOLAR DISORDERS (DEPRESSIVE
DISORDERS)
• These include Major Depressive Disorders and
Dysthymias
a.) Major Depressive Disorders
• This is a mood disturbance characterised by
emotional and vegetative changes:
Emotional Features:
Mood: depressed mood, nearly every day
Guilt: Feeling of helplessness, worthlessness or
inappropriate guilt 154
Vegetative Features:
Sleep: Insomnia or hypersomnia
Interest: marked decrease in interest and
pleasure in most activities
Appetite: increased or decreased appetite
 Weight: weight gain or weight loss
Energy/activity: fatigue and loss of libido
Psychomotor: Agitation or Retardation
Concentration: decreased concentration or
increased indecisiveness
Suicidality: recurrent thoughts of death, suicidal
ideation, suicidal plans or suicidal attempts.
155
 b.) Dysthymia
• Dysthymia is a chronic less severe form of major
depression with characterised by depressed
mood for most of the day for at least 2 years.
• Treatment is similar to major depression.

156
Risk Factors/ Causes of Major Depression
• The cause of depression is idiopathic.
• However, there are a number of factors that
may make a person more likely to experience
depression.
• Predisposing Factors
1. Genetic factors which runs in families
2. Biochemical and physiological factors which is a
result of alteration in catecholamine (Nora
adrenaline) and/or serotonin biosynthesis.

157
3. Physical factors such as diseases or disorders
which may directly or indirectly cause a person
become depressed.
4. Psychological factors that may cause a person to
have feelings of helplessness and vulnerability,
anger, hopelessness.
5.Social factors such as family disharmony, parent
neglect, loss of a parent, separation, and loss of
loved one.

158
MANAGEMENT
1. Medical Management
• Investigations
• Diagnosis is based on the criteria documented in
the DSM IV.
• The criteria are that at least 5 of the following
symptoms must have been present during the
same two week period and represent a change
from previous functioning.
• One of the symptoms must be either depressed
mood or loss of interest in previously
pleasurable activities. 159
• Substance abuse disorders and schizophrenia
must be ruled out.
The symptoms are as follows:
• Depressed mood most of the day, nearly every
day .
• Markedly diminished interest or pleasure.
• Significant weight loss or weight gain.
• Insomnia or hyper insomnia, nearly every day.
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness nearly every day.
• Diminished ability to think or concentrate nearly
every day.
160
Treatment
• The treatment goals are:-
1. Relief of psychotic symptoms being exhibited by
the particular patient
2. Return to the highest possible level of
functioning
•The Antidepressants are drugs used in the
treatment of depression.
• These drugs mainly act by elevating the brain
biogenic amines (NA and/or 5HT) by inhibiting
their re-uptake.
161
Examples of Antidepressants
1. Amine Re-uptake Inhibitors (Noradrenaline
(NA) and/or Serotonin (5HT) Re-uptake Inhibitors)
e.g.
Tricyclic Antidepressants (such as Amitriptyline,
Imipramine, Clomipramine),
Selective Serotonin(5HT) Re-uptake Inhibitor
(such as fluoxetine and fluvoxamine)
Inhibitor of both NA and 5HT Re-uptake (such as
Venlafaxine).
• Mechanism of Action- These drugs mainly act by
elevating the brain biogenic amines (NA and/or
5HT) by inhibiting their re-uptake.
a.) Tricyclic Antidepressants-
Amitriptyline (Triptizol, or Elavil)
• Dose: Depression 75mg PO OD. Injection 10-
20mg qid. Dose range(25-150mg) in divided
doses or as a single dose at bed time.
• Side effects: sedation, dry mouth, blurred vision,
nausea, constipation, difficulty in micturition,
postural hypotension, syncope, Erectile or
ejaculation dysfunction.
Imipramine (Tofranil)
• Dose: Depression 75mg PO OD. The dose can be
gradually increased from 150- 200mg). As a
single dose at bed time.
• Side effects: sedation, dry mouth, blurred vision,
nausea, constipation, lowers seizure threshold,
Erectile or ejaculation dysfunction.
b.) Selective Serotonin(5HT) Re-uptake Inhibitor
(such as fluoxetine and fluvoxamine)
Fluoxetine (Prozac)
• This drug act by prolonging the action of
serotonin in the brain.
• Dose: 20- 60mg PO OD in the morning.
• Side effects: nausea and vomiting, diarrhea,
neuroleptic malignancy syndrome, Erectile or
ejaculation dysfunction.
2. Atypical Antidepressants e.g. Mianserin,
Trazodone.
• Mechanism of Action- These drugs act by
blocking alpha2 adrenoceptor activity and
inhibitory alpha2 auto receptors, thereby
increasing NA amounts in the synaptic cleft.
3. Monoamine Oxidase Inhibitors (MAOIs) e.g.
Phenelzine and Moclobemide.
• Mechanism of Action- These drugs inhibits
mono enzyme oxidase for metabolism of
biogenic amines in the nerve endings thereby
increasing the biogenic amine stores in the
cleft.
NURSING MANAGEMENT
• Depressed patients presents with a variety of
clinical manifestations ranging from emotional
to vegetative signs and symptoms of depressed
mood so its important to create a therapeutic
rapport so as the patient can gain trust and
confide in you.
• Also take a brief history either from the patient
or from relatives, and the Physical and Mental
status of the patient can help you come up with
a nursing diagnosis.
• Take vital signs and record them
167
Nursing Diagnoses
1. Self esteem disturbance related to self defeating
thought patterns and behaviours such as feeling
of helplessness, worthlessness or inappropriate
guilt.
• Help the client discover own irrational beliefs or
other cognitive distortions by allowing him to
talk about and writing down his feelings where
possible.
• Assure and counsel the client that they can do
better, its not their fault and that they are
important to alley feelings of helplessness,
worthlessness or inappropriate guilt
168
• Teach the client effective interpersonal
communication
• Encourage the client to talk about past and
present situations that endangered feelings of
self worthy
2. Impaired social interaction related to depressed
mood, marked decrease in interest and pleasure
in most activities, and lack of energy/ fatigue.
• Establish daily interaction time with the client
• Encourage the client to attend group activities.
• Arrange brief visits by a family member or
friend. 169
• Help client to discover and verbalise which
circumstances or stressors result in social with
draw
• Encourage the client to identify and discuss
factors that contribute to problems in social
relationships.
3. Risk for self directed violence related to suicidal
attempts, recurrent thoughts of death, suicidal
ideation, and suicidal plans.
• Remove any object that the patient can use to
commit suicide from the patient’s environment
• Teach the client non destructive methods of
expressing intense emotions and Explore the
feelings of loss and facilitate the grieving process.
170
• Discuss self defeating behaviours, unrealistic
expectations and possible distortions of reality
4. Self-care deficit related to depressed mood,
fatigue/lack of energy and feelings of
helplessness, worthlessness
• Supervise the client’s bathing, grooming and
toileting.
• Give the client small frequent amounts of mixed
diet.
• Monitor the client’s elimination, as inactivity
predisposes to constipation
• Teach the client how to perform or maintain self
care activities 171
5. Impaired sleep pattern related to insomnia or
hypersomnia
• Give diazepam 5-10mg as it produces sleep
when given in high doses at night
6. Impaired cognitive judgement related to
decreased concentration or increased
indecisiveness
• Have enough time and be patient when
explaining to the patient as the patient has
decreased concentration.
• Assist the patient in decision making as the
patient has difficulties with decision making. 172
Rehabilitation
• Rehabilitation is the restoration with the
community’s active involvement of the
individual’s ability to function adequately as a
member of the community.
• There are various approaches that are used in
rehabilitating the mentally ill persons and these
include the following:
– Psychosocial Stimulation: This encourages the
revitalization of the integrity and individuality
of each client.
173
– Social interaction: This can be effective in
drawing individuals out of passive withdrawal,
hostile rejection or channel acting out or
disruptive behaviour through socially
acceptable and mutually rewarding
interpersonal involvement.
– Behaviour modification and habit training:
Support is given to the client to maintain
acceptable behaviour and these increase
functional levels of the clients.
– Sensory Stimulation: Helps the regressed
patient to come back in touch with the
surrounding. 174
– Group Counselling Strategies: -
• Group members can provide both support
and insight for each other.
• Interpersonal skills can be tested in a non-
threatening environment.
• Self esteem and self worth can be
enhanced.

175
IEC TO RELATIVES ON DISCHARGE
• Teach them about the illness. The more they
know about the disorder, the better equipped
they will be of help to the patient.
• Be understanding. The family should be there
for the patient to provide a sympathetic ear,
encouragement, or assistance with treatment.
• Be patient. Managing a mental illness is a
lifelong process and therefore the family should
not expect a quick recovery or a permanent cure
• Spend time with the person. Psychiatric
patients often feel isolated and discriminated and
so sharing your company can help them.
176
• Have careful conversation with patient. Since
patients are highly irritable, relative should not
argue or debate with a patient. They should avoid
intense conversation.
• Prepare easy-to-eat foods and drinks
• Avoid subjecting the person to a lot of activity
and stimulation.

177
cheelo 178
cheelo 179
1. WHAT DO YOU THINK THE PERSONS ABOVE
ARE SUFFERING FROM?
2. WHAT IS MANIA?
3. WHAT ARE THE SIGNS AND SYMPTOMS OF
MANIA?
4. WHAT ARE THE CAUSES OF MANIA?
5. HOW WOULD YOU TREAT AND MANAGE A
PATIENT WITH MANIA?

180
2. Bipolar Disorders:
Bipolar I Disorders- most serious form and
diagnosed at least after one episode of mania.
Bipolar II Disorders- characterised by hypomania
and episodes of major depression.
MANIA
• With manic episode, the client experiences a
euphoric, expansive, or irritable mood.
Clinical Features
– Mood elevation or hyper-excited
– Talkativeness, due to rapid thought process
– Inflated self esteem or grandiosity 181
– Extravagance, due to delusions of importance
and rapid thought process.
– Excessive involvement in pleasurable activities
that have a high potential for painful
consequences such as increased libido
– Weight loss due to hyperactivity
– Insomnia due to rapid thought processes and
hyperactivity
– Increased goal directed activity
– Delusions of importance
– Distractibility or inability to concentrate on
one activity at a time. 182
CAUSES/ RISK FACTORS
• The cause of mania is idiopathic. However, the
following may play a part in the cause of mania:
• Predisposing Factors
– Hereditary incidence of mania is higher in the
maternal side.
– Biochemical factors such as high levels of
norepinephrine, serotonin and dopamine are
associated with mania. Also, intracellular
sodium concentration increases during illness
and returns to normal with recovery.
– Psychological causes. Emotional and physical
trauma such as bereavement, disruption of an
important relationship or severe accident
injury may precede the onset of bipolar.
– Physical factors. These may include;
• Side effects of drugs e.g. Mostly
Amphetamines and Antidepressants.
• Infections such as AIDS and encephalitis.
• Connecting tissue disorders such as
systemic lupus erythmatosus.
• Neurological disorders such as brain
tumours and head injury. 184
MANAGEMENT
Medical Management
Investigations
• Diagnosis is also based on the DSM IV.
• There is an experience of elevated mood.
• During the period of mood disturbance at least
3 of the following must have been present to a
significant degree these include:
Inflated self esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep
185
talking
Flight of ideas
Increased goal directed activity or psychomotor
agitation
Excessive involvement in pleasurable activities
that have a high potential for painful
consequences
Treatment: The treatment goals are:-
Maintenance of safety for the person
experiencing psychosis
Relief of psychotic symptoms
Return to the highest possible level of
functioning 186
Mania without psychotic symptoms
• Patients with Mania without psychotic
symptoms only require mood stabilizers:
Mood Stabilizers e.g. Lithium and
Carbamazepine.
1. Carbamazepine (Tegretol)
• Drug action: Mood stabilizer and anticonvulsant.
• Dose: 200 mg OD PO or 100mg BD PO.
• Side effects: nausea, vomiting, dizziness,bone
marrow depression, stevenson jonhnson
syndrome, impotence.
187
2. Lithium Carbonate
• Dose: 1.5-2g daily but not recommended in
children.
• Side effects: nausea, vomiting, mild diarrhea,
fine tremors, weight gain and oedema
Mania with psychotic symptoms
• This requires treatment with Antipsychotics plus
mood stabilizers.
Antipsychotics
1. Haloperidol (Haldol or Serenace)
Dose: 10mg im stat, then 5mg im tds for 24
hours; then 5mg bd or tds po daily if condition
stabilises..
Side effects: high incidence of movement
disorders, muscle hypotonia, hypotension.
2. Chlorpromazine Hydrochloride (Largatil)
Indications: it is very sedative and used in
psychotic features in which patient is violent.
Also used in intractable hiccup, nausea and
vomiting.
Dose: Adult: Acute excitement states, 50mg-
100mg IM to a max of 300mg in 24 hours.
Side-effects: Sedation, apathy, constipation,
urine retention, hypotension, parkinsonism,
haemolytic anaemia, & cholestasis jaundice.
Mood Stabilizers e.g. Lithium and
Carbamazepine.
1. Carbamazepine (Tegretol)
• Drug action: Mood stabilizer and anticonvulsant.
• Dose: 200 mg OD PO or 100mg BD PO.
• Side effects: nausea, vomiting, dizziness,bone
marrow depression, stevenson jonhnson
syndrome, impotence.

191
2. Lithium Carbonate
• Dose: 1.5-2g daily but not recommended in
children.
• Side effects: nausea, vomiting, mild diarrhea,
fine tremors, weight gain and oedema.
NURSING MANAGEMENT
• Manic patients presents with a variety of clinical
manifestations ranging from mood elevation or
hyper-excitement to psychomotor agitation.
Nursing Diagnoses
1. Self esteem disturbance related to inflated self
esteem or grandiosity, psychomotor agitation
and delusions of importance
• Help the client discover own irrational beliefs or
other cognitive distortions.
• Assist the patient in activities of daily living such
as bathing, feeding. 193
2. Impaired social interaction related to
talkativeness due to rapid thought process and
mood elevation or hyper-excitability.
• Give prescribed mood stabilizers and
antipsychotic drugs when the elevated mood is
coupled with psychosis
• Holding conversations- this provides a way of
examining and modifying their own thoughts
and behavior.
• Group therapy: Establishing and maintaining
friendships- as it will help patient have good
communications and interpersonal relations
194
3. Extravagance, due to delusions of importance
and rapid thought process and excessive
involvement in pleasurable activities that have a
high potential for painful consequences such as
increased libido.
• Incorporate behavioural modification where
abnormal behaviours can be changed into good
or acceptable behavior using behavior
modification skills and principles of classical and
operant conditioning and modelling.
• Give prescribed mood stabilizers so as to
decrease goal directed activities and delusions
of importance. 195
4. Self-care deficit related to depressed mood,
fatigue/lack of energy and feelings of
helplessness, worthlessness
• Supervise the client’s bathing, grooming and
toileting.
• Give the client small frequent amounts of mixed
diet.
• Monitor the client’s elimination, as inactivity
predisposes to constipation
• Teach the client how to perform or maintain self
care activities

196
5. Impaired sleep pattern related to insomnia or
hypersomnia due to rapid thought processes
and hyperactivity
• Encourage client to maintain regular sleep.
• Ensure that patient does not take any alcohol as
this can worsen the condition.
• Give diazepam 5-10mg as it produces sleep
when given in high doses at night
• Or Phenobarbitone 60-180mg OD Nocte.

197
6. Distractibility or inability to concentrate on one
activity at a time due to hyperactivity.
• Have enough time, use simple words and be
patient when explaining to the patient as the
patient has decreased concentration.
• Health care workers should keep the voice low
and speak slowly because high sounds will
worsen he patient’s problem.
• Focus and direct the patient’s attention to
concrete things in the environment.
• Give prescribed mood stabilizers to help calm
the patient and decrease the hyper-activeness. 198
7. Imbalanced nutritrition less than body
requirement due to hyperactivity.
• Provide foods that the patient can eat while
walking e.g fruits, bread, snacks, etc
• Offer small nutritious frequent meals.
• Give the patient food before medications.
• Encourage family to bring patient’s preferred
food to encourage patient to eat.
• Supervise the patient during meals to ensure that
they take adequate food.
Rehabilitation
• Rehabilitation is the restoration with the
community’s active involvement of the
individual’s ability to function adequately as a
member of the community.
• There are various approaches that are used in
rehabilitating the mentally ill persons and these
include the following:
– Psychosocial Stimulation: This encourages the
revitalization of the integrity and individuality
of each client.
200
– Social interaction: This can be effective in
drawing individuals out of passive withdrawal,
hostile rejection or channel acting out or
disruptive behaviour through socially
acceptable and mutually rewarding
interpersonal involvement.
– Behaviour modification and habit training:
Support is given to the client to maintain
acceptable behaviour and these increase
functional levels of the clients.
– Sensory Stimulation: Helps the regressed
patient to come back in touch with the
surrounding. 201
– Group Counselling Strategies: -
• Group members can provide both support
and insight for each other.
• Interpersonal skills can be tested in a non-
threatening environment.
• Self esteem and self worth can be
enhanced.

202
IEC TO RELATIVES ON DISCHARGE
• Teach them about the illness. The more they
know about the disorder, the better equipped
they will be of help to the patient.
• Be understanding. The family should be there
for the patient to provide a sympathetic ear,
encouragement, or assistance with treatment.
• Be patient. Managing a mental illness is a
lifelong process and therefore the family should
not expect a quick recovery or a permanent cure
• Spend time with the person. Psychiatric
patients often feel isolated and discriminated and
so sharing your company can help them.
203
• Have careful conversation with patient. Since
patients are highly irritable, relative should not
argue or debate with a patient. They should avoid
intense conversation.
• Prepare easy-to-eat foods and drinks
• Avoid subjecting the person to a lot of activity
and stimulation.

204
205
PERSONALITY DISORDERS
• Personality disorders are set of mental
disorders, patterns or traits that hinder a
person’s ability to maintain meaningful
relationship, feel fulfilled and enjoy life.
• It is an enduring pattern of inner experience and
behaviour that deviates markedly from the
expectations of the individual’s culture, is
pervasive and inflexible, the onset is in
adolescence or early adulthood, leads to distress
or impairment (Shea et al, 2002).

206
CLASSIFICATION OF PERSONALITY DISORDERS
• According to DSM-IV, there are ten types of
Personality Disorders Classified into three
clusters:

 Cluster A (odd/Eccentric)
• Paranoid personality disorder
• Schizoid personality disorder
• Schizotypal personality disorder

207
 Cluster B (Dramatic/ Emotional)
• Antisocial personality disorder
• Borderline personality disorder
• Histrionic personality disorder
• Narcissistic personality disorder
 Cluster C (Anxious/Fearful)
• Avoidant (Anxious) personality disorder
• Dependent personality disorder
• Obsessive-Compulsive personality disorder

208
AETIOLOGY/ CAUSES/RISK FACTORS OF
PERSONALITY DISORDERS
1. GENETIC FACTORS: genetic factors predispose
to the development of some personality
disorders.
• For instance:
• Cluster A disorders which include paranoid,
schizoid and schizotypal are more common in
biological relatives of schizophrenic patients.
• Cluster B are associated with antisocial,
borderline, histrionic and narcissistic are
associated with antisocial behaviour traits. 209
• Cluster C personality disorders such as obsessive
compulsive, avoidant and dependant have
higher concordance in monozygotic twins.

2. TEMPERAMENTAL FACTORS
• A disparity between the parent and children’s
temperament may lead to personality
difficulties in adulthood.
• A poor match between a temperament and child
bearing practices may lead to certain personality
disorders.
210
3. BIOLOGICAL FACTORS
• The male sex hormones testosterone and 17-
estradiel are associated with aggression and
sexual behaviour in some primates.
• Endorphins (endogenous neurotransmitters)
have effects similar to those of morphine and
other exogenous opiates, are associated with
passive personality traits.
• Low levels of 5-hydro-indole acetic acid (5-
HIAA), a metabolite of serotonin are low in
patients who attempt suicide and those with
impulsive and aggressive traits.
211
TYPES AND CHARACTERISTICS OF PERSONALITY
DISODERS
• According to DSM-IV,
 Cluster A: Odd or Eccentric Behavior
1. Paranoid Personality:
• People with a paranoid personality are
distrustful and suspicious of others, and
anticipate harm and betrayal.
• Based on little or no evidence, they suspect that
others are out to harm them and usually find
hostile or malicious motives behind other
people's actions. 212
• Thus, people with a paranoid personality may
take actions that they feel are justifiable
retaliation but that others find baffling.
• This behavior often leads to rejection by others,
which seems to justify their original feelings.
They are generally cold and distant in their
relationships.
• People with a paranoid personality often take
legal action against others, especially if they feel
righteously indignant.
• They are unable to see their own role in a
conflict. They usually work in relative isolation
and may be highly efficient and conscientious.
213
• E.g. Sometimes people who already feel
alienated because of a defect or handicap (such
as deafness) are more likely to suspect that
other people have negative ideas or attitudes
toward hem.
• Such heightened suspicion, is paranoid
personality if it involves wrongly attributing
malice to others.

214
2. Schizoid Personality Disorder
• People with a schizoid personality are
introverted, withdrawn (emotionally detached),
and solitary (prefer to be left alone).
• They are emotionally cold and socially distant.
They are most often absorbed with their own
thoughts and feelings and are fearful of
closeness and intimacy with others.
• They talk little, prefer theoretical speculation to
practical action. Fantasizing is a common coping
defense mechanism.
215
3. Schizotypal Personality Disorder
• These people have odd thoughts, affects,
perceptions and beliefs
• Some people with a schizotypal personality
show signs of magical thinking that is, they
believe that their thoughts or actions can
control something or someone
• For example, people may believe that they can
harm others by thinking angry thoughts. People
with a schizotypal personality may also have
paranoid ideas.
216
• In addition, they display oddities (peculiarities)
of thinking, perceiving, and communicating
similar to those of people with schizophrenia.
• Although schizotypal personality is sometimes
present in people with schizophrenia before
they become ill, most adults with a schizotypal
personality however do not develop
schizophrenia.

217
 Cluster B: Dramatic or Erratic Behavior
1. Histrionic (Hysterical) Personality
• People with a histrionic personality
conspicuously seek attention (powerful need for
attention), are dramatic and excessively
emotional, and are overly concerned with
appearance.
• Their lively, expressive manner results in easily
established but often superficial and transient
relationships.
• Their expression of emotions often seems
exaggerated, childish, and contrived to evoke
sympathy or attention from others.
218
• People with a histrionic personality are prone to
sexually provocative behavior or to sexualizing
nonsexual relationships.
• However, they may not really want asexual
relationship; rather, their seductive behavior
often masks their wish to be dependent and
protected.
• Some people with a histrionic personality also
are hypochondriacal and exaggerate their
physical problems to get the attention they
need.

219
2. Narcissistic Personality Disorder
• People with a narcissistic personality have a
sense of superiority, a need for admiration,
appear arrogant, entitled and a lack of empathy
or concern for others, but suffer from extremely
low self-esteem.
• Their sense of self-importance is generally
extravagant, and they demand attention and
admiration.
• They have an exaggerated belief in their own
value or importance, which is what therapists
call grandiosity.
• They may be extremely sensitive to failure,
defeat, or criticism. When confronted by a
failure to fulfill their high opinion of themselves,
they can easily become furious or severely
depressed.
• Because they believe themselves to be superior
in their relationships with other people, they
expect to be admired and often suspect that
others envy them.
• They believe they are entitled to having their
needs met without waiting, so they exploit
others, whose needs or beliefs they deem to be
less important.
221
• Their behavior is usually offensive to others,
who view them as being self-centered, arrogant,
or selfish.
• This personality disorder typically occurs in high
achievers, although it may also occur in people
with few achievements.

222
3. Antisocial Personality Disorders
• People with an antisocial personality most of
whom are male, show callous disregard for the
rights and feelings of others, repetitively
disregard the rules and laws of society and
rarely experience remorse for their actions.
• Dishonesty and deceit permeate their
relationships.
• They exploit others for material gain or personal
gratification unlike narcissistic people, who
exploit others because they think their
superiority, justifies it.
223
• People with an antisocial personality are prone
to alcoholism, drug addiction, sexual deviation,
promiscuity, and imprisonment.
• They are likely to fail at their jobs and move from
one area to another.
• They often have a family history of antisocial
behavior, substance abuse, divorce, and physical
abuse.
• As children, many were emotionally neglected
and physically abused.
• These people per have a shorter life expectancy .
• The disorder tends to diminish or stabilize with
age. 224
4. Borderline Personality Disorder
• People with a borderline personality, most of
whom are women, are unstable in their self-
image, moods, behavior, and interpersonal
relationships.
• They are angrier, more impulsive, and more
confused about their identity than are people
with a histrionic personality.
• Borderline personality becomes evident in early
adulthood but becomes less common in older
age groups.
• People with a borderline personality often
report being neglected or abused as children.
225
• Consequently, they feel empty, angry, and
deserving of nurturing.
• When they fear being abandoned by a caring
person, they tend to express inappropriate and
intense anger.
• People with a borderline personality tend to see
events and relationships as black or white, good
or evil, but never neutral.
• When people with a borderline personality feel
abandoned and alone, they may wonder
whether they actually exist (that is, they do not
feel real).
226
• They can become desperately impulsive,
engaging in reckless promiscuity, substance
abuse, or self-mutilation.
• At times they are so out of touch with reality
that they have brief episodes of psychotic
thinking, paranoia, and hallucinations.

227
 Cluster C: Anxious or Inhibited Behavior
1. Avoidant Personality Disorder
• People with an avoidant personality are overly
sensitive to rejection, and they fear starting
relationships or anything new.
• They have a strong desire for affection and
acceptance but avoid intimate relationships and
social situations for fear of disappointment and
criticism.
• Unlike those with a schizoid personality, they are
openly distressed by their isolation and inability
to relate comfortably to others. 228
• Unlike those with a borderline personality, they
do not respond to rejection with anger; instead,
they withdraw and appear shy and timid.
• Avoidant personality is similar to generalized
social phobia.

229
2. Dependent Personality Disorder
• These are extremely needy, relying on others for
emotional support and decision making.
• People with a dependent personality routinely
surrender major decisions and responsibilities to
others and permit the needs of those they
depend on to supersede their own.
• They lack self-confidence and feel intensely
insecure about their ability to take care of
themselves.
• They often protest that they cannot make
decisions and do not know what to do or how to
do it.
230
• This behavior is due partly to a reluctance to
express their views for fear of offending the
people they need and partly to a belief that
others are more capable.
• Sometimes adults with a prolonged illness or
physical handicap develop a dependent
personality.

231
3. Obsessive-Compulsive Personality Disorder
• People with an obsessive-compulsive
personality require a great deal of orderliness,
perfectionism, and control.
• They are reliable, dependable, orderly, and
methodical, but their inflexibility makes them
unable to adapt to change. Because they are
cautious and weigh all aspects of a problem,
they have difficulty making decisions.
• They take their responsibilities seriously, but
because they cannot tolerate mistakes or
imperfection, they often have trouble
completing tasks.
232
• People with an obsessive-compulsive
personality are often high achievers, especially
in the sciences and other intellectually
demanding fields that require order and
attention to detail.
• However, their responsibilities make them so
anxious that they can rarely enjoy their
successes.
• They are uncomfortable with their feelings, with
relationships, and with situations in which they
lack control or must rely on others or in which
events are unpredictable.
233
Other Types of Personality
• Some personality types are not classified as
disorders.
1. Passive-Aggressive (Negativistic) Personality
• People with a passive-aggressive personality
behave in ways that appear inept or passive.
However, these behaviors are actually ways to
avoid responsibility or to control or punish
others.
• People with a passive-aggressive personality
often procrastinate, perform tasks inefficiently,
or claim an implausible disability. 234
• Frequently, they agree to perform tasks they do
not want to perform and then subtly
undermine completion of the tasks.
• Such behavior usually enables them to deny or
conceal hostility or disagreements.
2. Cyclothymic Personality
• People with cyclothymic personality alternate
between high-spirited buoyancy and gloomy
pessimism. Each mood lasts weeks or longer.
• Mood changes occur regularly and without any
identifiable external cause. Many gifted and
creative people have this personality type. 235
3. Depressive Personality
• This personality type is characterized by chronic
moroseness, worry, and self-consciousness.
• People have a pessimistic outlook, which impairs
their initiative and disheartens others.
• To them, satisfaction seems undeserved and
sinful.
• They may unconsciously believe their suffering is
a badge of merit needed to earn the love or
admiration of others.

236
MANAGEMENT OF A PATIENT WITH
PERSONALITY DISORDERS
1. Medical Management
Aim
• Relief of anxiety, depression, and other
distressing symptoms (if present) is the first
goal.
Diagnosis
• History
• The diagnosis of a personality disorder is based
on a person's history, specifically, on repetition
of maladaptive thought or behavior patterns.
237
Treatment modalities
• Medical treatment is difficult because patients
do not perceive self as sick.
• Medications are used for the relieve symptoms:
Mood stabilizers are used for mood instability
and impulsiveness
Benzodiazepines for anxiety and antisocial
behaviours
Low dose Antipsychotics for paranoid
personalities

238
SSRIs for depression, obsessive-compulsive and
eating disturbances
In general, Psychotherapy is recommended for
most personality disorders. Cognitive,
behavioural and family therapies are also used.
Dialectical behavioural therapy was developed
for the treatment of borderline personality
disorders.

239
Nursing Management
1. Impaired social interaction resulting in
argumentativeness, critical comments about
others, aggressiveness and defensiveness
Nursing Interventions
• Use an objective matter of fact, approach with
client to help him identify the nurse as a reliable
person who will respect him without arguments.
• Use concrete specific words rather than global
obstructions.
• Keep verbal and non-verbal messages clear and
consistent. 240
• Conduct brief one to one sessions daily to
decrease fear and anxiety.
• Involve client in communication skills group such
as assertiveness training or any other
associations to help client gain awareness of
personal behaviours contributing to isolation.
• Inform client of the emotional cues he/she is
doing to other such as suspiciousness and
intimidation.
• Self-awareness is enhanced with non-
threatening feedback.
241
2. Impaired Verbal Communication because of
unfriendliness, excessive social anxiety and
fragmented speech patterns.
Nursing Intervention
• Encourage the client to select one activity for
the group (in a support system), three times
weekly.
• Encourage the client to remain out of the room
at least 4 hours daily.
• Encourage the patient to speak for 5 – 10
minutes without introducing circumstantial
material 242
3. Self-care deficit as a result of lack of knowledge,
inadequate living arrangements or lack of
interests and motivation
Nursing Interventions
• Encourage the client to link up with fellow
clients during meals, so as to promote adequate
nutrition and increased social interaction.
• Encourage client to eat 2 to 3 balanced meals
every day.
• Help client prepare a list identifying foods
he/she eats and has access to daily.
243
• Teach client to minimize daily requirements for
an adequate diet and to provide these
requirements from the foods currently used in
the diet.
• Teach client how to chew small bite-sized pieces
of food slowly.

244
4. Personal identity disturbance related to physical
verbal abuse
Nursing Intervention
• Encourage client to discuss personal body
image.
• Help client deal with loss of body image
associated with history of abuse.
• Help client examine belief systems and identify
how perceptions and beliefs influence
responses.
• Encourage client to write an autobiographical
essay or story and give feedback if able to read
and write. 245
• Help client accept disappointment by altering
thoughts within statements like “It will be nice if
……………….” Rather than magnifying loses.
• Encourage participation in a variety of group
situations.
• Provide systematic, concrete self-care
instructions when the client is unable to make
decisions.
• Establish schedules for personal acre activities
and provide sufficient time for client to complete
tasks.
• Teach female clients the appropriate use of
cosmetics and encourage male clients to shave
frequently and care for facial hair. 246
5. Ineffective individual coping because of self-
doubt and the exclusion of self-pleasure
Nursing Interventions
• Encourage physical activity, this reduces tension
and fosters relaxation.
• Discuss with the client on how to recognized
behaviour changes, this strengthens self-
awareness.
• Help client identify coping methods to deal with
stressful situations.

247
• Help client identify feelings of anxiety generated
in stressful situations and the usual responses to
this anxiety, future behaviour can be altered
based on understanding the past.
• Teach clients how to use human in situations of
stress, human and laughter, provide a release of
tension and anxiety.
• Encourage the client to maintain routine
schedules and appointments, consistency
enhances trust and reduces anxiety.

248
Preparation for discharge
• The critical focus of the inpatient stay should be
establishing the involvement of family members,
significant others and follow up providers in
discharge planning that increase the potential
for on-going care.
• The Nurse must be knowledgeable about the
patient’s environment.
• Potential needs and resources are identified on
admission.

249
• Once the Nurse has decided what knowledge,
skills and behaviours can help the patient adapt
to the discharge environment, creative and
purposeful activities to provide the needed
resources are planned.
• Information regarding supportive resources and
medications should be provided to patients and
their families to encourage functional
independence and decrease the chores of
relapse once discharged.

250
• This can significantly influence patient’s ability
to maintain adaptive coping responses.
• Psychiatric discharge planning for personality
disorders can be considered as part of the
psychiatric rehabilitation model that addresses
bio-psychosocial needs in a manner similar to
the physical rehabilitation process.

251
• Areas pertinent to discharge planning that
should be included are:
Medications
Activities of Daily Living
Metal Health Aftercare
Residence
Physical Health Care
Special Education and the need for financial
assistance also should be reviewed with the
patient and family.

252
• Strong communication linkages between
hospital – based and community – based
providers are essential in order to ensure:
Continuity of care
Minimize the value of hospital – based services
and
Minimize future admissions

253
254
cheelo 255
INTRODUCTION
• Organic Brain Syndrome (OBS), also known as
Organic Brain Disease (OBD) are physical
disorders that cause impaired mental function.
• Originally, the term was created to distinguish
physical (termed "organic") causes of mental
impairment from psychiatric (termed
"functional") disorders.
• Organic brain disorders can be found in all age
groups, but the elderly are more susceptible.
• The organic mental disorders fall roughly in two
categories as follows: 256
Acute Organic Brain Syndrome
• This is a recently appearing state of mental
impairment, as a result of intoxication, drug
overdose, infection, pain, and many other
physical problems affecting mental status.
• In medical contexts, "acute" means "of recent
onset".
• A more specific medical term for the acute
subset of organic brain syndromes is Delirium.

257
Chronic Organic Brain Syndrome
• This is long-term. For example, some forms of
chronic drug or alcohol dependence can cause
Organic Brain Syndrome due to their long-lasting
or permanent toxic effects on brain function.
• Other common causes of chronic organic brain
syndrome sometimes listed are the various
types Dementia, which result from permanent
brain damage due to Strokes, Alzheimer's
disease, or other damaging causes which are not
reversible.

258
DEFINITION
• Organic Brain Syndrome (OBS) is a general term
used to describe decreased mental function due
to a physical or medical disease, other than a
psychiatric illness.
• Organic Brain Syndrome is a constellation of
behavioral or psychological signs and symptoms
including problems with attention,
concentration, memory, confusion, anxiety, and
depression caused by transient or permanent
dysfunction of the brain.

259
CAUSES OF ORGANIC BRAIN SYNDROME
a) Drugs
• Steroids- many steroids cause depression
• Isoniazid may cause mania and delirium.
• Excessive caffeine show sign of anxiety,
• Depression and toxicity may be produced by
some hypertensive such as propranolol,
methyldopa.
• Cannabis and Cocaine; these drugs cause
hallucination, distortion of behaviour.
• Sedatives: psychotic behaviour may be caused
by withdrawal of too much sedative medication.
260
b) Lead and Mercury; Cause depression, dementia
and psychosis
c) Toxic Causes : Acute alcohol intoxication and
Excessive alcohol consumption is a prominent
cause of altered mental status.
d) Head Trauma
• Any severe trauma to the head may cause
dementia, delirium or occasionally even
depression.
• Brain injury caused by trauma include;
– intracerebral hemorrhage, subarachnoid
hemorrhage, and subdural hematoma 261
e) Infections
• Infections that cross the blood brain barrier may
precede the onset of psychological symptoms.
• These include :
i) Fungal infections such as cryptococcal
meningitis.
ii) Bacterial infections such as meningitis, syphilis.
iii) Viral infections such as HIV, CMV
f) Breathing conditions
– Low oxygen in the body (hypoxia)
– High carbon dioxide levels (Hypercapnia)
262
g) Neoplasms
• Brain Tumours and Metastatic tumours are
known to cause almost all psychiatric syndromes
including anxiety, depression, delirium, mania,
psychosis and dementia.
h) Nutritional causes.
• Niacin deficiency may cause anxiety irritability,
depression and dementia.
• Folic acid deficiency (Korsakoff’s disease) and
Vitamin B12 deficiency (Wernike’s disease)
• Vitamin B12 and folate deficiencies may cause
dementia and irrational behaviour as well as
depression. 263
i) Collagen Vascular and auto immune
• Systemic lupus erythematosus can cause
different psychiatric syndromes; Memory loss
and confusion, depression, anxiety, and
depersonalization.
j) Congenital and Hereditary
• Some hereditary conditions have been
associated with mental illness. Huntington’s
chorea has presented with personality change,
apathy, quarrelsomeness, paranoia, depression
and anxiety in many patients.
• Others include Down’s syndrome, Wilson’s
disease and Galactocaemia.
264
K) Endocrine
• Several endocrine illnesses can produce
psychotic symptoms e.g. delirium, dementia in
conditions such as Hyperthyroidism,
Hypothyroidism, Cushing syndrome, Diabetes
mellitus.
l) Metabolic
• Uraemia especially when it develops insidiously
can present with lethargy, anorexia, depression
or dementia.
• Cerebral hypoxia, hypercapnia can alter brain
functioning so as to produce confusion and
delirium.
265
J) Cardiovascular disorders such as;
• Abnormal heart rhythm (arrhythmias)
• Brain injury due to high blood pressure
(hypertensive brain injury)
• Dementia due to many strokes (Multi-Infarct
Dementia)
• Heart infections (Endocarditis, Myocarditis)
• Stroke
• Transient ischemic attack (TIA)

266
TYPES OF ORGANIC MENTAL SYNDROMES (OBS)
• There are two main types of OBS:
1. Delirium and
2. Dementia.
3. Amnesia is also another type.
1. Delirium is a reversible state of global cortical
(mental) dysfunction caused by a general
medical condition, substance intoxication and
withdrawal, and/or multifactorial causes
characterised by attention and cognitive
impairments.
267
2. Dementia is an irreversible brain neuronal loss
that may be due to neuronal degeneration or
cell death secondary to a general medical
condition (Alzheimer’s, Vascular, HIV, head
trauma, infarction, hypoxia, infection or
hydrocephalus), substance related, and/or
multifactorial causes characterised by memory
and cognitive impairments.
3. Amnesia is a disorder of memory impairment
alone without cognitive defects.

268
DELIRIUM (ACUTE OBS)
• This is a potentially reversible condition that
usually comes on suddenly; the person has
diminished ability to pay attention and is
confused, disoriented, and unable to think
clearly.
• And Murphy et al (1998) defined delirium as a
reversible state of global cortical dysfunction
characterized by alterations in the attention and
cognition, and produced by a definable
precipitant.
269
• Delirium is of acute onset and, can lead to death
or permanent cognitive decline in some cases if
not treated.
• Delirium should be considered when there is an
acute change in mental status.
• People in old age are at risk.
CAUSES OF DELIRIUM
• Delirium is a syndrome with many causes. Most
frequently, delirium is the result of:
1. General Medical Condition such as:
Infections (UTIs, Meningitis, Sepsis)
270
Metabolic (Hyponatremia, Hepatic
encephalopathy, Hypoxia, Hypoglycaemia, Fluid
imbalance, Uremia, Hypercalcemia)
Postsurgical
Hyper/hypothyroidism
Head trauma
Miscellaneous (Fat embolism, Thiamine
deficiency, Anaemia)

271
2. Substance-Related
Substance Intoxication (Alcohol, Hallucinogens,
Opioids, Marijuana, Stimulants, Sedatives)
Substance Withdrawal (Alcohol,
Benzodiazepines, Barbiturates)
Medication- Induced (Anaesthetics,
Anticholinergics, Meperidine, Antibiotics)
Toxins (Carbon monoxide, Organophosphates)

3. Other Predisposing factors include Old age,

fractures, and pre-existing dementia.
272
CLINICAL FEATURES
• The key features of Delirium are:
Disturbance of Consciousness, especially
attention and arousal
Alterations in cognition, especially memory,
orientation, language, and perception
Acute onset (develop with hours to days)
Presence of medical or substance related
precipitant
In addition, sleep-wake cycle disturbances,
psychomotor agitation may occur.
273
Waxing and waning levels of consciousness
Poor attention, disorientation and confusion
Disturbed memory (long and short term)
Psychosis e.g. Tactile hallucinations
Fearfulness with agitation and aggression
Seriously impaired insight and judgment
Seizures

274
DEMENTIA ( CHRONIC OBS)
• Dementia is characterized by the presence of
memory impairment in the presence of other
cognitive defects.
• Dementia is maladaptive cognitive response
that features a loss of intellectual abilities and
interferes with the patient‘s usual social or
occupational activities.
• These abilities include an impairment of
memory, judgement, and abstract thought.
• The patient with dementia does not have the
clouding of awareness or the rapid onset that is
seen with delirium.
275
• The onset of dementia is usually gradual may
result in progression deterioration or condition
may become stable.
CAUSES OF DEMENTIA
• Generally, dementia is due to neurological
degeneration or cell death secondary to trauma,
infarction, hypoxia, infection, or hydrocephalus.
• Dementia can be caused by a number of disease
processes.
• Approximately 60 per cent of people with
dementia have the following as causes:
276
Alzheimer’s disease, a consequence of
degenerative brain changes as an individual age.
(most common cause of dementia)
Vascular dementia (Cardiovascular or
Cerebrovascular disease) is the second most
cause resulting from small brain infarcts; small
brain hemorrhages.
Parkinson’s disease is also common
Excessive alcohol consumption is another
prevalent cause.

277
• Other illnesses that cause dementia, although
less common include:
Multiple sclerosis
HIV/AIDS
Huntington’s disease
Creutzfeldt-Jacob disease.

278
CLINICAL FEATURES
• Insidious (gradual) onset (weeks to years)
• Short-term memory impairment (Loss of
memory= Amnesia) AND
• At least one of the following cognitive defects:
– Aphasia - language impairments
– Apraxia - motor memory impairments
– Agnosia - sensory memory impairments
– Abstract thinking
• Impairment in social and/or occupational fn
• Not explainable by another disorder 279
TYPES OF DEMENTIA
• There are two main types:
Pre-senile and
Senile Dementia
1. Pre-Senile Dementia
• Comes before age of 65 which is characterized
by gradual decline in personal care, errors in
judgment, impaired capacity for abstract
thought, apathy, irritability, night hallucinations,
and rambling incoherent speech.
• Associated with Alzheimer’s disease.
280
2. Senile Dementia
• Occurs after age 65 as a result of normal age
processes.
• It includes the following characteristics:
• Gradual rise in difficulty in
– thinking,
– Remembering,
– Communicating and
– Relating to others.

281
MANAGEMENT OF DELIRIUM AND DEMENTIA
Medical Management
NOTE: Delirium is often difficult to differentiate
from Dementia, because dementia is a risk
factor for delirium and thus they frequently co-
occur.
1. Diagnosis-
• History Taking- is very important particularly in
regard with the time of onset (usually acute
onset) and pre-existence of dementia, medical
or substance related precipitant.
• History taking can also reveal the symptoms 282
• Mental state examination, Physical examination
and Laboratory investigations are helpful in
identifying general medical and substance
related causes.
• The Laboratory Investigation may include
urinalysis, FBC, ABGs, CX-Ray, EEG.
2. Treatment
• Treat the underlying medical cause or removing
the substance related precipitant
• Must look for medical cause(s) and treat

283
• In general, non-pharmacological approaches are
first-line treatment for behavioural and
psychological symptoms of dementia.
• If symptoms are moderate to severe and impact
on the person’s quality of life or functioning,
medication may be needed, often in conjunction
with non-pharmacological interventions.
NON-PHARMACOLOGICAL STRATEGIES
Communication strategies should include using
clear, plain language and short sentences that
convey one idea at a time.
Use of gestures, pictures and body language
can enhance the effectiveness of the message.
284
• Drugs such as Cholinesterase inhibitors (such
as:
Donepezil (23mg PO OD),
Galantamine (4mg BD for several weeks, then
increased to 8-12mg BD PO)
And/or Rivastigmine (1.5mg PO OD)) may
help to slow the progress of the disease in the
early stages.
• These drugs work by preventing breakdown of
the neurotransmitter acetylcholine, which is
needed for cognitive function.
285
Memantine is another cholinesterase inhibitor
(Dose: tablets 5mg OD, increased to 5mg BD,
or capsules 7mg OD, dosed increased weekly
by 7mg OD until maximum dose of 28mg OD
is reached).
• This drug inhibits the release of glutamate (a
neurotransmitter), is indicated for more
advanced disease and may be used in
conjunction with a cholinesterase inhibitor.
• It disrupts the release of toxic levels of
glutamate which damage brain cells.

286
• A cocktail of vitamins, such as Folic acid 5mg
OD for 1 month, B12 and B6 1 tab OD for a
month improves memory.
• This treatment has to be given simultaneously
once daily (OD) for one month and then the
client to be observed for signs of
improvement.
• Antipsychotic medication is most effective in
the treatment of Dementia/Delirium Psychotic
symptoms (such as hallucinations and
delusions) and behavioural symptoms (such as
physical aggression.
287
NURSING MANAGEMENT OF DELIRIUM AND
DEMENTIA
Environment
• Provide an environment that supports flexible
but anticipated routines:
• Bed space should be easily differentiated from
others through use of colour codes or pictures
to orient the patient as they have memory
problems
• Bed space and toilet should be signposted
• Provide orientating cues such as a clock and
calendar. 288
• Levels of light and noise should be maintained
as patients with dementia and delirium are
sometimes agitated.
• Check noise levels regularly and reduce them
if necessary by turning off the radio and
television.
Communication
• Communication is central to high quality
nursing care:
• Simple adjustments that can help to improve
communication in patients with short-term
memory impairments (dementia) include
Communication strategies such as:
289
• Using clear short sentences that convey one
idea at a time
• Using plain language or familiar vocabulary
• Using a warm tone
• Use of gestures, pictures and body language
can enhance the effectiveness of the message
• Explain to the person who you are, what you
want to do and why.
• Smile — the person is likely to take cues from
you, and will mirror your relaxed and positive
body language and tone of voice.
290
• It is important to be patient while having a
conversation with these patients e.g. have
time for them to reply, and listen carefully.
• Avoid questions that might be difficult for the
patient.
Medication
• Patients with dementia often have problems
taking medication because of forgetting. This
means they may forget to take them or have
already taken them and inadvertently take an
additional dose. So this as a nurse needs to be
ascertained.
291
Nutrition
• Monitor food and fluid intake and elimination
— dehydration or constipation can exacerbate
confusion.
• Poor controlled glucose levels can affect
orientation and memory.
• Hence hypoglycaemia and hyperglycaemia
should be avoided.

292
Pain Management
• Patients with dementia may have the inability
to express pain verbally and may lead to
behaviour that can be difficult for nurses to
cope with.
• E.g. shouting or hitting out, protecting the
body, wandering, grimacing or groaning.

293
Depression can be treated with low dose of
antidepressants like sertraline
Agitation and Psychotic symptoms can be
treated with low doses of antipsychotic like
Risperidone and haloperidol.
Comfort measures include reorientation
strategies, reducing stimulation, frequent
reassurance

294
GUIDELINES FOR RESPONDING TO A PERSON
WITH DEMENTIA
Arrange for a review of the person’s medication
and an initial or follow-up psychiatric
assessment if their care plan needs reviewing.
A mental health assessment may be appropriate
to undertake.
A person’s cultural background can influence the
way symptoms of mental illness are expressed
or understood.
It is essential to take this into account when
formulating diagnosis and care plans. 295
Explain to the person who you are, what you
want to do and why.
Smile — the person is likely to take cues from
you, and will mirror your relaxed and positive
body language and tone of voice.
Move slowly, you may have a lot to do and be in
a hurry, but the person is not. Imagine how you
would feel if someone came into your bedroom,
pulled back your blankets and started pulling
you out of bed without even giving you time to
wake up properly.

296
If the person is resistant or aggressive but is not
causing harm, leave him or her alone. Give the
person time to settle down and approach the
task later.
Distract the person by talking about things he or
she enjoyed in the past and by giving him or her
a face washer or something to hold while you
are providing care.
Do not argue with the person. The brain of a
person with dementia tells the person that he or
she cannot be wrong.

297
If the person is agitated, maintain a quiet
environment. Check noise levels regularly and
reduce them if necessary by turning off the
radio and television.
Provide orientating cues such as a clock and
calendar.
Give the person a comfortable space. Any
activity that involves invasion of personal space
increases the risk of assault and aggression.
Always provide care from the side (not the front)
of the person. If you stand in front, you are
easily hit or kicked if the person becomes
aggressive.
298
Be vigilant if the person is climbing out of bed.
Refer to your workplace policy on restraint. If
you cannot work out a reason for this behaviour,
you might walk with the person or engage him
or her in an activity. This helps to maintain his or
her mobility, and eventually he or she may tire
and go back to bed. Encourage family or
volunteers to help with this.
Monitor compliance with medication and
general physical health (including nutrition,
weight, blood pressure, etc).
Monitor food and fluid intake and elimination —
dehydration or constipation can exacerbate
confusion. 299
People with dementia are at increased risk of
developing delirium, so be aware of risk factors
for delirium (such as medication interactions,
infection and the postoperative period).
Provide family members and careers with
information about the illness if appropriate, as
well as reassure and validate their experiences
with the person.
Encourage family members and careers to look
after themselves and seek support if required.

300
Be aware of your own feelings when nursing a
patient with dementia. Arrange for debriefing
for yourself or any colleague who may need
support or assistance — this may occur with a
clinical super visor or an Employee Assistance
Service counsellor

301
 Delirium vs Dementia (summary)
• General rules of thumb:
Delirium Dementia
Acute Chronic
Reversible Irreversible
Physiological Structural
Primary attention Primary memory

• Delirium and dementia can coexist; in fact

delirium is very common in demented patients
302
AMNESTIC SYNDROME (AMNESIA)
• Amnestic disorder is an isolated disturbance of
memory without impairment of other cognitive
functions (Murphy 1998).
• Amnestic disorders are caused usually by:
General medical conditions
Or substance related causes.
• General medical conditions include head
trauma, hypoxia, viral encephalitis and posterior
artery infarction.

303
CLINICAL FEATURE
• It is type of memory impairment in short and
long memory which is due to specific organic
factor.
• Patient is not able to learn new information or
to recall previously learned information.

304
MANAGEMENT
• Treat the underlying medical condition, and in
case of substance related Amnestic disorder,
avoid exposure.
• Pharmacotherapy is directed at relieving signs
and symptoms, commonly anxiety and mood
disturbance.
• Patients should be placed in a safe, structured
environment with frequent memory cues.

305
• REHABILITATION FOR PATIENTS WITH OBS
• Rehabilitation is the process of helping the
person return to the highest possible level of
functioning.
• This requires the nurse to focus on there (3)
elements, the individual, family and community.
1. THE INDIVIDUAL
• The nurse identifies and reinforces measures to
help patient cope with the condition at home E.G
Occupational Therapy- This is rehabilitating a
client in the use of activities of daily living e.g.
washing of clothes, shopping, food preparation,
knitting etc. 306
Recreational Therapy-
• This involves taking the patients out for outdoor
activities such as; watching movies, sports
dancing etc.
 Bibiliotherapy-
• This includes use of different literature for
clients who are able to read and write.
• They can be given novels and other interesting
books to read.

307
2) FAMILY
• It is important to educate the family in the care
of the client as it is going to offer lifelong
support to the client.
• Education for family members includes
information about disease and training in coping
skills, nurses should offer expertise to families in
the area of communication skills.
• Families taking care of mentally ill patients often
feel isolated in dealing with the challenges of
care.
• Therefore, the family needs assistance in
rebuilding their social support.
308
3) THE COMMUNITY
• The social amenities of well-integrated
communities as well as work opportunities
should be open to the public and to the
mentally ill.
• The mentally ill should also be linked to support
groups existing in the community, if not
available work with the community to have
them established.

309
 DISCHARGE PLAN
• Discharge plan is the process that incorporates
the assessment of the patient’s needs with
inputs from patients, significant others and the
health care team which results in a plan to co-
ordinate available resources to meet patient
needs.
• Discharge plan should be initiated on admission
by involving the patent and family members to
prepare for continuity of care after discharge.

310
• There is need to have an in depth assessment of
the patient so that the nurse builds rapport with
the patient and know his needs.
• The discharge plan is done by a team of health
care providers and the nurse is the co-
coordinator.
• Successful discharge planning depends on the
exchange of information among the client, the
care givers and those responsible for care of
clients in hospital and at home.

311
HEALTH EDUCATION ON DISCHARGE
1. Written instructions about drug administration
must be given to the patient and relatives
clearly specifying the dose, route etc.
2. The importance of prolonged therapy and side
effects of drugs are explained to the patient and
relatives.
3. The importance of coming for review is
explained to the patient and relatives.
4. The relatives are encouraged to provide a
balanced diet for the patient to enhance
healing. 312
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HIV/AIDS RELATED PSYCHOSIS
Introduction
• People with HIV infection are at risk of
developing psychiatric symptoms and disorders
similar to those seen in general population.
• Symptoms of anxiety and depression may be
related to apprehension about the disease
progression and death, sadness from loss of
health and the virus invading the central
nervous system.

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• Psychosis is more common among people with
HIV infection is due to the contributing factors
that may include:
Direct effect of HIV on CNS,
Opportunistic infection,
CNS neoplasm,
ART medications especially EFV,
Substance use disorder and
Other psychological stresses.

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MANAGEMENT OF PSYCHOSIS IN HIV INFECTED
INDIVIDUALS
• EVALUATION: The clinical evaluation of HIV-
AIDS patients with psychotic symptoms requires
broad history taking and physical examination,
to rule out other known causes of psychosis.
• A careful history should include information
about the onset and course of the patient’s
symptoms.
• Signs of medical illness, drug intoxication, or
medication toxicity should be considered during
the examination.
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MANAGEMENT
Investigations
(i) History Taking
• This involves the past and present medical
history.
• Family mental history
• Social history will look at habits like substance
abuse i.e., smoking and drinking
• Trauma, to the head e.g. Head injury.
ii) Physical examination
• General survery, examine the patient head to
toe to rule out infections.
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(iii) Laboratory Investigations
• Full Blood count to rule out infections
• Blood slide to rule out malaria, complicated into
cerebral malaria.
• Rapid Plasma Reagin to rule out syphilis.
• LFTs / U + E and creatinine tests prior to
treatment.
• Blood for CAT (Cryptococcal antigen test).
• CSF analysis
(iv) Skull X-ray
• To exclude trauma to the skull.
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(v) Computed Tomography Scan / Magnetic
Resonance Imaging
• -May show space occupying lesions (SOL) in the
brain or presence of neoplasm.
(vi) Electroencephalogram (EEG) - To assess
electrical impulses from the brain.

2) Medical Management
• Treatment depends on the disorder.
• Many of the disorders are treated mainly with
rehabilitation and supportive care to assist the
person in areas where brain function is lost.
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TREATMENT
• Medication side-effects and drug–drug
interactions are important considerations when
patients are prescribed antipsychotic agents for
the treatment of new-onset psychosis while
concomitantly receiving HAART.
• For example, the enzymatic inhibition seen with
protease inhibitors may lead to increased serum
levels of antipsychotic agents and a greater
potential for side-effects.
• Hence, pharmacological considerations should
be considered when prescribing these drugs.
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• As patients with HIV-associated psychosis are
more sensitive to extrapyramidal side effects, so
they require lower doses than other patients
with psychosis.
• The use of atypical antipsychotics in the
treatment of new-onset psychosis in HIV
positive persons has proven helpful in reducing
cases of extrapyramidal symptoms.
• For example the use of Risperidone (1mg-3.3
mg), Olanzapine (10 mg) and Clozapine (mean
27 mg) given in smaller dosages minimize
extrapyramidal symptoms.
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• Thus, since pts with HIV-associated psychosis
are more sensitive to extrapyramidal side
effects, they need lower doses of antipsychotic
drugs than other patients’ with psychosis.
• Also some antiretroviral agents (e.g. AZT, EFV)
cause CNS effects (e.g. nightmares,
hallucinations) may also complicate the
treatment of psychiatric disorders.
• Hence a preferred ART regimen for a patient
with HIV Psychosis in HIV/AIDS is: First line ART:
TDF+FTC+ NVP
OR Alternative ARVs: ABC + 3TC + NVP , if pt
has renal issuficiency
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Tenofovir (TDF)
• Dosage; PO 300mg OD
Emtricitabine (FTC)(emtrivia)
• Dosage; 200mg daily
Lamivudine (3TC)
• Dose; Adult: 150mg BD or 300mg once daily,
Nevirapine (NVP)
• Dose: 200mg OD PO daily
Abacavir(ABC)
• Dose; 300mg BD or 600mg OD
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