Care and management of and other minor mental disorder | CHAPTER 4 | Psychiatric nursing

Care and management of and other minor mental disorder– This book covers the entire syllabus of “Psychiatric Nursing” prescribed by the Universities of Bangladesh- for Basic and diploma nursing students. We tried to accommodate the latest information and topics. This book is an examination-friendly setup according to the teachers’ lectures and examination questions.

At the end of the book previous university questions are given. We hope in touch with the book students’ knowledge will be upgraded and flourish. The unique way of presentation may make your reading of the book a pleasurable experience.

Care and management of and other minor mental disorder

Obsession:

Recurrent and persistent ideas, thoughts, impulses or images that are experienced at some time during the disturbance, as intrusive and inappropriate that causes marked distress or anxiety, e.g. thoughts of committing violence.

Or

The personal attempts to ignore or suppress such thoughts, impulses or images to neutralize them with some other thought or action.

(Ref: KP Neeraja/1/Vol-2/430)

Compulsion:

Repetitive behaviour or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

Or

Mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation, however these mental acts either or not connected in a realistic way with what they are designed to neutralize or prevent clearly excessive.

[Ref: KP Neeraja/1″/Vol-2/430]

A compulsion is a repetitive act carried out in a stereotyped manner. It may manifest itself as repeated washing of hands, a long time over baths, repeated checking or counting, setting in order or arranging compulsive urge to tell or ask something or confess.ettod

[Ref: S Nambi/24/58)

Obsessive compulsive disorder (OCD):

OCD is a psychiatric anxiety disorder, characterized by a subject’s obsessive, distressing, intrusive thoughts and related compulsions/tasks/rituals attempt to neutralize the obsessions. Obsession and compulsions are source of distress, time consuming and causes impairment in individual’s ability socially, occupational and school functioning

Ref: KP Neeraja/1/Vol-2/430)

Or

This disorder is characterized by persistent and uncontrollable thoughts and irrational beliefs that cause an individual to perform compulsive rituals that interferes with his or her daily life. Patients have either recurrent, persistent ideas, thoughts or images (obsessions), or repetitive, stereotyped, seemingly purposeless behavior (compulsions).

[Ref: S Nambi/2/58)

It is characterized by obsessive thoughts which are recurrent, unwanted and usually anxiety provoking, and by compulsions which are repeated acts performed to relieve feelings of tension.

[Ref-Davidson’s/24 edition)

Causes of OCD:

1. Autoimmune responses to group a streptococcal infection. 2. Unconscious conflicts manifested as OCD symptoms (Sigmund Freud). 1019

3. Abnormality in the neurotransmitter serotonin or blocked or damaged receptor sites that prevent serotonin from functioning to its full potential.

4. Miscommunication between the orbital-frontal cortex, the caudate nucleus and the thalamus may be a factor.

5. Familial origin, in monozygotic twins, 1 degree relatives of OCD clients the disease is common.

6. Mower’s 2 stage theory: Role of exposure and response prevention.

7. A neutral stimulus become associated with fear, as it occurs with an event, which provokes discomfort. Due to this association, various objects, thoughts, images also capable of causing discomfort.

8. Responses that reduce anxiety or discomfort are developed and maintained.

9. Psychological factors

10. Maladaptive thinking and learning; strained interpersonal relationship, stress.

[Ref: KP Neeraja/I/Vol-2/431-432)

Principle features of OCD:

1. Severe anxiety, worry, or distress

2. Avoidant behavior

3. Excessive time spent on parts of daily routine, that is, showering, cleaning

4. Obsessions and compulsions

5. Odd or excessive behaviors

6. Significant impairment (i.e., patient is unable to work/attend school or participate in social activities).

[Ref: Clinical Consult to Psychiatric Nursing/1/213)

Or

Principal features of obsessive compulsive disorder:

✓ Obsessional symptoms.

✓ Thoughts.

✓ Ruminations.

✓ Impulses.

✓ Phobias.

✓ Compulsive rituals

✓Abnormal slowness.

✓ Anxiety.

✓ Depression.

✓ Depersonalization.

[Ref-Michael Gelder/5th/196]

Clinical features of OCD:

OCD sufferers performs task or compulsions to seek relief from obsession related anxiety – like

1. Repeatedly checking that one’s parked car is locked before leaving 2. Turning lights on and off a set number of times before exiting the room

3. Repeatedly washing hands at regular intervals throughout the day.

4. Rearranging matters rigidly

Obsessional rituals-

1. Repeated clearing of the throat, although nothing may need to be cleared

2. Specific counting systems, e.g. counting in groups of 4, arranging objects in groups of 3, grouping objects in odd/even numbered groups etc.

3. Perfectly aligning objects at complete, absolute right angles or Parallel

4. A fear of contamination – some sufferers may fear the presence of human body secretions, e.g. saliva, sweat, tears, vomit, mucus or excretions, e.g. urine, faeces

5. A need for both sides of the body to feel even

6. If one hand gets wet, the sufferer may feel very uncomfortable, if the other is not

7. If the sufferer while walking, bumps into something, he/she might hit the object/ person back to feel a sense of evenness,

8. These symptoms also experienced in a reversed manner.

An obsession with numbers –

1. Twisting the head of a toy around, then twisting it all the way back, exactly in the opposite direction.

2. The compulsions are purely mental, often called as, the secret illness’

3. Feelings of distress and anxiety

• Obsessional thoughts: words, ideas and beliefs that intrude forcibly into patient’s mind; unpleasant and shocking to the patient.
• Obsessional images: vividly imagined scenes, e.g. violent or disgusting kind.
• Obsessional ruminations: everyday actions are reviewed endlessly.
• Obsessional doubts: Actions not completed adequately, e.g. forgets to turn off the stove; doubting
• existence of God, etc. Obsessional impulses: urges to perform acts, e.g. violent or embarrassing type of activities.
• Obsessional slowness: in performing daily activities.

[Ref: KP Neeraja/1/Vol-2/432-433]

Differential diagnosis of OCD:

1. Organic disorder

2. Schizophrenia

3. Anxiety neurosis

4. Depressive disorder.

Treatment of OCD:

Combination of therapies is helpful than single option.

1. Drug therapy:

• Clomipramine is considered to be an effective drug in managing OCD..
• Fluoxetine another antidepressant is also considered to be effective (20-120 mg/day).
• Sertralin,
• Fluvoxamine
• Paroxetine

2. Behaviour Therapy:

• Systematic desensitization
• Flooding
• Modeling
• Implosion
• Shaping
• Aversion therapy
• Reinforcement

➤ Positive-suggestive measures, emotional education

➤ Negative practice-time out, aversive training

• Emotional education,

3. Cognitive Therapy

• Self-monitoring and control
• Thought stopping-control the obsessive thoughts by producing a strong stimuli which interferes the ongoing thought process, e.g. shouting, ‘stop’ or a loud bang. The procedure can be modified to result in replacement of neutral thoughts in the place of original obsessions.

4. Self-monitoring and control:

• Psychodynamic psychotherapy-supportive insight-oriented.

[Ref: KP Neeraja/1/Vol-2/433+ S Nambi/2/39)

Nursing management of OCD:

1. Physical Needs

• Encourage personal hygiene
• Care of skin
• Improve appetite and weight
• Improve sleep pattern.

2. Psychosocial Needs

• Psychotherapeutic environment
• Help in coping with obsessive compulsive behavior
• Improving communication
• Enhance self-concept and socialization
• Reduce anxiety.
• Recreational Activities

➤ Playing games

➤ Hearing music

➤ Exercise

➤ Dancing

3. Spiritual Needs

• Meditation
• Yoga
• Moral Stories,

4. Discharge Plan

• Follow-up care
• Health education.

(Ref: S Nambi/2/591

Nursing care plans for OCD:

(Ref: KP Neeraja/1/Vol-2/434-435)

Epilepsy

Epilepsy is the name given to a sudden loss of consciousness which is often accompanied by repeated jerky movements called convulsions.

[Ref: S Nambi/2211

Types of epilepsy:

There are three types of epilepsy:

1. Grand mal or generalized epilepsy.

2. Focal epilepsy (including temporal lobe epilepsy).

3. Focal epilepsy becoming generalized.

Causes of epilepsy;

Epilepsy, which has no known physical or other cause, is primary or idiopathic epilepsy. It is more common in children and adolescents. When the cause of epileptic fit is known the condition is called secondary or symptomatic epilepsy.

Causes:

A. Primary epilepsy: Unknown-genetic or biochemical predisposition.

B. Secondary epilepsy:

Intracranial

1. Tumor

2. Vascular (infarct or hemorrhage)

3. Arterio-venous malformation

4. Trauma (birth injury, depressed fracture, penetrating wound)

5. Infection(abscess, meningitis, encephalitis)

6. Congenital and hereditary disease (tuberous sclerosis).

Extracranial

1. Metabolic

2. Electrolyte

3. Biochemical

4. Inborn errors of metabolism

5. Anoxia

6. Hypoglycemia

7. Drugs

8. Drug withdrawal

9. Alcohol withdrawal.

[Ref: S Namb/2/121-1221

Nursing care of epilepsy:

Nursing care during an attack:

The nurse should know what she must do and what she must not do during a seizure:

Dos

1. Keep calm. Help the patient lie down, remove glasses, loosen tight clothing.

2. Clear the area of hard, sharp or hot objects which could hurt him. Keep rolled up towel or pillow under his head.

3. Turn him to the side to drain saliva from mouth, which prevent aspiration.

4. After the attack, if the patient is sleepy allow him to rest.

Don’ts

1. Do not allow people to gather around him. Allow free air circulation and open all windows.

2. Do not restrain the convulsive movements (fit)

3. Do not force anything between his tightly held teeth.

4. Do not offer anything to eat or drink till he is fully conscious.

Need a doctor when –

• If patient is injured
• Has repeated seizures?
• Is unconscious for a long time?
• Has difficulty in breathing?
• It is going to be the first attack, especially after the age of 40.

Long-term Nursing Care of Epileptic Patients:

Health education regarding epilepsy to the patient’s relatives to the community is very essential. Misconceptions about epilepsy are to be clarified. The nurse should educate them of the following important facts:

1. Epilepsy is not due to sin or evil spirits-it is a disease due to disturbances in the brain function.

2. Epilepsy can be effectively cured. Medical treatment is essential and should be started during the initial stage itself.

3. Long-term maintenance of drug treatment is essential for complete cure.

4. Treatment should be continued till the patient is fit free for a three year period. Then, after consultation with the doctor, the treatment can be stopped.

5. Few patients require continued treatment to control their fits. It is only for very few patients that drug treatment may not respond.

6. Patients and relatives should be educated to identify certain side effects of drugs given for treatment. Some of the side effects are unsteadiness of gait, slurring of speech, double vision, etc. this has to be immediately brought to the notice of the doctor.

7. Hot water baths, frequent watching of television and sudden exposure to powerful lights may precipitate an attack

8. Patients suffering from epilepsy can have normal marital life.

9. They can be employed anywhere except those places involving heavy machinery fire and driving.

[Ref: S Nambi/2/124-126)

Difference between hysteric fit & epileptic fit:

Hysteria

This is a condition of unconscious want of relief from intolerable stress characterized by clear cut physical signs and mental symptoms in absence of any pathological changes in the body.

Causes of hysteria:

1. Age: The peak incidence is between the ages of 20 to 30 years, Children and adolescents people show a high incidence of this illness

2. Sex: The incidence is higher in woman than in men

3. Intelligence couple with low intelligence suffer from hysteria.

4. Hysteric type of personality is usually seen.

5. Marital status: Hysteria is reported to be more common in the unmarried aged and the divorced.

6. Socio-cultural factors. Hysteria is more common in primitive, developing andless sophisticated or cultured societies.

7. Parent child relationship: History of unhappy childhood, abnormal parent child relation, broken home and unsatisfactory relationship between the parents.

1. Conversion symptoms (physical symptoms):

a. Motor: e.g paralysis, parents, tremors, rigidity, abnormal gait, ataxia, fit.

b. Sensory general: Anaesthesia, paraesthesia, hyperalgesia, pain. Sensory special: Visual difficulties, blindness, deafness, loss of taste, loss of smell.

c. Visceral: e.g. Hiccough, vomiting, retention of urine, constipation.

2. Dissociative symptoms (Mental symptoms)

a. Amnesia: Typically stats suddenly, log period of life are forgotten, sometimes even personal identity,

b. Fugue state: It is a state of wandering with amnesia for the period during which the wandering occurred.

c. Hysterical seizures: They usually lack a number of features of true epileptic seizures eg. lack of unconsciousness, an unusual pattern of physical consequence of seizure (tongue bite, incontinence) do not occur in sleep.post seizures-confusion, headache, body ache, vomiting

Types of Hysteria:

1. Conversion Reaction

2. Dissociation Reaction

Management of Hysteria:

1. Isolation of the pt from pathogenic environment and it is necessary in the acute attack.

2. Visitors should not be allowed to meet the pt.

3. Reassure the pt.

4. Take immediate action to resolve any stressful circumstances that provide reaction

5. Encourage the pt to do normal

6. Nurse will take detail history from the pt- and the family members separately

7. Cold applications to the head, face and neck are helpful

9. Nurse will establish good rapport and explain the pl exact nature of problems with relatives

10. Keep records and reports about pts general condition and behavior. 11. Care of nutrition, hydration, elimination and maintain personal hygiene.

12. Counseling to hoth the patient and relatives for better adjustment.

13. Psychotherapy is the principle treatment for hysteria.

14. Inj. Diazepam 10 mg im, as ordered. (No drug treatment is advocated in conversion disorders.)

Personality Disorders

Personality:

Personality can be defined as the sum total of a person’s intellectual, emotional and volitional traits; and it is revealed by his appearance, behavior, habits and relationship with other people, which differentiate him as unique individual.

(Ref: S Namb/2/701

Or

The term personality refers to enduring qualities of an individual that are shown in his ways of behaving in a wide variety of circumstances.

(Ref-Michael Gelder/5/127)

Importance of personality in psychiatry:

• Some specific types of personality may have association with some specific psychiatric disease.
• Personality affect the way patient approach to specific psychiatric treatment.

Or

Importance of personality:

Variations in personality are important because

✔They may predispose to psychiatric disorder.

✔They may account for unusual features in a psychiatric disorder (they are ‘pathoplastic” factors). ✓ They may affect the way that patients approach psychiatric treatment.

(Ref-Michael Gelder/9/127)

Point in assessment of personality:

1. Character

2. Attitude

3. Habits

4. Relationship

5. Mood and emotional status.

Personality disorder:

Personality disorder is defined as the possession of one or more personality traits so deviated from the normal that they interfere with his well-being or adjustment to society and require psychiatric attention.

[Ref: S Nambi/2/70)

‘An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the culture of the individual who exhibits it’.

[Ref: American Psychiatry Association]

‘When personality traits are inflexible maladaptive and can cause either significant functional impairment or subjective distress’.

[Ref: DSM IVI

Classification of personality disorder: DSM-IV classified personality disorders into –

A. Cluster A (odd or eccentric disorders)

1. Paranoid personality disorder

2. Schizoid personality disorder

3. Schizotypal personality disorder

B. Cluster B (dramatic, emotional, erratic disorders)

1. Antisocial personality disorder

2. Histrionic personality disorder

3. Narcissistic personality disorder

C. Cluster C (anxious and fearful disorder)

1. Avoidant personality disorder

2. Dependent personality disorder

3. Obsessive compulsive personality disorder.

[Ref: KP Neeraja/I/Vol-2/444)

Or

(Another Answer)

ICD-10 (F60-F69) classified personality disorders as

1. Paranoid personality disorders

2. Schizoid personality disorders

3. Dissocial personality disorders

4. Emotionally unstable personality disorders

• Impulsive type
• Borderline type

5. Histrionic personality disorders

6. Anakastic personality disorders

7. Anxious, avoidant personality disorders (avoidant)

8. Dependent personality disorders

9. Other personality disorders (narcissistic personality disorders).

[Ref: KP Neeraja/P/Vol-2/445)

Withdrawn (odd and eccentric)

1. Schizotypal

2. Schizoid

3. Paranoid.

4. Dependent (anxious and fearful)

5. Anxious (avoidant)

6. Dependent

7. Passive aggressive.

Inhibited

1. Anankastic (obsessive compulsive)

2. Hypochondriacal

3. Depressive (Dysthymic).

4. Antisocial (Dramatic, emotional, flamboyant and erratic)

5. Histrionic

6. Impulsive co-borderline

7. Narcissistic

8. Psychopathic

[Ref: S Namb/2/10-711

Causes of personality disorder:

1. Genetics or heredity, e.g. Obsessive compulsive personality disorders, paranoid personality disorders; schizoid personality disorders and antisocial personality disorders

2. Family history, e.g. Borderline personality disorders and antisocial personality disorders are common among first degree relatives

3. Brain dysfunction. (Frontal lobe and amygdala part), abnormal brain processing of emotionally charged; low threshold of excitability of the limbic system

4. Alteration in levels of neurotransmitters. e.g. decreased level of serotonin and dopamine and increased level of norepinephrine will cause borderline personality disorders

5. Release of toxic chemical substances

6. Post-traumatic stress disorder, e.g. borderline personality disorders

7. Developmental factors, e.g. extreme parental rage or humiliation defect in parental role, loss of a loved person, child abuse-physical, emotional and sexual abuse, etc. are prone for borderline personality disorder

8. Child neglect

9. Childhood trauma, adverse or painful experience or head injury prone for cluster B personality disorder, borderline personality disorder, histrionic personality disorder and cluster C personality disorder

10. Children with alcoholic and drug abuse parents

11. Parental failures in early childhood prone for borderline personality disorders

12. Childhood pathology, e.g. antisocial and impulsive behavior

[Ref: KP Neeraja/I/Vol-2/445]

Or  (Another Answer)

1. Psychological factors

• Example: early attachments, maladaptive learning.

2. Constitutional factors

• Example: Prenatal factors.

3. Hereditary factors

• Example: Genetic predisposition or chromosomal abnormality such as XYY pattern seen in psychopathy.

4. Environmental factors

• Example: Poverty, low socioeconomic class, broken home.

[Ref: S Nambi/24/72)

Characteristics of personality disorder:

1. It is not a mental illness.

2. It is a maladaptive behavior

3. It is re possession of abnormal personality traits

4. It is a long lasting, most of the time life-long problem

5. It causes significant impairment in social or occupational functioning

6. It produces distress to the individual and to others.

[Ref: S Nambi/2/701

Psychopathic (antisocial) personality disorder:

Abnormally aggressive and extremely irresponsible person whose behavior brings him repeatedly into conflict with society and the law. Its prevalence varies from 0.06 percent to 1.5 percent. The person usually comes from a deprived or broken family, or having an alcoholic or psychopathic parent.

Clinical features of psychopathic personality disorders

• The patient is basically a guiltless and loveless individual, highly impulsive in nature, with no regret for his misdeeds.
• He lacks normal drive or motivation.
• He cannot establish a sustained relationship with anybody.
• Superficially charming but can quickly become irritable and highly selfish.
• He has low frustration tolerance and blames others for his behavior.
• He does not learn from his experiences, so again and again commits the same mistakes or criminal behavior.
• There is usually a history of stealing, lying, fluting, running away from home and cruelty to animals from childhood to adolescence which continues in adult life.
• He may cheat, misappropriate funds, swindle and tell fantastic lies (pathological liar).

(Ref: S Nambi/2/721

sociopath

Sociopathy and sociopath are informal terms that refer to a pattern of antisocial behaviors and attitudes, including manipulative and deceitful behavior, often arising from environmental factors. In the Diagnostic and Statistical Manual of Mental Disorders (DSM), sociopathy is most closely represented by Antisocial Personality Disorder.

It is important to note that sociopathy is not a formal diagnosis, but is often invoked in discussing people on the antisocial spectrum, who generally display callous behavior with little regard for others.

Sociopaths may or may not be criminals, but they are often difficult to identify until one is very familiar with their behavior. Sociopaths are often manipulative, lie frequently, lack empathy, and have a weak conscience that allows them to act recklessly or aggressively, even when they know their behavior is wrong.

sociopath act

The public idea of a sociopath is often a serial killer, a con artist, or another lawbreaker, but this is not necessarily the case. Indeed, in recent years, several influential books have attempted to dispel the myth that most sociopaths are ruthless killers and criminals. On the contrary, they argue, the nearest sociopath might be a boss, a partner, or a parent.

While sociopaths may not all be literal outlaws, however, they can share certain traits with them. This includes a lack of remorse, a propensity for untruthfulness, and a tendency toward behavior that benefits the sociopath at the expense of others.

Ultimately, the defining characteristic of sociopaths is a profound lack of conscience-a flaw in the moral compass that typically steers people away from breaking common rules and treating others decently. This internal moral disconnect, however, is often masked by a charming demeanor

Though the terms “sociopath” and “psychopath” are often used interchangeably and refer to similar behaviors, there is a generally agreed-upon difference. Sociopaths are individuals whose callous, deceitful behavior is shaped by environmental factors, such as child abuse and exposure to expedient behavior. Psychopathy is considered inborn and immutable, hence it is classified as an antisocial personality disorder.

Because both conditions can lie on a spectrum, and the origins of a disorder are murky, it can be difficult to know whether someone displays sociopathic or psychopathic behavior. Because sociopathy is not an innate characteristic of an individual, sociopaths are considered more amenable to behavioral change and rehabilitation, while psychopaths are considered to be largely impervious to treatment once they reach adulthood.

Schizoid personality disorder:

‘Schizoid Personality disorder is a personality disorder characterized by lack of interest in social relationships, a tendency towards a solitary lifestyle, secretiveness and emotional coldness’.

Clinical features of schizoid personality disorder:

1. Emotional coldness, detachment or reduced affection

2. Limited capacity to express either positive or negative emotions towards others

3. Consistent preference for solitary activities

4. Very few friends or relationships and a lack of desire for such

5. Indifference to either praise or criticism

6. Taking pleasure in few activities

7. Indifference in social norms and conventions

8. Preoccupation with fantasy and introspections

9. Lack of desire for sexual experiences with another person.

[Ref: KP Neeraja/I/Vol-2/460]

Narcissistic personality disorder:

‘A pattern of grandiosity in the patient’s private fantasies or outward behaviour, a need for constant admiration from others and lack of empathy or others’. Clinical features:

1. Significant emotional pain or difficulties in relationships and occupational performance

2. Grandiose sense of self-importance, e.g. demanding special favours from others or choosing friends and associates on the basis of prestige and high status rather than personal qualities

3. Lives in a dream world of exceptional success, power, beauty, genius, perfect love

4. Thinks themselves as ‘special’ ‘privileged’ only can understand by higher status people

5. Demands excessive amounts of praise or admiration from others

6. Feels entitled to automatic deference, compliance or favourable treatment from others

7. Exploitative towards others and takes advantages of them

8. Lacks empathy and does not identify with other’s feelings

[Ref: KP Neeraja/1″/Vol-2/458)

Paranoid personality:

It is a long term, wide spread disorder and people with paranoid personality disorder are unwarranted suspicious and mistrustful that other people are hostile, threatening and demeaning. Patients with paranoid personality disorder are not delusional, most of the time they are in touch with reality, misinterprets others’ motives and intentions.

They feel that others are trying to humiliate them, hostile and they like to live socially isolated manner. They will not formulate and maintain intimate relationship with others.

Causes of paranoid personality:

1. Chronic schizophrenia, delusional disorder, psychotic disorder

2. Interpersonal causes

3. Childhood traumatic experiences

4. Stressful environment

5. Genetics, e.g. twins may prone to get.

Clinical features:

1. Suspiciousness carry over in all realms of life, mistrustful

2. Difficulty in maintaining jobs

3. Have fewer close relationships, as they feel others will hurt them, like to be isolated avoiding social relationship

4. Angry, aggressive, hostile, unfriendly, argumentative

5. Generalized distrust of other people

6. Full of insults and threats

7. Feel insecure

8. Violent

9. Frequently convinced that their sexual partners are unfaithful

10. Hidden criticisms

11. Never inclined to share intimacy

Treatment

1. Psychotherapy-After establishing professional relationship, developing trust, winning confidence, demonstrate non-judgemental attitude and a professional desire to assist the patient psychotherapy is initiated.

2. Group therapy-Include family members, encourage them to meet the ‘self-help groups’ dedicated to recover from this disorder.

3. Supportive psychotherapy-Analyse the problem in dealing with other people, the patient’s motivations and possible sources of paranoid traits, never challenge the patients’ thoughts too directly

4. Medication-If the client is anxious, anti-anxiety drugs may be prescribed, during high stress and extreme agitation, low dose of antipsychotic, neuroleptics can be given. Selective serotonin reuptake inhibitors, eg. Prozac, for the clients with angry irritable and suspicious To reduce symptoms, antidepressants can be given.

Nursing Management:

1. Develop and maintain therapeutic nurse patient relationship

2. Encourage the client for effective communication

3. Encourage for healthy interactions and identify the stressors for the frustration

4. Never whisper or criticize in front of the client

5. Encourage the client not to have inhibitions, heitation, support the client in stressful time

6. Provide support and guidance to the client, when he is performing the activities in a desirable manner

7. Motivate the client to express his feelings

[Ref: S Nambi/2/452)

Dependent personality disorder:

Dependent personality disorder is described as “a pervasive and excessive need to be taken care of that leads to a submissive and clinging behavior as well as fears of separation. The dependent and submissive behaviours are designed to elicit caregiving and arise from a self-perception of being unable to function adequately without the help of others.”

Clinical features of dependent personality disorder:

1. Experiences great difficulty in making everyday decisions

2. Tends to be passive and allow other people to take the initiative and assumes responsibility for most major areas of their lives

3. Depends on a parent or spouse to decide where they should live; what kind of job they should have and who are their friends, how to spend their free time, which school they have to attend

4. Assumes responsibility, goes beyond age appropriate and situation-appropriate requests for assistance from others

5. Difficulty in initiating projects or doing things independently.

[Ref: KP Neeraja/1/Vol-2/458]

Antisocial personality disorder:

‘A condition in which individuals exhibit a pervasive disregard for the law and the rights of others’.

Clinical features of antisocial personality disorder:

1. Indifferent to the needs of others

2. Manipulate through deceit or intimidation may have trouble holding down a job

3. Fails to pay debts or fails to fulfill parenting or work responsibilities

4. Usually loners

5. Aggressive, violent, involves in fight

6. Frequent encounters with the law

7. May also possess a considerable amount of charm and wit

8. Persistent lying or stealing

9. Tendency to violate the rights of others (property, physical, sexual, emotional, legal)

10. Inability in keeping jobs

11. A persistent agitated or depressed feeling (dysphoria)

12. Inability to tolerate boredom

13. Disregard for hurting others

14. Impulsiveness

[Ref: KP Neeraja/I/Vol-2/448-449)

Nursing care for antisocial personality disorder:

1. Observe the behaviour, set limits which are not acceptable

2. Provide congenial, safe and calm environment to express their feelings

3. Explain in slow tone, the ways of unacceptable behaviour, which is harmful to both, self and to others

4. Teach relaxation exercises and motivate them practice

5. Encourage the individual to participate in diversional activities, where he can express his feelings in an acceptable manner like drawing, music, writing

6. Teach self-control behaviour modification techniques, allow him to Practice

7. Administer the drugs as per orders

8. Assign some responsibilities and observe how he is able to do

9. Provide positive feedback for healthy independent behaviour

10. Enhance problem-solving skills, client’s strengths, coping skills

[Ref: KP Neeraja/1″/Vol-2/450]

Histrionic personality disorder:

‘Characterized by a pattern of excessive emotionality and attention seeking including an excessive need for approval and inappropriate seductiveness’.

Clinical features:

1. Pervasive and excessive pattern of emotionality and attention seeking, ie, constant seeking of reassurance or approval

2. Individuals are lively, excessive dramatics with exaggerated display of emotions

3. Enthusiastic and flirtatious

4. Inappropriately seductive appearance or behavior

5. Excessive concern with physical appearance

6. Self-centeredness, self-indulgent and intensely dependent on others

7. Low tolerance of frustration or delayed gratification

8. Rapidly shifting emotional states that may appear shallow to others

9. Opinions are easily influenced by other people, but difficult to back-up details

10. Tendency to believe that relationships are more intimate than they actually are

11. Makes rash decisions

[Ref: KP Neeraja/P/Vol-2/450-4511

Avoidant personality disorder:

‘Personality disorder characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoiding social interaction’.

Clinical features:

1. People with avoidant personality disorder consider themselves to be socially inept or personally unappealing and avoid social interaction for fear of being ridiculed, humiliated or disliked

2. They typically present themselves as loners and report feeling themselves as loners due to fear of being shamed or ridiculed

3. Feels a sense of alienation from society (self-imposed social isolation)

4. Exaggerates the potential difficulties, physical dangers or risks involved in doing something ordinary, but outside their usual routines

5. Avoids activities that involve significant interpersonal contact, because of fears of criticism, disapproval or rejection

6. Will not possess any close friends

7. Easily hurts by criticism or disapproval or rejected (hyper-sensitive)

8. Embarrasses by blushing, crying or showing signs of anxiety in front of other people

9. Avoids occupational activities

10. Emotional distancing related to intimacy

11. Unwilling to get involved with people unless, certain of being liked

12. Highly self-conscious

13. Preoccupied with being criticized or rejected in social situations

14. Feelings of inadequacy inhibits new interpersonal situations

[Ref: KP Necraja/I/Vol-2/460)

Premorbid personality:

A personality characterized by early signs or symptoms of a mental disorder. The specific defects may indicate whether the condition will progress to schizophrenia, a bipolar disorder, or another type of condition.

Or

1. Character traits which were present prior to physical damage or another damaging occurrence or prior to the cultivation of an illness or disorder.

2. Character strengths and weaknesses which make someone more likely to incur troubles with cognitive or physical health, or a specific cognitive disorder.

ID: The primitive unconscious part of the personality. ID is the source of instinctual energy, which works on the pleasure principle. ID seeks complete and immediate gratification of desire.

Ego: Ego is the reality-based aspect of the self. Ego is that part of the personality that seeks to satisfy the Id and the super ego. It is the reality and practical mind.

Super ego: Super ego is the moral branch of mental functioning. It is the controlling mind.

(Ref: S Nambi/24/15-16)

Psychosomatic Disorder/Somatoform Disorders

Psychophysiologic disorders:

The word, ‘Psychophysiologic disorders’ indicates ‘alteration in physiological functioning of the individual due to psychological factors’, changes occurs both in ‘Psychic-Mind’ and ‘somatic-Bodily’, manifesting physical symptoms or bodily complaints, suggesting diseases without demonstrable organic pathology.

Definition:

‘A syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long term seeking of assistance from health care professionals.”

(Ref: KP Neeraja/1/Vol-2/555)

Or

‘Psychological factors can influence the course of the general medical condition, which can be inferred by a close temporal association between the factors and the development or exacerbation of or delayed recovery from the medical condition’.

[Ref: American Psychiatric Society, 2000)

Or

‘A group of ailments in which emotional stress is a contributing factor to physical problems involving an organ system under involuntary control.

[Ref: Bimala Kapoor, 1994)

Types of psychophysiologic disorder:

1. Cardiovascular disorders

• Coronary heart diseases
• Essential hypertension
• Migraine headache
• Angina pectoris
• Myocardial infarction.

2. Gastrointestinal disorders

• Peptic ulcer/stress ulcer
• Irritable bowel syndrome
• Ulcerative colitis
• Esophageal reflux
• Crohn’s disease
• Obesity
• Anorexia nervosa
• Eating disorders.

3. Endocrinal disorders

• Diabetes mellitus
• Hyperthyroidism
• Pre-menopausal syndrome.

4. Musculoskeletal disorders:

• Backache
• Rheumatoid arthritis.

5. Immune disorders:

• Viral infections
• Systemic lupus erythematosus

6. Respiratory disorders:

• Bronchial asthma
• Hyperventilation

7. Skin disorders:

• Neurodermatitis
• Eczema
• Psoriasis
• Alopecia
• Trichotillomania (Hair pulling)
• Pruritus
• Urticaria
• Acne vulgaris

8. Genitourinary disorders

• Non-specific urethritis
• Chronic prostatitis
• Menstrual disorders
• Dysmenorrhoea
• Amenorrhoea
• Menopause

9. Miscellancou

• Accident proneness
• Headache
• Sleep disorders
• Visual disturbances
• Cancer
• Conversion disorders
• Tinnitus
• Hypochondriasis
• CNS disorders

Somatoform disorder:

It is a group of disorders in which there is repeated presentation of physical symptoms accompanied by persistent requests for medical investigations. If physical disorders are present, they do not explain the nature or extent of symptoms. Repeated negative findings and reassurance have little effect and patient usually refute the possibility of psychological caution.

[Ref-Davidson’s/24 edition)

Classification of somatoform disorder:

1. Conversion reaction,

2. Pain disorder,

3. Hypochondriasis,

4. Body dysmorphic disorder,

5. Dissociative – disorders

6. Amnesia,

7. Fugue,

8. Depersonalization,

9. Identity disorder,

10. Mood disorder – mania, MDP,

11. Thought disorders

12. Psychosis – schizophrenia,

13. Cognitive impairment disorder.

Q. List the causes of somatoform disorder?

[Ref: KP Neeraja/1/Vol-2/555)

Causes of somatoform disorders:

1. Biological predisposition: Family history or hereditary, possible biochemical alterations

2. Vulnerable personality: Type ‘C’ personality suppression of anxiety, frustration, exhibits calm and placid, depressed, despair, low self-worth and self-esteem, self-pity

3. Extreme or significant psychosocial stress:

4. Severe emotional stress, crisis, traumatic life events

5. The interaction between psychological, social and biological factors

6. Social environment: Poor IPR, deprived bondages, cultural or religious factors, disharmony between family members, altered family dynamics, low socio-economic, educational difficulties, absence of support systems, unfulfilled needs for nurturing and caring.

7. Personality traits: Tense, under pressure, dependent, attention seeking, timid, weak ego

8. Maladaptive health behaviour: Variations in eating pattern, lack of exercise, unsafe practices

9. Stress related physiological or behavioural factors: Interpersonal factors, weak ego development; unacceptable emotions, repressed anger

10. Occupational difficulties

11. Smoking

12. Chronic usage of anti-inflammatory agents

13. Imbalance of angiotensin and prostaglandins

14. Increased sympathetic nervous system stimulation

[Ref: KP Neeraja/I/Vol-2/556)

Clinical features of somatoform disorders:

Psvcho neurological symptoms:

• Signs and symptoms of conversion disorder, e.g. paralysis, aphonia, seizures, coordination disturbances, dysphagia, retention of urine, akinesia, deafness, blindness, double vision, hallucinations, pain sensation, amnesia, loss of consciousness other than fainting
• Sleep disturbances like insomnia, hypersomnia and parasomnias.

Sexual symptoms:

• Sexual indifference, ejaculatory dysfunctions, irregular menses, excessive bleeding, hyperemesis
• Significant impairment in social, occupational and other areas of functioning
• Withdrawal behaviour/socially isolated behaviour.

GIT Symptoms:

• Nausea, bloating, vomiting, diarrhoea, dehydration, intolerance of certain foods.

Other symptoms:

• Feelings of helplessness, guilty and insecurity
• Developmentalregression
• Angry, hostility, aggressiveness
• Feelings of low self-esteem and worthlessness
• Bodyaches, headache, migraine, dysurea, dysmenorrhoea, dyspareunia
• Unpleasant activity
• Attention seeking behaviour
• Depression
• Unexplainable fears
• Social isolation
• Preoccupied with anxiety, fears, separation

[Ref: KP Neeraja/I/Vol-2/5581

Complications of somatoform disorder:

• Withdrawal symptoms
• Risk to self and others
• Become dependent on addictive medications.

Treatment:

Principle of Rx;

1. Communication

2. Explanation of ill-health, including diagnosis and causes

3. Education about management (including self-help leaflets)

4. Stopping drugs (e.g. caffeine causing insomnia, analgesics causing dependence)

5. Rehabilitative therapies

6. Cognitive behaviour therapy (to challenge unhelpful beliefs and change coping strategies)

7. Supervised and graded exercise therapy for approximately 3 months (to reduce inactivity and improve fitness)

Pharmacotherapies:

• Specific antidepressants for mood disorders, analgesia and sleep disturbance
• Symptomatic medicines (e.g. appropriate analgesia, taken only when necessary).

[Ref-Davidson’s/22/245-46)

Nursing care plan for somatoform disorder:

1. Help the client

2. To recognize and accept the physical complaints even though no organic pathology

3. To recognize the gains that the physical symptoms which are providing for the client, e.g. dependency, distraction, attention, deficit

4. To withdraw attention to physical symptoms

5. Refer the client if any additional symptoms occurs.

6. Advise the client to use possible alternating coping strategies

7. Identify the ways to achieve recognition from others

8. Ask the client to keep a record of physical symptoms and stressful situations

9. Administer the drugs as per physicians orders

10. Provide comfort measures

11. Encourage the client to verbalize his psychological feelings, current life situations

12. Teach the client to recognize different aspects of behaviour whether healthy behaviour or deviated behaviour Provide positive feedback for the acceptable behaviour of the client

13. Counsel the clients, encourage them to participate in social activities.

14. Assist the client to recognize their own strengths/abilities, weakness, accomplishment, provide positive feedback by appreciation, small token to adopt socially acceptable behaviour

15. Encourage the client to perform self-care activities

16. Maintains non-judgmental attitude, when providing assistance to the client

17. Encourage the client to perform independent activities when he is able to do, avoid dependency

18. Allow sufficient time for the client to perform activity

19. Encourage the family to provide attention and concern, when the client is in ‘sick role’

20. When the client has fewer complaints, ask the family members to decrease special attention

21. Motivate the client to identify the relationship between stress, physical symptoms and coping strategies

22. Provide community based care-establish trusting relationship with the client; provide empathy and support, appropriate referrals, assistance from support groups, encourage the client to spend in pleasurable activities for attention and security, health promotion activities.

(Ref: KP Neeraja/P/Vol-2/559)

Conversion Disorder

In DSM M the terms, Conversion and Dissociative disorders’ were synonymously used. In ICD-10 F. it was indicated that both the terms are interchangeable and are described under ‘dissociative disorders’. In these disorders, ability to exercise conscious and selective control is impaired to a degree that can vary from day-to-day or even from hour-to-hour, ie, onset or exacerbation of the symptoms.

Conversion disorder refers to a condition in which there are isolated neurological symptoms that cannot be explained the mechanism of pathology.

Or

(Ref-Michael Gelder/5/206]

Conversion reactions are partial or complete loss of normal integration between immediate sensations and control of bodily movements or deficits involving voluntary motor or sensory functions due to underlying psychological conflicts and anxiety.

Causes of conversion disorder:

1. Traumatic events/unacceptable emotions

2. Sexual abuse in childhood

3. Disturbance in CNS arousal 4. Lack of situational support.

[Ref: KP Neeraja/1/Vol-2/568/

Subtypes of conversion disorders:

Conversion disorder is divided into four subtypes:

1. With motor symptom or deficit: This subtype includes such symptoms as-

• Impaired/coordination or balance.
• Paralysis or localized weakness.
• Difficulty swallowing or lump in throat.
• Aphonia
• Urinary retention

✔With sensory symptom or deficit: This subtype includes such symptoms as-

• Loss of touch or pain sensation.
• Double vision.
• Blindness Deafness
• Hallucinations

✔With seizures or convulsions: This subtype includes-

• Seizures or convulsions with voluntary motor or sensory components.

✔With mixed presentation: This subtype is used if symptoms of more than one category are evident.

[Ref-Michael Gelder/5/206]

Clinical features of conversion disorder:

Motor deficits:

1. Tremors,

2. Mutism,

3. Hysterical convulsions,

4. Aphonia,

5. Lack of coordination or balance,

6. Weakness,

7. Dysphagia,

8. Akinesia,

10. Lack of clients’ social, occupational or other area of functioning.

9. Urinary retention,

11. Paralysis

Sensory deficits:

1. Anaesthesia,

2. Paraesthesia,

3. Hyperaesthesia,

4. Loss of one of the special senses like blindness, double vision, deafness,

5. Sensation of a lump in the throat,

6. Lack of pain sensation,

7. Hallucinations,

8. Environmental misperceptions,

9. Hysteric symptoms;

[Ref: KP Neeraja/1/Vol-2/568/]

Diagnosis:

1. Conversion symptoms rarely conform fully to known anatomic and physiologic mechanisms

2. Extensive physical examination and laboratory test fail to reveal a disorder that can fully account for the symptoms and its effects

3. A trusting therapeutic nurse client relationship is essential

4. Reassure the client that the symptom do not indicate a serious underlying disorder, the client feels better when the symptoms fade,

Treatment:

1. Psychotherapy.

2. Hypnotherapy-when the client is hypnotized, the aetiologic psychologic issues were explored.

3. Narcoanalysis.

4. Behaviour modification techniques

5. Relaxation techniques.

[Ref: KP Neeraja/1/Vol-2/568)

Difference between conversion and somatoform disorder;

Nursing management of conversion disorder:

1. Nurse has to be non-judgmental.

2. Encourage the client to accept and participate in decision making process and in group activities.

3. Identify the strengths, abilities, accomplishments.

4. Provide positive feedback and reinforcement for corrective behaviour.

5. Encourage the client to withdraw their attention on physical symptoms.

6. Assertiveness technique and communication techniques has to be taught to the client.

7. Assist in self-care activities.

8. Encourage independency in behaviour.

9. Explain the effects of psychological factors on physical silness

10. Provide guidance and counselling service to the client and his relatives

11. Advise the family to provide stuational support to the client

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