AFFECTIVE DISORDERS

Depression, Nursing the Depressed Patient Mania, Nursing the Overactive Patient

INTRODUCTION

The Affective Disorders are those disorders where the MOOD [Affect] is the dominant feature of the illness. The mood may be either very Low with Unhappiness (Depression) or very raised with Happiness and Over activity (Mania).

All of are sometimes happy or sad. Affective states become disorders if they interfere with out daily lives, have no apparent cause, the response is not appropriate to the cause, or the reaction goes on for too long.

DEPRESSION

Depression is the commonest mental disorder. Studies in the United Kingdom and the USA (Ingram, 1981. Paykel & Rowan, 1979) have found that about I in 10 of the population will be affected by depression at some time in their life. The incidence of depression is higher in young women and decreases with age. The opposite pattern occurs with men.

Depression may be divided into :

1. REACTIVE DEPRESSION(Exogenous,Neurotic)

In Reactive Depression it is usually clear that the person is Reacting to a LOSS or a set of circumstances. Someone close to the patient may have died or become seriously ill, there may be a broken love affair, the husband may have taken another wife. Other causes may include unemployment or financial loss. In many of these cases the patient will have lost Self-Esteem and feel a failure.

In Reactive Depression the patient retains INSIGHT (they know that they are ill). Psychotic Symptoms such as Hallucinations and Delusions are absent. They do not have PSYCHO-MOTOR RETARDATION, though they complain of constant tiredness and be unable to Concentrate.

They will often find it Difficult To Go To Sleep, but when they do go to sleep they find it difficult to get up in the morning. They will often feel better in the morning and get worse as the day goes on.

2. ENDOGENOUS DEPRESSION(Psychotic)

In Endogenous Depression there is no Obvious cause for the depression. There is a very strong Genetic link to Endogenous Depression.

In some patients there is a pattern where the individual has severe Mood Swings, from Deep Depression a very Elated Mood; this is called MANIC DEPRESSIVE PSYCHOSIS or BI-POLAR AFFECTIVE DISORDER. Other individuals have a Mood Swing from Very Depressed to Normal and back to Very Depressed;

PSYCHO-MOTOR RETARDATION is the main characteristics of Endogenous Depression. Mental Function and Behavior are slowed down. The patient. looks sad and unhappy with shoulders hunched over.

PSYCHOTIC SYMPTOMS may include DELUSIONS of Guilt, Unworthiness, Poverty. Nihilistic Delusions may also be present. HALLUCINATIONS may be present, especially Auditory Hallucination, where voices may tell them that they are wicked and should kill themselves.

SLEEP PATTERNS may be disturbed. They can get off to sleep easily. but they wake up in the middle of the night and cannot get back to sleep. They tend to feel worse in the Morning and get better towards the Evening. They will often complain of Physical symptoms such as Constipation, Headaches and Muscle Pains.

PHYSICAL TREATMENT

Three Groups of Drugs used in the treatment of Depression are:

A. TRICYCLIC ANTIDEPRESSANTS

1. Amitriptyline (Tryptizol)
2. Imipramine (Tofranil);
3. Clomipramine (Anafranil)

Tricyclics take about 2-3 Weeks to have maximum effect. Patients need to be told this otherwise they may feel that the treatment is failing. It is important to remember that the patient may recover their energy and motivation before the mood begins to improve, so the Risk of Suicide is increased.

COMMON SIDE EFFECTS include Dry Mouth, Dizziness. Hypertension, Constipation, Retention of Urine and, rarely, Blood Dyscrasias.

B. MONOAMINE OXIDASE INIHBITORS (MAOIs):

1. Phenelzine (Nardil)
2. Tranylcypromine (pamate)

MAOIs are rarely used because of the serious side-effects. There may be a reaction between the Amino acid TYRAMINE and MAOIs. This reaction can cause a HYPERTENSIVE CRISIS leading to a Stroke or Death. A Card is always given to patients on MAOIs telling them what Foods to Avoid which include: Cheese, Alcohol, Meat Extracts (Bovril) Yeast Extracts (Marmite), Broad Beans.

C. LITHIUM :Lithium Carbonate (Priadel)

Lithium is a MOOD STABILIZER and is used in Bi-Polar and Uni-Polar Affective Disorder. Patients who are given Lithium on a long term basis have Fewer and Less Extreme Mood Swings. There is a very narrow band between the Therapeutic and Toxic Blood levels. During your clinical assignment Find Out what the Therapeutic Blood Level is and how often the blood levels are checked. Also find out what advice you would give to the patient on his diet.

Toxic Effects Include: Weight Loss, Diarrheoa, Tremors, Slurred Speech, Vomiting, Confusion, Restlessness, Fits, Coma.

NURSING CARE

A patient who is depressed Will Recover. It is important, therefore, to give them Hope and to Prevent them from Harming themselves.

These patients have a very low Self¬-Esteem and expect to Fail. Therefore we must be careful to praise them and reinforce everything they do which is successful. Any tasks given to them should be within their ability and complicated tasks avoided.

Even if they do not react to you, take time to sit with them and talk to them. Make a special effort to try and involve them in activities but do not try to force them to take part in group activities.

Depressed patients will be Anorexic. To help them eat it is better to give small Frequent Meals. At first the patient may prefer to eat on their own. Being with a lot of people, especially if they are noisy and happy, may make them more depressed.

They may need help with personal hygiene and should be encouraged to take physical exercise. Patients with Reactive Depression may want to talk about their problems, and this should be encouraged. If there are specific problems such as family arguments these need to be settled.

REMEMBER THE GREATEST RISK OF SUICIDE IS WHEN THE PATIENT IS GETTING BETTER

KEY POINTS:

I) In Affective Disorders the MOOD (Affect) is the dominant feature of the illness.

2) The mood may be either very Low. Depression of very raised, Mania. ¬

3) Reactive Depression is a Reaction to a LOSS or a set of circumstances

4) Endogenous Depression has no obvious cause. There is a very strong Genetic link to Endogenous Depression.

5) Endogenous Depression may be Bi-Polar or Uni-Polar.

6) In Reactive Depression the patie11t retains INSIGHT. They do not have PSYCHO¬MOTOR RETARDATION. They will often find it DifflCul1 to Go to Sleep. They will often feel better in the morning and get worse as the day goes on.

7) PSYCHO-MOTOR RETARDATION is the main characteristic of Endogenous Depression. PSYCHOTIC SYMPTOMS may include DELUSIONS and HALLUCINATIONS.

8) In Endogenous Depression they can get off to sleep easily, but they wake up UI the middle of the night and cannot get back to sleep. They tend to fell Worse in the Morning and get Better towards the Evening.

9) The Three Groups of Drugs used UI the treatment of Depression are Tricyclic Antidepressants, Monoamine Oxidase Inhibitor_ (MAOIs) and Lithium.

10) There may be a reaction between the Amino Acid TYRAMINE and MAOIs causing a HYPERTENSIVE CRISIS. A card is given to patie11ls on MAOIs telling them what? Foods to A void.

11) Lithium is a MOOD STABILIZER and is use in Bi-Polar and Uni-Polar Affective Disorder. There is a Very narrow band between the Therapeutic and Toxic Blood Level.

12) A patient who is depressed will Recover. It is very' important to Prevent them from Harming Themselves.

13) These palie1ltS have a very' low Self-Esteem. Therefore praise everything they do which is successful

14) Even if they do not react to you. take time to sit with them and talk to them.

15) Give Small Frequent Meals. At fist the patient may prefer to eat on their own.

16) They may need help with personal hygiene and should be encouraged to take physical exercise.

17) Patients with Reactive Depression may want to talk about their problems, and this should be encouraged.

18) THE GREATEST RISK OF SUICIDEI( WHEN THE Patient is getting better

AFFECTIVE DISORDERS [MANIA, Nursing the Overactive Patient]

MANIA

Is more common in those individuals with a CYCLOTHYMIC PERSONALITY [Where the Mood of the person Often Swings quickly from Happiness to Sadness].

It is characterized by an ELATED, EUPHORIC Mood and PSYCHOMOTOR OVER ACTMTY. Their Thoughts can be compared to a tape recorder on "fast forward". The ideas go through his mind too quickly for him to concentrate on one idea (FLIGHT of IDEAS). When he tries to tell you about his ideas he has to do it very quickly, or he will have moved on to another thought (pressure of SPEECH).

He may have GRANDIOSE DELUSIONS where he believes that he is a very important and rich person. his mood is usually very happy and most nurses and patients enjoy being with a patient in an overactive manic state. However, they easily become bored and FRUSTRATED, and interfere with other people. If they are not diverted into harmless activities they can either become AGGRESSIVE or make others aggressive.

PHYSICAL TREATMENT

Drugs used in the treatment of Mania are: 

a. LITHIUM: (Reverse symptoms in 70-80% of cases)

b. NEUROLEPTICS

c. Haloperidol [Haldol, Serenace]

d. Phenothiazines [Chlorpromazine, Triflouperazine]

e. CARBAMAZEPINE [An Anti-Conversant that seems to be effective]

f. ELECTRO CONVULSIVE THERAPY:¬ May be used where Chemotherapy has no effect. or where the patient's life is in danger from exhaustion.

NURSING CARE

These patients have far too much energy to Eat, Drink or Sleep. There is a very real danger that they will die from DEHYDRATION and EXHAUSTION.

They need to be nursed in a NON¬STIMULATING environment. Food and Drink needs to be given in small amounts and frequently. Trying to get them to sit down to eat or drink may provoke aggression.

Trying to restrain and quietness these patients will Not be successful and will only frustrate the nurse and the patient. It is more sensible to have a number of small tasks of physical activities to do WITH the patient to divert him.

The overactive patient may lose any sense of

DANGER or what is RIGHT or WRONG. They may become UNINHIBITED and take off their clothes and make sexual approaches to other patients. Therefore to protect them LIMITS may be set to their behavior. In this Limit Setting and the Administration of Medicines Physical Restraint may have to be used as a Therapeutic Technique.

KEY POINTS

I) Is more common in those with a CYCLOTHYMIC PERSONALITY

2) It is characterized by an ELA TED, EUPHORIC Mood and PSYCHOMOTOR OVER ACTIVITY.

3) Ideas go through his mind so quick(v that he has FLIGHT of IDEAS and PRESSURE OF SPEECH.

4) He may have GRANDIOSE DELUSIONS, become bored and FRUSTRATED, and then, either become AGGRESSIVE, or make others aggressive.

5) LITHIUM, NEUROLEPTICS, CARBAMAZEPINE and ELECTRO CONVULSIVE THERAPY are physical therapies used in the treatment of Mania.

6) There is a very real danger that they will die from DEHYDRA TION and EXHAUSTION.

7) They need to be nursed in a NON¬STIMULA TING environment. Food and Drink needs to be given in small amounts and frequently.

8) Have a number of small tasks or physical activities to do WITH the patient to divert him.

9) They may become UNINHIBITED "and take off their clothes and make sexual approaches to other patients. Therefore to protect them LIMITS may be set to their behavior.

NORMALITY and ABNORMALITY

Perceptions of Normality and Abnormality differ between cultures, subcultures, individuals and change over time. The extreme selfishness of a child is accepted as normal; in an adult such selfishness would be regarded as abnormal. Men holding hands is normal in some societies, in others it is regarded as abnormal.

For a person to be quiet and withdrawn may be normal for THAT individual. For a person to be noisy and active may be normal for THAT individual. If the individual's behavior CHANGES then, FOR THAT PERSON, the behavior may be abnormal. Therefore, we have to take account of all the factors relating to an individual before LABELLING their behavior abnormal.

It is important for treatment and research that health professionals use the same language when describing a disorder. In these sessions a classification system will be introduced for use in the rest of the course.

NORMALITY

As we have seen, normality means different things to different people at different times in different settings. If, as a soldier, we shoot someone in wartime we may receive a medal; if we shoot someone in peacetime we will be put in prison. If we lose our job and someone close to us dies then it is normal for us to be unhappy and depressed. In fact if we were not unhappy and depressed it would be abnormal. Therefore we have to look at emotions and behavior in the context in which they occur.

THE FOLLOWING IS ONE SUGGESTION OF THE CHARACTERISTICS OF A NORMAL MENTALITY, PERSON

1. EFFICIENT PERCEPTION OF REALITY

They have a realistic view of their strengths and weaknesses. They know what they have the ability to do and what they cannot do. They have a realistic Perception of what is happening around them and their reactions to those events.

2. SELF KNOWLEDGE

They have an understanding of WHY they do things [MOTIVATION] and WHY they have certain emotions. None of us has complete Insight into our feelings and behavior but normal people have more Insight than the mentally ill.

3. ABILITY TO CONTROL BEHA VIOUR

Occasionally normal people may act impulsively [Without thinking] but normally they can control DRIVES such as aggression or sexuality.

4. SELF-ESTEEM

They know their own value and feel happy with their achievements and abilities. They feel accepted by those around them. They may wish that they were more handsome or intelligent but they don't allow these ideas to rule their lives. They know that though they may not be handsome they have a nice personality or, that though they cannot be a university professor they are doing a useful job which brings in money for the family to live on. 

Mentally disordered people often feel that they are worthless and not accepted by other people. They may blame society or other people for their feelings of worthlessness and Rejection.

5. ABLE TO FORM CLOSE RELA TIONSHIPS

NORMAL people are able to form close and satisfying friendships and relationships. They are aware of other peoples feelings and beliefs and adapt to them.

Mentally disordered people often think only of their own problems and are unable to care about other peoples problems [they are often Self-centered]. Sometimes they do not want to form close friendships because at some time in the past they were emotionally hurt by the breakup of a relationship.

PRODUCTIVITY

They are able to channel their energies into work' and social life. They are enthusiastic about their lives and enjoy activities.

Mentally disordered people often feel chronically tired and each day is an obstacle to be suffered, not enjoyed.

ABNORMALITY

DEFINING ABNORMALITY IS AS DIFICULT AS DEFINING NORMALITY. THE FOLLOWING ARE THE CRITERIA OFTEN USED IN DEFINING ABNORMALITY

1. DEVIATION FROM SOCIAL NORMS

Every society has certain standards [or Norms] of behavior that it expects. Such things as the way we dress, politeness, bad language are subject to certain rules [often unwritten]. However, Social Norms are different in different societies. Eating in public during the day at Ramadan would be regarded as a deviation in the Emirates and would be punished. It would not be a deviation in a non-Islamic country.

Eye contact between a superior and inferior is regarded as a deviation in some parts of the Sub-Continent. A student who looked his teacher in the eye would be regarded as rude and arrogant. This has created problems for individuals from some parts of the Subcontinent when taking examinations in the United Kingdom. Where avoiding eye contact is regarded as a sign that the person is guilty and has something to hide.

Ideas of what is normal and abnormal also change over time. At one time, in the history of England, it was normal for men to wear earrings. When the author of this unit was a boy a man wearing an earring would be regarded as a homosexual and probably attacked if he wore earrings in the street. Now many young heterosexual men wear earrings and it is accepted behavior.

2. MALADAPTIVE BEHA VIOUR

Behavior is abnormal if it is Maladaptive ie: it has an adverse [bad] effect on the well-being of the individual or society. For example a person who is so frightened of crowds that he cannot leave his home or a person who drinks so much alcohol that he cannot live a normal life. Individuals who are violent and aggressive have a bad effect on society. They may release their aggression on the roads and cause traffic accidents or indulge in crime.

3. PERSONAL DISTRESS

In this criteria one would look at the person's subjective [internal] feelings rather than their [external] behavior. They may feel unhappy, depressed and agitated. They may be unable to concentrate or sleep. They may hide these feelings from others and their behavior may appear normal. There may be the "Smiling Depression" where an individual is very depressed but hides that depression from family and friends. Often the first that his family know of the depression is when he attempts to kill himself. 

KEY POINTS:

1. Mental Disorder has Physical, Psychological and Social Dimensions.

2. Judgments of psychological and social functioning have reference to social and cultural norms.

3. Many mental disorders are not Illness but are responses to problems in living. Labeling may prejudice our judgment as professionals.

ANXIETY

INTRODUCTION

Anxiety is a normal emotion. It would be abnormal if we did not react to certain situations by becoming anxious. It becomes abnormal if there is no apparent cause for the anxiety, or if the anxiety is out of proportion to the cause. or if it interferes with our daily life. Low or Moderate Anxiety Levels tend to improve our reactions and performance. However, as anxiety levels increase to High reactions and performance deteriorate.

ANXIETY STATES

[Generalized Anxiety Disorder, Anxiety Reaction]

In this disorder there is Free Floating anxiety. The patient feels continuously anxious but does not know why. They are tense all the time and have all of the physical effects of chronic anxiety, with Palpitations, Air Swallowing and Gastric and Bowel disturbances. Its Onset is usually in early adulthood and it affects women twice as often as men. There is evidence that there is a genetic influence.

INSIGHT PSYCHOTHERAPY

To uncover unconscious conflicts and increase self-knowledge.

RELAXATION TECHNIQUES

To help the patient gain some voluntary control over Autonomic Nervous System reactions.

PHYSICAL 

ANXIOLYTICS are usually prescribed for these patients and this creates problems when medication is withdrawn. Tricyclic Antidepressants are often used especially if there are Panic Attacks.

PROGNOSIS

Prognosis is poor with about one third of patients recovering completely. As the patient gets older the anxiety tends to reduce. At one time Psycho-surgery used to be carried out in order to relieve the symptoms.

PHOBIC STATES

In this disorder the anxiety is Focused on a particular object or situation. The phobia may be about a fear of Open or Closed Spaces or objects such as animals or insects. The fear is out of all proportion to the stimulus and often results in a Panic Attack where the patient Hyperventilates. and loses all ability to think clearly. The individual often realises that the fear is abnormal but can do nothing to control the reaction. They will go to great lengths to avoid the situation

which causes their fear. Some are so frightened of Open Spaces that they become trapped in their homes. often for years at a time. One patient I knew in Bahrain had not left her room for fifteen years. Within twelve weeks of treatment she was able to walk out in the streets.

PHOBIAS MAYBE DIVIDED INTO:

 SIMPLE: Fear of a specific Object. Animal or Situation eg : Snakes, Insects. Enclosed Spaces

 SOCIAL: Fear of Embarrassing themselves in a Social Situation eg: Eating or Speaking in Public

 AGORAPHOBIA: Fear of Open Spaces or Crowds. It is the most common Phobia [60%].

SIGNS and SYMPTOMS

Even thinking about the phobic object or situation provokes anxiety. As the object or situation becomes nearer anxiety increases until there is a PANIC ATTACK.

BEHAVIOUR THERAPY

Operates on the principal that the Phobic Object is a Conditioned Stimulus and that the Phobic Response is a Learned

Response. The most common form of Behavior Therapy used is a GRADUAL DECONDITIONING [SYSTEMATIC DESENSITIZATION]. The patient is gradually brought close to the Phobic Stimulus under Controlled Conditions while at the same time using Relaxation Techniques.

The patient makes a list of all the anxiety provoking situations from Least provoking to Most provoking. The patient then goes through this list in their imagination. As their Anxiety Increases they are supported psychologically and taught to use Relaxation Techniques to control that Anxiety. After they have learned to control the Anxiety in their imagination they learn to do this in the actual Phobic Situation.

FLOODING is another type of Behavior Therapy where the patient is confronted by the Phobic Stimuli without them being given the chance to escape. Eventually they "Bum Out" their fear and learn to accept that the situation cannot harm them. This is not used very often as it is very unpleasant and the results from Systematic Desensitization are just as good.

PHYSICAL 

Anxiolytics are often prescribed with Tricyclic Antidepressants to control the Panic Attacks.

NURSING CARE

• Nurses who have the appropriate training may be entirely responsible for the patient and carry out the Behaviour Therapy instead of a Psychologist. The results from clinical trials show that . Specially Qualified Nurses are just as effective as Psychologists.
• It is very important to build up a trusting relationship with these patients. The nurse has to be Calm and Competent to serve as a Role Model and give Psychological Support during Panic Attacks and Desensitization.
• The nurse's role in Behavior Therapy will depend on the type of therapy prescribed. Often these patients will be treated as Outpatients or in their Own Homes by a Community Psychiatric Nurse.
• It is the responsibility of the nurse to become expert in the techniques of Psychological therapy used with these patients. As well as giving Psychological Support they can reinforce specific Behavioral Techniques.

KEY POINTS:

1. Anxiety is a normal emotion. It becomes abnormal if there is no apparent cause for the anxiety, or if the anxiety is out of proportion to the cause, or if it interferes with our daily life.

2. Low or Moderate Anxiety Levels tend to improve our reactions and performance. High anxiety levels decrease performance.

3. In this disorder there is Free Floating anxiety. The patient feels continuously anxious but does not know why.

4. Treatment includes Insight Psychotherapy Relaxation Techniques, Anxiolytics and Tricyclic Antidepressants.

5. In Phobias the anxiety is Focused on a particular object or situation The fear is out of out proportion to the stimulus and often results in a Panic Attacks.

6. Phobias may be divided into Simple, Social and AGORAPHOBIA.

7. Treatment consists of Behavior Therapy, Systematic Desensitization Flooding, and Anxiolytics with Tricyclic Antidepressants

8. It is very important to build up a trusting relationship with these patients. The nurse has to be Calm and Competent to serve as a Role Model and give Psychological Support.

9. It is the responsibility of the nurse to become expert in the techniques of Psychological therapy used with these patients. As well as giving Psychological Support they can reinforce specific : Behavioral Techniques.

HYSTERIA [Conversion Disorder, Dissociative Disorder]

In this disorder the patient's mental conflicts are expressed UNCONSCIOUSLY by converting the Mental stress into a Physical Disorder or Dissociating their Conscious from their Unconscious mind. It begins in Adolescence or Early Adulthood and is more common in Women than Men.

SIGNS and SYMPTOMS

A. CONVERSION SYMPTOMS 

Can present as any organic disease and will depend on the level of knowledge of the individual. Blindness. Deafness, Paralysis, Convulsions or the Inability to Feel Pain may all be presenting symptoms. 

B. DISSOCIATIVE SYMPTOMS

Amnesia is the commonest presenting symptom. In its severest form it presents as a FUGUE STATE where the individual loses ALL memory about himself and past life. He may wander off and make a new life for himself even to the extent of getting married and having children. Years later he may suddenly recover his memory for his past life and have total amnesia for the Fugue Period. The signs and symptoms produce a PRIMERY and SECONDARY GAIN. The Primary Gain is the relief from Stress and Tension: The Secondary Gain is the sympathy and help they receive for their illness.

TREATMENT

Physical causes for the presenting symptoms must be excluded before the disorder is classified as a psychiatric illness.

The nurse's observation may be very important in determining whether any Physical Conversion sign is part of a physical or mental illness. For example if the patient has Fits is it a true fit or not.

Remember that the patient is Not Aware that their Conversion signs and symptoms are caused by a psychiatric disorder. They need sympathy and help it does no good to tell them to "Stop Acting, and Grow up". These symptoms will disappear under Hypnosis or in Narco analysis, but it is dangerous to remove the symptoms with out dealing with the underlying cause. Cases have occurred where "Stage Hypnotists" have "Cured" patients of paralysis and the individual has walked out of the theater and killed themselves.

These patients need strong support from the nurses in order to gain Insight and develop other Coping Mechanisms.

OBSESSIVE-COMPULSIVE DISORDERS

Is a disorder where there are repetitive THOUGHTS [Obsessions] and a Need to care out certain ACTS [Compulsion]. If they do not carry out these Acts they get more and more anxious and may go into a panic attack.

SIGNS and SYMPTOMS

A. OBSESSIONS 

Ideas, Words or Images force themselves into the patient's mind and he cannot resist them. All of us. have at some time, this happen to us, "Did I Turn Off the Cooker? Did I Lock the Door?" We are sure that we did turn off the cooker. but we feel anxious until we have checked. The individual who has Obsessive Compulsive Disorder has unwanted thought continuously going through his head. He is unable to concentrate as he try's to force the ideas away. Even when he drives them away he knows they will soon be back. The ideas are often about Religion, Sex or Contamination by Dirt or Bacteria.

B. COMPULSIONS

The patient is forced to carry out these acts even though he knows that they are strange and he doesn't want to do them. Very often they are in the form of a RITUAL [They have to be done in an Exact way], if he makes a mistake in the Ritual he has to start all over again. Common Compulsions are repeated Hand Washing and having to put on clothes in an exact way. Often they cannot lead a normal way because they have to wash their hands 20 to 30 times over the space of a few hours.

TREA TMENT

Behavior Therapy Techniques as discussed earlier are very effective in reducing the symptoms of this disorder. However, the patient will often relapse and require further treatment If the disorder is treated at an early stage the results are much better.

KEY POINTS

1. In Hysteria the patient's menial Conf1icts are expressed UNCONSCIOUSLY by converting the Mental stress into a Physical Disorder or Dissociating from their Conscious Unconscious mind

2. Conversion Symptoms Can present as any organic disease and will depend on the level of knowledge of the individual

3. Dissociative is the Symptoms. Amnesia commonest presenting symptom. I" its severest form it presents as a FUGUE

4. The Primary Gain is the relief from Stress and Te1I!iion. Secondary Gain is the sympathy and help they receive for their illness.

5. Obsessive-Compulsive Disorder is a disorder where there are repetitive THOUGHTS /Obsessions and a Need to care out certain ACTS(/Compulsion)

6. Behavior Therapy Techniques are very effective in reducing the symptoms of this disorder.

ORGANIC STATES

INTRODUCTION

Organic States are neurological disorders where there are physiological changes in the brain. Organic states may be either ACUTE or CHRONIC. As people live longer, and with the breakdown of Extended Family. Chronic Organic States are becoming a major Social and Health care problem in many countries. 

ACUTE ORGANIC STATES
[Toxic- Confessional State/Acute Delirious Reaction]

Onset is Sudden with a fairly Rapid Recovery. In most cases there will be Complete Recover)'. In some cases there will be Permanent Brain Damage.

ETIOLOGY:
1. INFECTION: Acute system, infections, meningitis, encephalitis.
2. IINTOXICASION: Alcohol, Drugs, Reaction to medication
3. METABILIC DISORDER: Electrolyte Imbalance, Liver and Renal Failure, Hypo or Hyper Glycaemia
4. TRAUMA: Head Injury
5. SPACE OCCUPYING LESION: Tumor
6. CARDIOVASCULAR DISORDER : CVA, Anemia, Anoxia
7. NERVOUS SYSTEM DISORDER : Multiple Sclerosis

PRESENTATION
The dominant symptoms are Clouding of Consciousness. Confusion and Restlessness. Illusions and Hallucinations may be present.

TREA TMENT
Treatment is for the disorder causing the Delirium.

NURSING CARE
Nursing care involves Reducing the amount of Stimuli the patient receives. Making as Few Changes to the Environment and caring Personnel as possible and constant Reassurance and Explanation. Subdued lighting is much better than bright light or complete darkness. Complete or near darkness encourages Illusions.

CHRONIC ORGANIC STATES[Dementia]

In this condition there is a Progressive and Irreversible Deterioration of Brain Function. The structure of the brain is damaged.

ETIOLOGY
1. INFECTION: Syphilis. Encephalitis. Jakob-Cremzfld Disease. HIV/ AIDS.
2. POISONS: Chronic Alcohol Use. Lead. Mercury.
3. BRAIN DAMAGE: Trauma. Multi-Infarct Dementia. CV A.
4. GENETIC: Huntington's Chorea.
5. DEGENERATIVE: Alzheimer's. Pick's Disease.

INFECTION
Cerebral Syphilis [GPI] is now very rare following the development of Antibiotics.

Jakob-Creutzfeld Disease is caused by a Slow Virus. It is not common and its mode of transmission is not clear. It has been transmitted by organ transplant.

POISONS
Chronic Alcohol Use leads to Korsakoff’s Psychosis because of a deficiency of Vitamin B from Malnutrition and Gastritis.

BRAIN DAMAGE
Multi-Infarct Dementia is one of the major causes of Dementia and is discussed in detail below.

GENETIC
Huntington's Chorea is a rare condition passed on by a Non-Sex Linked Dominant Gene
What % of Children will Inherit the Disorder ??1.
The disorder normally appears when the patient is in his/her 40's. There is Dementia with Choroid Movements and Ataxia. The disorder may last from 15-20 years before death occurs. Death may be from Suicide. Choking or Pneumonia.

DEGENERA TIVE
Alzheimer's and Pick's Disease are discussed below.

MULTI-INFARCT TYPE DEMENTIA
This disorder used to be called Arteriosclerotic Dementia as the dementia was thought to be caused by narrowing of the arteries in the brain. Now it is known that small areas of the brain are destroyed [INFARCTS] when the blood supply is cut off by small blood clots [EMBOLI].

It is more common in Men and age of Onset is late 60's to 70's. Onset is Sudden and may follow a mild stroke. The signs and symptoms depend on the area of the brain affected by the Infarct. It develops in a Steplike way with each deterioration following a period of Clouding of Consciousness. Depressive symptoms are common and Suicide is a Risk.

Treatment of disorders such and Diabetes Mellitus and Hypertension is Very Important. Treatment with low daily dosages of Aspirin is now common.

DEGENERATIVE TYPE DEMENTIA
ALZHEIMER'S DISEASE is due to a Degeneration of the Brain Cells. The brain Atrophies and cells are lost from the Cerebral Cortex and other areas. Onset may be PRESENILE [50 to 60's] or SENILE [70 to 80's]. PICK'S DISEASE is similar in presentation to Alzheimer's and the difference is usually discovered at Post Mortem.

PRESENTATION

MEMORY
Memory Loss is very severe. At first this tends to be for Recent Events [Anterograde]. Later this becomes so severe that they may not even able to remember their own names. This becomes e:\'1remely dangerous when they begin to cook and forget that they have a saucepan on the cooker.

CONFUSION & DISORIENTATION
Is related to memory loss with total disorientation to Time, Place and Person. They will often lose track of night and day and dress themselves for shopping in the middle of the night. Giving them heavy Night Sedation only increases their confusion the next day.

INTELLECTUAL DETERIORATION
They become rigid and unable to Accept or Adapt to new situations. Their Judgment becomes Faulty and they may make serious money or moral mistakes.

EMOTIONAL LABILITY
They easily move from laughter to tears and may over react to situations. Deep depression may occur in the early stages.

TREATMENT
At present time there is no treatment for the Chronic Organic States. Associated disorders such as Hypertension or Alcoholism have to be controlled.

NURSING CARE
Individuals have to be assessed properly and a Rating Scale will be given to you to try out. Individual care programmes must be worked out for each patient. The nurse has to remember that these patients have led long and responsible lives, often they have brought up families and are used to respect. They may find it very difficult to be organized by nurses who are younger than their daughters.

The Dementia may be complicated by physical deficits caused by aging [Mobility, Hearing and other Special Senses). Part of the assessment will include these physical deficits. If the patient has difficulty in seeing or hearing, glasses and hearing aids need to be acquired. Anorexia may be due to unusual food or bad teeth. Before arranging a "Soft Diet" the patient's likes and dislikes for food should be discovered and dental care arranged.

Always take time to explain and lead the patient rather than pulling them. Remember that the reason the hospital exists [and you are employed] is for the patient. and not for the staff. If the routine means that patients have to be rushed to get washed and dressed for breakfast. then the routine needs to be changed.

Whenever approaching the patient use Reality Orientation. Tell them who you are. talk them through any walks to the toilet or garden or bed. Routine should be stimulating but fairly rigid with few daily changes. Family contact should always be maintained even if the patient does not appear to respond to visits.

In many countries such patients are maintained as long as possible at home with the aid of HOME HELPS, NURSING VISITS MODIFIED HOMES, SHELTERED HOMES DAY CENTRES, MEALS-ON- WHEELS.

KEY POINTS
1. Organic States are neurological disorders where there are physiological changes in the brain. Organic states may be either ACUTE or CHRONIC.
2. In Acute Organic States Onset is Sudden with a fairly Rapid Recovery.
3. The dominant symptoms are clouding of Consciousness, Confusion and Restlessness. Illusions all Hallucination may be present.
4. Treatment is for the disorder causing the Delirium.
5. Nursing care involves Reducing the amount of Stimuli. making as Few Changes to the Environment and Personnel as possible.
6. In Chronic Organic States there is a Progressive and Irreversible Deterioration of Brain Function. The structure of the brain is damaged.
7. Multi-Infarct Type Dementia used to be called Arteriosclerotic Dementia as the dementia was thought to be caused by narrowing of the arteries in the brain. Now it is known that small area of the brain are destroyed when the blood supply is cut off by small blood clots.
8. The signs and symptoms depend on the area of the area of the brain affected by the Infarct. It develops in a Step like way with each deterioration following a period of Clouding of Consciousness.
9. Alzheimer's Disease is due to a Degeneration of the brain Cells. The brain Atrophies and cells are lost from the Cerebral Cortex and other areas. Onset may be Pre-Senile (50 to 60's) or Senile (70 to 80's).
10. Memory loss is very sever. At first this tends to be for Recent Events Confusion is related to memory loss with total disorientation to Time, Place and Person.
11. They become Rigid and unable to Accept or Adapt to new situations. They easily move from laughter to tears and may over react to situations. Deep depression may occur in the early stages.
12. Individuals have to be assessed properly and individually. The Dementia may be complicated by physical deficits caused by aging [Mobility, Hearing and Other Special Senses].
13. Take time to explain and lead the patient rather than pulling them. When approaching the patient use Reality Orientation. Tell them who you are, talk them through any walks to the toilet, garden or bed.
14. Routine should be stimulating but fairly rigid with few daily changes. Family contact should always be maintained even if the patient does not appear to respond to visits.
15. 1 n many countries patients are maintained as long as possible at home with the aid of Home Helps, Nursing Visits, Modified Homes, Sheltered Homes, Day Centers and Meals on Wheels.

MOTHERHOOD and MENTAL DISORDER

INTRODUCTION

Pregnancy and childbirth are significant life events for a woman. Not only are there the Physiological changes but also new Psychological and Social Roles for her to undertake. The majority of women cope with these changes in a positive way and see them as an enhancement of their life. A few. however, may suffer from mental health problems following birth.

FACTORS INFLUENCING MENTAL HEALTH FOLLOWING CHILDBIRTH:¬

 Stress of Delivery

 Endocrine Changes

 Was the Baby Wanted

 Experience of Child Rearing and Support Structures

 Social Stresses [Bad Marriage, Bad Housing, Financial Problems]

 Previous Mental Illness

POST NATAL BLUES:

About 50% of new mothers experience a degree of Post Natal Blues. The Onset is 3-7 Days after birth when the mother becomes tearful. irritable and depressed. The mother has some physical discomfort from the birth. is tired and has to care for the baby. It is. therefore, very difficult for her to regain her balance and cope with her new role. The majority of mothers recover after 10- I 5 days. If there are other stress it may take as long as 6 months to a year. About 25% go on to develop:¬

POST NATAL DEPRESSION:¬

Is a clinical depression and much more severe than the above. The mother becomes Depressed, Irritable and cannot concentrate. S1eep is disturbed and they feel tired all the time with no energy. They feel very Negative about themselves and have a low Self-Esteem. They may also Reject the baby.

They may have SUICIDAL THOUGHTS or IDEAS OF HARMING THE BABY. These MUST be taken seriously to avoid the risk of Suicide or harm to the Baby. A woman with this disorder is not in control of herself and needs Protection until she recovers.

The disorder is treated as a Clinical Depression with Antidepressants but additional support has to be provided to help the mother cope. Some hospitals have Mother and Baby Units so that they are not separated during treatment. but the safety of the baby has to be considered. Also. if the mother is breast-feeding the baby, the possibility of the medication being passed on to the baby has to be considered. If left untreated the Depression may go on for many years. and there is a strong risk of relapse following future childbirth.

PUERPERAL PSYCHOSIS

Is a rare reaction to childbirth [0.3% of live births]. Onset is acute and may occur up to 14 days after birth. The psychosis may present as any of the Functional Psychoses and the treatment is the same. The safety of the Baby, both from the mother and the drugs that the mother is on [Breast Feeding. Dizziness] has to have priority in the care plan.

The majority of the women 3 out of 4 will recover, but some will be left with residual problems. The risk of further problems following future pregnancies is increased.

KEY POINTS:

1. Pregnancy and childbirth are significant life £-'Vents for a woman there are Physiological changes and new Psychological and Social Roles for her to undertake.

2. Influencing Factors include Stress, Endocrine Changes, Experience of Child Rearing, Support Structures, Social Pressures and Previous Mental Illness

3. Post Natal Blues occurs 3-7 Days after birth when the mother becomes tearful, irritable and depressed. Post Natal

4. Depression Is a clinical depression and much more severe than the above. The mother may have SUICIDAL THOUGHTS or IDEAS OF HARMING THE BABY.         These MUST be taken serious(v to avoid the risk of Suicide or harm to the Baby.

5. PUERPERAL Psychosis may present as any of the Functional Psychoses and the treatment is the same.

6. The safety of the Baby has to have priority in the care plan.

AGGRESSION

Is a normal human emotion that becomes Abnormal when it is not an accepted response to a provocation or is too extreme to be acceptable. Aggression may be a Positive emotion if it is directed properly. In a Psychiatric unit aggression may be the result of Frustration., Confusion, Hallucinations or Delusions. Aggression to Violence may be seen as a continuum:

VERBAL ------- VIOLENCE TO OBJECTS ------ VIOLANCE TO PEOPLE

The best way to deal with Aggression is to prevent it or redirect it. It is very frustrating to be confined in a hospital with no outlet for your energies. Therefore one of the methods used is to divert the energy and aggression into sports or physical activity. If a patient is feeling frustrated and angry they should be allowed to VENTILATE their thoughts and feelings verbally.

A close Therapeutic Relationship will also reduce the risk of Violence. The nurse "ill be able to identify problems Before they reach crisis point and defuse the situation. Medication changes may also be made if the nurse observes that Hallucinations or Delusions are leading to aggression.

DEALING WITH A VIOLENT INCIDENT:

1.  Never try to deal with a violent patient on your own. GET HELP
2. Either You or the Patient will get hurt if you deal with a situation on your own.
3. Do Not Panic, Keep Calm.
4. THE FOLLOWING IS WHAT THE TRAINED STAFF WILL DO.
5. When help arrives clear other patients from the area and remove articles that could cause injury from the area.
6. One Nurse must take charge, do All the Talking and organize the restraint.
7. Individual nurses should be designated to hold each limb near a Major Joint
8. Pressure should Never be applied to the Neck, Chest or Abdomen.
9. The patient should be Brought to the Ground and placed Face Down while being held.
10. Physical restraint should not be released until the patient either Stops the Attack or has been sedated.
11. The incident should be analyzed afterwards so that lessons can be learned.

KEY POINTS:

• Aggression is a normal human emotion that becomes Abnormal when it is not an accepted response to a provocation or is too extreme to be acceptable.
• Aggression may be a Positive emotion if it is directed properly. In a Psychiatric unit aggression may be the result of Frustration, Confusion, Hallucinations or Delusions.
• The best way to deal with Aggression is to prevent it or redirect it. Divert the energy and aggression into sports or physical activity. A patients should be allowed to VENT/LA TE their thoughts and feelings verbally.
• A close Therapeutic Relationship will reduce the risk of violence
• Never deal with a violent patient on your own. Keep Calm. Clear other patients from the area and remove articles that could cause injury. One Nurse must take charge. Nurses should be designated to hold each limb near a Major Joint.
• Pressure should Never be applied to the neck, Chest or Abdomen. The patient should be Brought to the Ground and placed Face Down while being held.
• Physical restraint should not be released until the patient either Stops the Attack or has been sedated.
• The incident should be analyzed afterwards so that lessons can be learned

SCHIZOPHRENIC DISORDERS

above: MRI imaging showing differences in brain ventricle size in twins - one schizophrenic, one not. (image courtesy NIH - Dr. Daniel Weinberger, Clinical Brain Disorders Branch)

Schizophrenia is a Functional Psychosis with age of Onset in Adolescence or Young Adulthood. It is a severe Psychosis and often become a Chronic Disorder. 15% of admissions to psychiatric hospital and 45% of long stay patients have Schizophrenia.

ETIOLOGY:

The cause of Schizophrenia is not known. There seems to be a strong GENETIC link, where the individual Inherits a TENDENCY to the illness. That is the individual Inherits the GENE [predisposing Factor] and STRESS [ Precipitating Factor] triggers the illness.

1. Monozygotic Twins : 60%
2. Dizygotic Twins : 18%
3. One Parent Schizophrenic : 12%
4. Both Parent Schizophrenic : 40%
5. General Population : 0.8%

Another theory on the etiology of Schizophrenia suggest that a BIO-CHEMICAL IMBALANCE causes the disorder. Certain drugs such a LSD [Lysergic Acid Diethylamide] produce effects similar to Schizophrenia. Individuals who take Amphetamines may develop Amphetamine Psychosis which is very difficult to separate from a Schizophrenic Psychosis.

These drugs have a similar structure to DOPAMINE [A Neurotransmitter in the nervous system]. Neuroleptics which reduce the symptoms of Schizophrenia block Dopamine Receptors whereas the above drugs have the opposite effect.

PATHOGENIC FAMILIES are also put forward as a cause. In this model children of schizophrenic parents are subjected to confusing and contradictory signal from the parent [DOUBLE BIND. The VERBAL signal (I love you) may be accompanied by a NON-VERBAL signal [Keep away, I hate you.]

PRESENTATION:

Schizophrenia may be either REACTIVE, [where an individual responds to a Crisis with a Schizophrenic Reaction}. or a PROCESS, [where the illness is a development of the individual's Personality]. The prognosis of REACTIVE Schizophrenia is very good.

In Process Schizophrenia the disorder is Development of the individual's PRE MORBID SCHIZOID PERSONALITY. Before the disorder develops the individual would have been quiet. withdrawn and isolated with a lack of drive.

Signs and Symptoms of Schizophrenia include DISORDERS OF:

1. THOUGHT
2. PERCEPTION
3. AFFECT
4. VOLITION (DRNE)
5. BEHAVIOUR

THOUGHT:

DELUSIONS may be PRIMARY and arise without any obvious reason or SECONDARY and build up into a SYSTEM with a whole collection of Delusions which explain and support each other.

THOUGHT BLOCK is common together with CONCRETE thinking and IDEAS of REFERENCE. The patient may experience ideas of P ASSMTY where their thoughts are controlled from outside and they are Forced to do things even to the extent of committing Suicide.

PERCEPTION:

The commonest disorder of Perception is the HALLUCINATION which may be:

a. AUDITORY [Commonest]

b. VISUAL

c. TACTILE

d. GUSTATORY

e. OLFACTORY.

AFFECT:

The dominant effect on Mood is a BLUNTING of AFFECT which may lead to APATHY and a. general loss of interest in what is happening in the worlds around them. They may also have an INCONGRUITY of AFFECT where their Emotional response in inappropriate.

The Blunting of Affect and Apathy lead to the biggest problem in the rehabilitation of patients with Schizophrenia which is the LACK OF VOLITION.

VOLITION:

The lack of Volition leads the patient to withdraw into an inner world of Fantasy and a disinterest in the real world. They have no motivation to try to return to a "Normal" state. When any stress occurs they retreat back into fantasy. This is a major problem in Rehabilitation as they are usually quite happy to stay in hospital where they are protected and don't have to worry about things such as work, clothing and food.

BEHAVIOUR:

Abnormal body movements may consist of :

a. Abnormal Facial Movements (Grimaces)

b. Strange movements of the Limbs

c. Strange Postures which are held for a long time(Waxy Flexibility) and Echopraxia.

d. Strange GAIT the way in which they walk.

TYPES OF SCHIZOPHRENIA:

1- SIMPLE

2- HEBEPHRENIC

3- CATATONIC

4- PARANOID

5- RESIDUAL

1. SIMPLE

Age of Onset during Adolescence. The onset in Insidious and slowly progresses with deterioration of the Personality. Hallucinations and Delusions may not be present with the Main Symptom being LACK of VOLITION. Many of these individuals end up as tramps or prostitutes who are "protected" by a "pimp". The Prognosis is very poor.

2. HEBEPHRENIC

Onset is in late Adolescence. Hallucinations and Delusions are present and are often very strange [Bizarre]. Behavior is very odd with them often laughing and making strange faces at mirrors and windows.

3. CATATONIC

Onset is in late Adolescence to the early Twenties. It is not very common and early and effective treatment means that the acute signs and symptoms are rarely seen. The main symptom is disturbed Behavior. The patient may go into a Catatonic STUPOR where full consciousness is retained. and Catatonic EXCITEMENT. Negativism, Echolalia and Echopraxia are common.

4. PARANOID

Onset is late from Thirty to Fifty years. The main symptoms are PERSECURITY Delusions with Auditory Hallucinations. Ideas of Reference are very common and may lead to aggression.

5. RESIDUAL

A chronic stage in the development of Schizophrenia. Characterized by long term Negative symptoms such as Blunting of Affect. Passivity, Poverty of Ideas.

PHYSICAL TREATMENT

CHEMOTHERAPY

These drugs were introduced in the 1950s and had a profound effect on the treatment of Schizophrenia. They are not just Tranquilizers but reduce the Psychotic symptoms Le.: Delusions and Hallucinations. The development of long acting DEPOT IN.JECTIONS has meant that many patients can now be discharged from hospital while COMPLIANCE with chemotherapy is possible through Outpatient or Community Psychiatric Nurse Visits.

ANTI PSYCHOTICS (Neuroleptics) :

a. Phenothiazines (Chlorpromazine, Triflouperazine)

b. Haloperidol (Haldol, Serenace)

DEPOT Injection :

a. Fluphenazine Decanoate (Modecate)

b. Flupenthixol Decanoate (Depixol)

ELECTRO-CONVULSIVE THERAPY:

Is rarely used in the treatment of Schizophrenia. It may be used where there is severe Mood Disturbance. or where a patient is in a Catatonic Stupor.

NURSING CARE:

• Individuals with Schizophrenia become Withdrawn. Isolated and Institutionalized. Nurses. therefore need to break down this isolation by providing Caring, Human Contact and maintaining . Communication even when the patient rejects this relationship.
• Passivity and Institutionalization are major reasons for patients witI1 Schizophrenia becoming Chronic and Long Stay patients in hospital. They must be involved in Decision Making about their care and treatment, and involved in social events.
• In the clinical area you will be involved with the patients in group social activities in Occupational Therapy. Sports.
• Gardening and Parties. You cannot involve patients in these activities unless you involve yourselves. Remember that when you take a group of patients to the park this is Not a day-out for you, but part of the patient's therapy.
• These patients are often Rejected b)' their Families, which increases their Isolation. Contact with the family must be encouraged especially when discharge is near. In any countries Half-way Houses and Hostels help with an effective rehabilitation. Long Term Follow Up through Day Hospitals, Out Patients and/or Community Psychiatric Nurses is very important to prevent relapses.

KEY POINTS:

I) Schizophrenia is a Functional Psychosis with Onset in Adolescence or Young Adulthood. It is a severe Psychosis and often becomes a Chronic Disorder.

2) The cause of Schizophrenia is not known The individual Inherits the GENE {Predisposing Factor/ and STRESS (Precipitating Factor/ triggers the illness.

3/) Another theory on the etiology of Schizophrenia suggest that a BIO-CHEMICAL IMBALANCE causes the disorder. DOPAMINE. A Neurotransmitter in the nervous system. may be involved in the etiology of Schizophrenia.

4) PATHOGENIC FAMILIES are put forward as a cause. Children of Schizophrenic parents are subjected to confusing and contradictory signal from the parents, DOUBLE BIND.

5) Schizophrenia may be either REACTIVE or PROCESS. The prognosis of REA CTIVE Schizophrenia is very good.

6) Signs and Symptoms of Schizophrenia include Disorder of Thought. Perception. Affect. Volition. and Behavior.

7) Types of Schizophrenia may include Simple. Hebephrenic. Catatonic. and Paranoid.

8) Ami Psychotic medicines are not just Tranquillizers but reduce the Psychotic symptoms of Delusions and Hallucinations. The development of long acting Depot Injections has meant that many patients can now be discharged from hospital

9) Electro-Convulsive Therapy is rarely used in the treatment of Schizophrenia. It may be used where there is severe Mood Disturbance, or where a patient is in a Catatonic Stupor.

10) Individuals with Schizophrenia become Withdrawn, Isolated and Institutionalized. Nurses need to break down this isolation by providing Caring, Human Contact and maintaining Communication.

11) Patients with Schizophrenia must be involved in Decision Making about their care and treatment. and involved in social events.

12/ Patients are involved in group social activities UI Occupation Therapy, Sports. Gardening and Parties.

13) Patients are often Rejected by the Families, which increases their Isolation. Contact with the family must be encouraged.

14) In many countries Half-way Houses and Hostels help with effective rehabilitation. Long Term Follow Up through Day Hospitals. Out Patients and/or Community Psychiatric Nurses is 'very' Important to prevent relapses.