Suicide is a Deliberate and FATAL act of SELF HARM

Is a NON-FATAL Deliberate of SELF HARM. Often the individual does not actually want to kill themselves, so it is not always an Attempted Suicide. Sometimes the Para suicide may be a CRY FOR HELP by someone who feels hopeless and desperate. ALL PARAS CIDES MUST BE TREATED SERIOUSLY.

In some countries Para suicide is the commonest reason for medical admission to hospital for women, and the second commonest for men.


METHODS OF SUICIDE, COMMON METHODS ARE:
1. Poisoning : With Drugs or Chemicals
2. Cutting Arteries : Neck or Wrist
3. Hanging/Suffocation : With a rope or Plastic Bag or Gas
4. Burning : With Petrol or Domestic Heating Fuel
5. Jumping : From High Building
6. Drowning : Often Hides the suicide as an Accident

FACTORS LINKED TO AN INCREASE IN THE RISK OF P ARASUICIDE:
1. MARITAL PROBLEMS:
• Divorce
• Husband Taking a Second Wife
2. ECONOMIC PROBLEMS:
• Low Wage
• Unemployment [Especially Men]
3. YOUNG AGE GROUP:
• 75% Under 40 Years of Age;
4. FEMALE SEX
• Twice as Many Women as Men;
5. ALCOHOL & DRUGS
6. MENTAL ILLNESS
• Especially Depression.

WHY DO PEOPLE KILL OR ATTEMPT TO KILL THEMSELVES:

In most of the worlds religions Suicide is a Sin [Haram]. In most societies Suicide brings Shame on the family. So for a person to commit or attempt to commit Suicide that person must be desperate. In some countries including Kuwait attempting suicide is against the law.

FACTORS LINKED TO AN INCREASE IN THE RISK OF SUICIDE ARE:

• Mental illness especially depression;
• Previous attempts at suicide
• Violence of the method used in earlier attempts
• Isolation from family and society
• Economic or family crisis
• Use of alcohol or illegal drugs
• Male sex
• Increasing age
• Occupational groups like doctors, nurses n& bartenders

NURSING CARE OF THE PATIENT WHO HAS ATTEMPTED SUICIDE:

Para suicide is a Psychiatric EMERGENCY and they must ALL be treated SERIOUSLY. You will hear Nurses say that those who attempt Suicide never commit Suicide, That is Wrong. About 1/2 of people who Commit Suicide have had previous attempts.

By the time an individual who has attempted suicide is admitted to the Psychiatric Unit they will be feeling very low in mood. Physically they will probably be very tired and the original problem which caused the Para suicide is still there.

In addition they may feel that they have. brought shame on their family. As attempted suicide is illegal in Kuwait they may also have been questioned by the Police. The patient may be grateful that he has been rescued and is being protected in the hospital or may become even more shamed that he is now Labeled a "Mental Case".

A judgment has to be made, by the Psychiatric Team, between raising the patient's self-esteem and Preventing any further Suicide attempts. It is the Duty of each nurse on a ward to find out what is the Suicide Prevention Policy for that particular ward and patient. Nursing care of the Depressed and/or Psychotic patient is discussed in other sections, this section deals only with suicidal behavior.

MAINTENANCE of PATIENT SAFETY

General Principles:

• ALL Staff, including porters and cleaners, on the ward must be Instructed in the Policy;
• Dangerous Articles such as Knives & Scissors Must be Removed from the Patient for safe keeping, and the patient should be informed in a Positive way about this policy;
• The environment should be Made, and Maintained, Safe. Windows locks act. should be checked.
• Remember that if the cleaner is not informed about the policy he may leave cleaning chemicals where the patient can use them, or buy something for the patient, in a shop outside, without realizing the danger.
• Also visitors Must be instructed to discuss with the staff the dangers of giving articles to the patient.
• When medication is given the nurse Must make sure that it has been swallowed and not kept under the tongue and saved up.
• The Most Important prevention. measures are:
- Assessment of the suicide risk; and
- Observation.

ASSESSMENT:
When deciding on the policy for a particular patient an assessment of the Suicide Risk will be made.
It will include factors such as:

a) What led to the attempt;
b) The Method used;
c) Was the attempt Carefully Planned; d) Is there any Mental Illness [Depression, Delusions, Hallucinations]
e) Does the patient Still want to Die;
1) Has he Planned another attempt.

Depending on the level of risk three levels of observation may be prescribed:

a) Close One to One Observation
b) Continuous Unobtrusive Observation
c) Timed Observation

a) Close One to One Observation
• The patient is under observation 24 hours per day;
• One Nurse is allocated to Special the patient in each shift;
• The nurse allocated to the patient is relieved by another nurse every two hours;
• The nurse with the patient is never more than One Arm's Length away from the patient at any time;
• Even when the patient goes to the toilet the above rule applies and the door to the toilet must remain open;
• When the Specialing nurse is relieved they must write down observation notes;
• The nurse should not just follow and observe the patient. The patient should be engaged in activities such as games, talking and reading.

b) Continuous Unobtrusive Observation
• The patient should be under Observation for 24 Hours Per Day;
• One nurse is allocated to observe the patient;
• This observation does not have to be obvious.
• When the patient goes to the toilet, they can be observed under the door.
• The nurse can observe the patient from across the room or can playa game, such as cards, with them. This is what is meant by Unobtrusive.
• The allocated nurse must write up observation notes at the end of the shift and hand over to the allocated nurse on the incoming shift.

c) Timed Observation
• All staff on the ward are made aware of the risk of suicide with the particular patient;
• One nurse is allocated to check on the patient at specified time intervals:
eg: 10 minutes
15 minutes
30 minutes
• The allocated nurse signs a form each time that they check the patient

Studies have shown that patients have both positive and negative reactions to "Specialing" but the reaction is mostly positive. The negative feelings occur when the nurse acts like a Jailer and doesn't communicate with the patient.

Bassett D. Tsourtos G. Inpatient suicide in a general hospital unit. A consequence of inadequate resources: General Hospital Psychiatry. 15[5]:30 1-6,1993 Sep Green JS. Grindel CG. Supervision of suicidal patients in adult inpatient psychiatric units in general hospitals: Psychiatric Services. 47[8]:859-63, 1996. Aug
Pitula CR. Cardell R. Suicidal Inpatients' experience of constant observation. Psychiatric Services. 47[6]:649¬51,1996 Jun.

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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.