Mental Health of GNM

Biyani's Think Tank
Concept based notes
Mental Health & Psychiatric

Nursing-I
(GNM)
Subita Fageria
Lecturer
Deptt. of B. Sc. (Nursing
Biyani Nursing College, Jaipur
Published by :
Think Tanks
Biyani Group of Colleges
Concept & Copyright :
Biyani Shikshan Samiti

Sector-3, Vidhyadhar Nagar,
Jaipur-302 023 (Rajasthan)
Ph : 0141-2338371, 2338591-95 Fax : 0141-2338007
E-mail : [email protected]
Website :www.gurukpo.com; www.biyanicolleges.org
First Edition : 2011
While every effort is taken to avoid errors or omissions in this Publication, any
mistake or omission that may have crept in is not intentional. It may be taken note of
that neither the publisher nor the author will be responsible for any damage or loss of
any kind arising to anyone in any manner on account of such errors and omissions.
Leaser Type Setted by :

Biyani College Printing Department
Mental Health & Psychiatric Nursing
Preface
am glad to present this book, especially designed to serve the needs of
the students. The book has been written keeping in mind the general weakness
in understanding the fundamental concepts of the topics. The book is selfexplanatory and adopts the Teach Yourself style. It is based on questionanswer pattern. The language of book is quite easy and understandable based
on scientific approach.
This is to help the students for clearing their doubts and for guidance and to
understand the subject why easily in a settled manner. This book covers the
diagnosis and management of both medical & nursing including the
psychopharmacology & general therapies of psychiatric disorders.
Any further improvement in the contents of the book by making corrections,
omission and inclusion is keen to be achieved based on suggestions from the
readers for which the author shall be obliged.
I acknowledge special thanks to Mr. Rajeev Biyani, Chairman & Dr. Sanjay
Biyani, Director (Acad.) Biyani Group of Colleges, who are the backbones and
main concept provider and also have been constant source of motivation
throughout this Endeavour. They played an active role in coordinating the various
stages of this Endeavour and spearheaded the publishing work.
I look forward to receiving valuable suggestions from professors of various
educational institutions, other faculty members and students for improvement of
the quality of the book. The reader may feel free to send in their comments and
suggestions to the under mentioned address.
Author
Mental Health/
Psychiatric Nursing
Course Description
This course is designed to help students develop the concept of mental health and mental
illness, symptoms, prevention, treatment modalities and nursing management of mentally
ill.
General Objectives:Upon completion of this course, the students will be able to:
1. Describe the concept of mental health and mental illness and the emerging trends
is psychiatric nursing.
2. Explain the causes and factors of mental illness, its prevention and control.
3. Identify the symptoms and dynamics and abnormal human behavior in
comparison with normal human behavior.
4. Demonstrate a desirable attitude and skills in rendering comprehensive nursing
care to the mentally ill.
Course Content
Unit I Introduction
Meaning of mental health and mental illness
Definition of terms used in psychiatry.
Review of mental mechanisms (ego mechanisms)
Review of personality and types of personality.
Unit II History of Psychiatry
Contributors to psychiatry
History of psychiatric nursing
Trends in psychiatric nursing
Unit III Mental Health Assessment

Psychiatric history taking
Interview technique and mental status examination.
Unit IV community Mental Health

Concept, importance and scope
Attitude and misconceptions towards mentally ill.
Prevention of mental illness (preventive Psychiatry) during childhood,
adolescence, adulthood and old age.
Community mental and old age.
Community mental health services.
Role of nurses in community mental health services.
Unit V Psychiatric Nursing Management

Definition of psychiatric nursing
Principles of psychiatric nursing
Nursing process
Role of nurses in providing psychiatric nursing care.
Therapeutic nurse-patient relationship
Communication skills
Unit VI Mental disorders and nursing interventions
Etiology various etiological theories (genetics, biochemical, psychological, etc)
Classification of mental disorders.
Organic mental disorder-Acute brain syndrome
Chronic brain syndrome
Functional mental disorder
Prevalence, etiology, signs and symptoms, prognosis, medical nursing

management
Schizophrenic disorders.
Mood (affective ) disorders.
Manic Depressive Psychosis
Anxiety Status.
Definition, etiology, signs, symptoms, medical and nursing management of:

Phoebic disorders, obsessive compulsive disorders, depressive neurosis, conversion
disorders, dissociative reaction, hypochondriasis, Psychoactive disorders, alcohol, drugs
and other psychoactive substance abuse.
Unit-VII Bio-Psychosocial
Psychopharmacology
Definition, classification of drugs, antipsychotic, antidepressant, antimanic,
antianxiety agents.
Role of nurses in psychopharmacology
Psychosocial therapies
Definition of psychosocial therapies.
Types of therapies; individual and group therapy, behavior therapy, occupational
therapy.
Role of nurse in these therapies.
Somatic therapy
History,
technique
of
electro
convulsive
therapy
(ECT)
contraindications.
Role of nurses before, during and after electroconvulsive therapy.
indications,
Unit VIII Forensic Psychiatry/Legal Aspects

Legal responsibilities in care of mentally sick patients.
Procedure for admission and discharge from mental hospital, leave of absence.
Indian Lunatic Act 1912
Mental Health Act 1987
Narcotic Drugs and Psychotropic Act 1985
Unit IX Psychiatric Emergencies and Crisis Intervention

Over active patient
Destructive patient
Suicidal patient
Unit I
Introduction
Q.1
Ans:
What do you mean by mental health?

According to WHO " Health is define as a state of complete physical, mental,
social and spiritual well being not merely an absence of disease or infirmity?
Mental Health means a Healthy mind in a healthy body. Mental Health is a part of
general health. It requires a balance between body, mind spirit and the
environment in which a person lines.
Mental Health
Environment
Body, mind & spirit
According to Kerl Malinger: The adjustment of human beings to the world and
to each other with a maximum of effectiveness and happiness."
According to WHO: "The capacity of an individual to form harmonious
relationships with other and to participate in or contribute constructively to
change in social environment".
Thus, Mental Health is positive state in which the person is responsible, selfdirective and displays self-awareness.
Q.2 Define Mental illness ;

Ans.: It is an opposition of mental illness. Mental illness occurs when a state of
physical, mental, social and spiritual well being is disturbed.
It is explained in 3 ways:
1.
Absence of Health: It defines illness is an absence of health. It emphasize

problem but does not solve it.
2.
Biology Approach : According to scadding "Mental illness is result of

biological disturbance".
3.
Pathological Approach: According to szusz "Mental illness only is term of

physical pathology".
According to American Psychiatric Association defines "mental illness or
mental disorder is an illness or syndrome with psychological or behavioural
manifestations and/or impairment in functioning due to social, psychological,
genetic, physical/chemical or biological disturbance. The disorder is not limited
to relation between the person and society. The illness is characterized by
symptoms and/or impairment in functioning".
Q.3
How will you differentiate the mentally healthy people from mentally ill
people?
Ans.:
S.No. Mental Health
1
Positive attitudes towards self
acceptance and self awareness
(Optimistic)
2
Able to solve problems by self with
creativity
3
Positive self concept relate well to
people and their environment
4
Able to cope up stress and reality
perception
5
Able to make decision and sound
judgment.
6
Able to establish and maintain healthy
relationship
7
Accepts the authority and
responsibility
8
Able to work effectively and
independently
9
Differentiate and analyze the
situations
10
Has good sense of humar
Mental illness
Negative attitude towards self
acceptance & self awareness
(pessimistic)
Avoid problems than solve
- Poor self concept
- Feels inadequate
Not able to cope thus stressful
situations
Poor decision making & judgments
power
Relationship with friends & family
are disturbed.
Unable to assume authority &
responsibility
Mostly dependent work
Unable to analyze
Easily get irritated
10
11
12
Behavioural that is generally

acceptable to others
Able to solve conflict very easily
13
Deeper insight
Maladaptive behavior
Always confused and unable to solve
conflict
Poor insight.
Q.4
What is mental (Defense) mechanism? How many types of mental

mechanism ?
Ans.: Sigmund freud the father of modern psychiatry coined the term, " Defense
mechanism". He described defense mechanism are unconscious processes that d
defined a person against anxiety.
It is often used by all people to feel free or relieved from the emotional stir,
internal conflict or anxiety. It gives ego satisfaction. Very commonly it is used : To solve mental conflict
To reduce fear or anxiety
Protect one's self esteem
Protect one's sense of security
Definition of mental mechanism :1. According to Bhatia & Craig : The individual has mental capacities or devices
for protecting himself against psychological danger & stress"
A defense mechanism is a coping mechanism used in an effort to protect the
individual from feelings of anxiety.
Types of mental mechanism and their origin
Origin in oral period (0-2 yrs)
Defense
mechanism
and their
origin.
11
Compensation
Displacement, denial
Fixation & substitution
Origin in habit training

(1-3 yrs)
Conversation
Identification
Introjections
Reaction formation
Transference
Sublimation
Origin in later period of childhood (13-6)
Repression
Suppression
Regression
Rationalization
Origin in latency period

(6-12 yrs age)
Other commonly use defense

mechanism
Projection
Isolation
Fantasy
Incorporation
Intellectualization
Symbolization
Undoing
Psychotic patient use defense mechanism:- Projection, denial, fantasy, regression,

symbolization and fixation.
12
Neurotic patient use following defense mechanism:- Repression, isolation,

reaction formation, displacement and dissociation.
Q.5
How mental mechanism help the person to react appropriately to the

situation?
Ans.
It is one of the coping mechanism used to reduce anxiety & fear.

It assist the client to identify the source of anxiety and explore the methods to
reduce anxiety.
It also keeps an individual temporarily free or away from the problem.
They protect the individual against psychological threats related to ego.
Helps the people to other people's behaviour and the factors associated with
their nature.
It helps the people to lead a satisfactory & productive life which prevents
mental illness, promote mental health of individual in specific family &
community in general.
For example:A graduate nurse is expected to do comprehensive nursing care, if
she fails to do so and the tutor identifies it and scolds, she cries like a child to overcome
her failure instead of putting more efforts and succeeding in it. Here, the nurse uses
regression mental mechanism.
Q.6
Define personality?
Ans: According to Allport: Personality is the dynamic organization within the

individual of those psychophysical systems that determine his unique adjustment to his
environment.
According to Taylor :
13
Personality refers to "the Aggregate of the physical & mental
qualities of the individual as these interact & function in characteristic fashion with his
environment.
Personality is expressed through the behaviour of a person. The characteristic

behaviour which is a combination of physical and mental characteristics of an
individual, differentiate one individual from another with his/her unique ident.
Q.7
Mention the factors affecting development of personality?
Ans.
Factors affecting development of personality :
Heredity
Embryonic factors
Fetal factor
Antenatal factor
I.
Biological Factors
II.
Physiological factors
Nervous system
Endocrine glands
III.
Social Factor
IV.
Emotional / Psychological Factor
V.
Biochemical Factor
VI.
Physique
Family
Scholastic Environment
Social-economic influences
Society
14
Q.8
Explain Freud's psychodynamic theory:
Ans.: Freud explained psychodynamic theory as :

1.
Conscious Level: It is awareness part certain thought which are pleasurable and
remembered
2.
Unconscious level: Some thought are completely repressed which the person
doesn't like is painful for ethical standard or self image. All ID are unconscious.
3.
Preconscious level: The memories/thought are easily available with a moment

reflection.
15
Unit II
History of Psychiatry
Q.1
Brief the historical development of psychiatry nursing?
Ans.: History of psychiatry: History is meaningful record of human achievement. The

term, 'History' is derived from a Roman word "Historics" which means
knowledge through" enquiry. The whole series & record of past events that
occurred chronologically in relation to psychiatry were described.
The following categories of periods are identified historically :
1.
The period of persecution : 1550 BC 1400 AD
2.
The period of Segregation : 1545 AD -1800 AD
3.
The humanitarian period 1745 1826 AD
4.
Beginning of scientific attitude : 1796 AD 1878 AD
5.
The period of prevention : 1885 AD 1960 AD
1. Past history:- In first century "CHARAK SAMHINTHA" has referred to psychiatric

as " Bhut vidhya" and personality was basically divided into 3 categories :
A. Satveek (Moral level)
B. Rajasse (Emotional level)
C. Tamsie (Said as mentally retard)
Mental disorders was known as " UNMADA" & fainting was known as " Murkh"
16
Psychotherapy process was present in form of "DAIUAIY APARYA

CHIKITSHA"
About 4th century method of treatment are :
-
Tortures
Burning
Jail
Asylum
1st Mental asylum established in India in "DHAR" (MP)
Philippe pinel (father of modern psychiatry) raise his voice against asylum.
II. Present History:

1.
First psychiatric nurse" Linda Richards" from America start training of

nurses for care of psychiatric patient in 1873.
2.
In 1953, national, legue of nursing (USA) publish a study's brought out

function's and qualification of a psychiatric nurse.
3.
In 1956 DPN (Diploma in psychiatric nursing) was started in

NIMHANS
(National
Institute
of
Mental
Health
Neurological
Science), Banglore, 1 year course.

4.
1960, psychiatric nursing was made a compulsory course in America.
5.
1973, standard of psychiatric nursing was established.
Past Situation :
1.
In 1946, bhore committee report recommend preparation of psychiatry

nurses.
2.
In 1965, INC - Psychiatric Nursing or a compulsory course in BSc. (N)
3.
In 1975, MSc. (Psychiatric Nursing) started in RAK New Delhi
4.
In 1983, DPN in Ranchi
5.
In 1986, Psychiatric Nursing In GNM
6.
17
In 1990, started in MG university Kottayam.
Present situation:
1.
22000 bed in 42 mental hospital
2.
2000-3000 bed in general hospital
3.
I bed for 32,000 population
4.
No. meaningful available for rural population
5.
1000-1500 psychiatrist in India.
6.
Every year 150 are being trained.
7.
All the same time number of psychiatric nurses only 900-950
8.
About 60 seat are available for DPN & may not be filled each year.
9.
1 Nurse for every 1,00,000 population.
18
Unit III
Mental Health Assessment

Q.1
What is mental health assessment?
Ans.: Mental Health Assessment is the first step of nursing process that includes
analysis of data collected from the patient and his family and identification of
nursing needs.
The data can be collected from primary source, that is from the clients his family
members (subjective data) or from secondary source e.g. Clients care record,
nurse notes or notes from health team members.
Q.2
How many types of basic techniques included in Mental Health Assessment?
Ans.
Three types of basic techniques included in mental health assessment:
1. History taking
2. Mental status examination
3. Psychological tests
Q.3 Describe the steps for taking psychiatric history?
Ans.: History taking and mental status examination are important measure for
diagnosis & treatment outline preparation of mental illness.
Psychiatric history included the following steps:
I. Identification data:
Name of the patient .
age..
Sex
Bed no. .
Hospital Reg. No. .

Education ..
occupation
Marital status ..
religion ..
Language..
nationality .
Income .
Address
Data of Admission
Final diagnosis
Identification mark.
II.
a) Informant ..
b) reliability of informant
III.
Present chief complain

According to patient .
According to relatives :
IV.
Onset of present complains ..
Duration of present complains.
Nature of present complains
Precipitating factors ..
History of present illness :

a. Time of onset of present episode of illness
b. Chronological arrangement of the symptoms
V.
Past history of illness:

a. Medical illness
b. Psychiatric illness
VI.
Personal history
1. Developmental History
a) Infancy history
19
20
b) Childhood history
c) Adolescence
d) Adulthood
e) Late maturity
2. Educational history
3. Play history
4. Occupational history
5. Sexual & menstrual history
VII. Family history :

Family structure
Family history of mental illness
Current social condition of family
VIII Premorbid personality
Q.4
Define MSE (Mental Status Examination).
Ans.: According to K. Lalitha: MSE is defined as systematic evaluation of

Behaviour, emotion, cognitive functions of an individual.
MSE in a standardized format is which the clinician records the mental sign &
symptoms present at the time of interview
Q.5.
What are the aspects of MSE?
Ans.
The aspects included in this examination are:-
1. General appearance & behavior: Consciousness

Physique
Personal hygiene
Posture
Facial expression
Gestures
2. Talk or speech :
a) Speech activity :i. Unusual pattern
ii. Unusual words
b) Tone and volume of speech
c) Speech pattern
d) Coherence
3. Mood or affect :A. objective mood

a) Appearance
b) Intensity of happiness
c) Consistency of word
d) Emotional Expression
B. Subjective mood
4. Thought process :
1. Thought at formation level
2. Stream of Thought
3. Thought at content level.
5. Perception :
a) Illusion
b) Hallucination
6. Cognitive function:
21
22
1. Level of consciousness
2. Attention
3. Concentration
4. Memory immediate/Recent memory/remote memory
7.
Orientation: time, place, person
8.
Intelligence: average/confused
9.
Insight: Present/Partial/Present/Absent
10.
Judgment: Personal/social
11.
Abstract ability:
12
General Information
13
Psychosocial factor
Stressor
Coping skills
Relationship
Socio-cultural aspects
Adaptability
Spiritual areas
Q.6
Ans.
Define interview technique?

Interview is an oral questionnaire where the interviewee gives the needed
information verbally in a face-to-face relationship.
Interviewer The person who conduct interview
Interviewer the person that interviewed
According to oxford English dictionary: - interview is a private meeting
between people where questions are asked & answered
According to Webster: Interview is a meeting at which information is obtaining
from a person.
Q.7 Mention the types of interview techniques :
Ans.: Interview Techniques:1. Observing
2. listening
3. Validating
4. Providing information
5. Restating
6. Clarifying
7. Paraphrasing
8. Pin pointing
9. Linking
10. Questioning
11. Focusing
12. Sharing summarizing
13. Reflecting
14. Confronting
23
24
Unit-IV
Community Mental Health
Q.1
Ans.
What are common misconceptions regarding mental illness?

Some of the misconceptions of community towards mental illness are:
1. Abnormal behavioural is bizarre.
2. Normal person will never be abnormal.
3. Mental illness is heredity.
4. Mental illnesses are not related to physical health.
5. Mental disorders are incurable.
6.
Mental illness is caused by supernatural power.
7. Mental illness is life long

8. Mental illness is contagious
9. Marriage can cure mental illness
10. Mentally ill person should only be treated in asylums.
11. Mentally ill patients are dangerous.
12. Mental illness sometimes to be ashamed.
13. Prevalence of mental illness is low in India
14. Professionals who works with psychiatric patients are likely to become disturb
themselves.
15. Mental hospitals are place where only dangerous mental ill individual are
treated with restraint as a major approach.
Q.2
Define community mental health nursing
25
Ans.: Community mental health nursing is the application of knowledge of psychiatric

nursing in preventing, promoting and maintaining mental health of people to help
in early diagnosis and to rehabilitate the client after mental illness.
It is also defined as to promote, maintain and conserve the health of population
aggregates in the community with emphasis on mental health.
Q.3
What are the facilities (Services) available in the community to strengthen

their mental Health ?
Ans.: varied community facilities are available to provide mental health care for total
population and self involvement for their future life.
1. Day hospital centre: Patient receives a full range of treatment, services during
day time and return home at the end of day. Patients develop routine &
discipline in life.
2. Half way house: These are for those who no longer need full services of a
hospital but are not yet ready for a completely independent living, still he may
require supervision for medication & carrying domestic activities
3. Quarter way house: Chronically ill patients are kept in quarter way homes.
These patients are enough improved to live in family but their family
members reject them
This home try to make these patients self dependent. It reduces gap
between hospital life & community life.
Ex. 13 & 14 ward at NIMHANS, Banglore.
4. Group homes: 15-20 recovered mentally ill patients (client) will be placed in this
home.
They stay together & provides moral, emotional, & social support to
each other.
5. Foster homes
26
It is a social agency sponsored programme in which recovering

patients are placed for family care.
This voluntary family is paid by social agency
This placement may be for short time or permanent.
6. Sheltered workshop
It is a work oriented rehabilitation facilities with a controlled working
environment to fulfill the individual vocational goals.
Appropriate for those patient who find difficult to complete for
employment.
7. Mental Health Emergency Care : Hotline : Telephone link
Walk-in-clinic psychiatric emergency room (24 hrs.)
Home visits
Crisis intervention centre
8. Self help Groups
Group of patients having same mental illness
Eg. Alcohol anonymous
Group of MR patient
9. Evening/Night Hospital:
Evening hospital provide mental health facilities on 5 evening of a
week
Night hospital for those patients who are unable to attend clinic due
to job in day time.
Q.4
What are the role of nurse in community mental health services?
Ans.
Nurse can play an important role in linking the community services to the
hospital. The following roles of nurse in community mental health services:-
27
1. Consultative role
2. Clinician role/Practitioner role
3. Therapeutic role
4. Researcher role
5. Educator role
6. Liason role
7. Coordinator role
8. Domiciliary role
9. Manpower facilitator
10. Social skill training
11. Manger/administration role
12. Preventive role
13. Other role :
Assertiveness training to improve self confidence
Conducts groups meeting.
Carryout community outreach services.
Provide crisis intervention services.
Q.5 What is preventive psychiatry?
Ans.: Preventive psychiatry includes preventive measures at three levels.
1. Primary Prevention:
Means reducing incidence of mental illness by controlling the factors
which cause mental illness.
It includes two component:
Health promotion
Specific protection
2. Secondary prevention :
28
Aims at early diagnosis and treatment of mental illness

It Includes following components :
Screening of population
Crisis intervention services
Mental health education
3. Tertiary prevention:
Aims at reduce the recurrence of mental illness & prevalence of residual defects
or disability due to mental illness.
It includes following components:
Intensive patient care
Rehabilitation services.
Follow up care of patient.
Interactional skill training
Recreational therapy
Individual & behaviour therapy
Preventive psychiatry includes different preventive measures according to age of
mental ill patient:1. Prevention during child hood
2. Prevention during adolescence
3. Prevention during Adulthood
4. Prevention during Old age
29
Unit V
Psychiatric Nursing Management

Q.1
Ans.
Define psychiatric nursing. Write the branches of Psychiatric Nursing.

Psychiatric nursing :
Mental health nursing or psychiatric nursing can be defined as a part of nursing
where nurse uses herself, her knowledge of social and behaviour sciences and
communication skills for the purpose of :
Promotion of mental health
Prevention of mental illness
Helping individual family and community to cope with mental disorders.
It is a branch of medicine deal with diagnosis and treatment of mental illness.

BRANCHES OF PSYCHIATRIC NURSING:
1. Community psychiatry
2. Forensic psychiatry
3. Cultural psychiatry
4. Geriatric psychiatry
5. Child psychiatry
6. Industrial psychiatry
Q.2
Ans.:
1.
2.
3.
What are the principles of psychiatric nursing?

Basic principles of MHN (Mental Health Nursing) are:
To Provide a sense of individuality, safety & comfort to the patient.
Economise her time & energy judiciously while nursing the patient.
Maximum therapeutic intervention
30
General principles are:

1. Accept the client exactly as he is :
a) Being non-judgmental & Non punitive
b) Sincerity & positive interest
c) Recognizes & reflects on clients feelings, which he expresses.
d) Be an active listener
e) Purposeful conversation.
2. Self understanding will be used as a therapeutic tool
3. Be consistent while working with patient with behavioural problem
4. Give reassurance to the client in an acceptable and realistic manner
5. Modify client's behaviour through emotional experience.
6. Avoid unnecessary increase in patient's anxiety.
7. Maintain therapeutic nurse patient relationship (T-NPR).
8. Be maintained objectivity in understanding client's behavioural.
9. Avoid physical & verbal restrains
10. Continuous close observation.
11. Explained ward routines & procedures at the level of pt's understanding.
12. Use appropriate language.
13. Treat and respect the client as an individual & specificity in nature.
Q.3
Ans.
Describe the role of Mental Health nurse in various setting?

Mental Health nursing practice encompasses various roles in different settings
like community hospital, varied agencies, therapies, etc.
A. Role of nurse in mental hospital:1. Direct patient care

2. Education
3. Communication of interpersonal relationship
31
4. Ward management
5. Role of nurse in psychotropic drugs
6. Role of nurse in psychotherapy :a. Nurse as a Psychotherapist
b. Nurse as a parent substitute
c. Nurse as a role model
d. Nurse as a resource person
e. Nurse as a supporter
f. Nurse as a socializing agent
g. Nurse as a communication
h. Nurse as a counselor
i. Nurse as a catalyst
j. Nurse as a Occupational Therapist
k. Nurse as a administrator
l. Nurse as a interpreter
m. Nurse as a teacher or technician
n. Role of nurse before during and after electro convulsive therapy (ECT)
B. Role of nurse in community setting :

Main function of nurse in community setting are :1. Case finding
2. Assessment of individual needs
3. Consultation with other professionals
4. Involvement in individual, family and group therapy'
5. Co ordination of health services for individual and family
6. Establishment of therapeutic milieu
7. Function as client advocate
32
8. Prevention of mental illness

9. Nurses' role in primary prevention, secondary prevention, tertiary
prevention.
Q.4
Ans.
Define Therapeutic - Nurse Patient Relationship (T-NPR)?

T-NPR :- Interaction occurs between two persons, the nurse who possesses the
skills, abilities and resources to relieve the clients discomfort and assisting him to
alleviate his existing problems.
According to Webster new collegiate dictionary defines "Relationship as
character of being related or interrelated".
Q.5
What is the difference between therapeutic relationship and professional

(social) relationship?
Ans.
S.No.
Character
Therapeutic Relationship
Technique
Planned
Interaction time
Planned for specific time & place
Objective
Helping the patient
Duration
Accountability
Depends on goal
time is limited
Nurse focus on goal during
relationship
Acceptance
Termination
Q.6
Ans.
Nurse accept the patient as "Here

and Now" without attaching
judgment & interest
Planned and discuss with patient
What are essential qualities of T-NPR?

Essential qualities of T-NPR:-
Professional
Relationship
It just happen with
mutual interest
May be planned &
unplanned & by
chance two people
meet
Satisfying needs of
each other
This varies & may
last for years
Both are
responsible in this
relationship
Based on shared
values and belief
Relationship exist
life long.
1. Genuineness
2. Respecting the client
3. Empathy
4. Self-discipline
5. Sincerity
6. Role model
7. Good communication skills
8. Good observer
9. Show love & affection
10. Active listeners
11. Good speaker
12. Exploration of the problem (catharsis)
13. Immediacy
14. Trustful
15. Professionalism
16. Caring
Q.7
Ans.
Why T-NPR is essential?

T-NPR is essential:
I.
1. Self realization, self acceptance and self respect.
2. Sense of personal identity and personal integration
3. An intimate interdependent and interpersonal relationship
4. Satisfying needs
5. Development goals.
II. Nurse helps the patient to
Cope with problems
Understand the problem
33
34
Face problem realistically

Find out alternate solution to problem
Tryout new pattern of behaviour
Communication freely
Socialize effectively
Find meaning in his/her illness.
Q.8
Ans.
What are phase involved in establishing and maintaining the therapeutic

relationship?
T-NPR involves series of phases:T-NPR Phases
I. Pre-Interaction
phase
II. Introductory or
Orientation phase
III. Working phase
IV.Termination phase
Phases of T-NPR :Quality
Definition
Task :
PreInteraction
phase
Begins when a
nurse assigned
a patient before
the nurse first
contact with
client.
1. Nurse
explore her
fear & anxiety.
2. Set objective
for
introductory
Introductory/
Orientation
phase
Begin when
nurse goes to
patient,
introduce herself
& get
introduction
about him.
1. Establishme
nt of contact
2. Developmen
t of an
agreement or
Working phase
Termination phase
(Resolution/End phase)
It starts when nurse and

patient are able to
overcome barrier of
orientation phase. Nurse
& patient actively works
on meeting the goals.
Begins during orientation

phase.
In this nurse develop pact
with patient
1. Nurse collect data and

identifying nursing
needs of patient.
2. Assist the patient to
identify his problem.
3. Help the patient to
socialize &
1. Bring a therapeutic end

of T-NPR.
2. Establish reality of
separation by attaining
specific goals.
3. Feeling of rejection,
III)
Barriers
Q.9
phase.
3. Take help of
clinical
supervisory to
overcome
anxiety and
fear.
pact
3. Talking with
the patient
1. Improper
self
awareness
and self
analysis
2. Anxiety &
fear towards
the client
3. Unplanned
goals
4. Uncertainty
about her
ability
1. Client
display
manipulative
behavior
2. Social class
of patient
3. Status of
patient
4. Anxiety
level of
nurse/patient
5. Transference
6. Counter
transference
35
communicate.
4. Help the patient to
find out alternate
solution to problem,
5. Encourage the patient
to use new pattern of
behaviour.
6. Set goals for relation
ship
7. Assist the patient to
achieve his goal.
8. Encourage the pt.
towards independency
decision making
ability.
loss of sadness & anger

are expressed &
explore.
4. Decrease patient
dependency and
increases with
independency in his
environment
1.
1. Develop termination
2. Develop sense of
disappointment &
feeling of sadness
3. Gift giving
4. Patient may like to
telephone the nurse.
5. Develops negative self
concept.
2.
3.
4.
Patient test the nurse

in various situations.
Nurse think that
patient's progress is
slow.
Resistance to explore
& to develop
independency
Fear of closeness
with patient.
Define communication, therapeutic communication and communication

skills?
Ans.
Communication: Communication refers to the reciprocal exchange of information,
ideas, belief, feeling and attitudes between persons or among a group of persons.
It is goal directed process in which people use a system of symbols & signs to
convey a message.
Therapeutic Communication: The therapeutic interaction between the nurse and the
client will be helpful to develop mutual understanding between two individuals.
It occurs when the nurse exhibits empathy, utilize effective communication skills
and responds to the client's thought, needs and concerns.
Communication Skills:It is the ability or efficiency of the nurse to utilize their knowledge systematically
and effectively
36
a) General ability: Ability to listen, interpret speak & express through writing.
b) Special ability:
Ability to observe or interpret observation
Ability to ascertain
Ability to recognize when to speak, silent smile, interact
Ability to wait, proceed, speed
Ability to maintain T-NPR
Q.10 What is communication process?
Ans.: Communication Process: Communication is two way process (sender &
receiver), multidisciplinary process, multistage process & goal directed process.
Communication between two or more persons involves a series of steps &
element this is known as communication process.
In communication process, we will discuss:
1. Stages of communication process
2. Steps of communication process
3. Elements of communication process
a) Stages of communication process (Multistage process)
1. Attention
2. Comprehension
3. Acceptance of the information
4. Retention & Action
B)
Steps of communication process:

1. Clear perception of the ideas, information or problems
2. Participation of other in the decision
3. Transmission of ideas or message
4. Ensuring that the receiver of the message acts & behave as derived by the sender.
5. Ascertaining the effectiveness of communication
C)
37
Element:
Stimulus
Need for information, comfort, advice etc.
Source / Sender
Ideas,
Encoding
Message filter
Can be : -
symbols
Through personal
Suggestion
Factors
Order
Channels
Request
Speech, written
Instruction
Message, gesture
Decoding
Receiver
Feed back
Receiver agree with
Message
Message
evaluated
Disagree with message
through
Needs classification
personal
Provides information
Factor
38
Q. 11 Classify the communication?
Ans.
Communication
On the basis of relationship
On the basis of flow
Formal
Informal
Communication
Communication
On the basis of expression
Verbal
Communication
Upward
communication
Downward
Communication
Nonverbal
Communication
Lateral/Horizontal
communication
Spoken/oral
Written
39
Unit IV
Mental Disorders and nursing

interventions
Q.1
What are common causes of mental illness or mental disorder?
Ans:
As there are many causes for single effect (Mental Retardation caused by gentio, birth
injury etc) and single cause for several effects (Parental neglect leads to behaviour
disorder, Suicide, depression etc.)
Many causes are responsible for mental disorders which are classified as:
Causes of mental Disorder
Predisposing
Precipitating
Perpetuating
Abnormal
Factor
Factor
Factor
Behaviour
1. Genetic factor
2. Obstetric
Complication
a. Antenatal
b. Intra natal
c. Postnatal
3. Personality
1. Physical Factor
2. Psychological
3. Social Factor
1. Isolation
1. Biological factor
2. Social withdrawal 2. psychosocial factor
3. Socio-cultural factor
4. Neuro biological factors
40
Diagrammatic presentation of causes of abnormal behaviour :-
Mono
Amines
Amino
Acids
Peptides
i. Neuro biological
factors
ii. Biological
Factors
Genetic factor
Constitutional factor
Physical handicap
Physical deprivation
Emotional factors
CAUSES OF
ABNORMAL
BEHAVIOR
iii.Social
cultural factor
War & violence
group prejudice
economic and
employment problem
technological
& social changes
iv. Psycho-Social
factor
Maternal deprivation
Pathogenic family
Pattern
Pathogenic IPR
Stress
Q.2
Write the Classification of mental disorder?
Ans.
Major classification of mental disorder are :
41
1. International classification of diseases by WHO (ICD-10)

2. Diagnostic and statistical manual of mental classification (DSM-IV-TR)
3. Research diagnostic criteria (RDC)
4. ICMI Indian classification of mental illness.
1. International classification of diseases:
Organic, including sympathetic, mental disorders. (F00-F09)
Mental & behavioural disorder due to psychoactive substance use (f10-f19)
Schizophrenia, schizotypal & delusional disorders (F20-F29)
Mood (affective) disorder (F30-F39)
Neurotic, stress related & somatoform disorders (F40-F49)
Behavioural syndromes associated with psychological disturbances and physical

factors (F50-59)
Disorder of adult personality & behaviour (F60-F69)
Mental retardation (F70-F79)
Disorder of psychological development (F80F89)
Behaviour & emotional disorders with onset usually occurring in childhood and
adolescence (F90-F98)
Unspecified mental disorder (F99)
2. Diagnostic & Statistical manual of mental classification: (DSM-IV)
Clinical psychiatric diagnosis
Personality disorders and mental retardation
General medical condition
Psychosocial & environment problems.
Global Assessment of functioning
42
3. Research diagnostic criteria: (R&C)

According to this, at least two of following symptoms for schizophrenic are
essential :I.
a. Withdrawal
b. Delusions of being controlled
c. Delusion other than persecution lasting at least one month
d. Delusion accompanying hallucination of any type for at least one week.
e. Current auditory hallucination
II.
Period of illness lasing for at least 2 weeks.
III.
No manic or depressive symptoms
4. Indian classification of mental illness :
43
Mental Illness
Organic disorder
Non-organic disorders
I. Dementia
II. Delirium
(Chronic brain syndrome)
(Acute brain syndrome) I. Psychosis
A. Psychotic (Adult)
Disorder
1. Schizophrenia
B. Childhood
Disorder
1. Mental disorder
2. Mood or Affective disorder ,

. Mania
. Depression
3. Psychosexual
2. Developmental
. Disorder
4. Substance abuse disorder
Disorders
3. Adolescence
a. Alcohol abuse
disorder
b. Drug abuse
5. Personality disorder
6. Psychosomatic disorder
Disorders
II. Neurosis
44
Neuropsychiatric disorder
Functional disorder
Anxiety Disorder
(Hysteria)
Panic
dis.
Dissociative
disorder
Conversion disorder
Dissociative Amnesia
Somatoforms disorder
Panic disorder
Dissociative Fugue
Body dimorphic disorder
Phobia
Somnambulism
Hypochondriasis
Post Traumatic Disorder
Depersonalization
Somatoform pain disorder
Obsessive Compulsive
Multiple personality
Conversion Disorder
Q.3
Ans.
Neurosis
Hypochondriasis
Neurasthenia
Depersonalization
What is the different between the organic psychosis and functional psychosis?
S.No. Organic Psychosis

1
Impairment of brain tissue function
due to head injury, toxic condition,
encephalitis, brain tumour.
Systemic infection etc.
2
Disturbance Of consciousness
3
Disturbance Of Memory, Orientation
& Intelligence Present
4
Visual hallucination
5
Emotional incontinence
6
Deterioration of personal & social
7
Physical examination reveals clinical
features of systemic disease.
Functional Psychosis
Caused by :
Biological factor
Psychological factor
Socio Culture factor
Very rare
Markedly affected
Auditory hallucination
Rare
It is uncommon.
Physical examination of patient
usually reveal no abnormality which
can explain mental illness
45
Psychological test
BGT Bender Gestalt test positive.
Laboratory & Radiological diagnosis
as EEG help in determining the
etiological factor responsible for
psychosis
Q.4
What is the difference between the psychosis and neurosis?
BGT Negative
These reveals no specific abnormality
S.No. Psychosis
1
Definition:
Very severe illness of personality
- Impairment of ego function
46
reality besting is highly impaired
Grave maladjustment to life
2
3
4
Etiology:
Biological factor
Psychosocial factor
Socio culture factor
Personality disintegrationtotal
Defense mechanism:
Denial (Run from reality)
Regression
Identification
Introjections (Self analysis)
Clinical Features :
- Impaired ego function
- Loss of reality testing
- Loss of insight
- Loss of judgment
- Presence of illusion &
hallucination
- Memory marked affected
- Impaired attention
- Intelligence absent
- Orientation absent
- Disturbance in consciousness
- Disturbance of thinking
- More behavioural change
- Social relationship affected
- Vocational, Social, Sexual,
Adjustment markedly
impaired
Treatment:
- Hospitalization present
- ECT
- Psychotherapy
- Psychotropic drugs
Prognosis:
- Bad prognosis
- Recurrence common
Neurosis
Definition :
Mild to moderate illness of
personality
Ego function & reality testing is
not affected much.
maladjustment to life is limited
Etiology :
Mainly due to psychological
factor
Personality disintegrationpartial
Defense mechanism:
Repression
Suppression
Conversion
Substitution
Reaction formation
Displacement
Undoing
Clinical Features
- Ego function affected much
- Not much affected
- Insight present
- Not lost
- Absent illusion &
hallucination
- Memory present
- Attention present
- Not affected intelligence
- Present Orientation
- Consciousness
- No disturbance in thinking
- Minor behavioural change
- Not affected
- Not markedly Impaired
Treatment :
- No need hospitalization
- No ECT
- Psychotherapy useful
- Psychotropic drug
Prognosis :
- Good prognosis
- Recurrence less
Q.5 What is the difference between the delirium and dementia?

Ans.:
47
48
S.No. Delirium
1
Etiology
Intracranial : Tumour, Injury, Epilepsy
(ii)
(iii)
(iv)
(v)
Metabolic : Acidosis/alkalosis
Endocrinal causes
Nutritional deficiency Example Vitamin B
Drugs Alcohol use, digitalis, bromide
Dementia
Etiology
i. De-generative brain diseases :
- Alzheimers disease
- Pick's disease
- Huntington chorea
- Parkinson's disease
Cerebral Arteriosclerosis
Drugs
Brain pathology
Other
- Co-poisoning
- Vitamin deficiency
- Hypercholesterolemia
- diabetes
- Koraskoff disease
[Delirium + thiamine
deficiency]
- Wernick disease
(vi)
Systemic deficiency example TB,

Septicemia
(vii) Others
post operative care
circulatory disturbance
2
Course reversible
3
Onset Acute
4
Duration few days
5
Clinical features:(i)
Clouded of consciousness
(ii) Impaired memory
(iii)
Orientation present
(iv)
(v)
(vi)
(vii)
(viii)
Illusion, hallucination & delusion present

Emotions labile mood
Inappropriate or violent behaviour
Intelligence deterioration
Other reasoning ability & judgment
impaired
course irreversible
onset chronic
Duration Months
Clinical features:No clouded of consciousness
Recent memory impairment is
greater than remote memory
Orientation absent (First involve
time)
Very rarely
Loss of emotional control
Indecent behaviour
Present Intelligence
Other : Neglect personal hygiene,
Anxiety, depression, loss of
learning, reasoning.
49
Q.6
Define personality disorder?
Ans.: Personality disorders is defined as any deviation in personality traits from the normal that
they interfere with his well being or adjustment to society and require psychiatric
attention.
Personality disorders is different from mental illness. The symptoms of mental illness are
mostly episodic & not continuous and starts from adolescence or even before. It is
commonly found in 18-40 years age.
Q.7
Ans.
Mention the different types of personality disorders?

Personality disorders can be classified into four groups.
Personality disorder
Withdrawn
Dependent
Personality disorder Personality
Disorder
Inhibited
personality
disorder
Anti-Social
Personality
disorder
1. Schizotypal
2. Schizoid
3. Paranoid
1. Hypochondrial
2. Depressive
3. Obsessive
Compulsive
1. Histrionic
2. Impulsive
3. Borderline
4. Narcissitic
1. Anxious
2. Dependent
3. Aggressive
Other types of personality disorder :

1. Cyclothymic Personality disorder
2. Hypomanic
3. Melancholic
4. Expolsive
5. Inadequate Personality
50
Q.8
What is the sign and symptoms of psychiatric illness?

OR
What are types of deviation from normal behaviour?
Ans.
Deviation from normal behaviour
Disturbance
Of conscio-usness
Disorders
of motor
Activity
Confusion
Clouding of consciousness
Stupor
Coma
Delirium
Dream State
Somnolence
Disorder
of
Perception
Disorders
of
Through
Disorder
of
Affecter or
Mood
Illusion
Hallucination
Disorder of memory Disorder of

or intelligence
orientation
Hyper Amnesia
Amnesia
Paramnesia
Dejavu
Dementia
Jamisvu
II. Disorder of motor activity
Increased activity (Over Activity)
Dysactivity
Repetitious
Behaviour
Compulsion
Negativism
Stereotype
Activity
Automatic
behaviour
1 Echoprexia
2. Echolalia
Stereotype
Position
Stereotype
Movement
Stereotype
Speech
Waxy
flexibility
Catalepsy
Mannerism
Verbigeration
Decreased activity
Violence
Suicide
Agitation
Tics
III.
Disorder of perception
Illusion
Auditory
visual
Gustatory
51
Hallucination
Olfactory
Tactile
Kinesthetic
Hypnogogic
Hypnosomatic
IV. Disorder of Thought
At Formation level
At progression (Association) level
At content level
1. Autistic thinking
2. Derestic Thinking
Structure
Speed of association Type of Association
of Association
1. Magical
Thinking
1. Neologism
Flight of ideas
Motor aphasia
2. Poverty of
2. Word salad
Clang association
Sensory aphasia
content
3. Circumstantiality Blocking of through Nominal aphasia
of speech
4. Tangentiality
Thought retardation
Syntactical
3. Overvalued
5. Perseveration
Poverty of speech
aphasia
ideas
6. Irrelevant answer
4 Delusion
7. Lossening of association
5. Obsession
8. Derailment
6. Phobia
7. Hypochondriasis
52
V. Disorder of affect
Pleasurable affect
Unpleasurable affect
Other affect
Euphoria
Depression
Anxiety
Elation
Grief and Mourning
Apathy
Exhaltation
Panic
Ecstasy
Inappropriate affect
Ambivalence
Depersonalization
Mood swing
Q.9 Define delusion. Mention the types of delusion?

Ans. Delusion is defined as false, fixed unshakable belief, not in accordance with one's
intelligence socio cultural and educational back ground.
For example : Sitting in a classroom as a student, thinking that he is the prime minister of the county
or he is supreme or god.
Types of Delusion :
1. Bizarre delusion
2. Delusion of grandeur
3. Delusion of self accusation
4. Delusion of control
5. Delusion of persecution
6. Delusion of reference
7. Delusion of jealousy/infidelity
8. Encapsulated delusion
9. Nihilistic delusion
10. Delusion of worthlessness and property
53
11. Delusion of thought possession

12. Hypochondrial delusion
13. Sexual delusion
14. Religious delusion
15. Delusion of loving
16. Delusion of influence
17. Delusion of dysmorphophobia
18. Erotic delusion
19. Somatic delusion
Q.10 What do you mean by phobia?

Ans. Phobia is an exaggerated pathological fear of a specific type of stimulus or situation
The fear that a person feels in the presence of particular object or experience.
An irritational fear of an object/situation that persist, although the person may recognize it as
unreasonable
Types of phobia :
1. Acrophobia Fear of heights
2. Agoraphobia Fear of Open spaces
3. Astraphobia Fear of Electrical Storms
4. Claustrophobia Fear of Closed Spaces
5. Haematophobia Fear of blood
6. Hydrophobia Fear of water
7. Monophobia Fear of being alone
8. Mysophobia Fear of dirt/germ
9. Nyctophobia Fear of darkness
10. Pyrophobia Fear of fires
11. Social phobia Fear of situation in which one might be criticized; fear of making a fool of
one self;
12. Xenophobia Fear of Strangers
54
13. Zoophobia Fear of animals
Q.11 Define Schizophrenia?

Ans.: In 1911, Eugene Bleuler, a Swiss psychiatrist explain the schizophrenia, which is
combination of two Greek words schizo means split and phrenic means mind.
In other words schizophrenia means splitting of mind. Split occurred between the
cognitive and emotional aspect of the personality.
According to ICD 10 & DSM-IV
Schizophrenia is a group of disorders manifested by fundamental disturbances in
thinking, mood (affect), behavior (BAT) last for at least a month of active phase
symptoms.
Disturbance in thinking is marked by alteration of concept formation which may

lead to misinterpretation of reality hallucinations and delusions.
Mood changes includes ambivalent constricted and inappropriate responsiveness

or blunted affect and lack of empathy with other.
Behaviour may be withdrawn regressive and bizarre.
Q.12 How schizophrenia is classified?

Ans. No accurate classification is possible because symptoms of one type of
schizophrenia may be observed in another type.
Schizophrenia
Typical Schizophrenia
Simple
Hebephrenic Catatonic Paranoid Undifferentiated

or mixed
Simple
Classification according to ICD-10 (F20-29)
F 20
Paranoid
F 21
Hebephrenic
F 22
Catatonic
F 23
Undifferentiated
Atypical Schizophrenia
Juvenile Late Schizoaffective Latent Residual

Psychosis
F 24
F 25
F 26
F 28
F 29
Post Schizophrenic depression

Residual Schizophrenia
Simple Schizophrenia
Other Schizophrenia
Unspecified Schizophrenia
Q.13 State the clinical features of schizophrenia?

Ans.
Bleuler has explained :
Primary/Fundamental symptoms
Secondary/Accessory symptoms
According to recent concept :
Positive symptoms
Negative symptoms
Positive Symptoms :
Aggression
Agitation
Delusion
Excitement
Grandiosity
Bizarre behaiour
Conceptual disorganization
Hallucination
Hostility
Suspiciousness
Negative symptoms :
Apathy
Blunted affect
Diminished Emotional Responsiveness
Stereotype thinking
55
56
Social withdrawal
Lack of spontanity
Avolition
Detachment
Primary/Fundamental Symptoms (Bleuler 4 A's)
Associative
disturbance
Autism
Affective
Incongruity
or
Inappropriate
Mood
Ambivalence
Secondary/accessory symptoms
Disorder Disorder
Or
of
Perception activity
Disorder
of
thought
1 Hallucination Negativism
(Auditory
automatism
Visual or
Echolalia
Gustatory)
Echopraxia
2 Illusion
Mannerism
Mutism
Stupor
Waxy
flexibility
Catatonic
Excitement
Deterio
rated
Appearance
Manner
Delusion
Self-care
(Grandiosity
& grooming
persecution
become
reference)
minimum
Depersonalization
Incoherence
Neologism
Clang
association
Perseveration
Disturbance Disturbance
in
in
Attention
behavior
Client is
unable to
held attention
for long
time
Insight
Agitation
Severly
bizarre
affected
Suicidal
and homicidal
tendencies
Sexual over activity
criminal behaviour
violent
Assaultive & destructive
behavior
Q.14 How schizophrenic patients are managed?

Ans. Treatment of schizophrenia depends upon the type of schizophrenia:1. Prevention of schizophrenia : by reducing etiological factors
2. Chemotherapy drugs
Sedative is indicated when patient is excited and restless
Hypnotics when patient is sleepless
disturbances
will
Blunting of
will power
(anergia)
Aloofness
(avoiding
mixing
with
friend
& family)
Inability
to take
decisions
57
Neuroleptics antipsychotics such as :
3.
Clozapine
Sulpride
Risperidone
Phenothiazines
Antiparkinsonian drugs
Electro conclusive therapy : (ECT)

Indicated when patient with severe schizophrenia
About 10-12 ECT in 4-6 weels
4.
Intense Psychotherapy : Indicated in

Early schizophrenia
Maintenance & rehabilitation of recovered patient
Psychotherapy are given follows:i.
Individual psychotherapy
ii.
Supportive psychotherapy
iii.
Group psychotherapy
iv.
Behavioural psychotherapy
v.
Occupational psychotherapy
vi.
Recreational psychotherapy
vii.
Social psychotherapy
viii.
Milieu therapy
ix.
Family therapy
5.
Psycho education
6.
Rehabilitation
Q.15 Define Manic-Depressive Psychosis (MDP)

Ans.: MDP is characterized by recurrent episodes of mania and depression in the same
patient at different times.
58
MDP is a mood disorder that is characterized by a severe disturbance of mood

manifested as elation and depression.
Q.16 What are the criteria to define mania and depression?
Ans.: Criteria to define mania (Triad Symptoms) :1. Elevation of mood
Euphoria
Elation
Exaltation
Ecstasy
2. Increase pressure of speech :

Flight of ideas
Increase tone of speech
More talkative
Delusion of grandeur
Increase self esteem
3.
Increase psychomotor activity
Over activeness
Restlessness
Person wants to keep himself busy
Unusually alert
Try to do many things at a time
Criteria to define depression (Triad symptoms):1. Sadness of mood (Depressive mood)

A. Mild depression
sensitivity to criticism,
Lack of confidence
B. Acute/severe depression
Head fixed face immobile
Look fixedly downwards
Social withdrawal
Persistent sadness
Hypochondrial ideas
C. Depressive stupor :
Intense form of depression
Clouding of consciousness
Marked ideas of death
2. Poverty of ideas :
Retarded thinking
Difficulty in thinking
Death of thought
Delusion of nihilism
Suicidal of ideas
Feeling of hopelessness
3. Decrease Psychomotor activity :
Reduce energy level
Negativism
Delusion of guilt
Frustration in day to day activity
Q.17 How will you classify the mood disorder ?
59
60
Ans.: I. Classification
Mood disorder
Manic-depressive psychosis (MDP)
Manic type
II.
depressive type
Involution psychotic reaction
circular type
Classification of Mood disorder
Unipolar disorder
Bipolor disorder
Only attack of depression
Bipolar I
Bipolar II
Episode of severe
Episode of depression Episode of major
Mania and
& Hypomania
depression
Bipolar III
depression
III. According to ICD10 classification of mood disorder (F30-F39)

F 30
Manic episode
F 31
Bipolar affective disorder
F 32
Depressive episode
F 33
Recurrent depressive disorder
F 34
Persistent mood disorder
F 38
Other mood disorder
F 39
Unspecified mood disorder
Q.18 What are the treatment modalities available for depression?

Ans.: 1. Hospitalization : indicated in
Severe attack of depression
Suicidal & homicidal tendencies
Stupor condition of patient
Psychotic & delusional depression
2. Electro convulsive therapy :
Total 6-8 Ect
3 in Ist Week
2 in IInd Week
1 in IIIrd Week
3. Drugs :
a) Sedatives if patient agitated
b) Hypnotics - if insomnia present
61
62
c) Tranquillizers:
Meprobamate 200-400 mg
Chlordizepoxide 10-20 mg
Diazepam 5-10 mg T.D.S. If patient is anxious
d) Neuroleptics - if patient agitated and anxious
Chlorpromazine hydrochloride
e) Antidepressant drugs :
Tricycle & Tetracyclic compounds

Such as immipremine, hydrochloride
amitryptiline Hydrochloride
Trimipramine
Mianserin
MAO (Mono amino oxide) inhibitors like phenelezine. It is more powerful anti
depressant drug
Recently more specific drugs are :
Aminiptine
Fluoxetine
Amoxopine
Tradozone
Psychotherapy :
Cognitive & behaviour therapy
Analytical psychotherapy
Occupational psychotherapy
Work therapy
Art therapy
Music therapy
Interpersonal therapy
63
Family therapy
Q.19 Define anxiety disorders ?

Ans.
Anxiety disorder are psychological disturbance where anxiety is the essential

symptoms anxiety is a normal phenomena. Every normal person experience
anxiety.
But when it cause excessive tension out of proportion & interfere with physical &
mental activities is known as pathological anxiety.
Anxiety reaction is a neurotic state of chronic apprehension with recurrence of
acute anxiety symptoms.
Q.20 Define obsessive compulsive neurosis (OCN) ?

Ans.: It is a psychiatric neurotic disorder in which obsession & compulsion are a
significant source of distress and interfere with an individual ability to function.
Obsession:- Recurrent & persistent unwelcome ideas & impulses or images. They
interfere with individual mind again and again in a stereotype from. Patient does
not enjoy getting those ideas.
Thoughts, images or impulses are not simply excessive worries about real life
problems.
They appear senseless to the individual. He actually feel miserable and guilty.
Compulsion:- Repetitive stereotype behavioural or mental acts that person feels driven
to perform in response to an obsession to relive tention even though they are
recognized senseless by the individual.
Eg. Hand washing, checking, counting.
Q.21 What do you mean by Hysteria?

Ans.
It is a neurotic disorder characterized by :
64
Hysterionic behaviour
Suggestibility (susceptible against any suggestion)
Transformation of an unconscious conflict into physical symptoms
Emotional outbursts
Repressed anxiety
It is of two types:Hysteria
Somatoform disorder
1. Body dysmorphic disorder
2. Hypochondriasis
3. Somatoform pair disorder
4. Conversion disorder
Dissociative disorder
1. Dissociative amnesia
a. Circumscribed amnesia
b. Selective amnesia
c. Continuous Amnesia
d. Generalized
2. Dissociative fugue
3. Somnambulism
4. Depersonalization
5. Multiple personality
Q.22. What is psychosomatic disorder ?

Ans: It is also called psycho physiological disorder :
It is characterized by physical symptoms resulting from psychological factor
(emotional stress) usually involving one system of body under voluntary control:
Types 1. GIT Peptic ulcer, Anorexia nervosa
2. CVS : Hypertension, Ischemic heart disease
3. Endocrine system Diabetes, thyrotoxicosis
4. Genito urinary system Impotence, menstrual disorder
5. Respiratory system Asthma
6. Integumentary - Psoriasis
7. Musculoskeletan System Arthritis, backache
8. Others headache, migraine
Q.23 Define alcoholism?
Ans.: Alcohol has been used for countries to obtain relief from discomfort & tention.
Alcoholisms or alcohol abuse disorder is defined as chronic dependence of alcohol
characterized by excessive and compulsive drinking that produces disturbances in mental
or cognitive level of functioning which interferes with social and economic functioning :
Alcoholism results due to
Excessive consumption
Alcohol related disability
Problem drinking
Alcohol dependence
Q.24 Mention the certain special alcohol withdrawal syndrome?

Ans.:
1. Simple withdrawal syndrome :
Mild tremors
Nausea & vomiting
Weakness
Irritability
Insomnia
Anxiety
Tachycardia
Hypertension
Impaired attention
2. Delirium tremens
3. Pathological darkness (Acute Alcoholic Psychosis)
4. Delirium
5. Alcoholic seizures
6. Alcoholic Hallucination
7. Dipsomania
8. Alcoholic paranoia
9. Dementia
10. Wernick's syndrome
11. korsakow's syndrome
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66
Q.25 How the psychoactive substances are classified?

Ans.:
Psychoactive substances
Narcotics
Opium &
its
derivatives
Eg. Opium,
heroin,
morphine,
Codeine
Synthetic
Narcotics
Such as
methadone
Sedative
Stimulants
& Depressant
Ethyl
alohol
sedative/
hypnotics
Eg.
Barbiturates
Nindral
Dalmane
Doriden
Hallucinogens
Amphetamines
Cocaine
Minor Tranquilizers
Cannabis eg ganja,
charas, bhang,
hashish
other
LSD: Lysergic
Acid
Diethylemide
Maprobamate
Diazepain
Chlordiazepoxide
Q.26 Define substance abuse/drug dependent?

Ans. Drug abuse/psychoactive substance abuse:
It is a term applied to pathological use of persistent or sporadic drugs with impairment
social & occupational functioning and a minimum duration of disturbance of at least one
month.
The substance abuse leads to many psychological dependence :1. Psychological dependence results in drug seeking behaviour
2. An inability to stop using the drug to physical dependence on the drug & tolerance
to its effect.
3. Continuous substance use results in physical & mental deterioration.
Drug Dependence: a maladaptive pattern of substance use leading to significant
impairment or distress as manifested by :Tolerance
withdrawal symptoms
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Frequent pre-occupation with seeking or taking the substance

Often takes the substance in larger amount or over a longer period
Often takes the substances to relieve or avoid withdrawal symptoms.
Q.27 Define childhood disorder?
Ans.: Childhood Disorder:Nursing personnel find various childhood & adolescent problems while working in
a hospital as well as in a community setting.
Disorders of psychological development & behaviour & emotional disorders with
onset usually occurring in childhood & adolescence.
The development phase from infancy to childhood is a significant period to
prevent a number of behavioural and other problems.
Childhood Disorders
Developme
ntal
Disorders
Disruptive
Behavioural
Disorder
1. Mental retardation
2. Pervasive disordersa. autistic disorder
b. childhood autism
c. childhood psychosis
d. pseudo defective psychosis
3. Specific development
disordersa. Specific reading disorder
b. Specific arithmetic
disorder
c. specific development
disorder of speech &
language
d. Specific developmental
disorder of motor function.
Anxiety
Disorder
of
Childhood
1. Attention
deficit
hyperactive
disorder
(ADHD)
2. conduct
disorder
Eating
disorders
1. Separation
anxiety
disorder
2. avoidant
Disorder
3. Overanxious
disorder
General
Identity
disorder of
childhood
1.Anorexia
nervosa
2.bulimia
nervosa
3. pica
4. rumination
disorder of
infancy
To disorder
Elimination
disorder
1.Trans
Sexuliasn
2. Gender
identity
disorder of
childhood
1.Eneuresi
s
2.Encopre
sis
Autistic
disorder
Speech
disorder
Other disorder
Stuttering
Childhood
Schizophrenia
Q.28 Mention the sleep disorders?

Ans.: Sleep can be regarded as a physiological reversible reduction of conscious
awareness.
Sleep deprivation is pressing health problem. If a person is not sleeping
continuously for few days or nights, it is harmful to his health.
Temper tantrum
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Types of sleep disorders
Primary
Sleep
Disorders
Secondary
Sleep disorder
(only sign &

symptoms of
abnormality)
(Clinical problem
accompanied by
specific or nonspecific
disturbance)
Cateplexy
Insomnia
Hypersomnia
Narcolepsy
Nightmares
Night terrors
Alcoholism
Anorexia
nervosa
Depression
Hyperthyroidism
Hypothyroidism
Schizophrenia
Parasomnias
(Walking up
during sleep)
Bruxisam
Nocturnal
Eneuresis
Sleep talking
Sleep Walking
Insomnia
quantitative and
qualitative
insufficient
Sleep based
On the
individual
Need.
Sleep onset
Insomnia
Frequent
Nocturnal
awakening
Early morning
awakening
Q.29 Classify the psycho sexual disorders?

Ans.:
Psychosexual Disorder
Sexual dysfunction
Not caused by organic
Disorder
Sexual inadequacies
Gender
identify
disorder or
Trans
sexualism
In male
In female
Erectile
Impotence
Premature
Ejaculation
Frigidity
Vaginismus :Involuntary
Contraction of
vaginal introits
at penetration
Disorder
of
sexual
preference
Fetishism
Transvestism
Exhibitionism
Voyuerism
Paedophillia
Sadism
Masochism
Sexual
orientation
disorder
Homosexuality
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Unit VII
Bio Psychosocial Therapies
Q.1 What is psychotropic drugs/psychopharmacology?
Ans. Psychotropic drug/psychoactive drugs is one which has mainly effect on the
behaviour experience and other psychological functions and will be used to treat
psychiatric condition.
The psychoactive drugs will have specific purpose and action, work on client symptoms
rather than diagnosis.
Psychoactive durgs are classified into five groups :
1. Antipsychotic Drugs
2. Anti parkinsonian agents
3. Antimanic Drugs
4. Anti depressant drugs
5. Anti anxiety drugs, Sedative and Hypnotics
Q.2 What are common antipsychotic drugs used?
Ans.: It is also known as neuroleptic drugs or major tranquilizers and used in the
treatment of psychosis.
Classification of antipsychotic drugs:-
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Antipsychotic Drugs
Conventional
Antipsychotic
drugs
Phenothiazines
Atypical
antipsychotics Es.
Clozapin
Risperidone
Thioxanthene
Chlorpromazine
Perphenazine
Fluphenazine
Trifluperazine
Prochorperazine
Thioridazine
Mesoridazine
Thio-thexene
Fluphenthixol
New generation
Antipsychotic
Drugs
Eg. Aripiprazole
Butyrophenones
Dibenzazepines
Dihydroindolane
Haloperidol
(Haldol)
Loxapine
Olanzapine
Molindone
(Morban)
Q.3 What are the indications & contraindication's of antipsychotic drugs?

Ans: Indications of antipsychotic drugs:1. Schizophrenia
2. Paranoid disorder
3. Mania
4. Organic psychosis :
Delirium
Dementia
Contraindication:1. Children under 3 Yrs. Of age

2. Comatose patient
3. Drug hypersensitivity
4. Severe depression
5. Other contraindications :
History of epilepsy
Pregnancy
Parkinson disease
Peptic ulcer
Q.4 Explain extra pyramidal symptoms (EPS) ?

Ans. It is the CNS side effect of antipsychotic agents. It includes :
1. Parkinsonism:
Akinetic form
Agitating form
2. Akathisia
3. Dystonia
4. Tardive dyskinesia
5. Neuroleptic malignant syndrome (NMS)
1. Parkinsonism :
It occurs in 40 percent of patient with EPS
It occurs one week after treatment
It is of two types :
(A) Akinetic form :
a. Impairment in masticating movement
b. Weakness
c. Muscle pain
d. Fatigue
(B) Agitating form:
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a) Muscle rigidity
b) Motor retardation
c) Mask like face
d) Shuffling gait
e) Slurred speech
f) Salivation
g) Tremors
2. Akathisia: Most common

Most common
Occurs in 50 % patient
Occurs two weeks after treatment
It includes
Difficulty in sitting skill or rest
Strong urge to move about (walking and talking)
Anxious and agitated
3. Dystonia: Occurs in 6 % of patient

Occurs within few minutes of medicine
It includesa. respiratory difficulties
b. Rapidly developing contractions of muscle of tongue jaw, neck (producing
torticolis) and extra ocular muscles,
c. occulogyric crisis (torticolis & extra ocular muscles)
d. Opisthotonous
e. It is painful and gives a frightened experience to patient.
4. Tardive dyskinesia :
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It is most severe condition

Occur in 3% patient
Occurs after sudden termination or reduction of antipsychotic after long term
high dose therapy
Features :Involuntary rhythmic stereotype movement
Protrusion of tongue
Gritting of teeth
Lip snaking
Puffing of cheek
Note: This condition is non-treatable.
C. Neuroleptic maligment syndrome (NMS) :
It is fatal and rare condition.
It may develop within hour or after year of continuous drug use.
Features Hyperpyrexia
Muscle rigidity
Altered consciousness
Tremors
Unstable Blood Pressure
Increases W.B.C.
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Q.5 Classify anti parkinsonian agents ?

Ans.: These drugs are used for treatment of EPS (extra pyramidal syndrome)
Antiparkinsonian Drugs
AntiCholinergic drugs
Agents :Benztropine
Biperiden, HCL
Procyclidine HCL
Promethazine
Dopamine
Agonists
Carbidopa
Livo dopa
Bromocriptine
Antihistamine
blockers
Muscle relaxant
Anti
dopaminargic
Dantrolene
Reserpine
Diphenhydramine
Q.6
Ans.
Write down about indication, Contraindications and action of anti manic

drugs?
Anti manic drugs are also called mood stabilizers.
Indications :
1. Mania
2. Manic Depressive Psychosis (MDP-Bipolar disorder)
3. Hypomania
4. Recurrent depression
5. Alcoholism
6. Schizo affective disorder
Contraindication :1. Side effect of renal, CVS, liver and respiratory system
2. Thyroid disorder (Hypothyroidism)
3. Diuretic potent
4. Dehydration
5. Child below 12 yrs. Age
6. Parkinsonism
7. Obesity
8. High grade fever
Mode of action:
It reduces the level of nor-epinephrine and serotonin or catecholamine.
Q.7
75
Classify the anti manic drugs?
Ans.: 1. Lithium carbonate (Lithane)

2. Anti convulsant/anti epileptic drugs : Carbamazapine
Sodium Valporate
4. Gabapentine
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Q.8 Write a short note on lithium toxicity?

Ans. Cade has describe the usage of lithium carbonate in treating mental illness. lithium
causes less drowsiness while controlling the marked psychomotor over activity because
of its toxicity.
Lithium toxicity:
1. Mild toxicity (Lithium level 1-2.5 m Eq/l) :- Diarrhea, nausea, vomiting,
drowsiness, muscular weakness, tremors, ataxia, cardiac arrhythmias, allergic
reactions, blurred vision, glycosurea, polyurea.
2. Severe toxicity : Cerebellar ataxia, seizures, hypotension and coma.
3. Chronic administration of lithium carbonate: Goiter, leucocytosis, and embryo
toxicity.
Note: Normal lithium level: 0.5, 1.5 mg/t
Q.9
What are the indications, contraindications and mode of action of anti

depressant drugs?
Ans: It is also called mood elevators.
Indications:
1. Major depressive illness
2. MDP depressive phase of bipolor disorder
3. Anxiety
4. Psychotic depression
5. Obsessive compulsive disorder
6. Migraine headaches
7. Panic disorders
8. Eating disorder (bullemia)
9. ADHD in children
10. Sleep apnoea
11. Cataplexy
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Contraindications:
1. Increase manic and psychotic episode of MDP.
2. CVS problem (arrhythmias)
3. Liver problem
Mode of action:
It acts by accelerate (increase level of) receptors of nor epinephrine and serotonin in the
central nervous system and reduce anxiety.
Q.10 How will you classify the antidepressant drugs?
Ans.:
Anti depressant drugs
Tricylic
Antidepressant
Tetra cyclic
antidepressant
MAO
Inhibitors
Sympatho
Mimetic
Stimulant
Imipramine
Tri-imipramine
Clonipramine
Amitriptyline
Doxepine
Nortriptyline
Mianserin
maprotiline
Phenezine
Isocarbaxazid
Tranylcypromine
Dextroam
Phetamine
Q.11
Ans.
Write is detail about anxiolytic drugs (anti-anxiety drugs). ?

It is also called minor tranquillizers
Indications :
1. Anxiety disorder/Panic disorder
2. Insomnia
3. Obsessive compulsive disorder
4. Depression
5. Alcohol withdrawal symptoms.
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6. Convulsions
7. Induce sleep pre-operatively.
Contraindications:
Patent with renal, liver, respiratory impairment and hepatic failure.
Mode of action: It acts by increasing GABA activity that can cause decrease activity of
neurotransmitter in brain results in decrease neural activity.
1. Tolerance/physical or psychological dependence
2. Inhibited behaviour
3. Memory disturbances: Anterograde & retrograde
4. CNS depression :
Drowsiness
Poor co ordination
Clouded sensorium
Confusion
Ataxia due to cerebellar action
5. Sexual dysfunction :
Erectile and ejaculatory disturbance
6. Miscellanceous :
Lethargy
Impaired psychomotor disturbance
Blurring vision
Gastric Upset
Urinary incontinence
Nightmares
Depression
Aggression
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Headache
Hypotension
Bodyache
Impotence
Nurses' role in providing ant anxiety drugs to the patient's

1. Assessment of patient prior to the use of anxiolytic drugs.
2. Appropriate nursing measures to induce sleep should be taken such calm & quiet
environment
3. While administrating the drug daily dose should be given at bed time to promote a
normal sleep pattern.
4. Look for side effects, record & report immediately if any occurs.
5. Give IM injection deep into muscles to prevent irritation.
6. Instruct the patient not to take any stimulants like coffee, alcohol.
7. Avoid excessive use of these drugs to prevent the onset of substance abuse.
8. Don't stop drug abruptly but it should be reduced gradually
9. For IV administration, do not mix with any other drug and give slowly.
10. Monitor vital signs during IV administration.
11. Administer with food to minimize gastric irritation.
Q.12 What are the common side effects of psychotropic drugs?

Ans.: There are following systemic side effects of psychotropic drugs :
1. CNS & ANS :
CNS :
Drowsiness
80
Confusion
Tremors
Convulsion
Ataxia
ANS :
Dry mouth
Tinnitus
Note : EPS (Extra Pyramidal Syndrome) : In antipsychotic drugs
2. Cardio-vascular system (CVS)
Tachycardia
Orthostatic Hypotension
Arrhythmia
Note :
Bradycardia : In Antimanic drugs
Palpitation : In anti anxiety drugs
3.
Hematopoietic System :
Agranulocytosis
Leukopenia
Leukocytosis
4.
Endocrine System :
Amenorrhea
Breast enlargement
Impotency
Change in Libido
Galactcorrhoea
Gynaecomostia
Hyperglycemia
5. Gastro Intestinal tract :
Constipation
Diarrhea
Anorexia
Nausea
Vomiting
Weight gain
Jaundice
Note : Weight gain : In antipsychotic and antimanic drugs

6.
Hepatic side effect : Liver toxicity
7.
Ocular effect :
Blurring of Vision
Dilated Pupils
Retinopathy
7. Allergic effect :
Dermatitis
Rash
Itching
Alopecia
8. Urinary system:
Urinary Retention
Oliguria
Polyuria
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Q.13 Write in detail about nursing care of patient receiving psychotropic drugs?
Ans.: Psychotropic drugs are used to treat the signs and symptoms of mental illness. But
all behavioural problem are not treated by the drugs. The treatment is based on the
thorough psychiatric evaluation of the patient.
Before administering any drug, the nurse should know about the drugs that is half
life period and after dose, the side effect of drug, age of the patient, to know the liver
metabolites and kidney excretion etc
Nurse's Role:
I.
General Role :
1. No drug should be administered without prescription
2. Do not leave the patient alone until the drug is swallowed
3. Do not allow patient to carry medicine to another patient.
4. Keep safety measures.
5. Give a glass of water after medicine.
6. Do not leave the drug tray within reach of patient.
7. All medicine given must be recovered on patient chart.
8. Do not force the patient orally.
9. Check drug daily for any change for colour order.
10. Drug bottle should be properly labeled .
11. Drug cupboard are always to be kept locked when not in use.
12. Nurse should know side effect indication and contraindication of drug.
13. Nurse must know the legal aspect.
II) Specific Role :

1. Close observation
2. Decrease EPS with antiparikinsonian drugs.
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3. While administrating drug, if any doubt arises without hesitation nurse should
consult with doctor.
4. Observe drowsiness, sore throat, fever
5. Record blood pressure.
6. Provider good oral hygiene to reduce dry month.
7. Weight recording and low salt in case of anti-psychotic/anti manic drugs.
8. Discourage the patient to take antacids as they cause decrease absorption.
9. Maintain intake/output chart
10. Advice to protect the skin.
11. Record in client's chart about which drug administered; if any side effects
observed.
12. Nurse need to have an effective drug attitude.
13. Nurse has to be familiar with regular usage of drugs, their actions, side effects and
they hold responsibility while administering to avoid errors.
14. Uses a variety of techniques with different clients in different situations.
15. While administering the drug, confirm the client by calling their name.
16. While administering lithium, complete investigation as urine analysis, BUN
creatinine electrolytes, 24 hrs creatinine clearance, thyroid test etc should be
checked.
17. Every 3 month, lithium level to be checked.
18. Blood level of lithium is tested 12 hrs after last dose. The therapeutic level should
always be maintained 0.6-1.4 m Eq/lt.
19. While administering MAOI, caution should be taken food substances, as cheese,
pickle, beer, red, wine chicken, liver, overripe fruit, banana peel, yoghurt and
some medications as cold medication, nasal and sinus decongestants, narcotics,
local anesthetics, epinephrine, cocaine, amphetamine should be avoided
84
20. While administering anxiolytic/hypnotic, care to be taken to avoid addiction and

not to disturb usual sleep pattern. For children, special care should be taken
especially while administering hypnotics and lithium.
21. In antipsychotic drugs, ask the client to take sugar free fluids and eating sugar free
hard candy to ease dry mouth.
22. Avoid calorie beverages and candy to avoid weight gain.
23. Usage of sunscreen lotion to overcome photosensitivity
24. Advice the patient not to increase/decrease stop drug without doctor permission.
25. Find out menstrual changes in female.
26. Advice not to get up quickly from lying down to sitting position.
27. Do not give medicine in empty stomach as patient complain nausea and vomiting.
Q.14 Define psychotherapy, write down the goals, indications, contraindications,
advantages and disadvantages of psychotherapy?
Ans.: Definition of Psychotherapy:
Psychotherapy is a treatment use for patient with emotional and mental disorder in which
the basic concept of therapeutic nurse patient relationship is maintained between nurse
and patient. The purpose of this is to modified/remove and reduce the factors causing
disturb behaviour.
Certain psychological processes are used for the treatment of emotional a problem in
which professionally trained person deliberately establishes therapeutic relationship.
According to psychiatric glossary: A process in which a person who wishes to relieve
symptoms or resolve problem in living or seeking personal growth, inter act with a
psychotherapist in a explicate/implicate manner.
Goals of psychotherapy:
1. To achieve remission of symptoms
2. To modify disturbed pattern of behaviour
3. To strengthen the ego
4. To improve growth & development of the client.
5. Modify environment causing maladaptive behaviour.
6. Improve IPR skills.
7. To produce deeper insight

8. To develop positive attitude
9. To modify deviated personality, thereby develops positive personality
10. To correct psychopathology
11. To helping the patient to over comes a feeling of handicap.
Indicated of Psychotherapy
1. First choice for neurotic illness
2.
Very useful in psychosomatic illness.
3. Schizophrenia
4. Mania, depression
5. Alcoholism
6. Drug addiction
7. Sexual deviation
8. Personality & character disorder
9. Childhood disorder
10. Marital disharmony
Contraindications
1. Severe psychotic illness
2. Unresponsive, unmotivated and in cooperated patient.
3. Violent/ excitement
4. Unconscious patient
5. Assaultive and destructive behaviour
6. Negativism
7. Organic Psychosis
8. Psychotic Depression
9. Group psychotherapy in hysteria and hypochondriasis.
Advantages:
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86
1. Reduce intensity of symptoms

2. Increase working ability
3. Increase adjustment in various condition
4. Increase understanding situation, self confidence, of request
5. Start goal directed activity
6. Bring positive mood changes
7. Reduce maladaptive behaviour
Disadvantages
1. Time consuming
2. Ineffectiveness caused waste of mental power
3. Inappropriate for who give best response to ECT and drugs
4. Patient become excessively depends on therapy and therapist
Q.15
87
How will you classify the psychotherapy?
Ans.
Psychotherapy
According to depth of probing

In the unconscious mind
Superficial or
short term
(supportive
psychotherapy)
Deep or long
term (analytical
psychotherapy)
Psycho-Educative
(Group Discussion)
According to No. of patient

treated in any one
therapeutic session
Counseling
I. Individual Psychotherapy
Psychoanalysis
Hypnosis
Abreaction
Reality
Insight
Supportive therapy
Mental Ventilation
Persuasion
Re-education
Re-Assurance
Suggestion
II. Group therapy
III. Behavioral psychotherapy
Systematic desensitization
Flooding
Aversion therapy,
Assertive therapy
Modelling
Shaping
Cognitive behavior therapy
Token economy
IV. Inter personal psychotherapy
Marital therapy
Family therapy
V. Other psychotherapy:
Therapeutic Community/Milieu therapy
Attitude therapy
Activity therapy
Recreational therapy
Occupational therapy
Play therapy
Art therapy
Music therapy
Dance therapy
Education therapy
88
Q.16 What are the role of nurse in psychotherapy?

Ans: Nurses role in psychotherapy :
Nurse plays various roles during psychotherapy
1. Nurse psychotherapist
2. Nurse as a parent substitute
3. Nurse as a role model
4. Nurse as a resource person
5. Nurse as a Supporter
6. Nurse as a socializing agents
7. Nurse as a communication
8. Nurse as a counselor
9. Nurse as a catalyst
10. Nurse as a occupational therapist
11. Nurse as a administrator
12. Nurse as a interpreter
13. Nurse as a teacher
14. Nurse as a technician
Following are the responsibilities of a nurse during psychotherapy :
Nurse should be a good listener
Should be have patience, sympathetic & tact full.
Should understand the patient's family & cultural background
Should not be upset with patient's irritational behavior
Should not show counter transference during psychotherapy
Nurse should have an interest in patient's problem
Manipulate environment according to type of patient.
Nurse should be non-judgmental

o Good listener
o Trustful
89
o Attractive
o Patience
Nurse should maintain T-NPR
Accept the patient as unique individual
Nurse should encourage the patient for involvement in psychotherapy
Nurse must know proper knowledge of different types of psychiatric illness
In occupational therapy, nurse help the patient to teach new skills related to as a
job.
Demonstration to the nursing students.
Q.17 What do you know about individual psychotherapy?

Ans.: Individual Psychotherapy : It is a method of bringing about change in a person by
exploring his or her feelings attitudes, thinking and behaviour.
Therapy is conducted on a one to one basis, that is the therapist treats one patient at a
time.
This therapy helps to:
1. Understand themselves and their behaviour.
2. Make personal changes
3. Improve interpersonal relationship
4. Get relief from emotional pain or unhappiness.
Indication:
Stress related disorder
Alchohol and drug dependence
Sexual disorder
Marital disharmony
Types of individual psychotherapy:

1. Psychoanalysis
2. Hypnosis or hypnotherapy
3. Abreaction
90
4. Reality therapy
5. Uncovering or insight psychotherapy
6. Supportive psychotherapy :
o Mental ventilation
o Environmental modification
o Persuasion
o Re-education
o Re-assurance
o Suggestion
Q.18 Define group therapy. Write in detail about the objective, types of groups,
steps & merits and demerits of group therapy.
Ans.: Definition : Group therapy is a mean of psychotherapy of psychological problem
in which a group of patients is provided psychotherapy by a group of psychiatrist as well
as the patient interact with each other & help in problem solving.
Description:
1. Group therapy is less time consuming
2. Group consist of 8-10 patient.
3. Session of psychotherapy are held once in a week & generally continue for 12-18
months.
4. Duration of session longer than individual therapy. It is one or two hour.
5. It uses many type of psychotherapy technique.
6. The patient in group generally have some problem eg. alcoholic patient.
Objective:
1. The member of group gain personal insight
2. The group member Improve their IPR
91
3. The patient can change their destructive behaviour & can modify their
behavior.
4. The patient can share their intimate feelings, ideas, experiences.
5. It provide an environment of mutual respect that further improve respect & self
understanding.
Types of Groups
1. Therapeutic groups: It is groups of patient. This group works together under
the guidance of a therapist to improve the mental health usually the patient self
help group.
2. Adjunctive group: It is not the group of patients it helps the other selective
group of patient by providing stimulation as music therapy, art therapy &
dance therapy.
3. Traditional group: The members of traditional group are patient from
hospital in patient department. The method of psychotherapy are lecture film
show. The therapist first says few words & then allows the patient to interact
with each other.
4. Non- traditional group: It is also called psychodrama. In this the group
member act out various drama based upon situation. This role play helps him
in expression of feeling, idea.
5. Encounter Group /"T" Group (Training Group): In this group, the focus is
on the expression & feeling of people that remain unexpressed. It is not
necessary for a group of member by ill patient. The inter action between
member of encounter groups is more intense or rapid.
6. Homogenous group: The members of homogenous are similar on basis of
sex, age, race, socio economical level in society etc.
92
7. Heterogeneous group: The group member does not have similarity on basis
of sex, age, socio-economic in society. It is just opposite to homogenous
group.
8. Open or close group: In open group member are free to join or leave the
group at any time. Closed group have certain number, certain duration. Patient
can not join or leave the group any time.
9. Group according To mental illness: The group classified according to their
nature of illness.
Psychotic group
Neurotic group
10. Psychodrama group : The group acts event from the life of one member.
Steps of group therapy:

1. Pre-interaction phase:
Determination of physical set up
Determination of place & time
Determination of types of group
Determination of session no. & no of group member.
2. Initial/orientation phase :
Introduction of group member To each other
Introduction of member To therapist
Instruction of group member
Selection of group member
Selection of group leader
Preparation of environment for problem solving
3. Working phase :
Problem solving with mutual understanding & co operation
Resolving of internal conflict
Role distribution to group member
Development of "we feeling"
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4. Termination phase :
Evaluation of group experiences
Evaluation of result
Merits of group therapy:

1. This method is cost effective. Many patients can be treated by this therapy at a
time.
2. Group member learn new method of problem solving through this therapy
3. It provides opportunity to know about the problem of other patients. It reduces
their feeling of hospitality loneliness.
4. Group therapy provides a safe environment for communication.
5. Group therapy provide an opportunity for patient to play a functional role.
Patient work as a co-therapist with therapist.
Demerits:
1. It is not appropriate for those patient who keep hesitation & unable to
communicate properly.
2. In group therapy patient loses his privacy because patients personal
emotional problem are discusses in open.
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Q.19 Explain behaviour therapy.

Ans.
Definition : Behaviour therapy is a type of psychotherapy that is based upon
learning theory & it focuses at changing or modifying the maladaptive behaviour.
Behaviour therapy is a type of psychotherapy in which conversational interchange

is the primary vehicle used to treat people with problems.
Behaviour therapy is more action oriented, directed towards changing specific

types of maladaptive Behaviour.
Concept of behaviour therapy:

1. Most abnormal behaviour are acquired & maintain as normal behaviour.
2. Abnormal behaviour can be modified through social learning principles.
3. People are best known by their behaviour in life situations.
4. The treatment method should be precisely specified according to behaviour &
should be objectively evaluated.
Indications: It is the treatment of choice in:
Anxiety
Phobia
Obsessive compulsive disorder
Hysteria
Nocturnal enuresis
Sexual disorder
Thumb sucking/nail biting/tics
Migraine
Anorexia nervosa
Bulimia nervosa
Obesity
Psycho somatic disorder
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Contra Indications:
Psychotic disorder that have acute pervasive symptoms and in which reinforcement is not
applicable
Steps: it has 3 steps
1. Training of relaxation technique before the main therapy.
2. Hierarchy formation - Patient is asked to construct a hierarchy of anxiety
causing stimulus.
3. Systemic desensitization:It is done in two ways:
(a) SD-1 the stimulus is confronted in imagination
(b) SD-2 The stimulus is confronted in reality
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Q.20 Write a short note on occupational therapy.

Ans. Introduction: Occupational therapy is a rehabilitation therapy. In occupational
therapy, focus is laid upon the use of activities of as treatment medium. Its short term goal
is improvement of quality of life & long term goal is rehabilitation.
Definition:
Any activity which engages a person's resources of time, energy & is composed of
skills and value.
"REED & SENDER SON".
Any goal directed activity meaningful to the individual providing feedback to him
about his worth & value as an individual & about his inter relatedness to other"JOHNSON".
Objectives:
The major goals of patient in rehabilitation:
1. To assess need of patient
2. To identify the skills of the patient
3. To remove or modify mal adaptive behaviour
4. To improve mood & reduce, anxiety
5. To role performance
6. To stimulate self confidence
7. To give opportunity for self expression
8. To reverse psychopathology
9. To increase socialization & communication
10. To improve old skills & acquire new ones.
Basic Requirement:
1. Knowledge levels of patient
2. Background of patient
3. Psychological problem/diagnosis.
4. Capacity or skills of patient.
5. Therapeutic nurse patient Relationship.
6. Interest of patient.
7. Continuous evaluation of progress.
Type of activity in occupation therapy :
Craft work
Needle and tailoring work
Basket making
Carpentry
Gardening
Painting
Mat weaving
Cooking
Various setting in occupation therapy :
1. Psychiatric hospital
2. Nursing home
3. Psycho-social rehabilitation centre
4. Physical rehabilitation centre
5. Sheltered workshop
6. Community group homes.
7. Community mental health centre
8. Day care centers
9. Half way homes
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10. De-addition centers
Process of occupation therapy:

Initial evaluation of pt.
Development of short term & long term objective
Development of therapy plan
Implementation of plan
Continuous monitoring of progress
Call for reviews meeting with patient & staff
Resetting of new goals
Discharge planning of patient.
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Q.21 Write a short note on aversion therapy ?

Ans. Version Therapy:
Indication:
Alcohol dependence
Homosexuality
Child disorder
Principle: Principle of this therapy is the pairing of the pleasant stimulus (eg - alcohol)
with an unpleasant response. This pairing convert the pleasant into unpleasant stimulus
after the therapy is over.
20-40 session are given.
Duration of session is about 1 hour
Booster sessions are given after completion of treatment.
E.g. : Pairing of alcohol [pleasant] with drug appmorphine disulfirum (unpleasant)

Thumb sucking (pleasant) with low voltage. Electric current (unpleasant)
Q.22 Discuss about the family therapy?
Ans: Family Therapy
Definition : It is a type of psychotherapy which involve both parents together with child,
Grand parents & other member of extended family.
Objective :
The main objective of family therapy is to improve family functioning & to help the
identified patient The other goals are :
To improve communication among family member.
To reduce conflict between parent or member
To reduce distress in the suffering member of the family
To determine role of each member & establish agreement about roles.
To provide sufficient autonomy for each member
Indication:
It is mainly used for young people in family, who have :
Communication problem
Substance abuse
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Conduct disorder
Role identify difficulty
Depression
Anorexia nervosa
Relapse in schizophrenia
Approaches in family therapy :

1. Psychodynamic
2. Structural Approach
3. Systemic approach
4. Electric approach
1. Psychodynamic: This approach is based on this concept that the entire family
problem arise from past experiences of each member & unconscious conflicts. The
therapist helps to gain insight that how their own problems, unconscious conflict
effect the inter relations.
2. Systemic Approach: It concentrates on the present problems rather than past
experiences. This therapy has 5-10 session with interval of month long. The
therapist arrange family interview to assess the family disagreement, ways of
communication.
3. Structural approach: The term family structure refers to the hierarchy in the family
& to a set of unspoken rules regarding task & responsibility.
Eg. Usually in every family both parents have more authority & responsibility. In
this therapy, the therapist identifies the rules which be family tension & try to
bring about changes.
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4. Elective family therapy: It is a short term method planned to bring about restricted
changes in the family. It also concentrates on the present situation of family & the
way of communication.
Q.23 Write a short note on activity therapy?
Ans. Activity therapy: Many patients in psychiatric hospital spend their energy in
destructive activities. For example: manic, violent patient: An activity therapy is an effort
to re-direct their energy into useful or meaningful activity. The example of activity
therapies are:
1. Occupational therapy
2. Recreational therapy
3. Play therapy
4. Biblio therapy
5. Dance therapy
6.
Art therapy
7. Education therapy
Aims of activity therapy:

1
to facilitate emotional expression.
To improve interaction & communication.
To provide outlet for aggressive feelings.
To release tension and pent up emotions.
To increase attention span and concentration power.
To improve cognitive skills. E.g. Learning, listening.
To increase self confidence and feeling of self worth.
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1. Recreational Therapy: It is a type of divisional therapy that encourage social

interaction as well as it increase physical confidence & feeling of self worth. It
provide activities that are enjoyable & self satisfying.
2. Play therapy: Play therapy is emerged out of efforts to apply psycho dynamic
therapy to children because children are not able to talk about their problems.
They also lack the capabilities for insight & self scrutiny. Through play, children
often express their feeling, fear, and emotions providing a clear picture of their
problems. Thus it has diagnostic functions also.
3. Education therapy: Education therapy is helpful when the problems arise out of
inadequate knowledge & misconceptions. In this therapy provide enough
knowledge about the disease, its causes, and its prognosis and treatment
modalities. This therapy is centered upon both patient and her family. This
knowledge may help in eliminating the psychological problems
4. Bibilo Therapy: Biblio therapy means treatment through reading In this therapy
patient is encourages to use library facilities Sometimes reading about other
emotionally disturbed patients and experiment of other may have therapeutic
effect. It is also a diversion therapy as well as it promote and sustain mental
health.
5. Music/Dance/Art Therapy: Music/dance and any form of art promote emotional
expression. It also promotes physical integration. The art & like poetry, drama act
as catharsis (emotional release).
Q.24 Define ECT. What are the types of ECT techniques/methods, indication
contraindications, complications of ECT?
Ans. Electro Convulsive Therapy:
It is a painless form of electric therapy primarily used for patients with depression and
schizophrenic disorders.
Definition: ECT is a physical/somatic therapy in which with the help of two electrodes,
current is passed through the temporal region in between the two hemisphere of the
brain, to produce a grand mal type of seizures.
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Cerleti and bini are the first neuropsychiatric who used ECT in 1937.
Method/Techniques of ECT :
ECT can be given by direct or indirect method.
I. Direct ECT
ECT has been used directly on the patient. The patient is administered atropine
subcutaneously (SC) 0.6 mg to 1.0 mg, half an hour before the treatment or IV
immediately before the treatment minor tranquilizers like calmpose is also used.
A gland mal seizure is induced in the patient by passing an electric current through
the temporal lobe Atropine prolongs the period of disorientation after the seizures.
It also reduces vomiting. Immediately after The ECT treatment appropriate
resuscitative and other emergency management equipment and supplies are kept
ready A skilled person & nurse to resuscitate the patient should be available.
ECT given by this technique causes a lot of anxiety to the patient.
II.
Indirect/Modified ECT : ECT is modified with the use of anesthesia, muscle

relaxant & oxygenation. Anesthesia is necessary to allay anxiety & achieve the
maximum effect, avoid compilation, modify the force of convulsion.
Placement of Electrode :
The location of electrode depends on the unilateral or bilateral ECT.
Bilaterally, ECT involves the placement of electrodes in the bitemporal
region.
To minimize post convulsive confusion & amnesia, unilateral ECT has
been devised in which electrodes are placed so as to avoid the dominant
temporal area.
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Amount of current :
The nature and range of a stimulus intensity setting varies from device to device.
70 to 1.50 volts for .1 to 1 sec. will produce a convulsive effect.
The actual amount, range from 200-600 milliamphers
No. & frequency of ECT treatment:

5-10 treatment for bipolar disorders, manic type, schizoaffective disorder or
catatonic schizophrenia.
20 to 25 treatment may required for chronically ill schizophrenic patient.
ECT can be given 3 times a week.
Preparation of patient for ECT

1.
Patient is called for ECT accompanied by his relatives.
2.
Starvation of the patient for at least 5 hours is necessary. Longer starvation

is desirable
3.
Informed consent of the patient & the relatives for the treatment is obtained.
The patient & the relatives are explained the risks & complications of
treatment before obtaining the consent.
Complete physical examination is absolutely necessary.
X-ray of the chest haemogram urine analysis and ECG should be given whenever
indicated.
4. Removal of denture if any is desirable
5. Mouth gag is put resting on the 3rd molar to prevent the tongue bite, cheek bite
and lip bite.
6. Physical restraints may be necessary to prevent powerful jerky movement of the
body.
7. The patient lies down comfortable on a bed in a supine position.
Observation following the ECT
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The patient must be observed for at least half an hour after the treatment is
given.
The production of gland mal seizure is necessary.
In direct ECT, the tonic phase i.e. muscle contraction last for 10 sec.
approximately. The clonic phase i.e. movement or convulsions last for 2530 sec. approximately. Then patent goes into relaxation phase.
Pulse & respiration recorded every 15 min.
The patient should be prevented from fall & injury.
If the patient become excited & rowdy IM inj. 8-10 ml of paraldehyde or
50-100 mg. if chlorpromazine or diazepam 5-10 ml have to be given to
control the patient.
Indication of ECT :
The indication of ECT depends upon the availability and non-availability of psychotropic
drugs. The common condition for ECT are :
1. Major depressive episode is primary indication 80 90 patient.
2. Involutional melancholia 80-90 %
3. Depression
Suicidal & stuporous patient
Endogenous depression of moderate to severe degree.
Delusional & psychotic depression
Unipolar - bipolor depression
Post partum depression
Depression of old age as long as there is no atherosclerosis & brain
changes.
4. Manic phase (mania)
1. Severe attack
2. Delirium Mania
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3. Mania not responding to drug

4. Destructive & assaultive behaviour
5. Catatonia
6. Schizophrenia
Catatonic & paranoid type
Other type of schizophrenia not responding to other treatment
7. Schizophrenia form symptom in case of epilepsy, alcoholism & drug
addiction
8. For symptomatic treatment of confusion in cases of organic psychosis
like GPI, atherosclerotic psychosis, senile & pre-senile dementia.
9. Other responsive groups to ECT treatment.
Premorbid personality
Stupor (catatonic)
Previous depressive episode
Paranoid delusion
Anorexia
Early morning insomnia
Weight loss
Lack of concentration
Ideas of guilt & worthlessness
Note:
ECT in not effectives in
Reactive depression (Neurotic)
Psychoneurosis, hysteria, hypochondrias, anxiety states.
Schizophrenia only hebephrenic and simple
Drug dependence
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Contraindication
No absolute contraindication
1. Patient with increased ICP
2. Including tumors.
3. Hematomas
4. Subarachnoid hemorrhage
5. Presence of an acute MI, hypertension
6. Patient with cardiac disease, aneurysm , thrombophlebitis, bleeding disorders
embolism
7. First trimester of pregnancy
8. Disease of bone like osteomalacia, fracture
9. Systemic disease involving heart, kidney, lung & other wise versa
Complication or side effect :
Complication may be reduced with modified ECT.
Complications are few and rarely serious.
Immediately after ECT body ache, headache, painful masticatory movement to
drowsiness
1. Abrasions on the lip of tongue bite
2. Dislocations of joints like shoulder & temporomendibular.
3. Fracture of bones like spine of vertebra
4. Confusion & excitement
5. Dyspnea & Apnea
6. Cardiac irregularities including arrest
Delayed Compilations i.e. after the patient had a few ECT.
1. Amnesia for recent events.
2. Confusional psychosis
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Impairment of memory may vary from mild tendency to forget name to sevre confusion.
Neurological & cardiac complications are very rare.
Q.
Ans.
Describe the role of nurse before, during & after ECT.

Role of nurse in ECT:
ECT can be administered in hospital/clinic/nursing Home.
It converts AC main supply into stimulus by using step down transformer.
In hospital setting, nurse sees the set up of ECT.
Waiting/ Resting room :

patient take rest before ECT
Room should be calm with dim light & light colour of wall.
Put some flower for pleasant feeling
Some magazines managing to divert mind & decrease anxiety
Preanaesthetic keep ready.
ECT Room :
(a) Article for patient comfort:
Room must be near to the waiting room
Bed side screen for privacy.
Well padded low level bed with railings.
(B) Article for patient preparation
Small pillow to put under patient waist to prevent injury.
Mouth gag [to prevent tongue bite & clear airway), curved tongue depressor,
Endotracheal tube sterile catheter
O2 cylinder & ambu bag.
(C) Article for the procedure:
Trolly with ECT machine in working condition
Jelly for putting electrode
Emergency drug
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Resuscitation tray
Mouth wipes.
B.P. apparatus, sterile syringe, spirit swab
3. Recovery Room
Observation of vital sign
Mouth wipe & toilet facilities
4. Role of nurse before ECT
Thorough physical examination
Informed consent
NBM (Nothing by mouth) before treatment
Remove metallic articles from body.
Remove lipstick, nail polish
Loosen the tight cloth
Empty bowel & bladder
Maintain personal hygiene
Give premedication, atropine, calmpose
Nurse should display a warm supportive attitude.
Take the patient to the waiting room
5. Role of nurse during ECT
Transfer the patient on a well padded bed placed in supine position.
Place tongue depressor in between teeth
Give short acting anesthetic to the patient
Support the shoulder or arm
Restraint the thigh with the help of sheet
Hyperextension of head with support to the chin give few breath of O2
(Oxygen)
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Apply jelly on temporal region.

Make observation of grandmal seizures.
6. Role of nurse after ECT
Placed the patient on a side lying position on a railed cot.
Observe & record vital sign.
Transfer the patient to recovery room, only if he can answer a simple
question.
Observe patient condition in every 15 minute, once stabilized, then
after 30 min.
Allow the patient to take sleep for 30 minutes to 1 hour.
Reassurance to patient.
Reorient the patient to time, place & person.
Note any injury or complain of pain. Encourage patient for bath &
change cloth.
Allow patient to take breakfast.
Help the patient in ADL's (activity of daily livings).
Make observation on any change.
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Unit-VIII
Forensic psychiatry/legal aspects

Q.1
Ans.
How a mentally ill patient get admitted in a mental hospital and how he get
discharged?
Admission and discharge of the clients in a psychiatric unit/mental hospital is
based on section 31,34 of Indian lunacy Act (ILA) 1912 later it was modified on
1st October, 1931.
Admission and discharge can be made in one of following:
1. Admission procedure on voluntary basis :
(a) For major client and desires to have admission into the mental
hospital based on his suffering:He will approach medical superintendent of hospital, along with two
visiting medical officers (who are appointed by state govt.) will observe
the case, at their own discretion, they can admit the case into the hospital,
provided the client has to submit the filled up performa stating that he is
interested to be admitted.
(b) For minor cases: the nearest guardian has to apply request for admission,
medical officer within 24 hours of receipt such application can admit the
case cast into the hospital.
Discharge Procedure :
(a) For major client: If he feels his condition is better, he can ask for discharge by
writing a written notice of 24 hours.
(b) For minor client: If minor attains "major" and "cured", he has to write an
application. The medical superintendent will observe and decide whether he
can be discharged or not, within a month.
2. Reception order on petition under special circumstances:
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Admission is made, if the family members or the relatives of the patient have
to submit the request or petition for admission of the client into mental
hospital.
The petitioner must be a major and personally observed the client within 14
days of making the petition. Petition Has to be written on a special form,
denoting all the particulars of an individual which has to be supported by two
medical certificate (one form greeted govt. medical officer and other from
registered medical practitioner) Both medical officers have to
be
independently examine the "alleged lunatic" at different times and within 7

days of applying for reception order and have to certify that the lunatic needs
admission and detained under care and treatment.
The medical practitioner has to be very careful in giving a certificate in order
to avoid legal complications for a wrong certification.
Discharge Procedure:
In this clause, the clients can be admitted for a period not exceeding 90 days.
If relative feels that medical officer is misusing the lunatic, he can obtain
permission from magistrate for discharge. The magistrate will verify the
condition of the client through personal inquiry and if he satisfies, thinks that
the client condition was improved, he recommends for discharge.
The petitioner has to apply to the superintendent of the mental hospital for
discharge. If the person is not dangerous and is fit to live safely, he can be
discharged.
3. Admission under temporary treatment order:

It was mentioned is MHA sections 20, 21 of 1981. When there is risk to their
own life or of others, magistrate will issue reception order. If medical officer
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in-charge feets that it is necessary to bring the legal authorities into the scene,
he can apply to the magistrate or relatives can approach magistrate to issue an
reception order for treatment. This order is valid for 6 months. In these cases
only one medical certificate is required.
Discharge: After recovery, if medical officer feels he can be fit to live safely
in the society, he will discharges.
4. Admission and discharge procedure through magistrate: On receipts of

petition by the relatives or the person who observed lunatic 14 days prior to
petition or if lunatic is causing harm either to himself or the other.
In these cases magistrate will inquiry in private and personally examines the
alleged lunatic. If he is satisfied he will issue reception order, if he is not
satisfies, he fixes a date for the consideration of the petition, in mean time he
carries out further inquires until then, he will order for the safe custody of
lunatic. If magistrate is not willing to issue an reception order and refuse the
petition, he will give the probable reasons in writing and a copy will make the
reception order often the medical in charge shows willingness to admit the
client and the petitioner would bear the maintenance cost.
Discharge procedure :
If he feels that client is having sound mind and capable of managing himself
and his affairs. The magistrate will obtain consent of medical officer in charge
regarding the soundness of the client to live safely in the society.
5. Admission in emergencies (immediate restraint of the insane) :
If insane is dangerous to himself or the other or likely to injure the property, he
can be lawfully kept, consent of low full guardian may be obtained.
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If the mentally ill patient is very dangerous, and the medical officer in charge
think that patient needs hospitalization, he can admit the patient but within 72
hours. The patient need to be examined by the magistrate to produce a
reception order.
Discharge procedure
If the client condition improves, he can be able to take care and found to be
sound, he will be discharged.
6. Reception order other than petition/ Admission through police: Police

officer can arrest any person, whom he believes to be a wandering, or a
dangerous lunatic, the arrested person has to be produced before a magistrate.
Magistrate will do personal inquiry and he asks the medical officer to examine
a case. If he feels the necessity, he will admit the case into hospital. After the
reception order has been passed, the magistrate has to arrange for suitable
place for detaining the lunatic, till he is transferred to a mental hospital.
Discharge Procedure: For discharging the client, when family member or
relatives agree in writing that they will take proper care and the client is found
to be medically fit.
7. Reception order After Judicial inquisition: If a person is found lunatic after
judicial inquisition, the high court or the district court has the authority to issue
reception order to admit the case into the mental hospital.
Discharge procedure : If client is found to be medically fit and family
members agree that they will take care of client, he may be discharged.
8. Reception of criminal lunatic : A criminal lunatic has to be admitted into a
mental hospital on the order of the presiding officer or court. The criminal
lunatic are to 3 types :
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1. Those who suffering with unsound mind and incapable of making their
defense.
2. Those who committed the crime, but were acquitted on the ground of
unsound mind at time of committing suicide.
3. Those who contacted the disease after imprisonment.
Discharge procedure: The visitors of the hospital has to report every 6 month once about
the client's mental status and authority which has ordered detention. As soon as the client
is fit to lead normative life they have to inform about the same to authority concerned.
The person will be handed over to the prison officer for the further legal action.
Q.2
What is Indian lunatic Act (ILA 1912) ?
Ans.: It is derived from English lunacy Act, 1890, contain eight chapters. ILA extends
whole of India except Jammu and Kashmir in act no-4.
Chapter I Terminologies
It contain some terms, preliminary conditions and its definition. Some of the terms used
are:
Asylum.
Cost maintenance
Lunatics
Criminal Lunatics
Reception order etc.
Chapter II Admission and transfer procedure

It describes voluntary admission, reception, order, through petition, admission of
dangerous lunatic or criminal lunatics, transfer of lunatics from one state to other state
with permission.
Chapter III-Board of visitors
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State govt. will appoint board of visitors (at least 3 members one medical officer not
necessary to have psychiatrist. Other two may by PSW or politicians)
It also deals about the treatment of client and his discharge.

Chapter IV The care of lunatic by family members or relatives
Court appeal by the lunatic or relatives for properties disbursement for a term not
exceeding 5 yrs.
Chapter V
Lunatic properties, court amendments for assessing, disbursement of properties
Fine of Rs.500/- will be collected by manager of lunatic appointed by court, if he
is not maintaining properly.
Chapter VI
Establishment of Asylums
Board of visitors has to conduct monthly visits and periodically they have to observe
standard diet, medical checkup, parameters etc. and report it to govt.
Chapter VII Expenses of lunatics

Asylums and state government will bear the expanses of lunatics.
Chapter VIII Rules

State govt. will formulate rules related to :
Prescribed forms for proceedings, place of detention and regulate the care and treatment
of a person detained.
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Q.3 Write a short on Indian mental Health Act, 1987 (IMHA, 1987) ?
Ans.: IMHA, 1987 is an amendment of Indian lunatic Act, 1912
Mental Health Act was introduced in Rajya Sabha in 1981, mental health bill no. XLI act
14 came into practice as a MHA from 22nd may 1987. Later government of India issued
order that came in force with effect from April, 1 1993 in all state and union territories of
India. It includes ten chapters. This act is applicable throughout India.
Objectives:
1. To formulate rules and regulation for the procedure related to admission and
discharge of the client in psychiatric hospital units
2. To regulate establishment & maintenance charges of psychiatric hospitals
3. To provide facilities for establishing the guardianship of mentally ill, who are
incapable of managing their own affairs.
4. Discarding custodial care, safeguarding mental patient from community and
incorporating better provision relating to treatment & care.
5. Judicial safeguard for patient right to prevent any dignity or cruelty to mentally ill.
6. Introduces humanitarian consideration
7. To establish and coordinate the central and state authorities for mental health
services.
8. To regulate the power of government for establishing, licensing and controlling
psychiatric hospitals.
Mental health act is divided in the ten chapters consisting 98 sections.
Chapter-I Terminologies (preliminary)
It deals with definitions related to mental health practice.
Mentally ill person :
A person who is in need of treatment of reasons of any mental disorder other than mental
retardation. The lunatic changed into mentally ill person.
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Mentally ill prisoner:

Criminal lunatics changed into mentally ill prisoner.
Cost of maintenance:
A mentally ill person admitted in psychiatric hospital shall mean the cost of such items as
per state government by general and special order specify in this behalf.
Licensing authority: State govt. will appoint and authorized an inspective officers, who
will have an authority to inspect any psychiatric hospital within the state and gives license
under section 8.
Licensee: The holder of a license:
Licensed psychiatric hospital:
Psychiatric hospital will be inspected and if it is appropriate to have the psychiatric unit
facilities will be given permission to admit and treat the psychiatric cases.
Minor and major:
Minor : client below age of 18 yrs.
Major : Client above 18 yrs. Age.
Reception order: Order made provision for the admission and detention of mentally ill
persons in a psychiatric unit.
Chapter II: Mental health authority
It deals with establishment of central and state authorities for development regulation,
direction and co ordination of mental health services.
Chapter III
It provides guidelines for establishment and maintenance of psychiatric hospital.
There is a provision of licensing authority who will process application for licenses.
Valid license has to be reviewed every 5 yrs.
Chapter IV
It describes the procedures for admission and detention of the clients in psychiatric units
Chapter V
It deals with inspection, discharge, leave of absence and removal of mentally ill person.
Chapter VI
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Judicial inquisition regarding alleged mentally ill persons possessing property, custody of
his persons and management of his property court may appoint guardian to look after self
and property.
Chapter VII
It deals with liability to meet the cost of maintenance of mentally ill person detained in
psychiatric hospital or nursing homes.
Chapter VIII
It aimed at protection of human right of mentally ill person. No, mentally ill
person during treatment will be subject during treatment to any indignity.
Mentally ill persons under treatment cannot be used for research purpose, Unless it
benefit him.
Consent has to be obtained either from client or from relatives for discharge.
No communication or no letter has to be sent to mentally ill cannot be read or
interpreted or detained or destroyed.
Chapter IX
It deals with penalties and procedures for establishment of maintenance of psychiatric
hospital or psychiatric nursing home.
Chapter X
It deals with provision for miscellaneous action.
It deals with clarification pertaining to certain procedure to be followed by the medical
officer incharge of the psychiatric hospital.
The Medical Officer prepares the report of hospital operations every 6 months once and
will send it to the authorities.
Incharge Medical Officer is responsible for the supply of requisites (like food, sanitation
etc)
in the psychiatric hospitals,
Q.4 what are the legel responsibilities of a nurse in care of mentally sick patient?
Ans.: Legals responsibilities/legal aspect :
A psychiatric nurse have many responsibilities while caring a psychiatric patient.
She is responsible for providing quality nursing care to reduce malpractice
litigation. Quality nursing care can only be legally proved by its accurate,
complete documentation. So a psychiatric nurse has some legal responsibilities are
as following :
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1. Collection of informed consent/substituted/consent:
mentally ill patient also
have right to informed consent before any nursing intervention for e.g.: before
ECT. Concept can defense a nurse against litigation.
Informed consent means the patients should:
Have a clear and full understanding of the nature of illness to be treated.
Should agree freely to receive the treatment
Should know about the procedure available and their probable side effect.
The competent to take decisions.
When consent is refused: The consent may be refused by both competent and
incompetent patient.
Consent is refused by competent patient due to misunderstanding or fear about the
illness and treatment. For this nurse should explain once made some patient
continue to refuse the treatment.
When consent is refused by incomplete patient there is provision for a form of
proxy consent such as the application of a guardian.
Situation when consent is not required:
When death is likely to occur without intervention and there is doubt the
competency of patient
Substituted consent: In minor cases and involuntary admission and when patient is
unable to understand their surroundings, the consent is obtained from another
person or from court appointed guardian on behalf of patient.
2.
To maintain confidentiality : confidentiality is particularly important in

psychiatric field become information in psychiatry is often collected about private
matters.
Confidentiality in an issue that establish trust in nurse patient relationship.

The principles related to confidentiality are :
1.
The personal information must be safeguarded, records must to kept securely and
unintentional disclosure should be avoided
2.
When there is need of disclosure, an informed consent should be taken for

disclosure.
121
3. The information can be shared with the parents who have a legal duty to act in
their children's best interest
4. Patient's permission should be obtained before information in sought from
other persons.
5. Patient should know from the start that information can be shared among the
members of health care team.
6. Rules of confidentiality can be breached in following condition:
In patient's interest
In the public interest
For legal representatives
7. The patient should be told in advance about the special condition in which all
the information may be revealed such as group therapy and family therapy.
Census report
Inter department report
Special report on unusual condition of patient.
Reports on mistakes.
Reports on complaints
Evaluation on report etc.
3. Protection of patient's right :

It is the responsibility of nurse of protects the right of patients because the psychiatric
patient are unable to protect their rights by themselves. The advocacy role of nurse is
more important here than providing nursing care.
Nurse have following responsibilities regarding protection of pt's right:
1. Nurse should discuss about right of patient within treatment team
2. Nurse should ensure that ward procedure and policy does not violet patient's right.
122
3. Nurse
should
review
periodically the
mechanism
that
provides
right
accountability.
4. Nurse should review periodically the rights & issues of violation
5. Nurse should know the right of psychiatric patient in specific condition for eg.
Involuntary patient have limited right to refuse medication:
5. To keep knowledge about right of patient :

A psychiatric nurse should have complete knowledge about the right of psychiatric
patient.
Right of psychiatric patients are :
1. The right to wear their own cloths
2. The right to see visitors everyday
3. Right to refuse ECT
4. Right to manage and dispose of property
5. Right to keep and use their own personal possessions, including toilet articles
6. Right to keep money for canteen expenses
7. Right to have ready access to letter writing material
8. Right to mail & receive unopened envelope.
9. Right to hold civil service status
10. Right to treatment in least restrictive setting.
6. Maintain standard of nursing care :
American nurses association has formulated many standards to follow and to
update her knowledge. This helps her to keep pace with the growing scientific
world.
Standard I Theory (Appropriate & scientifically sound)
Standard II : - Data collection
Standard III : - Diagnosis

Standard IV : Planning
Standard V : Intervention
a. Psychotherapeutic Intervention
b. Health Education
c. Self care activities
d. Somatic therapies
e. Therapeutic environment
f. Psychotherapy
Standard VI : Evaluation of her nursing action.
Standard VII: Peer Review
Standard VIII: Continuing Education/Action
Standard IX : Interdisciplinary collaboration
Standard X : Utilization of community health system
Standard XI : Research
123
124
Unit IX
Psychiatric emergencies and crises

intervention
Q.1
Ans:
Define psychiatric emergencies, write the classification of psychiatric

emergencies.
Emergency: It is situation in which immediate action is essential for the survival
of system.
Psychiatric Emergency : It is explained as a disturbance is behaviour, affect and
thought (BAT) to that extent, that it needs immediate therapeutic intervention.
It is defined as a sudden onset of an unusual disorder and socially inappropriate
behaviour caused by an emotional situation.
-"Bimla Kaooor, 2002"
Classification of Psychiatric Emergency
Psychiatric Emergency
Over activity/
Underactive
Over excitement
Patient
1. Violent
2. Anxious
3. Drunkenness
4. Drug withdrawal
Suicide
1. Depression
2. Catatonic stupor
Note : AIDS : Acquired immune deficiency syndrome

Q.2
How will you manage the psychiatric emergency?
Others
1. AIDS associated
2. Adolescent crisis
3. Post partum psychosis
Ans.
125
Nurse have to assume overall in-charge for interventions and seeks guidance from
the psychiatrist whenever necessary.
Handle the case tactfully
Provide calm & watchful environment
Emergency cases has to be shifted as early as possible where he will be
safeguarded against injury either to himself or to the others.
Protect other patient.
Encourage verbal expression of feeling.
Provision of care in meeting the client's need accordingly.
Use communication techniques
Always remain with patient.
Build trusting relationship with patient.
Talk in simple language and slow volume.
Do not threaten theater the patient but set limit on his behaviour
Remain aware of pt's right, feeling & dignity
Constant observation on patient activity
Crises intervention
Education to family and friends of patient.
Q.3
Ans.
Define suicide, what are the risk factors of suicide? Classify the suicide and
how the patient with suicidal ideation be managed?
Suicide:
It is commonest psychiatric emergency
It is act of killing on self.
Patient's threats, gestures are always taken seriously.
Definition of suicide:
"Aggression towards the self following the internalization of frustration or disappointment
related to loved one".
According to Clayton
"Ultimate act of self destruction"
126
Myths about suicide:Suicidal threat is just a bid for attention and should not taken seriously
It is not harmful for a person to talk about suicide.
Only psychotic person commit suicide.
Nice home, good job, intact family prevent suicide.
Risk factors of suicide:
1. Psychotic disorder :
Schizophrenia
Depression
Alcoholism
2. Social Causes :
Failure in exam
Love failure
Marital disput
Social isolation
Parental separation
Family problem with substance abuse
Lack of parental & maternal care
More scholastic difficulty
Unemployment of parents
3. Medical disorder :
AIDS (Acquired Immune deficiency Syndrome)
Cancer
Estimation of lethality & degree of suicide
127
High lethality
Low lethality
Use of gun
Wrist cutting
Hanging burning
Hypochondriasis
Jumping from a high building, Train
Inhaling domestic gas

Mild depression
Classification of suicide :
In 1951 E-mail Durkheim classified social categories of suicide:
1. Egoistic suicide: one who may lose social integration with their social group.
2. Altruistic suicide: Results from a response to a cultural expectation e.g. sathee
sahagamanam which has followed in ancient India.
3. Anomic suicide: Occurs in response to the changes occurs in individual life. For
e.g.: divorce, loss of job.
4. Sam sonic suicide of revenge:
Experiencing as being unfriendly for e.g.: if the husbands is unfaithful to his wife.
She may attempt to commit suicide to take revenge from him.
Management of suicidal patient:

"When the firstly patient come in emergency main attention to stabilize physical
conditions" then:
1. Inform psychiatrist
2. A taking psychiatric history
3. MSE
4. Past medical history of patient
128
5. Continuous survey
6. Provide calm & safe environment to the patient.
7. ECT for major depression
8. Antidepressant for OPD patient.
9. Keep strict observation to prevent repeat attempt.
Nursing management :
1. Make a treatment plan
2. Conduct suicide assessment, lethality plan
3. Engage the client in purposeful activities by diverting the mind.
4. Careful observation of client is needed in vulnerable time.
5. Provide symptomatic psychotherapeutic treatment.
6. Administer the drug, if any prescribed.
7. Report to the team members if any clues related to suicide are identified.
8. Encourage the client to develop optimistic ideas or sense of hope and self
control.
9. Motivate the client to express his repressed feelings
10. Involve the family members in provisions of care and guide them to provide
situational support.
11. All psychiatric drugs should be kept under lock
12. Patient should not left alone.
13. Constant observation on patient activity.
14. Give the patient opportunities to express feeling.
15. Remove object which might be used as a means of suicide.
16. Teach better problem solving techniques, alternative expression, sense of
achievement in personal life, decision making ability and importance of
positive self esteem.
129
17. Encourage the client to explore his hobbies one by one, restart it
constructively.
18. Staff has to be aware of problems raised by the client.
19. If client leave ward without intimation take immediate action.
20. Discharge plan has to be made in advance, inform follow up visits.
Q.4
Define crisis, what are the types of crisis situation? Which types of techniques
used in crisis intervention and describe nurses role in crisis intervention?
Ans. Crisis: In Chinese language crises word has two meaning:

1. Danger
2. Opportunity
When people face problems which they are unable to solve by well tried defense
mechanism, a brief psychotherapeutic intervention focus on the immediate crisis can be
great assistance.
Definition:
1. According to oxford English dictionary: crisis is " A time when a problem, great
danger difficulty or uncertainty is at its worst points and needs immediate
attention.
2. Crisis in an initial disturbance that results from a stressful event or perceived
threat
3. "A sudden event that occurs in one's life, which disturbs the individual
homeostasis and usual copying mechanism, will not resolve the problem.
Classification/types of crises situation:
Crises are classified in various types:
1.
Development crisis/maturational crisis/Internal crisis: Erik H Erikson divided
the whole life into eight development stages. When a person enters into next phase from
one phase he goes through many emotional and psychological changes. This transition
phase make work as a crisis for that person. For e.g.: Puberty, adolescence, adult, old,
age menopause, pregnancy, retirement etc. Maturational, crisis involves how an
individual will perceive themselves, their role and their status.
130
2.
Situation crisis/External crisis/Accidental crisis: If biopsychosocial equilibrium
upsets because of external event or due to environment influence. It is sudden,
unexpected onset for example :
Death loved one
Loss of employment
An accident
Marital disput
Sexual assault
Change in living place
Severe suicidal ideation
Loss of status an acute illness
Loss of valued object
Technological changes
3.
Accidental crisis adventitious/community crisis: It is most common type, also
called unexpected crisis, results in multiple loses may be because of environment changes.
For Ex.
Any Accident
Severe illness
Loss of both parents
Natural disasters
Tidal waves
Nuclear war etc.
4. Crisis resulting from traumatic stress: It results when unexpected stress
over which individual has little or no control.
For e.g.:
Rape
Robbery
Terrorism
5.
6.
Socio cultural crisis : For e.g. Discrimination between race & robbery
Psychiatric emergencies :
131
For e.g.:
Suicide
Addicts
Techniques used in crises intervention:
Aguilera modal of crises intervention:
Human being
Stressor Balanced condition stresses
Imbalance state
Felt need was not fulfilled
To restore equilibrium
Presence of Balancing
Factors
Absence of one of more balancing

factor
Right perception of event
Wrong perception of event
Adequate situational
Support
Inadequate situational
Support
Resolution of problem
No resolution
Normal condition
Crisis
132
Crisis Intervention: Crisis intervention is form of psychotherapy which includes

ventilation, abreaction,. Resolving the conflict. It starts with identifying the problem &
ends with helping the patient to understand the methods to solve them.
Crisis intervention is type of brief psychological method of treatment in emotional crisis.
Techniques:
1. Reassurance
2. Sedative/Hypnotics
3. Suggestion
4. Mental ventilation
5. Environmental modification
6. Behaviour modification
7. Abreaction
8. Providing support
9. Clarification
10. Manipulation
11. Raising self-esteem
12. Exploration of situation
13. Support of defenses
Role of nurse in crisis intervention: Nurse has the following role in the crisis
intervention: Establish trusting relationship with patient.
Actively listen the problem of patient and his family it is challenging but very
important skill.
Encourage an honest disclosure, ensure confidentiality.
Do not attempt to avoid emotional reaction such as anger or crying.
A change in environment may serve to alleviate stress and may produce a sense of
comfort.
133
Support the patient in use of defense mechanism that supports an adaptive

adjustment.
Never criticize the patient's method of coping at a time of crises.
Be aware of crisis groups or support group in their local communities for reference
purpose.
Use warmth, acceptance, empathy, reassurance to provide general support of
patient.
Use various techniques of crisis intervention.
Identify feeling of anger, guilt, and hopelessness and not to reinforce these
feelings
Guide the patient through complete problem solving process. It may bring positive
life changes.

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What are the different types of crises situations classified?

What are the different types of crises situations classified?

What are the techniques used in crisis intervention?

What are the techniques used in crisis intervention?

Biyani's Think Tank

Concept based notes

Mental Health & Psychiatric

Biyani Shikshan Samiti

First Edition : 2011

Leaser Type Setted by :

Mental Health & Psychiatric Nursing

am glad to present this book, especially designed to serve the needs of

Mental Health & Psychiatric Nursing

Unit III Mental Health Assessment

Unit IV community Mental Health

Unit V Psychiatric Nursing Management

Prevalence, etiology, signs and symptoms, prognosis, medical nursing

Definition, etiology, signs, symptoms, medical and nursing management of:

Mental Health & Psychiatric Nursing

Unit VIII Forensic Psychiatry/Legal Aspects

Unit IX Psychiatric Emergencies and Crisis Intervention

What do you mean by mental health?

Body, mind & spirit

Q.2 Define Mental illness ;

Absence of Health: It defines illness is an absence of health. It emphasize

Mental Health & Psychiatric Nursing

Biology Approach : According to scadding "Mental illness is result of

Pathological Approach: According to szusz "Mental illness only is term of

Behavioural that is generally

What is mental (Defense) mechanism? How many types of mental

Mental Health & Psychiatric Nursing

Origin in oral period (0-2 yrs)

Origin in habit training

Origin in later period of childhood (13-6)

Origin in latency period

Other commonly use defense

Psychotic patient use defense mechanism:- Projection, denial, fantasy, regression,

Neurotic patient use following defense mechanism:- Repression, isolation,

How mental mechanism help the person to react appropriately to the

It is one of the coping mechanism used to reduce anxiety & fear.

Ans: According to Allport: Personality is the dynamic organization within the

Mental Health & Psychiatric Nursing

Personality refers to "the Aggregate of the physical & mental

Personality is expressed through the behaviour of a person. The characteristic

Mention the factors affecting development of personality?

Factors affecting development of personality :

Emotional / Psychological Factor

Explain Freud's psychodynamic theory:

Ans.: Freud explained psychodynamic theory as :

Preconscious level: The memories/thought are easily available with a moment

Mental Health & Psychiatric Nursing

Brief the historical development of psychiatry nursing?

Ans.: History of psychiatry: History is meaningful record of human achievement. The

The period of persecution : 1550 BC 1400 AD

The period of Segregation : 1545 AD -1800 AD

The humanitarian period 1745 1826 AD

Beginning of scientific attitude : 1796 AD 1878 AD

The period of prevention : 1885 AD 1960 AD

1. Past history:- In first century "CHARAK SAMHINTHA" has referred to psychiatric

Psychotherapy process was present in form of "DAIUAIY APARYA