Lesson 1

Mental health Nursing.

Definition:
• A state of well being in which your behaviours, feelings and
which are age congruent are demonstrated and are socially
accepted.
• Age congruent: Your behaviours should be in consistence with
your age.
• Characteristic of a person with good mental health.
• Able to create good interpersonal relationship with other
people.
• Able to adjunct to a new environment so that he/she can be
accepted.
 Characteristics cont.
• Able to face the reality of life: Face problems and
solve them.
• Able to achieve satisfaction in life: With himself,
his job, his salary etc.
• Able to set his goals of his/her life: Gaols which
can be achievable, realistic goals.
• Able to identify himself or herself.
• Who am i?,What do I need in future? What do I
want to do with my life?
 Terminologies used in mental health.
• Psychiatry:
• Field of medicine that deals understanding,
assessing, treating, and prevention of mental illness.
• Psychiatrist: A medical doctor who is specialist in
diagnosing, treating and prevention of mental
illness.
• Psychiatric nurse:
• A field of nursing that is specialized in caring for the
patients suffering from mental illness.
 Structures of personality cts.
• Id:
• First to develop,
• Present at birth,
• It ensures the survival of infants and young children.
• It operate on Pleasure principles.
• It demand immediate satisfaction.
• It does not recognize the out side world.
• So when the baby is hungry, it will cry to be feed,
• When wet, it will cry to be changed ctc.
 Mental illness.
• Definition:
• These are the diseases which affect the functioning
of the mind.
• Our mind functions at three levels:
• Id,
• Ego,
• Supper ego.
• These levels are also called the structures of
personality, or the systems of personality.
 Ego
• It develops after 5years,
• Its objective is to ensure that the ID demand are met in a
more realistic manner.
• It operates on reality principles.
• When it develops, the child start being reasonable.
• The child start appreciating a little delay before the
demand is met.
• Some time, if the child need food when the mother is
cooking will go to the main house, come with plate and
tell mom that he want food.
 Super ego.
• It is the last to develop, from 18 years.
• It operate on moral principles.
• It is concerned with the morals of an individual.
• It is moulded by the parents and community at
large.
• It deals with human feeling and consciences.
• Do you feel uncomfortable is you offend some
body?
 Causes of mental illness.
• Mental illness have no cause, but there are factors which
predispose an individual from suffering from mental illness.
• Genetic factors:
• The mental illness runs in some families.
• Confirmed by twin studies:
• Identical twins…….56% chances.
• Fraternal twins…….20% chances.
• Sibling…………………..14% chances.
• Half sibling…………….7%.
• General population…0.85%.
 Causes of mental illness.
• Constitutional factors:
• It refers to the physical appearance of an individual.
• It describes body build of individuals.
• Pyknic body build:
• Short person,
• Short neck,
• Broad chest,
• A lot of fat around the abdomen.
• If he/she suffer from mental illness will suffer from Manic-
Depressive Psychosis.
 Causes ct.
• Asthenic body build:
• Tall person/Thin person/Weak person.
• Poor distribution of fat.
• If he/she suffer from mental illness ,will get a disease called
SCHIZOPHRENIA.
• Athletics body build:
• A tall, very strong person.
• Strong muscles,
• Well distribution of fats.
• If this person suffers from mental illness will get a disease called
Schizophrenia.
 Biological factors.
• This refers to the neurotransmitters in the brains.
• They are produced in the synapses so that the action
potential can move from one neurone to the other.
• Examples:
• Dopamine,
• Epinephrines,
• Norepinephrines.
• These Neurotransmitters must be produced at certain level.
• If too much is produced causes mental illness: Manic
psychosis/or Schizophrenia.
 Neurotransmitters ct.
• If too few of this transmitters is produced causes
mental illness called Depression.
• Chemical factors:
• Alcohol abuse causes mental illness.
• Drug abuse like Opium,Cocain,Cannabis Sativa,Khat
all causes mental illness called Organic Psychosis.
• Physical factors:
• Any condition that may interfere with your brain.
• Examples: Head Injury, Brain tumours,etc
 Physical factors.
• Conditions that may affect our brains.
• Examples of head injuries, brain tumours,
brain haemorraghe,
• Infections like Meningitis,Cerebro malaria,
• Condition like epilepsy.
•
 Pathogenic Family Patterns.
• Pathogenic family:
• A sick family/un health family.
• These families predispose their children to developing
mental illness.
• Characteristics portrayed by these families:
• Rejection:
• They reject their children:
• If mother rejecting……….Maternal rejection.
• If father rejecting………….Paternal rejection.
• If both of them……………..Parental rejection
 Types of rejection.
• Physical rejection:
• Parents they leave the children alone.
• Not there to provide physical support like food,
clothing, shelter etc.
• Poor families the most affected by this problem.
• Emotional rejection:
• Parents are present physically, they even provide
their children with all physical support.
• But they do not provide emotional support
 Effects of rejection.
• The two types of rejection have the same effects:
• Children feel insecure,
• Become fearful,
• Self brame for their problems,
• Attention seeking behaviours:
• Example :Braking properties/ Aggressiveness,
• Run away from school.
• Overprotection:
• Could be either maternal/ paternal protection.
 Overprotection ct.
• Child who is likely to be over protected:
• The only child in the family,
• The only sex in the family,
• The last born,
• A child with physical deformity.
• The child is given too much protection.
• The child is prevented from taking risk,
• Protected from out siders.
• The child is over dressed in cold climate.
• If the child is sick it is taken to several doctors, can even
be overdosed.
 Effects of overprotection.
• Lack of self confidence,
• Not be able to cope with reality,
• Not able to make his/her own decision.
• Passive personality,
• Tend to depend on others so much.
• Some develops mental retardation because the brain
was not stimulated.
• When the reach marrying age, the marry older
partner than them.
 Overindulgence.
• The child here is provided with every thing it
need.
• Parents cater for every demand of this child.
• What ever the child demand is provided very fast.
• The child will eat what it want/ dress the way it
want.
• Go to the school it want.
• Effects of this behaviour.
 The effects of overindulgence.
• The child become spoilt,
• Very demanding child,
• Very impatient child,
• Child is provided with false reality, growing
thinking that every thing is easy.
• Very selfish person.
• If the demand is not provided in good time the
child will become very aggressive.
 Perfectionist.
• The parents also are perfect and want their children to be perfect
like them.
• What ever the children do cant satisfy their parent.
• The parents of these children are always complaining , you have
not dressed your self properly, you have not swept the house
well etc.
• Effects of perfectionist:
• Children feel inadequate,
• Lack of initiative.
• View themselves as failures,
• They develop I can do it syndrome
 Faulty discipline.
• Children should disciplined.
• If not disciplined, become spoilt.
• Positive discipline:
• Must be firm,
• Consistence,
• Guidance,
• On the spot.
• Negative discipline:
• The child is severely disciplined even for minor misbehaviour.
• Child could be beaten severely, denied food, reprimanded
 Effects of faulty discipline.
• The children become fearful,
• They develop hatred towards authority.
• Loss of initiative for fear of being punished.
• Become timid.
• If home becomes so hostile , they leave home
to the street.
 Faulty parental models.
• Children mould their behaviour or their personalities by
imitating their parents or care takers behaviours.
• The imitating other peoples’ behaviour is called
Significant others.
• The first significant others is the parents/ siblings/ those
very close to the child.
• The 2nd significant others are teachers,peers,community
leaders etc.
• After imitating the behaviours, they internalize them.
• After internalization, those behaviour become part and
percales of the child.
• As the father as the son.
 Personality ct.
• The parents should have good/health behaviours so that their
children will have good behaviours.
• Please note:
• You cant’ tell a child that smocking is bad if you are smocking.
• The parents should portrays the following behaviours:
• Treat their children with love.
• Have consistent behaviour.
• Should guide and teach their children.
• Disciplinarian to the children.
• They should prepare their children for tomorrow.
 Faulty parental behaviours.
• Alcoholic parents.
• Drug abusers.
• Broken marriages.
• Nagging parents.
• Parents who are practicing prostitution.
• Effects of all the above behaviours:
• Insecurity to the children.
• Types of insecurity:
• Physical insecurity: Parents not with their children, in the
bar taking alcohol.
 Parental model ct.
• Any thing can happen to the children at home
alone.
• Emotional insecurity:
• Filled with fear,
• Fear of their future.
• Lack of love.
• Full of tense.
 Faulty communication.
• Children uses concrete type of thinking.
• The child can not make meaning out of context.
• They take words the way they are produced.
• Yes/NO STATEMENT.
• The mother is going to the market and tell a five year
old child[drink your brothers milk while I am away].
• What does this statement mean?.
• To a child of 5years it means [drink the milk while I am
away].
• To an older child of 8years it means[do not drink your
brothers milk].
 Faulty communication ct.
• Double bind statements:
• Where your statement does not agree with your
facial expression.
• You tell the child I love you but the tone of your
voice says some thing different.
• Or your facial expression tell different.
• Faulty communication causes a lot of confusion
to the children and may later causes mental
problems.
 Psychopathology
• Psychopathology is clinical presentation of patient
suffering from mental illness.
• General appearance:
• Some appear very happy[Elation]
• If you ask them what they are feeling, they tell you that
they are happy.[Manic illness].
• Some appear very sad.
• They could even be tearing. If you ask them how they
are feeling, they say very bad.[Depressed patient].
• Some appears fearful. Present with a thing sweating
[Anxiety patient].
 Personal hygiene.
• Majority of mentally sick patients are unkempt.
• They do not take care of their personal hygiene.
• Come when they are dirty ,untidy.
• Some dresses very queerly.[Schizophrenia].
• A few appear when the are very smart.
• You may not even think they are the patient.
• A patient with Minor mental problem /Paranoid schizophrenia
present that way.
• Nutritional status:
• Some are well nourished.
• It shows that the relatives care for their patient.
• Or the disease is of sadden onset and the relatives wasted no
time to bring him to the hospital.
 Nutritional status.
• Some come when they are malnourished.
• This tell us that the disease is chronic or relatives do not
feed the patient well.
• Behaviour patterns:
• Overactivity:
• Psychomotor activities are increased.
• Patient always on the move, no rest, no time to feed, no
time to go to the toilet.
• If nothing is done the patient collapse with exhaustion.
[Manic psychosis]
 Psychomotor retardation.
• When the body activities are reduced.
• Patient like staying at one position for a long time.
• They have no energy to feed.[Depressed patient].
• Stupor:
• The worst level of psychomotor retardation.
• The patient become completely motionless.
• No feeding/ No eliminating/ completely helpless.
• Examples Schizophrenia/ Severe depression.
 Stereotypy.
• Repetition of some form of movement of either hands or
head.
• Or patient going round and round for a very long time.
• Negativistic behaviours:
• Patient refusing all the commands and request.
• Or the patient doing opposite of what is expected.
• Echopraxia:
• The patient repeating the action he has seen from patients
or staffs.
• They do it very blindly.
 Echolalia.
• A patient repeating words or statement he has
heard around.
• He will keep on parroting the words or statement
until he hears another word or statement.
• Ambivalence:
• Patient moving in one direction is suddenly
countered by moving in opposite direction.
• Or a patient wanting to put something in the
mouth suddenly with drawn.
 Compulsions.
• Patient feel compelled to carry out some certain
activities[Rituals].
• Patient himself knows that those rituals are illogical but he
cant’ have peace if he does no carry the out.
• Some rituals:
• Hand washing.
• Checking and rechecking of the door.
• Checking and rechecking water tap.
• Obsession:
• It is a recurrent fixed thought in a patient.
• The patient may recognize the obsession as illogical, but he
cant remove the obsession from his mind
 Obsession ct.
• Example: An adolescent boy with a female voice may
have an obsession that he is turning to be a woman.
• He can go from one doctor to the other asking that
question.
• Note:
• Obsession and Compulsion are associated.
• Patient may start with obsession[his hands are
dirty]then start washing his hands
endlessly[compulsion].
• Some time referred to as Obsessive-Compulsive
Psychosis.
 Folie du doute.
• It is the worst form of Obsessive- Compulsive
psychosis.
• Patient constantly start doubting whether he
has done some necessary activity
• Example locking the door before sleeping.
• Check several times ,no release until forced to
sleep on the door.
 Speech disorders.
• Pressure of speech:
• The patient speech is accelerated.
• Patient is forced to talk all the time.
• No time for feeding, No time for sleeping, No time for
going to the toilet.
• The patient does not even listen to anybody.[Manic
patient].
• Flight of ideas:
• The thought process of the patient is faster than the tongue
could handle.
• Hence the patient speech is dominated by several ideas
which are not connected[Manic psychosis]
 Retardation of speech.
• The slowing of the patient 'stream of thought
which reduces the patients’ speech.
• The patient is not able to construct a sentence.
• If asked a question he responds by saying yes
or no.[Depressed patient].
• Mutism:
• The patient does not talk at all.
 Aphonia.
• The patient does not produce sound as he talk.
• The patient talks with whispering.[Hysterical patient].
• Incoherence:
• The patient’s speech has no glimmer of sense.
• Neologism:
• The patients’ speech is dominated by new words which
are not in any vocabulary.
• No body apart from the patient who knows the meaning of
those words.
• A time even the patient does not know their meaning.
 Circumstantiality.
• The patients’ speech is dominated by a lot of unnecessary
details.
• The patient will ramble on and on and you will not make
sense of what he is saying[Epileptic].
• Thought disorders:
• Delusions:
• A false belief which is not in keeping with the patients’:
• Race/Religion/Educational back ground/Status/Cultural
beliefs and which can not altered by a logical arguments
reasoning.
• If you have never gone to school, and you belief you are
university graduate, that is delusion
 Systematised delusion.
• A patient has a delusion and act as per
delusion.
• At the same time demand to be treated as per
delusion.
• Unsystematised delusion:
• Patient has a delusion but act quite contrary to
delusion. Example patient belief he is the son
of a king yet he cleaning the toilet.
 Types of delusions.
• Persecutory delusion:
• Patient belief that people around him want to kill
him/Harm him/Destroy his business etc.
• The patient may start arming him to protect him self.
• Some times he can attack those he is suspecting.
• Ideas of reference:
• The patient belief that people are making bad
comments about him, or the press men are writing
bad stories about him.
 Delusion of guilt.
• Patient may belief he has committed a crime against God/State
Or people.
• He belief also that he cant’ be forgiven.
• If calamities happens he belief those people are punished by
God because of him sins.
• Delusion of grandeur:
• Patient belief he is very powerful/influential/
• Or he has special power to make rain.
• Nihilistic delusion:
• The patient belief that he is dead/some of his body parts are
not there e.g. stomach.
• Others belief they are suffering from un incurable disease like
 Disorders of perception.
• Perception:A process through which the sensory stimulation
is transmitted into awareness.
• Hallucinations:
• Sensory perception without external stimulus.
• Hallucinations affects all the sensory organs.
• Types of hallucinations:
• Auditory hallucinations.
• Affect the sense of hearing.
• The patient is able to hear voices which are not existing.
• The voices could be discussing the patient/or giving patient
command to carry out.
• Some times the patient obeys those command.
 Visual hallucinations.
• They affect the organ of sight [Eye].
• The patient is able to see objects which are not
existing.
• They see these objects very vividly hence you
cant ’convince them that they are not there.
• Some see flashes of light like a torch/People
killing each other/people dancing/or million of
small animals like rats.
 Gustatory hallucination.
• The patient is able to taste abnormal taste on food.
• Some taste urine on food/others poison on food/others can
taste faeces on food.
• The patient may belief he is being poisoned and may refuse
food. Or even becomes very aggressive to the people he
may suspect.
• Tactile hallucination:
• Affect the sense of feeling.
• Patient is able to feel millions of insect crowing on his skin.
• The patient may think the cloth he is wearing is having lice
or frees and he may remove the cloth to stay naked.
 Illusions.
• Illusion is miss interpretation of external stimulus.
• The patient may be seeing a snake instead of a belt.
• Some time you may enter into a patients room in a tie and
the patient start shouting that you have a big snake
around your neck.
• Perseveration:
• Persistence of a behaviour and thought after it have
ceased to be relevant.
• Example: You show a patient a pen, you even name it
correctly. You remove it and show him something else
like a stick , when you ask him what you are holding he
tell you it is a pen.
 Disorders of affects.
• Affects:
• It means emotional status of an individual.
• Depressed mood:
• Patient feeling very sad/tearing.
• Some feels very dejected.
• Some look very gloomy.
• Elation:
• Patient feels very happy.
• He also look happy on facial expression.
• Full of confidence/Optimistic.
 Inappropriate mood.
• Also referred to as Incongruous mood.
• The patients’ mood is not consistence with the
ideas held by the patient at that particular time.
• The patient could be giving you a story of how
she was raped, yet she is laughing.
• Apathy:
• Patient lack emotional respond from the facial
expression
 Labile affect
• The patients’ mood is dominated by quick changes of
happiness and sandiness.
• One minute he is very happy after another minute he is very
moody.
• Some time no cause for the mood change.
• Memory disturbances:
• Amnesia:
• Loss of memory which could be complete or partial.
• Remote memory:
• The patient is able to remember incidences which happened
very long time but he cant’ remember recent incidences.[old
age or senile dementia].
 Recent memory.
• The patient here remembers only the recent incidences but not
the remote incidences.
• Hypermnesia:
• Excessive retentions of memory.
• The incidences which happened almost 20years ago are
recalled with all the details as if it happened a few hours.
Manic patient.
• Confabulation:
• Patient fabricate stories to cover lost memory.
• The fabricated stories may not related with the main story. The
alcoholic patient have this problem.
 Deja vu.
• French word meaning….Already seen.
• Strange events/situations/or a stranger patient
meeting for the first time appearing very
familiar.
• Jamis vu:
• Opposite of the déjà vu.
• Familiar incidences/people/situation suddenly
appearing very unfamiliar . Epileptics patients
 Classification of mental illness.
• All mental illness are broadly classified into two classes:
1. Psychosis,
2. Neurosis.
Psychosis:
Major mental illness.
Also divided into two classes.
Functional psychosis.
The individual is mentally sick according to the behaviour and
thinking.
But no organic cause can be identified.
This type of problem associated with genetic factors.
 Functional psychosis ct.
• Examples of functional psychosis:
1. Schizophrenia.
2. Manic-depressive psychosis.
3. Psychotic depression.
• Organic Psychosis:
• The 2nd class of major mental illness.
• The type of mental illness which has a precipitating factor.
• Examples of organic psychosis:
• Alcoholism/Drug abusers/Epilepsy/Head injury.
• Mental retardation.
 Organic psychosis ct.
• Psychosis associated with child birth.
• Infection…..Meningitis/Encephalitis/Syphyllis
.
• NEUROSIS:
• The other class of mental illness.
• Also referred to as Minor mental illness.
• A group of mental illness which are
manifested by mental and physical suffering
without any organic cause.
 Examples of minor mental illness.

• Hysteria.
• Anxiety.
• Neurotic depression.
• Obsessive-Compulsive neurosis.
• Hypochondriasis.
• Phobia
Summary of the causes of mental illness.
• All the factors which causes mental illness are divided into two
classes.
1. Predisposing factors.
2. Precipitating factors.
• Predisposing factors:
• These are the factors which are latent in an individual and which
make one susceptible to mental illness.
• Examples:
• Hereditary factors.
• Childhood experiences e.g. over protection/sexual abused
child/Painful childhood experience.
• Severe dependence.
• Faulty communication
 Precipitating factors.
• These are the incidences which occurs before
the onset of the mental illness.
• The lay men call them the causes of mental
illness.
• Examples:
• Abuse of alcohol/Drugs/Epilepsy/Cerebral
malaria.
• Brain injury/Brain haemorrhage/Brain tumours.
• Loss of property/Status/Part of your body.
Difference between psychosis and neurosis.

• Severity:
• Psychosis is very severe form of mental illness.
• Neurosis is a minor mental illness
• Insight:
• A psychotic patient is not aware of his illness.
• Neurotic patient is aware of his illness, hence come to the
hospital for help.
• Personality:
• The total personality of an individual with psychotic illness is
completely destroyed.
• Neurotic illness only destroy a part of the personality.
 Differences ct.
• Contact with reality:
• A psychotic patient has no contact with reality because
they suffer from delusion sand hallucinations.
• Neurotic patient has contact with reality because they
dont’ suffer from delusions and hallucination.
• Nature of illness:
• Psychosis is a genetic determined disease.
• Neurotic patient is reacting to stressful situation at the
unconscious mind.
 Modern method of classification of mental
illness.
• Two methods of classification is used.
• International Classification of Disease [I.C.D].
• Diagnostic and Statistical Manual [D.S.M].
• DSM:
• Done by American Psychiatric Association.
• Only used in America.
• ICD:
• This method was developed by .W.h.O.
• Currently they are in 10th edition hence referred to as [ICD
IO].
 ICD 10 CT.
• FO…….Organic disorders.
• F1……..Mental and behaviour disorders due to
• psychoactive substance.
• F2………Schizophrenia.
• F3……….Mood[affective] disorders.
• F4………..Neurotic disorders.
• F5…………Behavioural syndrome associated with
physiological disturbances.
• F6………..Personality disorders [adult].
 ICD 10 ct.
• F7……..Mental retardation.
• F8………Disorders of psychological
development.
• F9……….Behavioural and emotional disorders
of childhood or adolescents.
 Mental health act.
• Mental health act:
• Act of parliament to amend and consolidate
the law relating to the care of person suffering
from mental disorder or mental abnormality,
for custody of the person[patient] and the
management of their resources and the
management of mental hospitals.
• It was 1st developed in Feb 1949,
• Then revised in 1962,1968.
• The current one was revised in 1989.
 Type of patients by this Act.
1. Voluntary patient.
2. Involuntary patient.
3. Emergency patient.
4. Armed force patient.
• Voluntary patient:
• A mentally sick patient who has an insight of his problem
and come for help.
• Or a parent has observed an abnormal behaviour and
brought his child for treatment.
Legal requirement for admission.
• If above 16years:
• A written application in duplicate on
prescribed form Medical[ med]613.
• This form is filled and signed by patient.
• Medical recommendation med615 filled by
doctor who is referring the patient in duplicate.
• The two forms must be brought to the hospital
before 14 days are over.
 Voluntary patient ct.
• If below 16years:
• The relative or guardian allowed by the law to fill the med
form 637 in duplicate.
• And the doctor fill med 615 in duplicate.
• The two forms brought to the hospital before 14 days are
over.
• Note:
• This patient should be discharged on his own request but
must give a written notice of about 72hrs.
• If the patient has not improved within 42 days, the law
requires that the mode of admission be changed to
Involuntary admission.
 Admission procedure ct.
• Involuntary patient:
• The mentally sick patient who have no insight of his/her
illness, hence brought to the hospital by his relatives.
• Legal requirement:
• The relative is allowed by the Law to fill med 614 in
duplicate.
• The referring doctor fill medical form 615.
• The patient taken to the hospital within a period of 14
days.
 Emergency patient.
• Any mentally ill patient who have no relative to care
for him . Such a patient is a danger to himself and
community.
• Or a suicidal mentally ill patient with nobody to take
care.
• Such a patient is admitted under emergency mode.
• Who should take him to hospital?.
• Any administrative officer is allowed to take the
initiative[Chief/Police officer/Headmaster/Principal
etc.
 Admission of emergency ct.
• The law requires that the officer take the
patient to the police station.
• The police must ensure the patient is taken to
the hospital within24hours.
• Requirement:
• The officer fill med 638 in duplicate.
• No medical requirement is needed.
 Admission of armed forces.
• Admitted through their medical officers.
• They should have observed him for 48hrs.
• On admission, they should only be treated for
only 28days.
• If he need more than28 days need to be
reviewed by two doctors, a psychiatrist and
general doctor.
• Discharge give a notice of 72hrs
 Offences under this act.
• Forgery of documents: Un authorised person filling and
signing the document.
• Giving false information about the patient.
• Assisting a mentally patient to escape from the hospital.
• Permitting the patient to escaping from the hospital
through wilful neglect or connivance.[ Being involved in
illegal or immoral behaviours]
• Ill- treatment of patient like: Abusing/Striking/
• Wilfully neglecting patients.
• Giving/Selling/Bartering of any commodity to patients
without permission.
 Offences ct.
• Publishing /or taking photograph of mentally
sick person.
• Note:
• If you are guilty of one of the above offences,
you can be jailed for a period not less than 12
months or fined not less than 10,000.00 or
both.
 Kenya Board of Mental Health.
• This board is allowed by the Mental Health Act.
• Members of the board:
• Director of medical services or his deputy.
• Psychiatrist appointed by Ministry of Health.
• Psychiatric Clinical Officer.
• Psychiatric Nursing Officer.
• Commissioner of Social Services.
• Director of education.
• A representative from each Province[County]
•
 Functions of the board.
• Co-ordinate mental health services in the country.
• Advice Government on matters related to mental
health.
• Inspection of mental health hospitals.
• Approve mental health hospitals.
• Assist the administration of the mental health hospitals.
• They receive and investigate any allegations from
patients, relatives and take an appropriate action.
• They initiate and organize Community health services
like Community psychiatry.
. History taking from psychiatric patient

• Welcome the patient.

• Introduce your self to the patient and relatives.
• Give them a place to sit.
• Collect all you need for admission before you
start, like Cardex/Observation charts/tools etc.
• Check the admission application forms to
ascertain their relevancy, the 614/615/etc.
• Don't’ forget expiry dates.
 History ct.
• Sitting arrangement:
• Round the table arrangement.
• Nurse sit where she can see the patient well.
• Face to face.
• A table separating him from the patient.
• Patient sit where he can be restricted in case of
emergency.
• Start history from getting allegations from the relatives.
• Confirm with the patient whether the allegations are
true.
 Personal History.
• All the names.
• Age
• Mile stones of the patient[parents].
• Where he was born in the hospital or at home.
• Did he cry immediately?
• Educational background.
• Compare his educational level with the parents.
• His place of work.
• Does he change jobs/Schools on and of ?[Psychopath].
 History ct.
• Leisure:
• How does he spent his free time.
• Does he smoke cigarettes and how often?
• Does he take alcohol/khart and how often?.
• Marital status
• Whether he/she is married.
• If married, how many children does he have?
• Sexes of the children,
• Are all the children his?
 Sexual life of the patient.
• If not married, does he/she have a girl/boy friend ?.
• How many of them?.
• How often does he/she have sex per day/week.
• Nymphomanic [woman]/Satyriasis:[man].
• Have sexual problem,
• They don’t get sexual satisfaction from one partner, have
several partners.
• If man could be unconsciously homosexual.
• If a woman she want to reduce men to nothing.
• These persons will have sex any where and with any body.
 Family history.
• Whether parents are alive.
• Are they working?
• Their level of education.
• Compare the patients 'level with the parent.
• Siblings…….List them from old to the youngest.
• Medical history.
• Any mental history in the family?
• Any suicide/any epileptic in the family?.
 History taking ct.
• After history taking:
• Release the relatives but before they go:
• Let them sign a consent of E.C.T.
• Let them know the visiting time, the doctors’
round, what they are supposed to bring their
patient.
• Give the relatives the patients’ valuables to take
them home. Examples money expensive
watches, shoes,etc.
 Mental status assessment.
• It is done to assess how severe the patient’s
condition is.
• Done on admission, on discharge, and any other
time a nurse is with the patient.
• Insight:
• A degree to which the patient is aware of his
illness.
• Ask whether he is aware of his illness.
• If he is aware of his illness, not very sick.
 Assessment ct.
• Orientation:
• Ask him whether he knows where he is.
• The day, month, dates, staffs, relatives etc.
• Comment: Well oriented for time etc.
• Memory:
• What you eat yesterday, when did you start the
journey to hospital?[Recent memory]
• When did you do form four exam?[remote memory.
When did you get married.
 Assessment ct.
• Concentration:
• Use serial 7 where he subtract 7 from 100 all
through.
• Or tell a story to the patient and tell him to repeat
and give meaning.
• Judgement:
• Ask him what he would do if a house is on fire and
there children crying inside?
• Or what can you buy with 100 .
 Thought process.
• Assesses both Abstract thinking and Concrete
thinking.
• Ask the patient to interprets proverb.
• If he does not interpret it logically, concrete
thinking.
• But if he does it logically, it is abstract thinking.
• Or tell him to tell you the difference between two
objects with the same similarities.
• Example, a child and a dwarf/ Or a fence and a wall.
 Assess Delusion.
• Who are you?
• How do you perform at your working place?
• Do you have some powers?.
• Hallucinations:
• Do you here some voices talking to you?.
• If you have a sweat give him, ask how it test.
• Illusions:
• Ask the patient what he can be able to see around?.
• General knowledge:
• Ask current affair questions.
• Any incidence prominently in the news.
• Observations:
• General observations and Vital observations.
 After observation:
• Provide him with uniform.
• If very dirty let him have a bath.
• Show him his bed.
• Introduce him to other patients.

•
END.
Principles of psychiatric nursing.
• Respect the patient:
• Respect him despite all him weakness.
• Respect him with no conditions attached Address him by him
name/Explain all the procedures/Listen to him.
• Offering self :
• Be available to patient.
• Sit and talk with the patient.
• Even when the patient is not responding be with him.
• Spontaneity:
• To be official/or being very firm or strict.
• Not very good for psychiatric patient.
 Principle ct.
• Be informal with them/discuss with them/be friendly with them/Dance with
them.
• Acceptance:
• We accept them just like any other patient.
• No harsh treatment/avoid being rude to them.
• No judgement/no punishment.
• Sensitivity:
• We must ensure that the ward environment is safe the patient: No broken brooms
around the ward/No broken chairs around/No naked electrical wires in site.
• Empathy:
• The process of putting our self into some ones’ condition.
• You feel with him but no emotional attach.
• Empathy leads to actions where you help him as much as possible.
 Principles ct.
• Observation:
• You must be a good observant.
• Observe facial expression which could suggest aggression.
• Observe drug reaction etc.
• After observation take an appropriate action.
• Keen listener:
• You must be a good listener to their problems.
• It help you to assess their progress.
• Listening make them talk more which releases them.
Treatments used in psychiatric patients.
• Several forms of treatments are used in the management of mental illness.
• All of them classified into two categories:
1. Physical treatment.
2. Psychological treatment.
Physical treatment:
Physical agents are used are used.
Example drugs and Electrical current[E.C.T.].
:Psychological treatment
Also referred to as Psychotherapy.
Treatment of mind without physical agent.

End of Lesson 1
 Lesson 2
Physical treatment.
• Use of drugs to treat mental illness.
• Classification of these drugs:
• Phenothiazine: Used to treat Psychotic
conditions.
• Anti-depressants: Used to treat psychotic
depression.
• Phenothiazine:
• Also called Tranquilizers/Or Psychotropic drugs.
 Phinothiazine ct.
• Phinothiazines is also divided into two classes.
• Major phinothiazine and Minor phinothiazine.
• Major phinothiazines:
• Patients who benefit:
• Schizophrenia.
• Manic psychosis.
• Drug abusers.
• Psychosis associated with child birth.
 Effects of this drugs.
• They calm the patients.
• They reduce or abolish mental symptoms like delusions
and hallucinations.
• They reduce anxiety and emotional tension.
• They reduce psychomotor activities.
• Examples:
• Chlorpromazine[Largactil]
• Dose:100-600mgs tds.
• Promazine[Sparine].
• Dose:50-150mg tds
• Fluphenazine[Modicate].
 Drug therapy ct.
• Medicate is a long acting phenothiazine.
• Only given as maintenance dose.
• Only given I.M.
• Dose:25-50mgs once per month.
• Thioridazine [Melleril].
• Dose:50-100mgs tds.
• Haloperidol[Serenace]
• Dose:o.5-5mgs tds.
• Very good for Manic patients.
 Anti-Parkinson drugs
• These drugs are prescribed together with phenothiazine to prevent
severe side effects.
• Effects:
• Reduce muscle rigidity.
• Reduce severe salivation.
• Improve ataxias.
• Examples:
• Benzhexol[artane].
• Dose:2-5mgs tds.
• Benztropine[cogentin].
• Dose:0.5-2mgs tds.
 Anti-Parkinson drugs ct.
• Procycline[Kemadrin]
• Dose:5-10mgs.
• Side effects of phenothiazine's:
1. Dizziness.
2. Fainting episodes.
3. Blurred vision.
4. Increased appetite.
5. Retention of fluids in the body.
6. Impotence for men.
7. Menstrual irregularities.
8. Skin rash.
9. Sensitivity for sun light.
 Minor phenothiazines.
• Also referred to as Anti-anxiety drugs.
• Or Benzodiazepines.
• These drugs are used for treatment of all those
patients with Minor mental illness.
• Indications:
• All neurotic patients.
• Patients with muscle spasms.
• Patients with tensional head aches
• Patient with severe back pains.
 Minor phenothiazine ct.
• Examples:
• Chlordiazepoxide[Librium].
• Dose:5-10mgs tds.
• Diazepam[Valium].
• Dose: 2-20mgs tds.
• Lorazepam[Ativan].
• Dose:2-3mgstds.
• Halazepam[Paxipam]
• Dose:20-40mgs tds.
 Anti-depressants.
• Used for the treatment of those patients
suffering from Psychotic Depression.
• Patients take about 3weeks after the drugs
have been started.
• These drugs are divided into classes:
1. Tricyclic anti-depressant.
2. Mono-Amine Oxidase Inhibitors[M.A.O.I.].
 Anti-depressants ct.
• Tricyclic anti-depressants:
• They are the 1st line of treatment.
• They are cheap and available.
• They have fewer side effects.
• Indications:
1. Psychotic depression.
2. Prophylaxis for conditions like Migraine[Amitriptyline].
3. Chronic muscle pains[Imipramine].
4. Enuresis[Imipramine].
5. Given to those patient with severe insomnia.
6. Very good for those with panic disorders.
 Tricyclic anti-depressant ct.
• Examples of tricyclic anti-de presents:
• Amitriptyline [Carboxyl/ Trytizol].
• Very good anti-depressant.
• Dose:100-300mgs tds.
• Imipramine[Tofranil].
• Dose:100-150mgs tds.
• Anafranil[Clomipramine]
• Dose:100-200mgs.
• Mechanism of action:
• They raise the level of neurotransmitters in the brain expecially
Epinephrine and Serotonin.
Mono Amine Oxidase Inhibitors.
• The 2nd class of anti depressant.
• Only used when the 1st line fails.
• Examples:
• Phenelzine[Nardil].
• Dose:15-90mgs tds.
• Always start with a smaller dose.
• Tranylcypromine[Parnate].
• Dose:10-20mgs tds.
• Marplan[Isocarboxazid].
• Dose:10-30mgs tds.

• :
 Mono amine ct.
• Mono amine react with Tyramine[amino acid].
• Causing severe hypertensive crisis.
• The patient present with:
1. Severe headache.
2. Severe palpitation.
3. Intracranial haemorrhage.
• That is why this class of anti-depressants is avoided.
• If patient is on this drugs should avoid all food with
tyramine eg cheese/bear/chicken/yeast.
 Side effects of anti-depressants.
• Three categories of side effects:
1. Anticholinergic side effects.
2. Cardiovascular side effects.
3. Others.
Anti-cholinergic side effects:
These drugs interfere with the functions of cholinergic nerve
fibres.
This nerve fibres are part of autonomic nervous system.
When these nerve fibres are stimulated ………production of
Neurotransmitters called Acetylcholine.
 Anti-cholinergic side effect ct.
• These anti-cholinergic side effects include:
1. Dry mouth.
2. Urinary retention.
3. Constipation.
4. Sweating.
5. Blurred vision.
• Cardiovascular side effects include:
• Tachy cardia/Arrhythamia/Palpitation.
• Orthostatic hypotension[Hypotension related to position
 Side effects ct.
• Others include:
• Skin rash/Insomnia/Tremours/Weight gain or loss.
• Advice of the patient with orthostatic hypotension:
• Not to stand quickly.
• Do some exercises before leaving the bed.
• Not to have hot bath.
• To dangle the feet before ambulance.
• Check his blood pressure when patient is standing
and while lying in bed.
 Electro-Convulsive Therapy[ E.C.T.].
• Another physical treatment.
• Where the electric current is used to produce an artificial
convulsion[Fit]
• The same like Epileptic convulsion.
• The treatment was discovered in 1938.
• Was discovered by two doctors who were working in an Epileptic ward.
• They had observed that Epileptic usually become
aggressive/nervous/irritated before getting an attack.
• They also observed that, once they get attack they get settled and
relaxed.
• From there they started working on how they can introduce an artificial
attach on mental patients .
• Expeciary the aggressive patient.
 E.C.T. CT.
• The treatment utilises the ordinary electric current passed to a
special machine.
• The special machine is connected to the patient around the
Temporal lobes both sides.
• Then the machine is pressed and only releases enough current
to produce a convulsion.
• Types:
• Straight ECT.
• Treatment is given when the patient is conscious.
• Need a lot of staff to restrain him.
• Most of these patient end up with fractures and dislocations.
• Not recommended these days.
 ECT CT.
• Modified ECT.
• Treatment is done when the patient is under general anaesthesia.
• Requires few staffs to restrain the patient.
• Also few patient end up with fractures and dislocation.
• The most recommended.
• Procedure:
• Done by the doctors.
• Patient put on the couch lies on the dorsal position.
• Machine is connected to the patient.
• Then the doctor presses a button and the machine.
 ECT CT.
• When the machine is put on, it release only 70-130 volt which
produces a convulsion.
• The success of the treatment is production of a convulsion.
• Preparation of the patient before ECT.
• Explain the procedure to the patient.
• Ensure the consent is given.
• The patient need to reviewed by the doctor before the procedure.
• Starve the patient 6 hrs before the treatment.
• Morning of treatment, patient have bath.
• Observation of T/P/R/Blood pressure.
• Premedication: Atropine 0.6 mg I.M.
 Preparation for ECT.
• Remove the dentures if any.
• Escort the patient to the treatment room.
• Care during the treatment:
• Let the patient lie on the treatment couch on dorsal position.
• No pillow.
• Apply the mouth gag to prevent patient from biting his
tongue.
• Support the major joints of shoulders/hips/knees.
• Support those joint with draw sheet or blanket to equally
distribute force of the support.
 Care ct.
• Also observe the patient to ensure the treatment is successful.
• Care after treatment:
• After the treatment, the patient is taken to recovery ward.
• If the patient is unconscious, put him on recovery position.
• Take the vital signs of T/P/R/BP.
• Do the physical observation Head-toe to rule out fractures
and dislocations.
• Check the mouth to rule out trauma on the tongue.
• Ensure you patient does not inhale secretions.
• When your patient become fully conscious return him to the
ward.
• Serve him with break fast.
 ECT CT.
• Indications:
• Depressive patient.
• Schizophrenia.
• Manic-depressive psychosis.
• Psychosis associated with child birth.
• Contra-indications:
• U.R.T. Infection.
• Heart conditions.
• Epileptic patient.
 ECT CT.
• Complications:
• Injuries to the tongue.
• Fractures.
• Dislocation.
• Confusion.
• Amnesia temporary.
• Severe head aches.
 Psychotherapy.
• The treatment of mind without use of drugs or ECT.
• The aim of Psychotherapy is to uncover the
information which is repressed at the unconscious
mind.
• This information is thought to cause a lot of
anxiety………Minor mental illness.
• Levels of mind:
• Our mind operates at three levels.
• Conscious level:
 Levels of mind
• The 1st level of mind.
• The part of mind that make you aware of the
environment.
• Helps you to make decisions: It is hot remove your
coat. I am in the classroom so no noise.
• Help you to solve daily problems.
• The part of mind that leads you to attention.
• It is the part of mind which is continuously
stimulated by environment.
 Levels of mind ct.
• Semi-conscious mind:
• Also called sub-conscious mind.
• It act like a store.
• We keep all the information we shall use in future here.
• Any important information that can be used in future.
• Information kept here can be retrieved easily.
• All you need is to try and remember and the information
comes to the conscious.
• All the notes you are writing is kept here because you will
use it in examination.
 Levels of mind ct.
• Unconscious mind:
• All the information which was once in the conscious is pushed here and
forgotten.
• All painful information and painful experience during the childhood is
pushed here and forgotten.
• All painful emotional thought are kept here.
• According to Sigmud Freud:
• These information keep on influencing the individual behaviours.
• Although the individual is not able to explain his behaviours.
• Example, if a small girl at 2/3years was raped by the father,
• She will push this painful experience at the unconscious mind and forget it.
• But at her adult age she may develop great hatred toward her father or all
men but she cant’ know the cause.
 Unconscious level of mind ct.
• According to Freud, there is a barrier that prevent information
from escaping from the unconscious mind to the conscious mind.
• But there are factors that weakens this barrier making this
information to reach conscious causing severe anxiety.
• These factors include:
• Sleep/Anxiety/Alcohol/Psychotropic drugs like khart.
• Evidence of this theory:
1. Slip of the tongue.
2. Forgetting of what is causing anxiety.
3. Dreams.
4. Neurotic mental illness.
The main objective of psychotherapy.
• To weaken the barriers so that the information
held in the unconscious mind is retrieved into the
conscious mind.
• Once this information is in the conscious, the
patient will talk about it freely.
• Effects of this behaviour:
• After the patient has talked, he becomes relieved,
that reduces or eradicates the anxiety all together.
• The information the patient has released can be
used to counsel him/her.
 Methods used in psychotherapy.
• Hypnosis:
• Done when the patient is either comfortably seated or lying
on a couch.
• The treatment is done by a trained person.
• The patient is driven into a complete relaxation both
mentally and physically.
• The patient is driven into a state of halfway awake and a
sleep.
• At this level the patient’ breathing will be reduced.
• When he is at this state, he is interviewed in all aspect of
life.
• No drugs are used.
 Methods ct.
• Abreaction:
• The same concept of weakening the barrier to release the
information.
• But in abreaction the drugs are to weaken the barrier.
• The drugs which are used:
1. Thiopentone.
2. Methedrine.
• These drugs are given i.v. very slowly.
• As it is given, the patient is asked to count 100 backwards.
Example 100,99,98,97,96,etc.
• When the patient start coughing or repeating him self, the
interviewed.
 Methods ct.
• Ventilation therapy:
• Here the patient is allowed to talk all she has without
interruption.
• The therapist talk very little to encourage the patient to
continue talking.
• He should also guide the patient the aspect he want the
patient to talk.
• Example:
• Tell me about your childhood, your parents ,your
schooling your sexual life ,etc.
• The therapist must be concerned, maintains eye to eye.
• He should not show some sign of hurriness or boredom
 Group therapy.
• Also referred to as Psychotherapeutic activity.
• This where the patients are put into a group and allowed to
discuss any problem which affect them all.
• If possible the patients having the same diagnosis eg
Alcoholics/Drug abusers/Schizophrenia.
• The problems they can discuss could be:
• Importance of taking drugs.
• Side effects of drugs.
• Problems of taking alcohol or smoking.
• The group should have 5-6 patients.
• The patients on the group are those who are recovering.
• The activity should take place after the ward routines are done.
 Group therapy ct.
• Role of a nurse:
• Prepare the venue.
• Introduce the topic of discussion.
• Control the group.
• Ensure every patient contributes to the topic.
• Control the domineering patients
• Controls the tempers if it arises.
• Return the group to the main topic of discussion.
 Group therapy ct.
• Benefits of group therapy:
1. It helps the patients to gain insight.
2. It improve their communication skills.
3. It make the patient feels a member of the community.
4. It allows the emotional discharge.
5. The patient benefit from one another as they realize
that others have the same problem.
6. The nurse will get an opportunity to observe the
patient and assess those who are recovering.
 Behaviour therapy.
• Behaviour therapy is a treatment procedure which is
aimed at modifying a deviant behaviour.
• The patient is trained to achieve a socially accepted
behaviour.
• Some unacceptable behaviours:
1. Alcoholism.
2. Sexual problems like homosexuality.
3. Phobias.
4. Drug dependence.
 Behaviour therapy ct.

• Forms of behaviour therapy:

• Desensitization:
• Also called Reciprocal inhibition.
• The patient is repeatedly exposed to the stimulus
which causes anxiety.
• The treatment is done in a calm and relaxed
environment.
• If a patient has phobia for snake:
• Name snake/write /draw/plastic snake/life snake.
 Behaviour therapy ct.
• Flooding methods:
• The patient is exposed to those stimulus which cause
anxiety at once.
• Example if patient has phobia for snakes is suddenly
put into a room full of snakes.
• The patient will scream, shout, jump here and there
until he will be tired.
• When he lies with exhaustion, cover her with the
snakes.
• The treatment is severally repeated until he no longer
fear the snakes
 Aversion therapy.
• This where unacceptable behaviour is abolished through
associating the behaviour with unpleasant stimulus.
• Patient who can benefit from this treatment:
1. An alcoholic patients.
2. A homosexual patient.
3. A drug dependency patient.
Procedure:
If you are treating an alcoholic:
You give the alcohol of the patient’s choice, together with an
emetic drug.
The drug will react with alcohol causing severe vomiting.
If the behaviour is repeated several time, the patient will associate
vomiting with alcohol and not the drug.
 Occupational therapy.
• Also referred to as Diversional therapy.

• Patient can be occupied with any activity of importance like:

1. Cleaning the ward.
2. Making beds.
3. Cleaning the ward compound.
4. Helping in medication.
5. Involve them with any ward routine.
• Benefits of occupation of patients:
1. It reduces delusions and hallucinations.
2. It prevent boredness which make the patient keep on thinking about his
illness.
3. Their energy can be used in constructive manner.
 Re-creational activities.
• Reading news papers.
• In-doors games.
• Foot balls/Net balls.
• Making baskets.
• Dancing/Listening to radios/tvs.
• Effects:
• Patients feel accepted as human being.
• Reduces boredom.
• Improve communication skills.
• Reduce hallucinations and delusions.
• The nurse will get opportunity to assess their recovery.
 Lesson 3
Schizophrenia.
• The most commonest mental problem.
• Affect about 30% of all the patients admitted in the mental hospitals.
• Avery complex mental illness.
• It occurs early in life.
• It tend to take a chronic line.
• Definition:
• Schizo…….means Mind.
• Phrenia……Split.
• The whole ward means Split mind.
• The main problem of the patient is Thought Disorders.
• Schizophrenia is not a single disease but several diseases combined to
form one.
 Schizophrenia ct.
• All these diseases called Schizophrenia have the
following symptoms:
1. Total distegration of personality.
2. Disturbances of thinking.
3. Distortion of perception.
4. Severe bizarre delusion.
5. Abnormal affect.
6. Severe withdrawal.
Causes of schizophrenia:
Causes are not known.
But there are factors which contributes to the disease.
 Schizophrenia ct.
• Factors:
• Genetic factors.
• Poor parental relationship:
• The mother of schizophrenia. Cold mother: No love to the child.
• Rejecting mother who did not provide emotional and physical
support.
• Overprotective mother. The child not given opportunity to explore
the world.
• The father of schizophrenia:
• Oppressed by his wife.
• Did not take active role in upbringing of his son.
• A passive father.
• Because of oppression he could be alcoholic or drug abuser.
 Schizophrenia ct.
• Communication in family setting:
• Faulty communication which causes confusion eg double bind
statements.
• Family patterns of the patient:
• The child comes from a problem family.
• Marital skew.
• A situation where by one of the partner is very domineering.
• Does not give other members opportunity to express themselves.
• Marital schism:
• A situation where by there emotional separation although the two
people are physically together.
• Physical factors.
• Examples like alcohol, drugs, head injuries etc.
 Pre-morbid personality
• Baby being different from others.
• Inactive baby/passive baby/inattentive to smile, talking etc.
• A child not interested with human being.
• But more interested with toes.
• A child who is unable to interact with its mother.
• School age:
• Not attentive child,
• Poorly demotivated to learn.
• Does not participative in the class.
• Lack social interaction.
• Withdrawn person.
• Some times extreme religious individual.
 Adult life.
• Withdrawn person.
• Low self esteem.
• Very little interest with the world.
• Very poor performer.
• Not very initiative.
• Epidemiology:
• Men and women affected equally.
• Start late in women hence better prognosis.
• More common among the singles/divorces/seperated probably due to the
stress.
• The disease more common among the poor.
• More observed in the urban area than in the rural setting.
 Clinical presentation.
• The main symptom of this disease is thought process.
• The clinical presentation is in two categories.
• According to psychiatrist called Schneider 1959.
• 1st rank symptoms:
• Thought broadcasting:
• Patient is able to hear his thought around.
• Whatever the patient is thinking, he/she hear it around.
• Auditory hallucinations:
• The patient is able to hear very clear voices,
• Voices discussing his weak areas,
• Voices giving him commands to carry them,
• Some voices he could be able to recognise but the person could be very
far.
 Symptoms cts.
• Running commentary:
• The patient hearing voices which are commenting on what the
patient is just about to do.
• Giving a feeling that he is being followed.
• Thought withdrawal:
• The patient feels that his thought is removed hence he cant’ think.
• Thought insertion:
• Patient believing that some one has inserted in thought into his.
• Bizarre delusion:
• Very abnormal delusion: The patient can meet some one in red
trouser and believe the end of the world has come.
• Somatic passivity:
• Patient experiencing abnormal psychomotor activities.
 2 rank symptoms.
nd

• Flattened mood.
• Severe withdrawal from the community.
• Sever lack of interest in nearly everything.
• Inappropriate mood.
• Aloofness, not concerned with people around.
• Neologism.
• Note:
• The 2nd rank symptoms are too general and there fore
not diagnostic.
 Types of schizophrenia.
• Simple schizophrenia:
• The disease start at puberty 12-13years.
• Very gradual onset.
• The patient withdrawn from community,
• He drop out from school, start staying at home.
• At home he with draw from the sitting room to his bed room.
• With time he lack interest with nearly everything.
• If you observe him through the key hole in his bed room he seem
to be day dreaming.
• Start neglecting personal hygiene.
• Star some petty crimes like stealing hens or prostitution.
• No delusions and hallucinations.
 Simple schizophrenia cts.
• The person can stay with this disease for a long time without being
noticed.
• The patient may be labelled a difficult child.
• Prognosis is very poor.
• Hebephrenic schizophrenia:
• The disease start from 15-25years.
• Continuation of simple schizophrenia.
• The patient now is very sick.
• Very confused,
• Severe thought disorders.
• Develop concrete thinking.
• Full of silly giggling.
• Develop primitive behaviour like eating faeces/smearing him self with
faeces.
 Hebephrenic ct.
• The patient now suffers from hallucination and delusions.
• Full of mannerism.
• His personality is completely destroyed.
• The prognosis here is very poor.
• Catatonic schizophrenia.
• The disease is of sudden onset.
• It affect the body much more than the mind.
• It comes into two forms:
1. Catatonic stupor,
2. Catatonic excitement.
 Catatonic stupor
• The psychomotor activities are severely reduced.
• Movement/thinking/speech are all affected.
• Patient stays at one position for a long time.
• At the corner of a ward.
• They assume the position of foetus at breech position.
• They are very negative and Echolalia.
• Muscle tone:
• May be quit rigid and hard like board.
• Other time the muscles could be like wax.
• The limbs can be folded in any manner called Flexibilities or
Waxy flexibility.
 Catatonic stupor ct.
• When the condition is severe, the patient
becomes completely motionless.
• No feeding, no opening the bowels, no
emptying the blander.
• The patient becomes completely helpless.
• Note:
• The patient usually records everything which
happening in the around.
 Catatonic excitement.
• The patient suddenly shift from stupor to excitement.
• Psychomotor activities suddenly increased.
• He becomes very mobile and destructive.
• He cant be controlled. Full of pressure of activities.
• Purposeless activities.
• Full of hallucinations/incoherent speech.
• No time to feed/sleep/going to the toilet/resting etc.
• If not controlled can collapse with exhaustion.
• This patient can be very dangerous especially if you made
a negative comment about him.
 Paranoid schizophrenia.
• Some called intellectual psychosis.
• The patient uses projection defence mechanism.
• The disease start from 35years when the personality is
already developed.
• The patient could be a professional working some where.
• The main symptom which is displayed by the patient is
delusion of persecution and grandeur.
• The patient does not have any thought disorder.
• He start thinking that a p
 Types of clinical presentation
• Positive symptoms.
1. Hallucination: sensing things while awake that appear to
be real, but instead have been created by the mind.
Types of hallucination
(a) Auditory hallucinations : Hearing voices when no one has
spoken (the most common type of hallucination).These
voices may be command someone to do something that
may cause harm to themselves or to others.
Hearing sounds, such as music ,footsteps, windows or doors
banging.
Continuation of positive symptoms
• Visual hallucination : seeing patterns lights or objects
that are not there .
• Olfactory hallucinations smelling's a foul or pleasant
odor odor are smelled that appear to be coming from
specific or unknown place.
• Tactile hallucinations feeling bodily sensations such
as a crawling feelings on the skin or the movement of
internal organs.
 Continuation of positive symptoms
• Delusions beliefs very common especially
persecutory delusion ideas of reference are in which
unrelated notices signs or remarks are believed to
be messages with specific meaning for the patient
• Thought insertion thought broadcast and thought
withdrawal .patient believes that other people know
why they are thinking either because they can be
heard or they are transmitted through TV or Radio.
 Continuation of positive symptoms
• Formal though disorder individuals have difficulty in
expressing their thoughts have loosening of
associations word salad or neologism
• Excitement or agitation
• Hostility or aggressive behavior
• Suicidal tendencies
• Suspiciousness or ideas of reference.
 Negative symptoms

• A logia refers to difficulty with speaking in some

schizophrenic patients a logia manifest as reduced
total speech output and reduced verbal fluency (the
ease with which words are chosen) patients
displaying a logia struggle to give brief.
• Answers to questions
• Associability impairment in social relationship which
include little interest in being with other people poor
social skills and few friends.
Continuation of negative symptoms
• A volition/apathy inability or lack of energy to
engage in routine e.g. poor grooming and personal
hygiene.
• Anhedonia inability to feel pleasure. Lack of interest
in or enjoyment in activities or relationships.
• Affective blunting decreased facial expression.
Types of schizophrenia
Disorganized schizophrenia
• This is a disorder characterized by in coherence
foolishness and regressive behavior
• Paranoid schizophrenia
• This is a disorder characterized by dilutions of
persecution or grandeur
Undifferentiated schizophrenia
• This disorder characterized by a variety of symptoms
found in several of the types of schizophrenia also called
simple schizophrenia
 Continuation of schizophrenia
Hebephrenic schizophrenia characterized by:
• silly and childish behavior
• Prominent effective
• Symptoms delusions
• Commons
• Residual schizophrenia absence of prominent
delusions hallucinations disogernised behavior with
presence of odd beliefs or negative symptoms.
 Continuation of schizophrenia
• Catatonic schizophrenia characterized by marked
disturbance of motor behavior may take the form of
catatonic stupor catatonic excitement or alternating
between stupor and excitement
• Catatonic excitement presents with increased
psychomotor activity i.e. restlessness agitation and
excitement increase in speech production loosening
of association.
 Continuation of schizophrenia
• Catatonic stupor presents with mutism lack of
speech rigidity maintenance of posture against
efforts to be moved waxy flexibility parts of
the body can be placed in positions that will be
maintained for long period of time stupor doer
not react to surrounding and appears to be
unaware of them.
Schnederian first rank
symptoms of schizophrenia
• Auditory hallucinations
• Delusions of control
• Thought broadcasting
• Though withdrawal
• Though insertion
• Somatic passivity : bodily sensations are experienced
as imposed on the body by external force.
• Made volition or acts one : own acts are experienced
as being under control of external force.
Bleuler’s Four A’s of Schizophrenia
• Eugene bleuler cited other symptoms called bleulers
four A’s symptoms which includes
• Autistic thinking: thought process in which individual
is unable to relate with others or environment
• Ambivalence : contradictory or opposing emotion.
Desires for Same person that feels bad about him/her.
• Associative looseness : inability to think logically
• Affective disturbance : inability to show appropriate
emotional response.
Etiology
• Biochemical imbalances : over activity of
dopamine within mesolimbic cortex.
• Environmental factors e.g. trauma during
childhood
• Genetic causes : high prevalence rates in
relatives of schizophrenic
 Differential diagnosis
• Mania ; characterized by prominent affective features
like grandiosity over activity and lability of mood.
Continuation of entomology.
• Depression ; chronic schizophrenia may mimic or
coexist with depression.
• Drug induced psychosis present with hallucinations
and delusions
• Dementia presents with impairment in thinking
schizoid personality disorder presents with delusions.
Medical management

• Acute phase : older or typical antipsychotics e.g.

largactil or haloperidol have most effect on positive
symptoms of schizophrenia
• Chlorpromazine is more sedating patients may benefit
from augmentation of antipsychotics with
benzodiazepines e.g. diazepam and lorazepam.
Continuation of medical management
• Commonly used convectional antipsychotics drugs are;
chlorpromazine 300-1500mg/day PO ,50-100 mg /day IM
• Fluphenazine deaconates 25-50 mg every month
• Haloperidol 5-100mg/day PO 5-20mg/day IM
• Commonly used atypical antipsychotics are:
• Clozapine 25-450mg/day PO
• Olanzapine 10-20mg/day PO
• Quetiapine 150-750 mg/day PO
• Ziprasidone 20-80mg/day PO
• Clozapine may cause agranulocytosis-potentially fatal blood disorder
marked by low white blood cell count and neutrophil depletion.
Continuation of medical management
• Chronic phase : depot antipsychotic injections e.g.
moderate (fluphenazine) may be used in patients with
poor compliance use of newer antipsychotics e.g.
clozapine ,olanzapine risperidone.
• ECT : Is indicated for catatonic schizophrenia and
severe depressive symptoms accompanying
schizophrenia.
Continuation of medical management
• Psychotherapy : counselling and advise to the patient
• Behavior therapy: patient is taught appropriate
behavior by direct instruction.
• Rehabilitation services to provide opportunities to
increase skills in living such as vocational
rehabilitation.
• Out patient treatment to provide aftercare
maintenance therapy, social support programs and
medical clinics.
 Management of the patient
• Medication
Antidepressants
Good pestle disease but takes too long to produce the effect 3-4
Tend to increase the brain.
• Two types
1.Tricyclic types
2.The first line of treatment produces less drastic sole effects.
• Examples
i. Topsail (tripremine) 50-100 per day
ii. Laroxyl (amitriptyline) 50-100 per day
iii. Ecavil (tryptizol) 30-60 per day
Continuation of management of the patient

•Monoamine oxidase inhibitors(M.A)

•The second line of the management
•Also takes long like the above
•Usually produces severe side effects
•Only preferred if a patient does not respond to the first group
•NB act by inhibitory monoamine oxidase which destroys
monoamine in the brain.
•Examples
•Nadal (phenalgine) 15-75mgs
•Parnale (tranylcypromine)10-30 mgs
•Nimadi (50-100mgs)
 General side effects
• Dry mental
• Dizziness (sudden waking from the bed)
• Blood pressure
• Constipation
• Sedative effects
 E.T.C
• The best form of treatment for the patient
• Get quickly especially the patient put on
antidepressert
• 6 chases given
• Most of the patient improve fast.
 Psychotherapy

• Good especially after the patient has improved.

• But the best treatment for the exoergic types of
depression.
Continuation of psychotherapy
• Continuation of phenothiazine + antidepressert if
there is delusions
• Severe depression.