Admission and discharge of a client in psychiatric unit

In 1987 Indian mental health act its chapter fourth and fifth deals with new procedure of admission and
discharge. The admission can be made by following way:-

 Admission on voluntary basis.

 Admission under special circumstance.
 Admission on reception order with petition/application.
 Admission on reception order without petition.
 Admission after judicial inquisition.
 Admission as mentally ill prisoner.

Procedure for admission in to a mental hospital:-

A. Admission on voluntary basis:-

If a client is major and desire to have admission into to

psychiatric hospital based on his suffering. He will approach medical superintendent in written
application form. The medical superintendent gives admission orders with consent of at least two
members of board of visitors.

In case of minor the guardian or parents has to apply request for admission, medical officer with in 24
hrs of receipt of such application will decide for further treatment based on the behavior of a patient.
The voluntary patient is now bound to the follow the policy of the hospital.

B. Admission under special circumstance:-

If mentally ill patient is not willing to get admission.

Relative can make a written application to the medical superintendent. After proper examination the
medical superintendent admit the client.

Here, two medical certificates should be with admission form. The certificate should clearly state that
the patient is mentally ill.

The medical certificate should be from two medical officers, one of them should be government servant
(gazette officer).

C. Admission under reception order with petition:-

The relative can apply to the

magistrate in written supported by two medical certificates for a admission of a mentally ill patient.
The petitioner must be a major and must have personally seen the patient within 14 days of making
petition.

Medical certificates should be two members one should be at least from gazette medical officers, other
certificates from any registered medical petitioner.

The magistrate will make a decision either with or without making an enquiry of personally examine the
patient. If he is satisfied he will a issue order, after getting consent from petitioner for cost of
maintenance of patient in mental hospital.

D. Admission on reception order without petition:-

Any police officer can arrest/detained any

person (who is wondering or mentally ill or neglected and cruelly treated by his family member) for 24
hours and then produce them before the magistrate.

After the examination, if he is satisfied magistrate issue an order.

If magistrate is doubtful, we send mentally ill person for medical examination.

Magistrate issue three reception order for 10 days:-

 The magistrate orders the relatives to sign a bond to pay the expenses of treatment.
 Renewal of reception order is necessary after 30 days.
 No magistrate can make reception order outside his jurisdiction area.

E. Admission after judicial inquisition:-

If a crime is found insane during judicial inquiry. The

high court or district court has authority to issue a reception order for admission into mental hospital
but the court should review his case from time to time.

F. Admission as mentally ill prisoner:-

Magistrate may give reception orders to keep prisoner

under observation for 10 days medical examination is made.

After examination report magistrate give reception order to intuition for 30 days.

The criminal lunatic can be three types:-

 Who cannot stand trial because of insanity?

 Who committed crime due to insanity?
 Who become insane during prison?
 SOMATFORM DISORDER

Somatoform disorder is a mental disorder characterized by symptoms that suggest physical illness or
injury symptoms cannot be explained fully by a general medical condition or by the direct effect of a
substance.

The diagnostic and statistical manual of mental disorder describes many disorder under the category of
somatoform disorders. These disorder are -

 Somatisation disorder
 Conversion disorder
 Pain disorder
 Hypochondriasis
 Body dysmorphic disorder
 Somatisation disorder –
Somatisation disorder is characterized by a history of multiple
unexplained medical problem or physical complaints beginning prior to age 30. For ex.
Headache, feeling sick, abdominal pain, sexual problems.
 Conversion disorder -
A somatic symptom disorder involving the actual loss of bodily functions
such as blindness, paralysis and numbness due to excessive anxiety
 Pain disorder –
Panic disorder is a condition where a person has a persistent pain that cannot be
attributed to a physical disorder.
 Hypochondriasis –
Hyponchondriasis is a condition in which a person fear about a having one or
more serious disease.
 Body dysmorphic disorder –
Body dysmorphic disorder is a condition where a person spends a
lot of time worried or concerned about their appearance.

Causes -
 Genetic and environmental influences.
 Children raised in homes with a high degree of parental somatisation.
 Sexual abuse.
 Poor ability to express emotions.
 Alcohol or drug abuse.
 Drug intoxication or withdrawal.

Sign and symptoms -

  Abdominal pain
 Difficulty in swallowing
 Joint pain
 Nausea
 Vomiting
 Back pain
 Dizziness
 Chest pain
 Shortness of breath
 Painful menstruation
 Amnesia
 Paralysis or muscle weakness

Management –
 Antidepressant drugs may help to relief to depression and anxiety.
 Cognitive behavioural therapy
 PERSONALITY DISORDERS

The personality disorder results when personality traits become abnormal, maladaptive significant,
social and occupational impairment.

Definition: -

A/C to American psychiatric association (APA):- An enduring pattern of inner experience and behavior
that deviates markedly from the expectation of the culture of the individual who exhibit it.

A/C to DSM IV:-

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

Classification:-

I. The diagnostic and statistical manual of mental disorders classifies personality disorders into
three major clusters:-
A. Cluster –A(ODD or eccentric disorders)
 Paranoid personality disorder.
 Schizoid personality disorder.
 Schizotypal personality disorder.
B. Cluster –B(dramatic, emotional, erratic disorders)
 Antisocial personality disorder.
 Histrionic personality disorder.

 Narcissistic personality disorder.
 Borderline personality disorder.
C. Cluster –C (anxious and fearful disorder)
 Avoidant personality disorder.
 Dependent personality disorder.
 Obsessive compulsive personality disorder.
 Passive aggressive personality disorder.

II. Classification a/c to ICD-10:- Disorders of adult personality and behavior

 Paranoid personality disorder.
 Schizoid personality disorder.
  Dissocial / Antisocial /Psychopath /Sociopath personality disorder.
 Histrionic personality disorder.
 Borderline personality disorder.
 Narcissistic personality disorder.
 Obsessive compulsive personality disorder.
 Dependent personality disorder.
 Avoidant /Anxious personality disorder.

Causes:-

a) Genetic or heredity factors:-

 The concordance rate for personality disorders is several times higher for monozygotic versus
dizygotic twins.
b) Biological factors:-
 Brain dysfunction.
 Alteration in levels of neurotransmitters (decreased level of serotonin and dopamine and
increased level of nor epinephrine).
 Post traumatic stress.
c) Developmental factors:-
 Loss of a loved one.
 Child abuse – physical, emotional, and sexual abuse.
 Child neglect.
 Children with alcoholic and drug abuse parents.
 Parental and peer group rejection.
 Excessive parental control and criticism.
d) Socio cultural factors:-
 Involuntary isolation, divorce.
 Broken families.
 Hospitalization.
 Prolonged separation and deprivation.
 Frustration and conflicts.
 Exposure to loss and death.

1. Paranoid personality disorder:-

A pervasive distrust and suspiciousness of others is present
without justification, beginning by early adulthood and is manifested by the following:-
 Suspiciousness carries over in all realms of life.
 Lack justification in sexual fidelity of spouse.
  Gives more importance to self.
 Sometimes they like to be aloof or isolated.
 Mistrustful.
 Sensitive.
 Argumentative.
 Irritable.
 Aggressiveness.
 Stub-born.
 Hostile

Treatment of paranoid personality disorder:-

 Medication:-
 If the client is anxious, anti – anxiety drugs may be prescribed.
 Selective serotonin reuptake inhibitors (Prozac) for the clients with angry, irritable, and
suspicious.
 Antipsychotic drugs.
 Antidepressants drugs.

 Group therapy:-Include family members; encourage them to meet the “self help groups”
dedicated to recover from his disorders.

 Psychotherapy: - Establishing professional relationship and developing trust.

2. Schizoid personality disorder:-Schizoid personality disorder is characterized by lack of

interest in social relationship, social withdrawal, a tendency towards a solitary life style and
emotional cold. The sign and symptoms are:-
 Emotional coldness detached or reduced affection.
 Inability to pleasure experience.
 Aloof.
 Lack of desire for sexual experiences with another person.
 Social isolation.
 Excessive preoccupation with fantasy and introspection.
 Humorless.

Treatment of schizoid personality disorder:-

 Individual psychotherapy.
 The ability to mobilize self preservative defenses and self reliance.
 Antipsychotic may have efficacy in alleviating them, resperidone to treat negative symptoms.
 Drugs: - MAOIS, SSRIs, low dose benzodiazepines.
 
 β- Blockers may help social anxiety in the schizoid personality disorder.
 To change fundamentally the old way of feeling and thinking.
 Adequate support for the emergence of the real self.

3. Dissocial/ antisocial/ sociopath/ psychopath personality disorder: - A condition in which

individual exhibit a pervasive disregard for the law and rights of others.

It is characterized by chronic antisocial behavior that deviated from the social norms.

 Failure to sustain relationship/ inability to make or keep friends.

 Usually loners.
 Lack of interest.
 Reckless behavior.
 Provoking arguments with a sibling or felloe being students.
 Failure to plan ahead.
 Aggressive behavior, violent.
 Tendencies to violate the rights of the others.
 Fails to fulfill parenting or work responsibility.

Treatment of antisocial personality disorder: - Approach has to be adopted to alleviate symptoms:-

 Medicine based on symptoms, if depression antidepressant will be administered.

 Antipsychotic drugs.
 Psychotherapy – to develop appropriate interpersonal skills.
 Develop and maintain strong therapeutic nurse patient relationship.
 Group and family therapy.
 Individual psychotherapy.
 Decrease the development of problematic behavior.
 Encourage study habit and minimize failures.
 Motivate the client to develop the social interaction consistent approach, provide respect for
others.

4. Histrionic personality disorder:-

Histrionic personality disorder is characterized by a pattern of excessive emotionally and attention

seeking behavior, beginning by early adulthood.

The sign and symptoms are:-

 Attention seeking behavior.

 Excessive concern with physical appearance.
  Low tolerance for frustration.
 Emotionally blackmail.
 A style of speech (excessive impression).
 Rapidly shifting emotional state.
 Selection of marital or sexual partners is highly inappropriate.
 Craving for novelty or excitement.
 Show self dramatic behavior.
 Failure or disappointment is usually blamed on others.
 Male show identity diffusion, disturbed relationship, Lack of impulse control.

Treatment of histrionic personality disorder:-

 Insight oriented psychotherapy is the treatment of choice.

 Antidepressant is used if depression is also present.
 Establish and maintain therapeutic nurse patient relationship.
 Provide safe and calm.
 Encourage to take sufficient time in taking decision.
 Observe the client’s behavior, watch for suicidal tendency.
 Advice him to the privacy and healthy manner the feelings related to sex appropriately.
 Encourage the clients to share their emotional feelings appropriately with the people who
exhibit concern.
 Teach adaptive coping strategies to overcome aggression.

5. Narcissistic personality disorder: The patient with narcissistic personality disorder is self-
centered, self-absorbed, and lacking in empathy for others.

The sign and symptoms are:-

 Lack of empathy.
 Dramatic behavior.
 Sense of self importance (grandiosity).
 Unable to face criticism.
 Painful emotions based on shame.
 Live in a dream world.
 Preoccupation with fantasy of sense.
 Easily depressed by minor events.

Treatment of narcissistic disorder:-

 Drug therapy- antidepressant to relieve narcissistic grandiosity.

 Psychotherapy- psychoanalysis.
 Enhance “parent child relationship”.
  Develop and maintain therapeutic nurse patient relationship.
 Family education has to be given for fulfillment of needs of children.
 Promote “emotional bondage” among family members.

6. Borderline personality disorder:-Borderline personality disorder is characterized by a pattern of

instability in interpersonal relationship or behavior.

A mental illness is characterized by emotional dysregulation, extreme black and white thinking
or splitting and chaotic relationship.

The sign and symptoms are:-

 Unstable interpersonal relationship.

 Unstable self image.
 Impulsive behavior is common (e.g. alcohol or drug abuse, unsafe sex, gambling, recklessness).
 Recurrent suicidal behavior.
 Ambivalent.
 Affective instability due to marked reactivity of mood behavior (irritability, anxiety).
 Self image rapid change from extreme positive to negative.
 Preoccupied or fearful attitude towards relationship.

Treatment of borderline personality disorder:-

 Medication: - antidepressant – selective serotonin reuptake inhibitors to relieve anxiety and

depression.
 Antipsychotic to treat distortion in thinking or false perception.
 Psycho- education and skill training.
 Marital and family therapy useful in stabilizing the relationship, to resolve stress and conflicts to
improve communication and problem solving provides support to family members.
 Cognitive behavioral therapy.

7. Obsessive compulsive personality disorder:- Obsessive compulsive personality disorder:- An anxiety

disorder characterized by a subjects obsessive, distressing, intrusive thoughts and related
compulsion(task or rituals) which attempt to neutralize the obsession.

People with this type of personality disorder usually exhibit rigid and non adaptive behavior but his
behavior is under control.

Clinical features of obsessive compulsive personality disorder are:-

 Feeling of excessive doubts.

 Preoccupation with details rules, list, order, organization and schedule.
  Repeated clearing of throat.
 Unwanted sexual thoughts.
 Rigidity and stubbornness.
 Unwelcome thoughts and ideas.

 Counting steps.
 Repeated hand washing.
 Excessive pedantry.
 Experience difficulty in work situation and intimate relationship.

 Treatment: - These patients usually retain insight and hence seek psychiatric help on their own.
 Behavior therapy: - Exposure and ritual prevention techniques. It involves gradually learning to
tolerate the anxiety associated with not performing the ritual behavior.
 Psycho analysis or psychoanalytical psychotherapy.
 Medications: - selective serotonin reuptake inhibitors like Paroxetine, Sertaline.

7. Dependent personality disorder: - Dependent personality disorder is described as a pervasive

and excessive need to be taken care of that leads to a submissive and clinging behavior as well
as fear of separation or rejection.

Clinical manifestations:- experiences great difficulty in making everyday decisions.

 Low self esteem power.

 Lake of self confidence.
 Avoiding personal responsibility.
 Self doubt.
 Feeling of uncomfortable and helpless when alone.
 Unable to meet ordinary demands of life.
 Easily hurt by criticism.
 Excessive Preoccupation.
 Do not trust their own abilities.

Treatment:-Behavior therapy in the form of assertiveness training and social skills training is useful.

Cognitive behavior therapy:- The focus is on negative thoughts and negative self appraisal.

Individual psychotherapy.

Group psychotherapy.

Drug therapy:- Antidepressant and sedatives.

9.Avoidant personality disorder:- Avoident personality disorder characterized by a pervasive pattern of
social inhibition, feeling of inadequacy, extreme sensitivity to negative elevation and avoiding social
interaction.

Clinical manifestations:-

 Low self esteem power.

 Fear of rejection.
 Avoid occupational activities.
 Easily hurt by criticism.
 Mistrust of others.
 Extreme feeling of anxiety.
 Feeling of inadequacy inhibits new interpersonal situations.
 Chronic substance abuse or dependent.
 Fixed fantasies.
 Uncommunicative in social situations.
 Self imposed social isolation.

Organic mental disorder

Organic brain disorder is behavioral or psychological transient and permanent brain disorder.

Delirium:- Delirium is marked by short-term confusion and change in cognition.

Dementia:- Dementia is marked by severe impairment in memory,, orientation and cognition.

Amnestic disorder:- Amnestic disorder is marked by memory impairment and forgetfulness.

Classification of organic brain disorder:-

F0-F9 Organic including symptomatic mental disorder

F0- Dementia in Alzheimer’s disease

F01-Vascular dementia

F04- Organic amnestic syndrome

F05- Delirium

F06- Other mental disorder due to brain damage and dysfunction.

F07- Personality and behavioral disorder due to brain damage and dysfunction.
Delirium:- (Acute organic brain syndrome)

Impairment of consciousness, perception, cognitive functioning, restlessness.

Definition:- Delirium is an acute organic syndrome is characterized by impairment in consciousness and

cognition disturbance in perception and restlessness.

According to DSM.:- Delirium is characterized by disturbance of consciousness and changes in cognition

that develop over a short time.

Etiology:-

 Encephalitis
 Meningitis
 Protein deficiency
 Vita.B1 deficiency
 Metabolic disorders:- Metabolic acidosis and alkalosis, fever, hypoxia, anaemia,
hypoglycaemia, water and electrolyte imbalance.
 Intracranial causes:- Epilepsy, brain tumour, stroke, Head injury, migraine, neoplasm infection.
 Miscellaneous causes:- Sleep deprivation or after surgery.

Clinical features:-

 Impairment of consciousness:- Clouding of consciousness ranging from drowsiness to stupor and

coma.
 Disorientation
 Perceptual disturbance:- Illusion, hallucinations
 Disturbance in cognition:- Impairment in thinking
 Disturbance in sleep, nightmare
 Psychomotor disturbance:- Hyper and hypo active.
 Impulsive, irrational and violent behaviour
 Lack of insight
 Emotional disturbance:- Apathy, depression, anxiety, fear, irritability

Management :-

Immediate management:-

 50% dextrose IV. For hypoglycemia.

 O2 for hypoxia
 100mg B1 IV for thiamine deficiency
  IV fluid for electrolyte imbalance and fluid.
 Benzodiazepines:- 10mg diazepam,2mg IV.
 Antipsychotic drugs:- Haloperidol 5mg, 50mg chlorpromazine IM.

Dementia
Introduction:- It is a chronic organic mental disorder. It mainly affects the intellectual abilities and
functioning.

The dementia word derived from Latin word Dementia meaning without mind.

Definition:-Dementia is a organic mental disorder characterized by-

 Impairment of intellectual functioning.

 Impairment of memory.
 Deterioration of personality with the lack of personal care.
 Dementia is acquired global impairment of intellectual, memory and personality but without
impairment of consciousness.

Etiology:-

 Mnemonic:- VINDICTIVE MAD

 V- Vascular- Shock, arteriosclerosis
 I- infection- Encephalitis, meningitis
 N- Neoplastic- Space occurring lesions, abscess condo
 D- Degenerative disorder- Senile and presenile dementia.
 I- Intoxication- Chronic barbiturates poisoning alcohol.
 C- Congenital- Epilepsy.
 T- Traumatic- Subdural and epidural hematoma, confusion condition.
 I- Interventricular- NPH (Normal pressure hydrocephalus).
 V-Vitamine- Deficiency of Vitamin Niacin, thiamine and Vita.B12.
 E- Endocrine- Autoimmune disorder, acid base balance, shock, uremia.
 M- Metals- Pb poisoning
 A –Anemia- Cardiac failure, aneurysm
 D- Depression- Sleep deprivation.

Others:- Untreatable or irreversible causes of dementia:-

 Alzheimer’s disease
 Pica disease
 Huntington disease
 Parkinson’s disease.
Clinical manifestation:-

 Personality changes:- Lack of interest in day to day activities, self centered, decrease self care.
 Memory impairment:- Recent memory is predominantly affected.
 Cognitive impairment:- Disorientation, poor judgment, decrease attention spasm, difficulty in
abstraction.
 Affective impairment:- labile mood irritable and depression.
 Behavioral impairment:- Alteration in sexual.
 Neurological impairment:- Aphasia, apraxia, seizure, headache
 Other symptoms:- Drowsiness, confusion, agitation, accident etc.

Management:-

 Training to thinking and memory functions are carried out carefully.

 Reality orientation therapy.
 Cognitive and behavioral intervention may be appropriate.
 Remotivational therapy:- To provide appropriate for the client to derive pleasure and sensory
stimulation by experiencing to feel safe and comfortable.
 Antipsychotic medication:- Such as risperidone, haloperidol may be used to decrease verbal and
physical aggressiveness to alleviate hallucination and delusion.
 Benz diazepam for insomnia and anxiety.
 Anticonvulsant drugs:- To control the seizure.
 Vitamin supplementation.

Autism/Autistic disorder
Introduction:-American psychiatric association classified autism as developmental disability then results
from central nervous system.

This disorder almost always develops the 3 years approximately 10 cases per 1000 individual more
common in males. 5:1 in first born male.
Definition:- Autism spectrum disorder(ASD)/autistic is the disorder are characterized by is a range of
complex neurological developmental disorder characterized by social impairment, communication
difficulties, restricted, repetitive and stereotyped pattern of behavior

Risk factor and causes of autistic disorder:-

 Abnormality in brain functioning-Deficit in temporal lobe and lateral lobe of brain, limbic
system.
 Genetic factors- Monozygotic and dizygotic twins and sibling.
 Biochemical factors:- Elevated plasma serotonin level.
 Abuse in pregnancy
 Maternal bleeding
 Maternal rubella infection
 Psychosocial factors:-
 Parental rejection
 Deviated personality
 Broken families
 Family stress
 Defective communication pattern
 Lack of affection
 Sibling conflicts
 Emotionally cold
 Aloofness

 Common sign and symptom of autistic disorder:-

a) Social skills:- Basic social interaction can be difficult for children with Autism spectrum disorder
symptoms may include:-
 Appropriate body language
 Inappropriate gestures and facial expression
 Avoiding eye to eye contact
 Lack of interest in other people

 Difficulty understanding other peoples, feelings, reaction, non verbal cues.
 Resistance to being a touching
 Failure to make friends with children the same age group.

b) Speech and language:-problems with speech and language comprehension are a tall tale
(convey the states of a situation) sign of the Autism spectrum disorder. Symptoms may include:-
 Speaking in an abnormal tone of voice.
 Repeating words and phrases over and over without communicative intent.
 Difficulty communicating needs and desire.
 Does not understand simple statement and question.
 Does not talk at all.

C) Restricted behavior and play:- Children with Autism spectrum disorder are often restricted, rigid,
even obsessive in their behavior, activities and interest. Symptoms may include:-

 Repetitive body movements (hand flapping, rocking, spinning) and moving constantly.
 Obsessive attachment to unusual objects(rubber bands, keys, light switches).
 Clumsiness (improper skill), abnormal posture, odd way of moving.
 Unusual attachment of toys.

 Diagnosis:-
 EEG(Electroencephalogram)
 Hearing test
 Metabolic screening-blood and urine lab test
 Magnets resonance imaging
 CT scan (Computer Assisted AxialTomography)
 Direct observation, interaction and interview assessment (information about-child emotions,
social, communication and cognitive abilities).
 Play best assessment
 IQ(intelligent quotient) test.

 Management of autistic disorder:- Most behavioral treatment programs include:-

 Clear instruction to the child.
 Immediate prize and rewards for performing those behavior.
 Educate the child about self care technique to the child.
 Set up play situation with peers; arrange games, music and cultural program.
 Motivate the child to express communicate his needs verbally.
 Teach the parents about the disease condition and its progress.
 To protect the child from injuries.