Mental health nursing 2nd year

Neurotic/anxiety disorder
 Neurotic disorders
Introduction:
Neurotic disorder (neurosis) is a less severe form of
psychiatric disorder where patient s shows either
excessive or prolonged emotional reaction to any given
stress. These disorders are not caused by organic disease
of the brain and however severe; do not involve
hallucination and delusions.
Definition
 The term neurosis is define as the presence of a
symptom or group of symptom which cause
subjective distress to the patient, the symptoms is
recognized as undesirable (i.e insight is present). The
personality and behavior are relatively persevered
and not usually grossly disturbed. The contact with
reality is preserved. There is an absence of organic
causative factors.
Causes of neurosis

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 Freud was the first to point out that neurosis are

caused by mental conflict they are:
1. Intrapsychic conflict (conflict within the mind): the
conflict is unconscious and not readily understood by
the patient.
2. Intrapersonal problems: this includes problems in
the family, at work or with friends.
3. The environmental stress: this includes loss of loved
one, failure. Disappointment and frustrations. A
severe stress can precipitate neurosis even in a
stable personality.
4. The individual susceptibility: this depends upon the
personality make –up of the individual and also
early-life experience.

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Psychotic disorder Neurotic disorder

 Severe type of mental  Less severe type of
disorder. mental disorder
-Etiology -Etiology
 Genetic factors in more  Less important
important
 Stressful life event is less  More important
important.

DIFFERENCES BETWEEN PSYCHOTIC

DISORDER AND NEUROTIC DISORDER

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Psychotic disorder Neurotic disorder

Clinical features Clinical features
 Disturbance of thinking and  Rare
perception is common
 Disturbance in cognitive  Rare
function is common.
 Behaviors are markedly  Rare
affected.  Not affected
 Judgments is impaired  Intact
 Insight is lost  Present.
 Reality testing is lost.

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Psychotic disorder Neurotic disorder

Treatment Treatment
 Drugs major tranquilizers are  Minor tranquilize
commonly used. antidepressants a
 ECT is very useful . commonly used.
 Psychotherapy is not much  Not useful.
useful  Very useful.
Prognosis Prognosis
 Difficult to treat, relapse is  Relatively easy to
complete recovery may not relapse is uncomm
be possible. complete recover

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Common neurotic disorders

1. Anxiety disorder
a. Generalized anxiety disorder.
b. Panic disorder
2. Phobic disorder
3. Obsessive compulsive disorder
4. Dissociative (conversion)disorder
5. Somatoform disorder
Anxiety
Anxiety is define as an unpleasant affect characterizes
by physiological, psychological and behavioral changes
in response to an intrapsychic conflict.
Normal anxiety becomes pathological when it causes
significant subjective distress and or impairment in
functioning of the individual.
A. Generalized anxiety disorder
A generalized anxiety disorder is characterized by a
generalized persistent anxiety of at least six months

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duration, and manifested by signs of motor tension,

autonomic hyperactivity, apprehensive expectation and
vigilance. The prevalence rate is about 2.5-8 percentage
and more common in female.
Clinical features
Psychological
Anxious mood (feeling of something terrible about to
happen)
 Worry or fear
 Irritability
 Inability to relax
 Restlessness
 Poor concentration
 Initial insomnia
 Feeling of being unable to cope.
Physical
1. Cardiovascular system
 Palpitation
 Discomfort in chest
 Chest pain
 Flushing
 Fainting
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2. Respiratory
 Confusion
 Difficulty inhaling
 Over breathing
 Chocking
 Gastrointestinal
 Dry mouth
 Difficult in swallowing
 Epigastric discomfort
 Frequent loose motion
 Abdominal pain
 genito- urinary
 Freqyency of micturation
 Sexual dysfunction
 Menstrual dysfunction
 Ammenorrhea
 5 neuromuscular
 Tremor
 Pricking sensation
 Tinnitus
 Tension headache
 blurring of vision
 Dilated pupils

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Panic anxiety disorder

Panic disorder is defined as a sudden attack of intense
discomfort, fear or terror, characterized by fear and
subsequent attempts to avoid of specific objects or
situation,which the person thinks are unreasonable.
Panic disorder is a powerful event, attacks usually occur
without warning.
Clinical features
1. Psychological symptoms
Intense anxiety
Fear of dying or loosing control
Depersonalization
De- realization
2. Physical symptoms
Increased heart rate
Sweating, dizziness, unsteady feeling of faintness
Numbness or tingling sensations
Trembling or shaking
Palpitations

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Chocking, chest discomfort or pain

Shortness of breath
Etiology of GAD and panic disorders
1. Genetic : anxiety disorder is more frequent among
relatives of patients with this condition.
2. Biochemical: disturbance in neurotransmitters
especially nor adrenaline, serotonin and GABA.
3. Psychological: as a result of intra-psychic conflict as
conditioned response-a maladaptive learning.
4. Cognitive theory: according to this theory anxiety is
related to cognitive distortions and negative automatic
thought.
5. Psychodynamic theory: according to this theory
anxiety is usually dealt with repression. When repression
fails to function adequately and the secondary defense
mechanisms are not activated. Hence anxiety comes to
the forefront.

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Management of GAD and panic disorder

 Evaluation of the patient’s symptoms
 Detailed history
 Understanding the relationship between symptoms
and life events
 Determination of a treatment plan
-Pharmacotherapy
 Benzodiazepines (e.g alprazolam, clonazepam)
 Anti- depressant for pani disorder
 Beta- blockers to control sever palpitations
-Psychological therapies
Explanation
Reassurance
Crisis intervention
Supportive psychotherapy
Relaxation exercise
Yoga, meditation, Jacobson’s progressive relaxation
technique.
Nursing intervention
 Help the patient to understand the realationship
between his symptoms and his problems, and explain
that the symptoms are not due to any physical disease
but due to a mild psychological problem.

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 Reassure the patient that many people have similar

problems: it is short live and can be managed
effectively.
 Be supportive to their patient and to the relatives.
 Patient develops a feeling of security in the presence
of a calm and tactful nurse.
 Keep the surrounding low in stimuli (dimlight, few
people).
 Find out the area of stress and talk with the patient
and his family about the way of helping him to lessen
his problems.
 Encourage patient with adapting a healthy life style,
such as a balanced diet , quality sleep , exercise
routine.
 Engaging in hobbies , noncompetitive activities that
are fun and laughter.
 Listening to favourite, calming and positive music.
 Getting a massage (body, hand and feet)
 The nurse should understand the ineffective coping
inanxiety disorder and teach the patient better coping
strategies.
 Allow patient to take as much responsibility as
possible for self care activities, provide positive
feedback or decision made.

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 Help the patient understanding their benefit of

relaxation in anxiety, provoking situation and teach
simple relaxatiomn exercise, deep breathing exercise,
physical exercise like a brisk walk, jogging,
meditation and so on . A relaxed body will help to
relax the mind.
 Administer medication as prescribed by doctor. Asess
for effectiveness and for side effect .

Phobic disorders
A phobia is an unreasonable fear of an object, or
situation or activity. Fear is rational reaction to an object,
identified external danger and may involve flight or
attack in self-defense.
Types of phobia
1. Simple phobia
2. Social phobia
3. Agora phobia
1. Simple phobia (specific phobia)
Simple phobia is a strong persisting fear of an object or
specific situation. It is more common than social phobia.
E.g of simple phobia include animal type, natural
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environmental type(e.g height, animals, close space,

water, blood injury), situational type (e.g places ,
elevators). It is more common in childhood.by early
teenage most of these fears are lost, but a few persist till
adult life.exposure to the phobic object results in panic
attacks.
2.Social phobia
Social phobia is a strong, persisting fear of an
interpersonal situation(fear of eating in public fear of
public speaking , fear of eye to eye confrontation or
social interaction)in which embarrassment can occur.it is
equality common in men and women.
It can severly disrupt normal life interfering with school,
work or social relationships.
3. Agoraphobia
Agoraphobia as the fear of being alone in public place,
open spaces and situation e.g supermarket, public
vehicles crowded shopping centers.it is characterized by
an irrational fear of being in places away from the
familiar setting of home.

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Etiology
 Traumatic social experience e.g embarrassment or by
social skills deficits that produce recurring negative
experience.
 Genetic factors
 Environmental factors
 Abnormalities are some neurotransmitters system
(e.g nor epinephrin, gamma aminobutaric acid
(GABA), dopamine.
Treatment
1. pharmacotherapy
 Benzodiazepines (e.g , alprazolam, clonazepam,
loraepam , diazepam)
 Antidepressants (e.g imipramine, seraline)
2. behaviour therapy
 Fooding
 Systematic desensitization
 Relaxation technique
 Exposure and response prevention
3. cognitive therapy is used to break anxiety pattern.
4. psychotherapy-supportive psychotherapy

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Nursing interventions
 Reassure the patient that he is safe.
 Explore patient‘s perception of the threat to physical
integrity.
 Patient may choose either to avoid phobic stimulus or
attempt to eliminate the fear associated with it.
 If the patient elects to work on eliminating the fear ,
techniques of desensitization or implosion therapy
may be employed.
 Encourage patient to explore underlying feeling that
may be contributing to irrational fears.
 Attend group activities with the patient that may be
frightening for him.
 Administer antianxiety medications as ordered by the
physican, monitor for effectiveness and adverse
effects.
 Positive reinforcement for voluntary interactions with
others.

 Obsessive compulsive disorder

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OCD is characterized by persistent and uncontrolled

thoughts and irrational beliefs that cause an individual
to perform compulsive rituals that interferes with
his/her daily life.
characterstics
 Ideas, impulses or images, which intrude(force) into
conscious awareness repeatedly.
 They are recognized as the individual’s own thoughts
or impulses.
 They are unpleasant and recognized as unable to.
 Failure to resist leads to marked distress.
 Rituals (compulsive) are performed with a sense of
subjective compulsion (urge to act)
classification
 OCD with predominantly obsessive thought or
rumination.
 OCD with predominantly compulsive acts.
 OCD with mixed obsessional thoughts and acts.
 Clinical syndromes
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1. Washers
2. Checkers
3. Pure obsession
4. Primary obsessive
1. washers
This is commonest type. Here the obsession of
contamination with dirt, germs and body excretion. The
compulsion is washing of hands or the whole body
repeatedly many times a day. it usually spreads on to
washing of clothes, washing of bathroom, bedroom,
doorknobs and personal articles.
2.checkers
 In this type, the person multiple doubts. E.g the door
has been locked, kitchen gas has been left open,
counting of money was not exact etc. the
compulsion of course is checking repeatedly to
remove the doubt. Any attempt to stop the checking
leads to more anxiety.
3.Pure obsessions

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This syndrome is characterized by repetitive (harmful

thoughts), impulse or images,mental images of
committing and act they consider to be harmful, voilent,
immoral, sexually inappropriate. which are not
associated with compulsive acts, obsessive rumination is
a preoccupation with thoughts. The person ruminates in
his mind about fore and against of the thoughts
repetitively.
4. Primary obsessive slowness
Severe obsessive ideas and excessive compulsive rituals,
in the relative absence of manifested anxiety this leads
to marked slowness in daily activities.
Etiology
 The exact cause is unknown.
 Heredity factors
 Deficiency of serotonin (biochemical)
 Obsessive personality
 Intra- psychic conflict.
Course and prognosis

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Course Is usually long and fluctuating. A good prognosis

is indicated by good social and occupational judgment.
prognosis is worse when the onset is in childhood, the
personality is obsessional, symptoms are severe , there
is co-existing major depressive disorder.
treatment
1. Pharmacotherapy
 Antidepressant e.g fluoxetine, sertaline.
 Anxiolytic e.g benzodiazepine.
2. Behavior therapy
 Thought stoppage
 Desensitization(the process of reducing sensitivity)
 Aversive conditioning (conditioning to avoid an
aversive stimulus(negative impulsive) )
 Exposure and response prevention.
3. Supportive psychotherapy
 Electroconvulsive therapy.
Nursing intervention

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 Work with the patient to determine types of

situation that increases anxiety and result in
ritualistic behavior.,
 Initially meet the patient’s dependency needs.
Encourage independence and give positive
reinforcement for independent behavior.
 Provide structured schedule of activities for patient
including adequate time for completion of rituals.
 Gradually begin to limit amount of time allocated for
ritualistic behavior as patient becomes more
involved in unit activities.
 Give positive reinforcement for non ritualistic
behaviors.
 Help patient learn ways of interrupting obsessive
thoughts are ritualistic behavior with the techniques
such as thought stopping, relaxation, exercise.

Dissociative (conversion) disorder(hysterical neurosis)

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Definition : conversion disorder is a psychiatric condition

in which emotional distress or unconscious conflict are
expressed though physical symptoms/
Or
this is defined as the unconscious process through
which anxiety is converted into the physical symptoms.
Thus, an emotional conflict is converted into physical
problem. here, the person dissociate or separate himself
from the self and acts in a new manner.
Clinica l manifestation
1. Hysterical seizures (fits)
2. Hysterical paralysis
3. Hysterical blindness
4. Hysterical aphonic(voiceless)
5. Hysterical anesthesia
6. Pathogenic pain.

etiology

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 The etiology of dissociative and conversion disorder

is not known.
 Risk and contributing factors:
 Sex: more common in women than men.
 Low self esteem.
 Family hhistory of similar disorder.
 Stress
 Substance or stimulant abuse.
 Common in adolescent any young adults.
 More prevalent in lower socioeconomic groups, rural
population and less educated clients.
 Treatment and management
 Psychotherapy, including suggestion, explanation,
and encouragement.
 Supportive psychotherapy
 Drug: anti- anxiety and anti- depressant drugs for a
short term period.
Nursing intervention

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 Identify primary and secondary gains.

 Don’t focus on the disability, encourage patient self
care activities as independently as possible .
Interfere only when the patient requires assistance.
 Withdraw attention if the patient continues to focus
on physical limitations.
 Encourage patient to verbalize fear and anxieties.
 Positive reinforcement for identification or
demostration of alternative adaptive coping
strategies.
 Identify specific conflict that remain unresolved and
assist patient to identify possible solution.
 Assist the patient to set realistic goals for the future.
 Encourage verbalization of feeling related to his
inability.
 Reassurance.

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