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Behavioral responses in mental illness

                                                                 By Sana Rajani

 On second week of my clinical rotation to a tertiary care psychiatric hospital I came across with a young male, having a diagnosis of Bipolar disorder. He was admitted the previous day with the complaints of aggressive behavior, social isolation and violence. He was in acute manic phase and was very talkative, a bit hyperactive. When I talked to him about his reason for coming to the hospital he said that he had beaten his wife and his mother a day before because they were having a fight with each other on some house hold things. He was sleeping at that time when suddenly he woke up because of their loud voices. He asked both of them to shut up but they continued fighting so he became aggressive and violent and abused and beated both of them. He also damaged his house hold things. He smashed the plates and mirrors; he also broke off the washing machine of his house. He also said that this is not the first time that he has behaved in this manner. On further exploration about the things that make him angry he said that he gets angry even on small thing very easily. He gets angry when anything happens against his nature. He is a driver by profession, so he said that that when I go to pick up kids from the school and if I get stuck in the traffic then even he gets angry and starts fighting with the people stuck around him. He gets angry when his wife or mother doesn’t obey him or when children play and shout in the home then even he gets angry and beats his wife for that. On assessing about the coping mechanism he said that he can’t control his anger, when ever he is at home he beats his family members and when he is not at home he fights with other people. He has been using charas since his childhood and is now very much addicted to it. He was not compliant to his treatment regimen because he told me that as his symptoms improve he stops taking his drugs prescribed by his doctor. It was an involuntary admission as he was brought to the hospital for the treatment by his family. He didn’t want to come to the hospital for the treatment. 

            The issues arising from the above mention scenario are patient's uncontrolled anger, often showed as aggression and violence, social isolation, ineffective coping, drug abuse and its impact on mental illness, non compliance and involuntary admission but the topic which is going to be discussed in this paper is behavioral responses in mania and how to deal with it.

            Bipolar disorder is one of the most distinct syndromes in psychiatry and has been described in numerous cultures over the course of history. It is a disorder that is biological in its origin, yet feels psychological in its experiences (Jamison 1995) as cited in Varcarolis (2006).  The unique hallmark of this illness is mania. According to Belmaker (2004) Mania is, in many ways, the opposite of depression. It is characterized by elevated mood or euphoria, over activity with a lack of need for sleep, and an increased optimism that usually becomes so extreme that the patient’s judgment is impaired. The signs and symptoms of the mania can be characterized into five broad categories i.e. emotional symptoms, cognitive symptom, behavioral symptoms, social symptoms and perceptual symptoms. The behavioral symptoms of the mania includes increases talkativeness, increased goal directed behaviors, agitation and aggression, excessive involvement in pleasurable activities. As the disease progress the person may exhibit extremes in appearance like wearing bright colors, unusual dressing, heavy makeup, engaging oneself more in the activities, taking on additional tasks. When the person is not able to deal with it effectively and feels overburdened then they become distractible, disorganized and very much agitated. They easily become aggressive and shout and even fight on the small things. They sometimes also execute violence. These behaviors then lead to problems such as unacceptance from the family and society, social isolation, development of a feeling that people don’t like me and they are against me.

According to WHO Report (2003) as many as 450 million people suffer from a mental or behavioral disorder or from psychosocial problems related to alcohol and drug abuse. A large proportion of these are from South Asia Region. In Pakistan there are only 4100 beds available for the psychiatric patients and there are only 345 psychiatrists in the country. The mortality rate of patients with manic depressive disorder in JPMC was 4.01% (n=6152) in 1997 and in community clinics it was 0.7% (n=700) (Gadit 2007).  In our culture there are many myths and beliefs which usually act as a barrier to the treatment of the mentally ill people.

Psychotic illness is considered as a "curse from God" or manifestations of evil spirits or punishment for sins of the past life. People do not sympathize with a mentally ill person, because they believe that the person lacks the will power to pull himself or herself and is just not making an effort. Many times patients are ignored, isolated or taken to faith healers and treated with rituals rather than with appropriate medical treatment (WHO 2001). In many mental health institutions still people are caged and restrained, are kept away or isolated from their family and loved one, are been treated heartlessly, are being secluded for a long period of time and are not provided properly with basic needs i.e. food, shelter and clothing. Their civil rights are also deprived and they face discrimination in all aspects of their life.

            Mental disorders are now widely recognized as a major contributor to the global burden of disease. As reported in the Global Burden of Disease report, five out of the ten most disabling disorders in the world are psychiatric in nature. Four of the six leading causes of years lived with disability are due to neuropsychiatric disorders (depression, alcohol-use disorders, schizophrenia and bipolar disorder). The cost of mental health problems in developed countries is estimated to be between 3% and 4% of GNP. (WHO 2001)  As cited in Mental Health, Human Rights and Legislation: WHO's Framework, 30% of countries don't have a specified budget for mental health. Of those that do, 20% spend less than 1% of their total health budget on mental health. There are huge regional variations in the number of psychiatrists from more than 10 per 100,000 to less than 1 per 300,000. Thus the above mentioned literature shows the high significance of the issue.

There are several behavioral responses that a human exhibit and those are passive, assertive and aggressive. Passive behavior and aggression are the two extremes of the continuum on behavioral responses. Aggressive people usually ignore the rights of other people, they like to fight for their own interest, and they tend to enhance their own self esteem through over powering others. When they are angry they usually are unable to cope with their anger and they speak loudly with great emphasis and often this anger and aggressive approach often leads to physical or verbal violence. ( stuart & laria, 1997) As my patient was also having aggressive behavior and he used to fight with others or beat his family members when he becomes angry. He also used to abuse his family members and other relatives often because of which people have now stopped talking to him, they don’t come to visit him at his home as a result patient is becoming more frustrated and he has isolated himself from others. He also has ineffective coping mechanism because whenever he is in stress he usually takes out his frustration on his family or he goes out to his friends and use charas etc as a way to cope with his problems. There are many factors that play a vital role in worsening of the disease process. Some patients are unable to work, some suffer overwhelming fears, and others grapple with constant negative thoughts, and may turn to alcohol. Drug abuse is also one of the factors that lead to aggravation of symptoms and further leads to deterioration of the disease. There is one more factor i.e. stigmatization of the mentally ill patients which affect the patients and as well as their families. These people are often rejected from the society. This also increases the economical burden of the government. As stated by WHO (2001) Mental disorders have a wide-ranging, long-lasting and significant economic impact. Measurable causes of economic burden include health and social service needs, impact on families and care givers (indirect costs) due to lost employment and lost productivity, crime and public safety, and premature death. Other factors that also have a significant impact on the disease includes poverty and interpersonal relationships.

As the significance of the issue has been discussed above, now it is very important to identify some of the generalized strategies that can help in dealing with the individuals who are suffering from mania and as well as to put a light on what has been practiced at the institutional, national and international level so as to deal with these kind of patients. Dealing with such patients on individual basis principles of limit settings should be kept in mind and should be applied. Other interventions that can be done with the patients at individual level includes  involving the  patient in activities to channel his aggression and other responses, promoting a healthy life style and relapse prevention, provide psychosocial support, if  the patient has an insight present regarding the symptoms or the disease then provide psycho education regarding the management of the symptoms and about the disease process but if the patient doesn’t have an insight then only symptomatic management and ways to deal with his/her anger should be taught. Cognitive-behavioral therapy and Interpersonal, social rhythm therapy and cognitive remediation are also useful in the treatment of mania and bipolar disorder. Interventions that can be done at the group level includes involving the patient in occupational therapy which will help them to socialize a bit and to know that they are not the only one who are going through this disease and also will help them to share the useful techniques to control their anger and other symptoms. Institutions can also play a vital role in that by arranging staff sessions regarding dealing with mentally ill, specialized trainings for the staff in mental health and by hiring competent staff. At community level awareness about mental illness should be given to the people who will help in enhancing social acceptance of mentally ill in the community and in reducing stigmatization of the mentally ill. Regarding raising the awareness about the mental illnesses media can also play a vital role so the government should also take measure to run campaigns in different parts of country with the help and collaboration of media. Development and implementation of mental health legislation is also an important intervention that a government must do. In Pakistan Mental Health Ordinance 2001 is present but is not very well implemented in the country. A global policy from WHO has also been created in order to raise the profile of mental health and fight discrimination. (WHO 2001)

Caring for and planning interventions for the patients are the nurse’s prime responsibility. When I got this patient I also did some of the assessment the finding of which here discussed very briefly. The patient was in his active phase of mania. He was socially isolated, was having pressured speech,  mood and affect was incongruent, thought content was intact but he was having circumstantility, was having auditory hallucinations, was conscious, oriented and alert, memory was intact, abstract thinking was present, judgment was present, attention and concentration was present but information and intelligence was impaired. Partial insight was present. The goals for planning the intervention for a patient would be to reduce or eliminate patients maladaptive responses, restoring patients in the society, improving patients quality of life and minimizing relapse by encouraging compliance to treatment regimen. As a student these goals might seems unrealistic but we have to try to help the patients as much as we can to obtain these goals as much as they can. Since we were not able to do any intervention with the patients I would like to recommend some of the strategies that I will do if I received a patient again with this diagnosis. The strategies include setting limits with the client at the start of the interaction and as well as during the interaction as needed, engaging the client in the activities to channel the aggression, actively listening to his/her concerns, providing him psycho-education regarding coping strategies, aggression management and relapse prevention. Involving the patient in group therapies is also useful in order to encourage them to work collaboratively with other patients, to help them in identifying their own strengths, to learn from other patients that how they are managing their disease/ symptoms and to socialize them. As compliance is another chief concern in the psychiatric patients so there is a model which will help in improving patients compliance towards the treatment. The model is Collaborative Practice Model for Bipolar Disorder.

This model suggests that by enhancing a) care providers support in terms of supporting patients, understanding their symptoms, being empathetic, involving patients in planning their care b) by providing patient education about their symptoms management, about coping skills etc and c) by providing the patients with the access to mental health care facilities we can enhance the ratio of continuity of care which will in turn lead to compliance of the treatment regimen.

Initially I was very scared dealing with such type of patients and that’s why I was not able to deal with this patient very efficiently but now after having a bit more exposure I think I think now I can deal with such kind of patients. Another thing that I observed and was not therapeutic was that we usually tends to leave the patient alone when they are very hyperactive or aggressive but now I have learnt that this should not be done. We should interact with the patients while they are angry in order to help them channelize their anger in a productive way. 

            In conclusion I would like to say that mental health has been hidden behind a curtain of stigma and discrimination for too long. Lee Jong-wook (WHO 2001) We really need to work hard in order to address the issues of the mentally ill patients and to help them cope with their illness. Measures should be taken in order raise the awareness among the people and to reduce the stigmatization.