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Susceptibility (risk) factors for in-patient violence at psychiatric hospitals

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The assessment and management of risk and susceptibility of violence in the patients with mental disorders residing in psychiatric hospitals have been extensively debated over the past many years. Some mental disorders and a few specific genetic factors have proven to modify the risk associated with violence. Skills for precise evaluation and management of risks are essential for psychiatrists and other clinicians involved in the treatment of mental disorders, to prevent undesirable results. Historically, risk assessment has been conducted basis the evaluators’ clinical impressions.

Despite the recent development and breakthroughs in the field of risk assessment, there has been a foreseeable risk of erroneous estimation of future violence. 4 techniques are principally used in risk management: monitoring, supervision, treatment, and victim protection. A recent trend in this field is bearing in mind protective factors, and some useful tools focused on this have been introduced in clinical setting. In future, biological factors may be integrated into risk assessment and estimation of treatment response.

The assessment and management of risk for violence presents significant disputes for forensic mental health practitioners. Mentally Disordered Offenders (MDOs) are subjects of psychiatry, and psychiatric nurses are therefore exposed to a high risk of persecution. In addition, accurate inference of risk and effective intrusion for the risk of violence, are necessary to proceed towards the deinstitutionalization of patients with mental disorders. Despite some opinions opposing the involvement of psychiatrists in violence risk management, mental health practitioners are expected to evaluate the risk of violence and estimate the necessity of confinement for patients with mental disorders. Ultimately, mental health practitioners need to develop skills to evaluate and manage the risk of untimely death of the patients and of others in the patients’ environment through risk assessment.

Risk management refers to the process of ameliorating a patient’s predisposition for violence to reduce the risk of unwanted outcomes.

There are several biological factors pertinent to the materialization of violence. The amygdala plays a crucial role in impetuosity, alongside the hypothalamus and prefrontal cortex. Prompting of the anterior, lateral, ventromedial, and dorsomedial nuclei in the hypothalamus causes hostility. The amygdala deregulates dread and disquiet, also resulting in violent behavior. Prefrontal cortex dysfunction can also lead to irresponsible & aggressive behavior.

Some neuro chemical transmitters also control aggression. Low serotonin and gamma-aminobutyric acid are linked with impulsivity. In addition, high doses of nor-adrenaline, acetylcholine, and dopamine are likely to cause aggression. Congenital / hereditary factors have also been under focus in relation to aggressive behavior. Also, currently, psychotic symptoms are widely considered to be associated with an increased likelihood of violence.

Structured Professional Judgment (SPJ), a process of risk assessment that is currently prevailing as the chief method of risk assessment, emphasizes on the importance of both static and dynamic factors of the subjects, and has overcome the shortcomings of both unstructured clinical judgment and actuarial risk assessment.

Risk assessment and management are essential tasks for forensic psychiatrists and other mental health professionals who operate in psychiatric hospitals or in other such IPD settings. General psychiatric practitioners can often be involved in this challenging work, as unavoidably. Thus, precise and well-balanced risk assessment methods are needed to efficiently tackle & avert the risk of violence at psychiatric hospitals.

Patient assaults among staff members of Mental Health Hospitals

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Patients physically assaulting the staff at mental hospitals where they are admit, which results in minor/ severe injuries or even deaths is alarmingly prevalent in the current scenario, especially in IPD settings (such as in mental hospitals).

Paramedical staffs, psychiatrists, psychologists and counselors face manifold types of antagonism, violence, and beating at work, collectively referred to as workplace violence, which usually is sparked off by patients. Whether workplace violence negatively affects staff well-being may be related not only to its presence, but also to a person’s pressure reactivity. The creation of a healing environment is a vital goal for psychiatric inpatient settings. Interpersonal hostility in the form of discord, antagonism, violence, and assault are common occurrences in mental hospital wards, and impair the development of a treatment-conducive environment. These also create hardships for staff well-being, detracting them from patient care.

Several studies have documented that psychiatric staff are at high risk of workplace violence, including physical assault and verbal aggression by patients, visitors, supervisors, and coworkers

Staff members are likely to appraise conflict with patients in a different way when compared to appraisal of conflicts with coworkers and supervisors, bearing in mind that it is a part of a patient’s pathology.

An international review of violence toward nurses establishes that 55% of nurses in psychiatric and mental hospital settings experienced physical assault and that psychiatric settings had a higher rate of violence than any other health care setting. It is generally accepted that these assault records’ data are underestimates, because many staff may under-report harassment or assault due to fear of being perceived as less competent or being blamed, peer pressure not to report assault based on the gender of the person assaulted, or a lack of desire to deal with excessive paperwork or even of the threat of being fired from the job. According to recent studies, staff who are assaulted tend to be young (less than 30 years old), less experienced, less educated, spend more time with patients and are less qualified.

Direct care staff can feel beleaguered, vulnerable, disturbed, and shamed by assault and spoken hostility in their respective mental hospital units. The most commonly reported poignant consequences of assault and verbal aggression are fright, annoyance, rage, dread, disquiet, stress, and irritability. Similar to persons who have experienced traumatic events in the past, psychiatric unit staff who have been assaulted by patients are at increased risk of developing PTSD (post traumatic stress disorder) and major depression.

Job performance can also be adversely affected by feelings of insecurity; staff members who feel unsafe at work may engage in behaviors that impair curative bonding with patients: such as avoidance, passivity, and inconsistent or harsh enforcement of ward rules.

Mental hospitals suffer as organizations when staff safety is jeopardized. The incidence of episodes of violence in mental hospitals has direct costs for medical care, litigation, worker’s compensation benefits, paid leave, and substitute staffing. Additionally, there are indirect costs related to low self-esteem, employment and retention difficulties, service disruption, compromised public relations, impaired job performance, and the development of a negative therapeutic environment.

Prevalence of self-stigma and its association with self-esteem among patients in mental hospitals

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Stigma against mental disorders cuts across all age, religion, ethnic origin or socio-economic strata. In the same way, self-stigma among psychiatric patients admit in mental hospitals or in other IPD settings is also prevalent worldwide. The consequences of self-stigma are low self-confidence, increased severity of symptoms, low adherence to prescribed medication & treatment, increased suicide rate and an overall decreased quality of life.

Mental disorders are accompanied by reactions from the societies and communities of the suffering persons, that adds a dimension of suffering to the existent condition of the sufferer, which is called “second illness” or “stigma”.

Most studies highlight the existence of two dimensions of stigma namely, public stigma and self-stigma or internalized stigma. Public stigma is comprised of the negative attitudes held by members of the public about devalued people. On the other hand, self-stigma occurs when people internalize those public attitudes and suffer numerous negative consequences as a result.

Negative attitudes of people in general (hospital staffs, other people in society) towards them, during the process of admission into a mental hospital, may be an underlying cause for them to internalize such negative attitudes leading to self-stigma.

According to a study, prevalence of self- stigma among psychiatric patients is high: ranging from 22.5 to 97.4% in different countries: it is 36% in USA, 97.4% in Ethiopia, 22.5% in Nigeria, 49.5% in China and 50–66% in India.

In addition to this, self-stigma among psychiatric patients is associated with poor quality of life, low treatment adherence, decreased esteem, increased severity of symptoms, low self-efficacy and poor recovery. In extreme circumstances, self-stigma is associated with a higher rate of suicidality.

Self-stigma is strongly linked with low self-esteem that is directly related to the prognosis and impediment of the disease condition. On the other hand, positive self-esteem is basic characteristic of mental health that protects the people’s mental health from the impact of negative influences of mental illness. Furthermore, it promotes and facilitates effective coping with stressful situations, thus acting as a protective factor in mental health. This imperative element of mental health is vulnerable to self-stigma among psychiatric patients.

Implementation of awareness programs could help in reduction of self-stigma.

Furthermore, self-stigma and self-esteem have a strong negative relationship, which implies that as self-stigma increases, self-esteem decreases.

So in order to protect the self-esteem of psychiatric patients residing in mental hospitals or other such IPD settings, self-stigma must be reduced.

Different interventions and therapies being practiced at mental hospitals, which are focused on reduction and elimination of self-stigma like healthy self-concept, self-stigma reduction program, ending self-stigma, and cognitive therapy might help in reducing self-stigma. Self-esteem enhancement programs can also decrease self-stigma. A reduction in public stigma is also suggested here.

Coping with Bipolar Disorder

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Bipolar disorder is a mood disorder which affects all spheres of a sufferer’s life, including her/his frame of mind, vigor, concentration and behavior. Although the treatment success rate of bipolar disorder may not be promising always, however, the symptoms of this mental disorder can be managed. Further making the individuals diagnosed with bipolar disorder live fuller & healthier lives. These measures may include a combination of support from a mental health practitioner, medication, therapy and lifestyle-alteration.

Following are a few steps to help individuals struggling with bipolar disorder:

  • Isolating oneself increases the peril of mood fluctuations going unobserved, so keeping in touch with society and staying connected with family, friends and colleagues/co-workers is of paramount importance for persons suffering from mood disorders.
  • Learning about the symptoms of manic and depressive episodes of bipolar disorder is important for individuals suffering from the same, making it important for them to educate themselves about the disorder they are suffering from. It also helps in developing an insight when they experience similar signs or symptoms in the future, helping them manage further episodes.
  • Setting up & following a daily routine is a great coping skill for prevention of manic or depressive episodes. This involves timely administration of medicines, ensuring sufficient sleep, exercising regularly & attending all appointments scheduled with mental health practitioners.
  • It’s important to create a crisis plan which one can adhere to when things spiral out of control or when an individual suffering from bipolar disorder experiences a manic or depressive episode. This may involve jotting down names (along with contact details) of a list of people whom one can contact during an emergency. Information regarding the medication to be administered may also be mentioned on this crisis plan.
  • Stress is the foremost bipolar trigger. One must do what one possibly can in order to simplify one’s life and relieve stress by striking a balance between one’s work and personal lives.
  • Excessive fatigue can set off mania in persons suffering from bipolar disorder, which makes it important for them to relax before going off to sleep. A person may follow healthy sleep ritual like having hot milk, reading, listening to calming music or taking a bath.
  • Regular exercise can help perk up an individual’s disposition. Exercising frequently is important for persons suffering from bipolar disorder to help assuage hypomanic symptoms. Moreover, exercising enhances concentration and helps create a body-mind balance, promoting a sense of control and encouraging person to lead his/her life.
  • Regulating the intake of caffeine, alcohol, and drugs. Caffeine is a stimulant, which can worsen mood symptoms. Alcohol and drugs can trigger a mood episode as they affect the functioning of various bio-chemicals in the body and medicines administered.
  • Keeping a journal can help to sort one’s thoughts and emotions. It also facilitates expression and emotional regulation.

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It might feel overwhelming to support someone with a mood disorder, so care takers should also consider practicing self-care. If you or someone you care for is suffering from Bipolar Disorder, please feel free to connect with our mental health experts using the following coordinates: Psychiatric Hospital in India

Bipolar Disorder Symptoms, Causes and Treatments | Tulasi Healthcare

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Bipolar Disorder

Bipolar disorder is a psychological state distinguished by intermittent agitated and dismal episodes, scattered with episodes of comparatively normal mental functioning of the affected individual. The abnormal mood swings usually have an adverse effect on the daily routine of an individual struggling with bipolar disorder.

Mood swings of individuals affected by bipolar disorder can be characterized by feeling excessively ecstatic or short-tempered at one end & feeling miserable and despondent at the other end.

Adolescents are primarily affected by bipolar disorder, but there is a high probability of its onset among children too.

During an episode of hyperactivity, the affected individual usually becomes imprecise, starts believing that she/he possesses unrealistic abilities and becomes ostentatious. The affected person, during this episode, usually exhibits perilous conduct and engages in activities such as betting & abuse of life threatening drugs. The duration of the first manic episode observed among individuals affected by bipolar disorder is approximately 3 months.

The depressive/drab episodes of bipolar disorder, which usually occur intensely, can happen for weeks together and are devoid of major causes or symptoms. Apart from feeling depressed, depressive episodes may also be comprised of insomnia, lethargy, frequent depletion of energy, despair, etc.

Diagnosis & tests

Basis the severity of manic symptoms, Bipolar disorder is divided into several subtypes.

Individuals affected by Bipolar I disorder experience at least 1 episode of mania and one depressive episode. The resultant mood swings are severe enough to disrupt the routine of activities conducted in offices, colleges, schools or even at home.

Bipolar II Disorder is a lot less severe as compared to Bipolar I disorder. Individuals affected by Bipolar II Disorder endure at least 1 hypomanic (which is not as severe as full-blown mania) episode, and at least 1 major depressive episode. In such cases, phases of depression usually last longer than phases of hypomania. Also, disruption of daily routine in such cases is rare.

Input and description of symptoms from relatives, guardians and friends can help in zeroing in on an accurate diagnosis.

Treatment & medication

Bipolar disorder is a permanently recurring mental disease which has no cure. Yet, prescribed medicines and remedial treatments can be used to help assuage the mood swings and other such associated symptoms of bipolar disorder in order to manage it and to avoid relapse in the long run.

Bipolar disorder is usually treated with mood stabilizers. In addition to medication, one can have psychosocial interventions, get patients involved in community activities, and also teach the family about management of the condition at home.

Mood stabilizers are used to avert and check the acute highs and lows.

In addition to these, other medicine types; such as antidepressants, anticonvulsants and antipsychotics may be used to treat specific symptoms.

Electroconvulsive therapy (ECT) is used to treat highly agitated patients with bipolar disorder, suicidal patients with bipolar disorder or those persons with bipolar disorder who exhibit psychotic or catatonic symptoms. ECT entails administering an electrical stimulus through the scalp into the facade of the brain.

Psychotherapy, especially Cognitive Behavioral Therapy can also be of great help to individuals struggling with bipolar disorder as it can stop negative thought cycles. Participating in various community programs and being part of support groups can also help individuals affected by bipolar disorder stay focused on recovery goals.

It is important for the kith and kin of the affected individual to take responsibility for ensuring her/his proper care and rehabilitation. If you or someone you care for is struggling with bipolar disorder, please feel free to reach out to us at +91-8800000255.

Tips to relearn social skills while in a Psychiatric Hospital

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Learning Social skills consists of learning activities utilizing behavioral techniques that enable persons with disabling mental disorders to acquire interpersonal disease management and independent living skills for improved functioning in their respective communities & societies. A large and growing body of research supports the efficacy and effectiveness of social skills training for mental illnesses & disorders. When the type and frequency of training is linked to the phase of the disorder, patients in psychiatric hospitals can learn and retain a wide variety of social and independent living skills. Generalization of the skills for use in everyday life occurs when patients at psychiatric hospitals are provided with opportunities, encouragement, and reinforcement for practicing the skills in relevant situations. Recent advances in skills training include special adaptations and applications for improved generalization of training into the community, short-term stays in psychiatric inpatient units, dually diagnosed substance abusing mentally ill, minority groups, amplifying supported employment, treatment refractory schizophrenia, older adults, overcoming cognitive deficits, and negative symptoms as well as the inclusion of social skills training as part of multidimensional treatment and rehabilitation programs being undertaken at psychiatric hospitals.

Given the key role of effective communication in obtaining one’s needs for normal community functioning, social competence is essential for a satisfactory quality of life. “Social competence” can be defined as the “ability to achieve legitimate, personally relevant goals” through interacting with others in all situations: work, school, home and neighborhood, recreation, shopping and consumer services, medical and mental care. In contrast, “social skills” represent the “constituent behaviors” which, when combined in appropriate sequences and used with others in appropriate ways and places, enable an individual to have the success in daily living reflected by social competence.

Skills are the raw material of social competence and comprise the full range of human social performance: verbal, nonverbal, and paralinguistic behaviors; accurate social perception; effective processing of social information to make decisions and responses that conform to the normative, reasonable expectations of situations, and rules of society; assertiveness; conversational skills; skills related to management and stabilization of one’s mental disorder and expressions of empathy, affection, sadness, and other emotions that are appropriate to the context and expectations of other patients at the psychiatric hospital. In summary, social skills represent the topography of social interaction, whereas social competence reflects the accumulation of self-efficacy and real-world success through experiencing the favorable consequences of interactions within the psychiatric hospital.

The term “skills”—in contrast to the term “abilities”—implies that they are predominantly based on learning experiences. Thus, social skills training utilizes behavior therapy principles and techniques for teaching individuals to communicate their emotions and requests so that they are more likely to achieve their goals and meet their needs for affinitive relationships and roles required for independent living. This modality of treatment at psychiatric hospitals and rehabilitation centers has been empirically validated for a broad range of mental disorders and other psychological problems. Because of its protean and generic applications to such disparate functions as family psycho-education, behavioral marital therapy, and dialectical behavior therapy, social skills training can be best defined by its operational components inside psychiatric hospitals, rehabilitation centres and psychiatric nursing homes, such as the ones being successfully run by Tulasi’s Group of Psychiatric Hospitals.

Hospitalization of Patients suffering from Bipolar Disorder

Stigma attached to Hospitalization of patients suffering from Bipolar Disorder

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35 years old Rohit told his family residing in Delhi about his extravagant expenditure of more than half a crore Indian rupees over a fortnight spent abroad. He then demanded provision of another 5 crore Indian rupees, following which his parents sought help from a psychiatrist. The mental health professionals at a reputed hospital told them that Rohit was struggling with bipolar disorder, which sets off capriciousness and emotional instability.

However, when the psychiatrists and psychologists suggested hospitalization for residential treatment using cognitive behavioural therapy and interpersonal therapy, his family members backed off, saying that admission into a rehabilitation centre or a psychiatric nursing home will lead to defamation in family & society owing to the negative stigma associated with it.

There are various forms of Bipolar disorder, but in its most harsh manifestation – manic depression – it leads to a plethora of wild mood swings which range from intense ecstasy to absolute desolation, which can last for months. While experiencing elation, the patients often become careless & indulge in gluttony and extravagance. Also, they don’t feel tired and sleepy for longer than usual time periods. When experiencing despair, they are usually devoid of energy and this is when they lose their desire for food and their self esteem. They frequently envisage plans to and sometimes do commit suicide.

The experience of stigma associated with mental illness is devastating and can be detrimental to recovery. Stigma can be defined in terms of five interrelated components: labeling, stereotyping, separation, status loss, and discrimination. Stigma is often the response to individuals who are expressing an undesirable or frightening characteristic and can be viewed as a continuum from intolerance or agitation to prejudice and discrimination. On the more negative end of the continuum, prejudice and discrimination are rooted in commonly held stereotypes that are associated with mental illnesses. These stereotypes are concentrated within an image that individuals with a mental illness are unable to make competent decisions, are dangerous to themselves and/or the public, and require coercive intervention as they will not seek treatment autonomously. In fact, the diagnosis of a mental illness is coupled with negative stereotypes regardless of the presence of abnormal behavior. Although work has been done to reduce stigma and educate the public about mental illnesses, significant barriers still exist to differentiate people with a mental illness from mainstream society
Many people want to distance themselves from someone who has a mental illness as much as they would with someone with a drug dependency or someone who has been convicted of a crime
The underlying factors which lead to development of bipolar disorder are not known yet- stress being a contributory factor.

Survival depends on one’s coping skills. Some take to smoking or drinking to cope with stress, which may be even more harmful.

Bipolar disorder can affect performance at work, and threaten both personal and professional relationships. The family should appreciate the fact that these are overworked people and should try their level best to provide them support.