A Closer Look at Disinhibited Behavior in Mental Illness
Disinhibited behavior is the failure to inhibit inappropriate responses to immediate situations (Spaulding, Sullivan & Poland, 2003). It includes acting without thinking about consequences, disrupting social norms, disrespecting others, oversharing personal information and hyper sexuality (Grafman, 2002). It can range from unpredictable agitation to inapt behavior (Cruz-Cunha, Tavares & Simoes, 2010). It is one of the most prevalent characteristics exhibited by schizophrenic clients in a mental health setting.
During my clinical rotation, I encountered the case of a 36 years old female patient. She was a known case of schizophrenia along with present complaints of auditory hallucination, visual hallucination, paranoid delusion and aggression since the last three years. She was continuously demanding to be discharged.
The patient had been observed to show disinhibited behavior on several ocassions, which included; taking off clothes in public, urinating on the floor, and verbally abusing the staff. After pacifying the patient once , I asked her about her disinhibited act but she denied and failed to recognize it. Patients often exhibit disinhibited behavior unintentionally because of mental illnesses such as, schizophrenia (Christian, 2014).
We know that every culture demands its followers to respect societal norms along with cultural models. Patients who show disinhibited behavior, basically perform actions that violate social norms. People however, regard this behaviour as ‘shameless, oblivious to the understanding that it is unintended and a part of their mental illness. (Shrivastava, Bureau & Johnston, 2012).
Secondly, most of Pakistani population link such conditions to false supernatural explanations and evil spirits. (Zafar et al., 2008). Moreover, people are afraid of them and prefer to isolate them from the society instead of identifying the real cause of such behavior. The intent of writing this paper is to create awareness, eradicate misconceptions regarding disinhibited behavior in mental illness, and propose strategies to help the patients to modify inappropriate behavior.
Literature points out several factors that cause disinhibited behavior which include; dysfunction of dorsolateral prefrontal cortex in schizophrenia resulting in the patient’s social and sexual disinhibited behavior (Yoon et al., 2008). Secondly, dopamine hypothesis states that an increased amount of dopamine is responsible for positive symptoms of schizophrenia (O’Brien, Kennedy & Ballard, 2013). Along with this, imbalance of neurotransmitters like glutamate, GABA, and acetylcholine are also associated with behavioral disinhibition in schizophrenia (Ritsner, 2011).
Furthermore, aggression in response to environmental triggers can be manifested in the form of disinhibited behavior (Karol, 2003). In my opinion, mentally ill patients are neglected a lot in our society so in order to show their existence they tend to exhibit such behavior to grab mass attention.
Disinhibited behavior has adverse effects on an individual’s mental health, physical health, and social life. From the mental health viewpoint, loss of inhibition can cause an individual to be the victim of crime or be a culprit of the crime (RiverWoods System, 2016).
I believe that due to disorganized behavior, patients fail to meet societal expectations that disturb their self-esteem. When people observe their behavior, they develop grudges against them and exclude them from society because of which the patient feels isolated and end up in further misery . It can cause depression, self-injury, suicidal thoughts, and substance abuse (Christian, 2014).
As far as physical health is concerned, it generates hygiene issues as the patient is not able to maintain personal cleanliness, malnutrition, as he is not capable of organizing meals, cardiac and respiratory problems may arise due to improper diet, lack of exercise, and substance abuse (Cruz-Cunha, Tavares & Simoes, 2010).
Socially, the patient will not able to study, attend educational institutions, maintain employment, and perform home tasks (RiverWoods System, 2016). Relating to my this scenario, she perceives that no one likes her, she is useless and cannot do anything which shows that her self-esteem is deteriorating. She is also not able to maintain hygiene. Her social life has suffered a lot as she is not able to continue her studies, participate in household activities, and maintain good relationship with friends and family.
To bring change in a particular behavior, identification of its cause is very important. Albert Ellis’s Antecedent-Belief-Consequence (ABC) framework says that there is an anteceding factor that can be environmental or physiological which leads to a belief that ultimately gives rise to a consequence. If the belief is irrational then the consequence will be negative and inappropriate behavior (McLeod, 2008).
Considering my patient, the activating factor for her was that other patients were getting discharged and she was not, because of which she developed an irrational belief that the hospital staff are her enemy and would never let her go back to home. This belief resulted in negative consequence and she became aggressive and exhibited disinhibited behavior.
I used this model for my patient to determine the cause of her irrational thoughts, and to change her attitude towards perception of the triggering factor by orienting her to the reality that hospitalization is required for treating illness and reducing the progression of disease.
Disinhibition can be social and sexual.Therefore, as a nurse, maintenance of a patient’s dignity should be the prime motive. Along with this, develop trustful relationship so that patients can ventilate their feelings and concerns, identify inappropriate behavior and its causes by continuous supervision or using ABC framework, sets limit for the client, if they perform any inappropriate behavior make it clear in a bold and firm manner that their behavior is not acceptable and they need to change that behavior.
Different strategies can be planned to help clients with disinhibited behavior. At national level, government should strictly monitor the implementation of laws related to the safety of mentally ill client rights. At community level, awareness session should be arranged regarding mental illness and behavior. Stigma related to mental illness prevails in our society because of which individuals fails to receive adequate care so here we need to teach clients and their families through education to stop stigmatization.
At institution level, medications and proper screening facilities should be available. The milieu therapy and social skills training should be done to help patients, distracting their attention from inappropriate activities. As, I have planned coloring and drawing activities for my patient. At an individual level, psychotherapy (Cognitive behavioral therapy) and talk therapy should be done for helping them to learn how to control inappropriate behavior and negative feelings (Gabbey & Jewell, 2016).
We should explain them the importance of compliance to psychotropic medication as this can reduce symptoms and inhibit disease progression. Along with this, we should encourage exercises, hygiene care, daily living skills training to assist client becoming independent.
In conclusion, we can say disinhibited behavior is the loss of inhibition due to which a person violates social norms, exhibits aggression and sexual behavior in public (Christian, 2014).
It is caused by environmental, psychological and neuroanatomical factors. Strategies can be planned and executed from individual to national level to create awareness about disinhibited behavior in mental illness, to help patients to manage this behavior and regain dignity. Although, the field of mental health has advanced but still the researches are needed to be done to see the efficacy of different medication regimen and psychotherapy in behavioral modification so that we can use effective methods to provide prompt and comprehensive care to the clients.
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