Mental Disorders with A Risk for Violent Behavior Who Have Risky Behaviors and Tend to Smoke: a Case Study

Smoking behavior in patients with mental disorders is known as a risk factor and can affect one aspect of treatment and change in behavior. In addition, smoking will also stimulate psychiatric symptoms and more severe symptoms of recurrence. The objective is to determine the extent of the impact or influence of smoking behavior on mental disorder patients with a risk of violent behavior who have risky behavior tending to smoke in Bantur Health Center. The method used in this research is a case study approach using qualitative and quantitative descriptive research types. This study involved 3 respondents. Data collection is based on interviews, observation


BACKGROUND
Mental disorders are disturbances in one's thoughts, feelings, or behavior, that cause disruption of daily life functions (Guntur et al., 2022).The high number of mental disorders is caused by several things, such as social, economic, and political demands, where people are required to be able to adapt, if individuals are unable to adapt, they will become depressed and experience mental disorders (Erawati et al., 2016).
The prevalence of mental disorders in the world, according to the WHO in 2013, was 450 million people with mental disorders.The distribution of the number of patients with severe mental disorders or schizophrenia in the working area of the Bantur Health Center in 2022, namely the village of Bantur, is 192 people, with more male patients with an average risky behavior tending to smoke (Guntur et al., 2022).
Smoking in schizophrenia has been known as a risk factor, besides that smoking also affects other aspects of schizophrenia treatment and changes in behavior in schizophrenics.Tobacco dependence in schizophrenics increases morbidity and mortality rates.Smoking in schizophrenia affects the treatment process so that it can interfere with reducing symptoms or changing behavior in people with schizophrenia.In addition, one of the harmful effects of smoking in people with schizophrenia is an increase in psychiatric symptoms and more severe relapse symptoms.This can happen because the nicotine contained in cigarettes can affect the production of dopamine in the brain (Priyanto & Permana, 2019).
Smoking is also associated with psychiatric disorders, especially in observational studies showing that tobacco smoking is much greater in schizophrenic and depressed patients.The harmful effects of smoking in patients with schizophrenia include high rates of cancer, cardiovascular, and respiratory diseases, as well as increased psychiatric symptoms and more severe relapses (Ayunita & Nuralita, 2018).
In patients with mental disorders at risk of violent behavior who have risky behaviors, smoking can affect several aspects, both in terms of behavior and treatment.This is in line with several studies, one of which is from (Kurniasih et al., 2017) which explains that smoking in people with mental disorders can affect behavior.Therefore, researchers conducted research in the form of a case study with the aim of knowing the extent of the impact or influence of smoking behavior on mental disorder patients with a risk of violent behavior who have risky behaviors and tend to smoke in the Working Area of the Bantur Health Center.

METHODS
The approach used in this research is a case study using qualitative and quantitative descriptive research types.Based on the results of the patient's assessment, there was no history of mental disorders either from the patient or from the patient's family.The treatment of the three patients was all successful, but there were patients who had to be reminded to take medication.While other predisposing factors such as rejection and fear of loss.

DISCUSSION
A mental disorder is a behavioral disorder caused by psychological pressure both from outside the individual and from within the individual (Kusumadewi et al., 2020).Likewise, research from (Alfianto et al., 2019) explains that there are deviant behavior disorders in people with mental disorders due to emotional distortions.
Based on data obtained by researchers from the three patients with mental disorders, they often experience relapse if they are late taking or stopping medication, where relapse is a condition in which the symptoms of mental disorders will appear in the patient, either the same or more severe, requiring treatment again.
According to (Bratha, Dewi Kasih et al., 2020), the relapse rate in patients with mental disorders is still relatively high and can be influenced by several factors.
According to Keltner & Steele (2015), this study also stated that relapse in patients with mental disorders was caused by noncompliance with treatment, not taking medication regularly because they felt they had recovered or felt healthy, and was driven by very disturbing stressors.In the research (Febrianita et al., 2021), it is explained that there are two types of patients who are non-adherent to drugs: the first is international adherence, namely patients who stop taking medication or reduce drug doses without the knowledge of a doctor.The second is unintentional adherence, where this type depends on the patient's cognitive abilities in taking medication, such as forgetting, and so on.This research is in line with (Kusumadewi et al., 2020) This research is in line with research (Annisa, 2021) The implementation carried out on the three patients could not control the patient's smoking behavior because, based on the results of interviews with all three of them, who had been active smokers since they were teenagers, this was rather difficult to change and also required a longer time.This is in accordance with research from (Hendriani et al., 2012) which explains that the process of getting someone to quit smoking takes longer with effort and a strong desire.

CONCLUSION
The study found that all three From the results of the client's nursing care carried out for several days by the researcher, the results were in the successful category, such as the client being able to build a trusting relationship within five days of meeting.However, the three patients had not been able to control their smoking behavior.This was seen in every meeting for five days; the patient continued to smoke uncontrollably even though he was interviewing the researcher.
And Generalist ners therapy sessions 1-5 for respondents with the risk of violent behavior resolved well, but not for smoking behavior because it takes longer and requires several processes and a stronger desire.
, who explains that individual factors, therapeutic factors, and environmental factors have links as factors that cause relapse in patients with mental disorders.Respondents from the study had a history of tantrums and violent behavior for a long time, whether it was slamming things or breaking things.This was because it was based on various triggers that occurred for the three respondents.In addition, patients also cannot control their emotions well, so they often have tantrums offset by smoking behavior.Smoking behavior is one of the factors that affect patients with mental disorders and plays a role in their behavior.This is in line with research from (Kurniasih et al., 2017), which explains that smoking behavior in mental disorders has been known as a risk factor because it can affect treatment and behavior.Patients will be easily emotional and pose a risk of violent behavior.In addition, one of the harmful effects of smoking on people with mental disorders is an increase in psychiatric symptoms.This can happen because the nicotine contained in cigarettes can affect the production of dopamine in the brain.According to (Priyanto & Permana, 2019), patients with a risk of violent behavior show several behavioral responses, such as: a) behavioral responses in the form of physically abusing other people.b) Social response in the form of verbal violence against other people c) Cognitive responses in the form of an inability to solve problems d) Physical Indriyawati et al. (2023) response in the form of increased respiratory rate, pulse, excessive sweating, sharp eyes, and a red face The three respondents who were taken by the researchers were ODGJ diagnosed with the risk of violent behavior, and from subjective data during interviews, the patient said that he often felt anxious, restless, and uneasy; this would disappear or be reduced by smoking.Besides that, objective data is also obtained in the form of loud voices, sharp views, stiff body postures, and a lack of eye contact.In addition, the three patients also had active smoking behaviors since they were teenagers.The data was obtained when conducting interviews with the three patients.The patient appeared to smoke, whether it was cigarettes he bought from the store or self-rolled cigarettes.This is in line with research from (Hulu, 2018), which states that the risk of violent behavior is an angry response expressed by making threats or injuring oneself or others.The risk of violent behavior is an expression of anger and hostility in response to anxiety or unmet needs.Nursing interventions for three clients were carried out using generalist nurse therapy from sessions 1-5 (Wandira et al., 2022).Interventions that have been developed to deal with violent behavior consist of generalist and specialist nursing actions.The generalist nursing actions that are carried out are that the client is taught and trained to recognize and control violent behavior physically, verbally, socially, spiritually, and obediently taking medication, while the family is also taught how to recognize violent behavior experienced by clients and how to control behavior.The researcher carried out the implementation of nursing for the three patients according to the nursing action plan that had been prepared, namely from SP 1-5, where the implementation carried out by the researcher showed no significant obstacles and the patient was able to carry out and follow the directions from the researcher quite well.The results of a study conducted on three patients showed that the most effective measures for controlling violent behavior were deep breathing and hitting pillows.This is because the patient can channel the anxiety and emotions felt by the patient more safely and comfortably.
patients with mental disorders tended to experience a relapse if they dropped out of treatment or were late to take medication, coupled with smoking behavior that could not be controlled in all patients, showing symptoms such as sharp eyesight, red eyes, a flat face, and high intonation of voice.The implementation carried out is that SP1-SP5 are taught and trained to recognize and control violent behavior physically, verbally, socially, and spiritually, and to adhere to taking medication.

Table 1 .
Clients characteristic Smoking habits are also not only carried out by adults but also by adolescents, both early and late adolescents.client's eye contact is quite sharp; the tone of speech is clear; the client's voice intonation is loud; the posture is rather stiff; and when talking, the client always maintains eye contact with the opponent.The client says he started smoking a long time ago and in a day can spend >6 cigarettes/day, and it can be even more if the client has a lot on his mind.The client claims he can't sleep or has trouble sleeping at night.Besides that, the client feels restless and wants to get angry-get mad if you don't smoke.When the nurse conducts the assessment, it appears that the client always smokes and will roll every time the cigarette runs out.On client 3, the client's appearance is quite clean and somewhat neat, with short messy hair and rather long and rather dirty nails.The client's eye contact is quite sharp, the client's tone is clear, and the intonation of the client's voice is not loud.

Table 3 .
The status of mental