Mental Health Theory: Exam 1 Comprehensive Guide

How is appearance assessed during Mental Status Examinations (MSE)?

Appearance: What does the patient look like? This is based on appearance of age, weight, attire, grooming, scars, or any other identifying characteristics. This is objective.

How is behavior assessed during Mental Status Examinations (MSE)?

Behavior: How does the patient act? See if the patient can cooperate, if they can be redirected, or if they refuse to speak. This may also indicate agitation, hyperactivity, or avoidance. Note if eye contact is present. And, monitor the patient’s gait (which is different than motor-related pacing). This is objective.

How is motor activity assessed during Mental Status Examinations (MSE)?

Motor Activity: How does the patient move? Are movements hyperactive (tremors, pacing, restlessness, fast eye-movements, fidgeting) or depressed? (psychomotor retardation/slow movements/bradykinesia, catatonia). It’s important to differentiate if this is due to medication side effects or from mental illness. This is objective.

How is speech assessed during Mental Status Examinations (MSE)?

Speech: How does the patient talk? Is speech hyperactive (speaking rapidly, loudly, pressured [rapid, loud, uncontrollable, disorganized, easily interrupted) or depressed? (speaking slow, flat, quiet, slurred). This is based on how a person uses their voice and not what they say. And, some people may naturally be quieter or more talkative depending on their personality. This is objective.

How is mood assessed during Mental Status Examinations (MSE)?

Mood: What does the patient tell you about their status? This is always in the patient’s own words, often using direct quotes. Ask the patient how they feel, and if they feel depressed, hyperactive, or agitated. This is subjective. Possible questions include:

• How are you feeling?

• Do you feel [more/less] energetic?

• Have you felt like you’ve been on edge?

How is affect assessed during Mental Status Examinations (MSE)?

Affect: Does the patient look like they reflect their status? This piggybacks off of mood, but this is the non-verbal portion. If a patient reports feeling depressed but there is no physical indication of it, this is noteworthy (meaning they are not congruent). This is objective, but based off of subjective information and the patient’s baseline. Types of affects include:

• Flat affects are dulled across the entire emotional range.

• Restricted/blunted affects have a limited emotional range.

• Euphoric affects demonstrate extreme happiness.

• Labile affects are rapidly changing.

• Inappropriate affects do not align with the current situation (like laughing at a funeral).

How is thought process assessed during Mental Status Examinations (MSE)?

Thought Process: What is the coherence of the content that the patient is saying to you? This takes into consideration how the patient may be thinking. If a patient is organized, then they are at a healthy baseline. Patients may also experience neologism, or using new words. This requires subjective questioning. Examples of increasing severity include:

• Linear thought processes are purely logical.

• Circumstantial thought processes have unnecessary details before getting to the point.

• Tangential thought processes never go back to the original point.

• Loose associations are only marginally related ideas.

• Thought blocking is when a patient suddenly stops speaking.

• Flight of ideas jump around without ever delving deep into the topic.

• Word salad includes random words with no connection.

• Clanging is like word salad but based on similar sounding words (almost alliteration-like).

How is thought content assessed during Mental Status Examinations (MSE)?

Thought Content: What is the content that the patient is saying to you? This is subjective.

• The most serious thought content includes suicidal or homicidal ideation, which requires the nurse to assess the patient’s immediate danger.

  • Ask the patient if they are considering harming themselves or others and if they have a plan in place.

• Delusions are another example, which are firm beliefs without evidence that are not culturally relevant.

  • Grandiosity causes patients to have significant self-importance. This includes god-like delusions or believing that they have magic powers. This also lowers impulse control significantly.

  • Persecutory delusions cause patients to believe they will be harmed without evidence. This includes false accusations, believing other people are reading their mind, or that the government or other agency is after them.

  • Reference delusions cause patients to feel as though mundane things have personal significance. This includes believing that objects are trying to send the patient a message, or that a TV show is personally trying to speak to them.

  • Somatic delusions may make patients feel as though they have an illness or condition that they do not have. This includes delusions of having parasites, pregnancy, or other physical defects.

• Patients may ruminate on the same thoughts over and over, including obsessions. And, they may have a lack of thought content, like in the case of extreme depression.

How is perception assessed during Mental Status Examinations (MSE)?

Perceptions: How well can the patient distinguish reality? Patients that experience hallucinations may not be able to delineate what is real and what’s not. Hallucinations can be visual, auditory (voices that may be distressing or distracting), tactile (can be felt on the body), olfactory (smell), or gustatory (taste). Get as much detail about hallucinations as possible when documenting. This is subjective.

How is cognition assessed during Mental Status Examinations (MSE)?

Cognition: How well can the brain function? This assesses cognitive status and LOC, concentration and attention, memory (immediate or delayed recall; short and long-term memory), and abstract thinking. This is subjective. Possible assessments are included below:

• Orientation: What is your name? Where are you at? What is the date today? Do you know why you’re here?

• Levels of Consciousness: Is the patient… vigilant, alert, drowsy, lethargic, stuporous, or comatose? Does it fluctuate?

• Attention: Recite a series of numbers or provide a word that a patient can spell backwards; ask patient to do a math equation.

• Memory: Ask about a recent memory and a remote or long-term memory. Ask the patient to remember something after 5 minutes (3 words) and ask them to repeat it.

• Abstract Thinking: Ask a patient to compare two objects, or how to interpret a common saying. Literal interpretations indicate concrete thinking.

How is insight assessed during Mental Status Examinations (MSE)?

Insight: How well does a patient understand their situation? It’s important to distinguish if patients understand that their hallucinations aren’t real, or if their depression symptoms are improving. This is subjective.

How is judgment assessed during Mental Status Examinations (MSE)?

Judgment: Can the patient make decisions that are good for them? This may cause patients to not take their medications, leading to worsening symptoms. To assess judgement, treat it like a game of hypotheticals, where you can ask patients what they would do in certain scenarios. This also relates to impulse control and reactivity. This is objective and subjective.

How are nurses meant to ask questions during the Mental Status Examinations (MSE)?

When asking questions, make sure to:

• Use open-ended questions and ask one question at a time to gather the most information and not overwhelm the patient.

• Build rapport while also maintaining professional boundaries.

• Make sure to reinforce understanding by asking follow-up questions.

• Let the patient know they can stop at any time and ask for consent.

• And, also assess your own feelings, either from the patent’s responses, or your potential biases towards the patient.

How is the MSE different from MMSE?

Mental Status Examination: A standardized examination done to assess patient status and the development of mental illness to establish a baseline of functioning. This captures both the objective and subjective signs of mental illness. This is completed during any change in mental status. Mental status is variable and may change frequently.

Mini-Mental Status Examination: An examination tool designed to specifically measure a patient’s cognition, memory, attention, recall, processing, and language.

How are mental status examinations documented?

1. Describe present symptoms only.

2. Use direct quotations, neutral and non-judgement language, and be descriptive while still being objective.

3. Do not use this to diagnose patients, predict their future status, or use it to draw conclusions.

What are the phases of the nurse-client relationship?

1. Pre-Interaction Phase: The nurse must be able to obtain information from the chart and other team members to start their assessment. And, nurses need to manage prior experiences and biases when working with certain populations.

2. Orientation Phase: The nurse and the patient become acquainted, build rapport and trust, make contracts, provide initial assessments, set goals, develop plans to reach goals, and become more comfortable with one another. This is also where we initially establish boundaries and explain the professional relationship. We introduce termination of the relationship at this stage.

3. Working Phase: The nurse maintains the trust and rapport from the previous stage and helps the patient overcome possible obstacles and resistance to help reach goals. This requires continuous assessments to measure progress and providing adequate coping strategies.

4. Termination Phase: This phase happens when goals have been released, when patients go through discharge, or when clinical orientation ends. This is when plans are put in place to continue care after leaving the facility, and when patients and the nurse share their feelings around discharge.

What is the difference between transference and counter-transference?

Transference happens when the nurse reminds the patient of someone from their past, possibly triggering anger or dependency. This may cause resistance from the patient. Addressing behaviors, validating feelings, exploring feelings, and setting boundaries can help to reduce this. Promote autonomy whenever possible to empower patient.

Countertransference happens when the patient reminds the nurse about someone from their past, or from their own past experiences. This can cause the nurse to feel anxious or uneasy about patients' behaviors, or it can cause the nurse to excuse them altogether. It may also cause boundary violations from the nurse. The nurse can separate feelings from the patient by maintaining professional boundaries, engaging in self-reflection, and seeking clinical supervision. Switching assignments is not always the answer.

What are some obstacles to the therapeutic relationship from the nurse?

1. Favoring one patient's care over that of another.

2. Keeping secrets with a patient. 

3. Changing dress style for working with a particular patient.

4. Swapping assignments to care for a particular patient. 

5. Giving special attention or treatment to one patient over others. 

6. Spending free time with a patient. 

7. Frequently thinking about the patient when away from work. 

8. Sharing personal information or work concerns with the patient. 

9. Receiving gifts from or continuing contact or communication with the patient after discharge.

What are some positive examples of therapeutic communication?

• Therapeutic silence. 

• Giving recognition. 

• Offering time to sit with a patient.

• Asking how the patient is feeling. 

• Asking open-ended questions. 

• Being interested in what they are saying. 

• Making observations. 

• Encouraging patients to elaborate. 

• Promoting change and growth.

• Using comparisons in speech. 

• Teach-back or paraphrasing with the patient. 

• Seeking clarification or validation.

• Presenting reality. 

• Voicing doubt. 

• Translating words into feelings. 

• Formulation of a plan of action.

What are some examples of non-therapeutic communication?

• False reassurance. 

• Rejecting the patient. 

• Passing judgement to a patient whether they did the right or wrong thing. 

• Agreeing or disagreeing with the patient. 

• Giving unwarranted advice.

• Probing and asking inappropriate questions that the patient does not want to answer. 

• Defending someone the patient criticizes. 

• Minimizing feelings.

• Using “why” questions.

• Requesting an explanation as to why a patient feels the way they do. 

• Attributing outside sources to the patient’s thoughts. 

• Belittling or minimizing feelings. 

• Using stereotypes and meaningless phrases.

• Using denial against a problem the patient has. 

• Overanalyzing the patient. 

• Introducing an unrelated topic.

How can the nurse demonstrate active listening to the patient using SOLER?

SOLER:

1. Sit squarely facing the patient. 

2. Use open-posture by uncrossing legs and arms. 

3. Lean forward to show that you are involved. 

4. Establish eye contact to show willingness to listen. 

5. Appear relaxed to put the patient at ease.

What are the four phases of a crisis?

Crisis can happen to any person, they have a pattern, they are acute, and they can either cause psychological growth or deterioration:

• Phase 1: The patient is exposed to a stressor.

• Phase 2: The patient has increasing anxiety when previous problem-solving techniques don’t help. 

• Phase 3: All stressors, internal and external, are called on to resolve the problem and relieve discomfort. 

• Phase 4: If resolution doesn’t happen, the tension rises to a breaking point.

What are the types of crises?

1. Developmental Crises: This occurs during a transitional period in someone’s life, or after a major life change.

2. Situational Crises: This occurs from unanticipated loss (relationships, grief, money, mental or physical health) that disrupts equilibrium.

3. Adventitious Crises: This occurs from natural and man-made disasters, including floods, war, riots, plane crashes, murder, child abuse, etc.

What are the phases of crisis intervention?

1. Assessment: The first phase. This is when the nurse asks about the stressor that’s causing crisis; how it happened, when it happened, if it’s happened before, suicide or homicide risk and plan, support systems, coping strategies, any substances they’ve taken, etc. This is gathered to make an appropriate nursing diagnosis. 

2. Planning of Therapeutic Intervention: The second phase. The planning phase, which is when the nurse makes action based on the nursing diagnosis, and starts to establish goals. 

3. Intervention: The third phase. This is when the second phase is implemented. Orient the patient to reality, help with the panic attacks, use active listening, attend to immediate needs, set limits on aggressive behaviors, acknowledge feelings without judgement, identify external support systems, and guide them through the problem solving process.

4. Crisis Resolution and Planning: The fourth phase. The nurse should assess the patient to see if positive behavioral changes occurred, if they developed adaptive coping strategies, if they have grown, if they can reduce the chance of future crisis, and if they have a plan of action.

   1. The goal is to restore the patient to their baseline functioning at a minimum.

What is an amygdala hijack? What can be done to help it?

Amygdala Hijack: When the emotional center of the brain reacts before the rational part (prefrontal cortext) can analyze it. This causes patients to have emotional struggles, and causes them to struggle with complex instructions.

• Label the emotion to bring attention to the prefrontal cortex.

• Use a lower voice and speak slowly.

• Use 5-4-3-2-1 or other mindfulness exercises.

What are some facts regarding suicide risk?

The Facts:

• Suicide can affect anyone! They don’t have to have a mental disorder.

• Suicidal feelings are often not permanent.

• There are often signs leading up to the suicidal event.

• Talking openly about suicide can decrease suicidal feelings.

• Reducing access and providing crisis management can decrease suicide risk.

What are some risk factors that increase the likelihood of suicide?

1. Mental Health History: Mental illness increases the risk of suicide tenfold. People that have previously been hospitalized for mental illness also have a higher risk, and suicide happens more often after a patient is discharged from an ER or mental health facility. This can also happen with mental health medications (black box warning). ACE and abuse and neglect history should be noted. The highest risk is a previous suicide attempt.

2. Chronic Illness: Almost 10% of individuals with chronic pain have had a previous suicide attempt.

3. Individual Life Stressors: Unemployment and lower socioeconomic status have increased risk of suicide. Individuals in rural areas have more access to firearms. Low education increases attempts between young men and women. 

4. Marital and Relationship Status: Widowers, divorced men, and socially isolated people are at an increased risk of suicide. If a major relationship status changes suddenly it can cause crisis.

5. Community Stressors: Discrimination, community trauma, lack of access to healthcare, and other suicides in an area increase risk.

6. Societal Stressors: Stigma, easy access, and media portrayals of suicide increase risk.

What are some protective factors that decrease the likelihood of suicide?

1. Coping strategies.

2. Support systems.

3. Conflict resolution.

4. Cultural identity.

5. Healthy relationships.

6. Religious beliefs.

7. Reduced access.

8. Healthcare access.

What are some of the warning signs of suicide?

First signs include:

• Talking about wanting to die.

• Feeling like a burden.

• Experiencing pervasive guilt or shame.

• Crisis-level emotions.

• Unbearable pain.

Later signs include:

• Making active plans.

• Giving away possessions.

• Impulsivity and risk-taking.

• Increased substance abuse.

• Extreme mood swings.

How can we use IS PATH WARM to determine suicide risk?

! - Ideation.

S - Substance abuse.

P - Purposelessness.

A - Anger.

T - Trapped.

H - Hopelessness.

W - Withdrawal.

A - Anxiety.

R - Restlessness.

M - Mood.

How can we ask questions to assess suicide risk?

CASE is a guide used to provide detailed information and feedback from sensitive conversations, like suicide. This is done through:

• Be direct when suicidal ideation is present. “Have you thought about suicide?”

• Ask about plans. “Do you have a plan to end your life?”

• Asking about behavioral events directly. “What did you do when ___…” “What happened next?”

• Gentle assumptions. “What other times have you felt like this?”

• When being denied, ask more specific questions. “[When, where, how] do you plan on ending your life?”

• Go through events chronologically. “What happened in the past? What happened before coming to the hospital? What’s happening now?”

What are some ways that nurses can create safe environments for suicidal patients in acute care settings?

• Ask about intent.

• Ongoing evaluations.

• Remove dangerous objects.

• Extra supervision during meals. 

• Perform room searches. 

• Maintain close observation of the patient. 

• Overlook medications carefully. 

• Use unpredictable rounding. 

• Encourage honesty regarding feelings. 

• Allow active participation in own care.

• Educate about feelings, strengths, and empathetic listening.

• Develop a safety plan.

• Use restraints if needed.

  • Never give a no-suicide contract.

What are the two types of coping strategies?

• Coping skills are the conscious efforts we use to help with everyday problems that are intentional and purposeful. These can be developed and strengthened over time. 

  • Can be constructive or maladaptive.

    • Mindfulness and social support, or substance abuse and avoidance. 

What is a defense mechanism?

Defense Mechanisms: Processes our minds do to protect us from emotional discomfort. This happens due to conflicts and perceived threats, which is often unconscious. Utilized by almost everyone, this provides immediate relief. 

• Primitive (immature and child-like), neurotic or less primitive (not processing emotions and teenager-like), and mature (transform thoughts into acceptable forms).

What are 10 examples of defense mechanisms?

1. Rationalization: Making excuses to justify behaviors.

2. Displacement: Directing anger to things besides what it causing the anger.

3. Regression: Returning to a previous stage of development.

4. Introjection: Copying others without thought of your own opinion.

5. Suppression: Choosing to push down unwanted thoughts through conscious avoidance.

6. Reaction Formation: Giving the opposite intended reaction to something.

7. Intellectualization: Dealing with distressing situations by focusing on logic.

8. Repression: Keeping unacceptable thoughts or traumas buried.

9. Undoing: Trying to reverse the damage from a previous situation through grand gestures.

10. Sublimation: Transforming unacceptable thoughts.

What are the characteristics of mild anxiety?

Mild anxiety causes increased awareness, sensory perception, and learning, but can cause some restlessness and irritability. This form is often not a problem and comes from day-to-day living.

• Stimming, exercising, caring for basic needs, and talking with someone can relieve symptoms.

What are the characteristics of moderate anxiety?

Moderate anxiety causes reduced alertness, attention, concentration, and learning, while causing increased restlessness and other physical symptoms (heart rate, sweat, GI upset, tension) and increase in speech rate and tone.

• Sigmund Freud notes that we have ego defense mechanisms in the face of threat, which is often maladaptive (like denial, displacement, intellectualism, isolation, projection, etc.).

• If anxiety stays at this level over long periods, it can cause physical or mental illness to develop.

What are the characteristics of severe anxiety?

Severe anxiety causes more severe symptoms of moderate anxiety. This includes dread and horror, along with total focus on the self. This manifests with headache, nausea, insomnia, palpitations, tachycardia, etc. Neurosis happens when excessive anxiety is expressed through defense mechanisms.

• They know they are in distress, but they feel helpless to change their situation.

What are the characteristics of panic anxiety?

Panic anxiety causes the complete inability to focus, learn, concentrate, comprehend, or verbalize. This causes feelings of impending doom and terror, along with shouting, screaming, and extreme withdrawal. Physical symptoms include hallucinations, dilated pupils, labored breathing, trembling, muscle incoordination, immobility, incoherence.

• Patients can lose contact with reality and enter psychosis.

• This can be life-threatening if this stage is prolonged.

What is generalized anxiety disorder?

Persistent and unrealistic anxiety that happens more days than not for 6 months (non-caffeine or thyroid related). This can cause patients to feel easily fatigued, have trouble with concentration, irritability, tenseness, and have trouble with sleep. This is enough to cause impairment in functioning and disrupt everyday life.

What is panic disorder?

A recurrent, unexpected attack that causes worry and/or maladaptive behaviors. Attacks can last minutes to hours, and can cause apprehension when an attack is currently not in place. Patients may experience palpitations, sweating, shortness of breath, trembling, choking, nausea, derealization, a fear of dying, or other symptoms. It can take days or months for another attack to happen. Remission and exacerbation is common, causing functional impairment in everyday life.

What are specific phobias?

Excessive fears of objects or situations that could conceivably cause harm, but the reaction is excessive. This has to impact daily living. Exposure to the phobia causes overwhelming panic and despair, even when just thinking about it. These can begin at any age, and ones that last into adulthood often require therapy; though, people seldom ask for treatment.

What is agoraphobia?

Fear of being in open, public spaces, including vulnerability and feeling unable to escape. This can cause panic symptoms while in a public place, and it can cause fear in-between episodes. Patients may fear public transport, enclosed spaces, bring in line, or being outside alone. Some individuals become completely confined to their home. 

What is social anxiety disorder?

An excessive fear of situations that may cause embarrassment or be seen negatively by others. This includes social actions, being perceived, or not conforming to social norms.

What is obsessive compulsive disorder?

A disorder that causes obsessions (intrusive thoughts), compulsions (ritual behaviors), or both, which causes distress and difficulty with daily functioning. Thoughts and rituals often last over 1 hour every day and are time consuming. The person knows the thoughts are unreasonable, but feels unable to stop with obsessions and/or compulsions.

What is post-traumatic stress disorder?

A condition caused from enduring a traumatic event, which are events that could distress almost anyone. Symptoms include a high level of anxiety or arousal, persistent nightmares, dissociative reactions or flashbacks, feelings of guilt or shame, and a numbing of responsiveness. It is possible to forget pieces of the traumatic event. It can either be developed first-hand, second-hand, or through details of a traumatic event from another person. Depression is common with this disorder, along with substance abuse, aggression, and relationship problems. Symptoms must be present longer than 1 month, and may begin within 3 months after the traumatic event (anything prior is considered acute stress disorder). 

What are some strategies for managing anxiety?

• Avoiding substances that contribute to anxiety, like caffeine and nicotine.

• Engage in relaxation techniques, like deep breathing, meditation, and exercises.

• Promote healthy diet and adequate sleep.

• Encourage alternative therapies (yoga, aromatherapy, massage, acupuncture).

• Suggest therapy through CBT, relaxation response therapy, etc. Combining therapy with medication makes it more effective.

• Practice coping skills, like PMR.

What are the main medications used for anxiety (anxiolytics)?

1. SSRIs (sertraline) are serotonin reuptake inhibitors that allow serotonin to stay in the synapse for longer periods of time to boost mood. These are the first line treatment for anxiety.

• Indications:

• Adverse/ Side Effects:

• Key Considerations:

2. SNRIs (venlafaxine) are serotonin and norepinephrine reuptake inhibitors that allow for each to stay in the synapse for longer. These are less effective than SSRIs but are still safe for usage.

What are benzodiazepines used for?

Benzodiazepines (alprazolam, lorazepam, diazepam) are CNS depressants that intensify the effects of GABA, producing anxiolytic effects.

• Indications: These provide relief from severe acute distress in the short-term for anxiety disorders, alcohol withdrawal, insomnia (hypnotic/sedative), muscle relaxation, and agitation from psychosis (given alongside antipsychotic).

  • These drugs are given until SSRIs become effective, which may take at least a month.

• Adverse/ Side Effects: These medications have a risk of abuse/dependence/withdrawal (Schedule IV). It may also cause patients to develop cognitive difficulty and excess sedation, making it riskier to take in older adults (caution with driving, machinery, activity). They also have a high risk for respiratory depression. After ceasing usage, rebound anxiety can occur; can worsen depression.

• Key Considerations: Do not take this medication with alcohol or it will increase risk of respiratory depression. Patients with ASPD and BPD are at a higher likelihood of abuse. Taper medications slowly.

What is buspirone used for?

Buspirone (buspar) is a serotonin partial agonist used in long-term treatment through an unknown MOA.

• Indications: Used for long-term anxiety. This medication has a lag period of 7-10 days.

• Key Considerations: Provide consistent administration with or without food. No risk of tolerance/dependence/abuse.

What antihypertensives are used for anxiety?

1. Prazosin (minipress) is an alpha 1 receptor blocker that is primarily used in the treatment of nightmares for post-traumatic stress disorder.

2. Propranolol (inderal) is a beta 1 and beta 2 receptor blocker that is primarily used in the treatment of social/performance anxiety through lowered heart rate and tremors. This should be given 1 hour before the triggering event.

3. Clonidine (catapres) is an alpha 2 agonist that reduces autonomic symptoms in patients with anxiety by reducing sweating and palpitations.

Which medications help with sleep?

1. Benzodiazepines.

2. Z-Drugs (zolpidem, zapelon, eszopiclone) are medications that are non-benzodiazepine hypnotics. Zolpidem and zapelon are used for short-term insomnia, causing drowsiness within 1 hour, with symptoms of sedation, dizziness, ataxia, amnesia, nervousness, and hallucinations as side effects. These are not absorbed well with food. Eszopiclone is safer for long-term use.

1. Trazodone is a depression, anxiety, and insomnia medication that can cause sedation, ataxia, and feelings of intoxication.

2. Antihistamines (diphenhydramine, hydroxyzine) can cause sleepiness, with benadryl causing drug-induced parkinsonism at times. These can also be used for anxiety, like in the case of hydroxyzine.

3. Melatonin.

What are important nursing considerations for anxiety medications?

• Inform patients about the dangers of abrupt withdrawal symptoms.

• Let patients know to take caution when driving or operating machinery when taking medications, or tell them to stop it altogether.

• Let patients know to not drink alcohol and be aware of black box warnings.

• Inform patients about increased suicide risk. 

• Educate the patient about keeping safe with orthostatic hypotension. 

• Tell the patient to contact the provider if they have paradoxical excitement, sore throat, fever, bruising, unusual bleeding, or if the patient is pregnant.