Psych/Mental Health Exam 1

Mental Health

foundational for:

• emotions

• thinking and learning

• communication

• relationships

• daily functioning

VITAL TO THE ABILITY TO INTERACT, THINK, AND HAVE A FULFILLING LIFE

cannot be HEALTHY without being MENTALLY HEALTHY

Mental Illness

DISABILITY = a physical or mental impairment that substantially limits major life activities

results in change in:

• emotions

• thinking

• behavior

associated with distress/problems in daily functioning

• social relationships

• work or school

factors associated with increased risk:

• traumatic life experience

• biology/genetics

• substance use

• loneliness/isolation

Mental Health Disorders

characterized by a group of clinical manifestations

examples:

• neurodevelopmental disorders

• neurocognitive disorders

• anxiety disorders

• eating disorders

Mental Health Continuum

Well-Being = experiencing an absence of mental illness

• Excelling = mental wellness… absence of mental illness symptoms

• Thriving = stress does not cause significant daily impairment

• Surviving = not a state of distress, but may need action… feel “on edge”

• Struggling = significant struggle, worry and misery on daily… worthlessness

• Crisis = severe clinical manifestations of mental illness + disruption of functioning

Mental Illness = difficulty functioning

Wellness

being in good physical and mental health; not the absence of disease

8 Dimensions of Wellness

• emotional

• spiritual

• physical

• intellectual

• environmental

• occupational

• financial

• social

Diathesis-Stress Model

Diathesis = genetics/biological predisposition for developing an illness

Stress = change in environment which may precipitate manifestations of mental illness

Impact = increased risk for developing a mental disorder linked to combination of genetics + stressors

EXAMPLE

Diathesis = Hx depression on paternal side

Stress = job loss + divorce

Impact = development of major depressive disorder

SAMSHA’s 8 Dimensions of Wellness

Emotional = coping with stress through skills + strategies

Social = developing a sense of connection + support system

Physical = recognizing the need for physical activity, diet, and nutrition

Intellectual = recognizing creative abilities + finding ways to expand knowledge

Environmental = occupying pleasant, stimulating environments to support well-being

Spiritual = search for meaning and purpose in human experience

Financial = satisfaction with present and future situations

Occupational = personal satisfaction and enrichment from one’s work

Social Determinant of Mental Health

CONDITIONS A PERSON LIVES IN + HOW IT IMPACTS MENTAL HEALTH

environmental factors = weather, housing, resources

genetics/behaviors = disability

socioeconomic = racism, job loss, divorce, education

contributing factors:

• life course = exposure to events at critical stages throughout life… ACEs (adverse childhood experiences)

• household = income, food, water, paternal health, social support

• community = violence, security, crime, natural environment

• local services = schools, health services

• community + glovbal = human rights, healthcare access, poverty, disasters

Stigma

a negative attitude or discredit against an individual/group in which the individual/group is labelled as different

public = there is a negative attitude toward those with a mental illness, expressed with discriminatory words + actions

self = an individual adopts internalized shame about condition… sees as a flaw

institutional = policies or organizations limit opportunities for those with mental illness

Bias

includes stereotyping, prejudice, and discrimination against a group of people that is unfair, often resulting in unfair treatment

• stereotyping = generalization about a group

• prejudice = preconceived belief not based on facts

• discrimination = unjust treatment

implicit bias = bias outside of conscious awareness

explicit bias = intentionally displaying discrimination

DSM-5

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS

defines and diagnoses mental health conditions in a common language

• does not teach how to treat or medicate

Cultural Humility

the practice of trying to appreciate and respect another’s culture and the role it plays in the individual’s life and health practices

client-centered care

Beneficience

obligation to act in a manner of DOING GOOD

Autonomy

clients should have ability to make rational decisions for themselves

Nonmaleficence

doing NO HARM

Justice

fair and equal care for ALL clients

Self-Determination

allows a client to refuse treatment

Confidentiality

ensuring privacy of information

Fidelity

keeping trust/a promise

Mental Health Parity and Addiction Equity Act

laws require EQUAL COVERAGE of mental + physical illness

Health Insurance Portability Accountability Act (HIPAA)

protects sensitive information that cannot be disclosed without consent

Duty to Warn

responsibility to warn when there is a threat from a client to cause harm to another

ex: a client says “tomorrow when my mom comes home, I am going to stab her with a kitchen knife”

Mandated Reporter

nurse is required to report when a vulnerable population is threatened/abused

threatened populations = elderly, children, disabled

Therapeutic Milieu

milieu = healing environment

MANAGE ENVIRONMENT TO PROMOTE HEALING + LIFE SKILLS IN A SAFE ENVIRONMENT

creating a therapeutic milieu:

• trauma-informed care

• physical, emotional, and psychological SAFETY

• open expression of feelings

• development of trust

• consistency

• self-management

nurse should allow for autonomy, safety, and orientation to the unit

Ethics

system of moral principles governing conduct

• relies on culture, personal values, and values of profession

principles:

• autonomy

• nonmaleficence

• beneficence

• fidelity

• veracity

• justice

• confidentiality

• informed consent

Code of Ethics

guides nursing ethics

• practice

• commitment and duty to society

• decision-making

Informed Consent

competency must be determined if client is undergoing an exacerbation of illness

must include:

• description of treatment

• possible benefits

• possible risks

• alternative treatments

• possible consequences of not receiving treatment

client CANNOT provide informed consent if:

• deemed legally is mentally incompetent

• alternate decisionmaker

Implied Consent

occurs in an emergency situation

• client unconscious

• unable to provide informed consent

assumes client action demonstrates willingness for treatment

Psychiatric Advanced Directives (PAD)

allows client with a mental illness to outline wishes before a mental health crisis

• surrogate decision-maker

• treatment choices

• medication choices

• choice of provider

De-Escalation Strategies

FIRST STEP TOWARD ASSISTING A CLIENT TOWARD SELF-CONTROL + MAINTAINING A SAFE + THERAPEUTIC MILIEU

directed at reducing a client’s agitation or aggression

• use clear and calm communication

• ensure body language is nonthreatening

• approach client with respect by being supportive of their concern

• create a sense of trust

• set clear limits or boundaries

• make a therapeutic environment- reduced sound, calm activity, lower lighting

Interventions: Timeout, Seclusion, and Restraints

timeout = allows client time to think, calm down, and prepare to control behavior

seclusion = involuntary confinement that prevents the person from leaving… usually in case if self-harm or harm of others

restraints = physically or chemically restricting movement + freedom

Physical Restraints

a manual method, mechanical device, or physical material/equipment that reduces movement or the ability of a client to move arms, legs, or body freely

Chemical Restraints

a substance or drug used to restrict movement or manage a client’s behavior or restrict their freedom

Restraint Protocol

protocol:

• provider order

• continuous focus on client well-being

• observation and client response

• care of basic needs

• release from restrains as soon as safe

Restraint Documentation

• prescription from provider

• behavior leading up to restraint use

• indication that de-escalation was attempted

• type of restraint

• interventions + client response

• ongoing + continuous monitoring every 15 mins

• plan for discontinuation

Restraint Care

• reassurance of safety

• skin and circulation assessment

• hydration, food, and elimination

• ROM

• medications

Least Restrictuve

de-escalation

timeout

seclusion

restraints

Voluntary Admission

at the request of the client

needs signed consent form

client recognition of need for care

ex: Sarah (28yo F) has been hearing voices telling her to kill herself, so she requests admission into a hospital and signs consent form

Involuntary Admission

client is at least one:

• danger to self

• danger to others

• unable to meet basic self-care needs

• mental illness prevents recognition or need for care

Physician’s Emergency Certificate (PEC) needed within 72 hours… document needing a legal healing to stay or leave

ex 1: Bob (30yo M) is walking up and down the street talking to himself and threatened to attack a police officer

ex 2: Miley (18yo F) confided in her friend that she is planning on killing herself with chemicals that night

ex 3: Jane (25yo F) has not left her house in a month, with no hygiene and nutritional needs met due to her depression

ex 4: Dylan (29yo M) is in a manic state where he cannot recognize his need for hospitalization

Emergency Admission

temporary admission

client imminent danger to self or others

for evaluation of mental illness

ex: James (24yo M) assaults a police officer in a manic state and attempts to kill himself

Client Rights to Privacy

confidentiality + privacy

exceptions:

• danger to self (suicidal)

• duty to warm (patient plans to harm another)

• evidence of abuse/reported abuse (against or perpetrated by client)

Client Rights to Treatment

right to treatment regardless of ability to pay

right to refuse treatment based on cost, lack of understanding, second opinion, serious mental illness

least-restrictive setting

Self-Awareness

the process of understanding one’s own beliefs, thoughts, motivations, biases, and limitations and recognizing how they affect others

look introspectively… what are my own biases + beliefs?

Peplau’s Therapeutic Relationship (Nurse-Patient)

pre-orientation

• recognize needs of client

• self-evaluation of beliefs + behaviors

orientation

• collect data, assess knowledge

• work with client to develop mutual goals

working

• nurse and client have established a mutual level of trust + comfort

• work toward goals together

termination

• original goals met

• improvement in self-reliance

• relationship ends

Techniques that PROMOTE Communication

• acceptance

• non-judgement

• observation

• open-ended questions

• active listening

• validation

• reflection

• clarifying

• silence

Barriers to Effective Communication

• advice

• agreement

• challenges

• false reassurance

• why questions

Therapeutic Communication

principles:

• client as primary focus

• non-judgmental attitude

• no advice

• no social relationships

• client confidentiality

• limit self-disclosure

Defense Mechanisms

psychological mechanisms that help individuals respond to and cope with difficult situations, emotional conflicts, and external stressors

Nonverbal Communication Strategies

need facial expressions to match tone + voice

Sit squarely to client

Open posture

Lean forward

Eye contact

Relax

Verbal Communication Strategies

open-ended questions

• keeps conversation going

affirmations

• convey support and encouragement

reflections

• restate what client said to confirm understanding

• simple = restate what client said with different words

• complex = attempt to convey what you think a client is feeling

summaries

• restate concepts to transition or close interview

Transference

client displaces feelings and past experiences towards nurse

ex: patient was mistreated by a nurse and now is hostile to all

ex: child lost mother young and clings to a maternal-feeling nurse

Countertransference

nurse displaces feelings and past experiences onto client

ex: nurse assumes a manic patient will be violent after a previous patient

Interview Techniques

determine goal + consider any challenges to gathering information

clarification = “tell me more about your current thoughts”

probe assumptions = “i wonder how someone would explain this belief”

probe reasons = “what do you think causes this to happen”

probe viewpoints = “what are the strengths of…”

probe implications = “what might be the consequence of…”

Suicide Phone Numbers

National = 988

CT = 211

Nursing Process

Assessment

Diagnosis/Analysis

Planning

Implementation/Intervention

Evaluation

Clinical Judgement Action Model

• recognize cues

• analyze cues

• prioritize hypothesis

• generate solutions

• take actions

• evaluate outcomes

Assessment

recognize clues

• affect

• mood

• orientation

• speech

• behavior

• thoughts

• appearance

physiologic status = is patient able to participate in assessment

physical health = medical clearance, labs, comorbidities r/o (withdrawal, infection, active drug use)

patient history = demographics, HPI, health hx, coping strategies, beliefs, current meds

PHYSICAL ASSESSMENT

• dental health (gums + teeth) → malnutrition, drug use, med SE

• eye health → ototoxic meds, psychotropic meds

• sexual health → STIs, hx abuse

SUBSTANCE USE

• tobacco, alcohol, opioids, street drugs

• current use, amount

PSYCHOLOGICAL

• MSE

• risk for suicide

• current treatments

• coping skills

Mental Status Assessment

allows determination of patient risk for:

• inability to care for self

• self-harm

• suicide

• harm to others

• child welfare

ABCT

Appearance

what they look like:

• grooming

• facial expression

• tremors

• dress

• skin condition

• identifying characteristics

• scars

• age

• body build

• position

• alertness

• affect

psychomotor:

• gait

• pacing

• crying

• withdrawn

• angry

• suspicious

• eye contact

Behavior

physical:

• pacing

• crying

• threatening

• tremors

• grimacing

speech:

• loud

• quiet

• slurred

• pressured

• incoherent

• stuttering

• mute

self-care:

• appetite good or bad

• sleep good or bad

Cognition

orientation = time, place, person

LOC = lethargic, drowsy, hypervigilant

mood = depressed, euphoric, labile

memory = impaired, intact

concentration = poor/good

judgment = poor/good

insight = none/limited/good

Thoughts

content:

• suicidal

• homicidal

• guilt

• worthlessness

• hopelessness

• ruminations

• phobias

• hallucinations

process:

• coherence

• logical

• flight of ideas

• tangential (jumping)

Holistic Assessment

family function

community needs

spirituality

cultural

situational

Analysis

analyzing cues

• recognize patterns

• link cues

• determine what is concerning

prioritize problems

• narrow possibilities

• determine order of prioritizes → Maslow

• risk

• problem list

use the DSM-5 to define and diagnose

Planning

generating solutions

• what is best outcome

• what care is needed (resources, people)

• collaborate with client + family to set goals

discharge planning

• begins at diagnosis

Implementation

take action

recovery framework

• wellness is not absence of disease

public health model

• primary = prevent → vitamins to prevent dementia

• secondary = screening → screen teens for depression

• tertiary = treat → prevent decline

IOM Model

• universal = everyone → class at school about mental health

• selective = those affected → group therapy

• indicative → those at high risk → treatment

Evaluation

did the interventions help the client achieve their goals?

• revise care plan as needed

• oversee treatments

• review interventions for efficacy

Freud

childhood experiences influence adult personality and life

transference + countertransference

• transference = patient projects biases/memories onto HC worker

  • ex: a patient is afraid of therapy because of mistreatment from a former HC worker

• countertransference = HC worker projects biases/memories onto patient

  • ex: a therapist is especially chatty with a patient who reminds them of a friend

defense mechanisms

• unconscious assists the ego in dealing with threats that cause a state of anxiety

Id, ego, superego

• Id = instant gratification through desires… DEVIL

• Superego = morals and what is right and wrong… ANGEL

• Ego = rational balance… DECISION-MAKER

psychosexual development

• stage 1 = oral (0-1yr) → oral gratification

• stage 2 = anal (1-3yr) → toilet training

• stage 3 = phallic (3-6yr) → pleasure via genitalia, fixation to caregiver

• stage 4 = latency (6-12yr) → act on impulses, libido repressed

• stage 5 = genital (13-18yr) → seeks independence, sexual desires, ego developed

Bandura

modeling = learning through imitation

self-efficacy = can deal with own issues w/ self-motivation

Skinner

operant conditioning

positive consequences vs negative consequences

Maslow

humanistic theory

NEED TO MEET MOST BASIC NEEDS BEFORE YOU CAN MOVE ONTO OTHERS

self-actualization = development of full potential

esteem needs = self-worth, positive self-image

love + belonging needs = affection + acceptance, intimacy

safety + security needs = shelter from harm, predictable environment

physiologic + survival needs = air, food, water, shelter, sleep, sex, exercise

Peplau

nurse-patient relationship

• pre-operative

• operative

• working

• termination

empathy

anxiety spectrum + response

• adaptive + maladaptive responses

Orem

self-care deficit- need to provide for a patient until they can provide for themself

Erikson

psychosocial development- NEED SUCCESS IN A STAGE TO MOVE ON + DEVELOP WELL

infancy = trust vs. mistrust

• birth to 18 months

• basic trust with primary caregiver developed

early childhood = autonomy vs. shame and doubt

• 18 months to 3 years

• self-control and interdependence… potty training important

late childhood = initiative vs. guilt

• 3 years to 6 years

• sense of purpose and can guide own activities

school age = industry vs. inferiority

• 6 years to 12 years

• self-confidence achieved though learning, performing tasks, and recognition

adolescence = identity vs. role confusion

• 12 years to 20 years

• developing an understanding of oneself

young adult = intimacy vs. isolation

• 20 years to 30 years

• forming relationships resulting in love and lasting bonds

middle adult = generativity vs. stagnation

• 30 years to 65 years

• ability to achieve life goals

maturity = ego integrity vs. despair

• 65 years to death

• reviewing life and finding purpose

continued aging = transcendence

• 80 years and older

• development of purpose and spirituality

Cognitive Theory

choice contends that human behaviors are influenced by an individual’s thought process

Social Cognitive Theory

social situations influence how a person thinks and behaves… peer pressure

Humanistic Theory

people are innately good and see the world based on their own experiences

Interpersonal Theory

talking with therapeutic communication

helps people feel better by improving their relationships and communication with others

effective for depression

Cognitive Therapy

based on the concept that problems, distorted thought pattern causes negative emotions, can lead to maladaptive behaviors

Cognitive Behavioral Therapy

unhealthy thinking → unhealthy behaviors → unhealthy patterns of living

goals:

• recognize unhealthy thought patterns

• learn new ways of thinking + coping

• gain healthy thoughts and behaviors

EFFECTIVE FOR DEPRESSION + ANXIETY

teaches patients to identify negative thoughts, recognize they are distorted, and help replace them with more positive thoughts

Dialectal Behavior Therapy

helps people with emotional regulation difficulties to improve coping and emotional regulation

CHIME

C = connections to others

H = hope for the future

I = identity… sense of self

M = meaning and purpose in life

E = empowerment… control + autonomy in life

Neurobiological Causes of Mental Illness

neurobiology- studies how the functioning of the brain impacts behavior

genetics- family study (genetic Hx), adoptive study (same environment different genes), twin study (genetic identical + behavior)

psychiatric pharmacogenomic testing- selecting a med based on genes + pharmacokinetics

stress- psychoimmunology… how stress impacts the immune system → process of neurotransmission

infection- may be link between viral infection + CNS alteration → mental illness

neuroplasticity- brain’s ability to adapt synaptic connections in response to stress, learning, or injury

Neuroplasticity

1. neurons first respond to a new stimulus by making chemical changes

2. structural change occurs to better support new stimulus

3. brain experiences change through utilization of new neuronal pathways

Neurons

cells that are prevalent in the brain and have a role in sending and receiving electrochemical messages

Neurotransmitter

chemical components that the neuron sends and receives which can excite or inhibit processes in cells by key and lock

Neurotransmission

KEY AND LOCK

presynaptic neuron releases a neurotransmitter KEY → goes through synapse → postsynaptic neuron has a receptor LOCK → neurotransmitter KEY binds to receptor LOCK → instructs postsynaptic neuron on how to function → neurotransmitter is reuptake/deactivated/inactivated

Serotonin

function = emotional regulation, sexual behaviors, temp regulation, sleep, pain management

action location = brain and gut

clinical relevance = LOW levels linked to DEPRESSION

domains = depression, obsession, migraines, anxiety, intestines, nausea, sexual side effects

SEROTONIN CONTROLS MOOD

INHIBITORY

Dopamine

function = movement, cognition, emotion, motivation, reward center

action location = brain

clinical relevance =

• LOW levels linked to Parkinson’s (movement problems)

• HIGH levels linked to Schizophrenia

domains = drugs, psychosis, prolactin, attention, motivation, involuntary movements, nausea, energy

DOPAMINE CONTROLS MOVEMENT + MOTIVATION

EXCITATORY

Norepinephrine

function = involved in fight or flight… controls alertness, focus, blood pressure

action location = brain and sympathetic ns

clinical relevance =

• LOW levels linked to depression

• HIGH levels linked to anxiety or stress

NOREPINEPHRINE ACTIVATES THE BODY

EXCITATORY

Histamine

function = keeps you awake and alert, regulates sleep-wake cycle, linked to learning + memory

linked to gastric secretions + allergic response

HISTAMINE MAKES YOU AWAKE + ALERT… antihistamines make you sleeepy

GABA

function = sloooows brain down → sleep + relax

clinical relevance =

• LOW levels linked to anxiety, sleep issues

drugs that work on GABA = benzos, barbiturates, alcohol

INHIBITORY

Glutamate

function = EXCITATORY, linked to affective + cognitive functioning, learning + memory

Acetylcholine

function = controls muscle contractions, learning, memory, attention

clinical relevance =

• LOW levels linked to Alzheimer’s