PSYCH EXAM 1

Basics of DSM-5

mental disorders are considered a manifestation of:
- behavioral
- psychological
- biological dysfunction

Prevalence of any mental illness

- 52.9 million adults
- women 21.7%
- men 14.5%
- 18 to 25 22.1%
- multiracial 35.8%

Average delay between onset of symptoms and treatment for any mental illness

10 years

Prevalence of severe mental illness

- 14.2 million adults
- women 5.3%
- men 3%
- 18 to 25 16.5%

Prevalence of anxiety disorder

19.1%

Prevalence of major depressive episode

8.4%

Prevalence of PTSD

3.6%

Prevalence of bipolar disorder

2.8%

Prevalence of borderline personality disorder

1.4%

Prevalence of OCD

1.2%

Prevalence of schizophrenia

Correlation between prevalence percentage and severity of illness

Percentages increase with a decrease in severity

Erickson stages of development

- trust vs mistrust (0-1.5)
- autonomy vs shame and doubt (1.5-3)
- initiative vs guilt (3-5)
- industry vs inferiority (5-12)
- identity vs role confusion (12-18)
- intimacy vs isolation (18-40)
- generativity vs stagnation (40-65)
- ego integrity vs despair (65+)

Why is it important to know Erickson for psychiatric and mental health patients?

- failures at one stage and be rectified at another
- determine what types of interventions are most likely to be effective

Why is it important to know a person's locus of control?

- find their motivation to improve their health
- internal will be self motivated
- external needs more guidance from outside sources

What is Maslow's hierarchy of needs?

1. Physiological needs
2. Safety and Security needs
3. Love and Belonging Needs
4. Self esteem
5. self actualization

Why is it important to know Maslow's hierarchy of needs?

- prioritize nursing actions
- focus on physiological and safety needs first when clients are acutely ill

What is Peplau's theory?

- the focus is on interpersonal relations between the nurse and client, and the development of the nurse-patient relationship
- as a nurse you serve as a resource person, counselor, and surrogate.

What are the phases of Peplau's theory?

- orientation
- working
- termination

What is the purpose of MMSE?

measures cognitive function and impairment

How is MMSE applied?

- orientation to time and place
- attention spam
- ability to calculate counting backwards
- recall ability
- language
- screens for dementia, severity and progression of a disease

What is level of consciousness?

how aware, alert, and awake the person is of his environment

What is mood?

subjective from the patient

What is affect?

what you are observing about behavior

Boundary settings

- transference (patient views the nurse as having characteristics of another person who has been significant in their life)
- countertransference (nurse displaces characteristics onto the patient)

Validation

- acknowledging the emotions without judgement
- Separate from the action
- Needs empathy

Is silence therapeutic?

yes

Is active listening therapeutic?

yes

What are the types of questions a nurse can ask that are therapeutic?

- open ended
- close ended
- projective
- presupposition

Open-ended questions

allows for spontaneous response and more interactive discussion

Close-ended questions

helpful if used sparingly to obtain specific information

Projective questions

"what if" to assist in exploring feelings

Presupposition questions

explores motivations and goals with a hypothetical question in which the patient does not have mental illness

Restating

- uses the client's exact words
- let the patient know whether an expressed statement has or hasn't been understood

Reflecting

- Directs questions or feelings back to patient so they may be recognized and accepted
- Mirroring

Paraphrasing

restating the person's message in your own words to confirm what has been communicated

Exploring

- Delving further into a subject, idea, experience, or relationship
- Goes back to a phrase or word that they said earlier

Offering general leads

- broad opening statements
- allows patient to select topic

Show acceptance

conveys positive regard

Focusing

taking notice of a single idea or even a single word

Giving information

Providing, in a simple and direct manner, specific factual information the client may or may not request

Presenting reality

clarifying misconceptions that client may be expressing

Summarizing

- Emphasizes important points and reviews what has been discussed
- Great for wanting to switch the topic without minimizing what y'all just talked about

Offering self

Demonstrate genuine willingness to spend time with patient

Touch

- Advanced technique, important to get consent and be aware of outside pressures
- Usually avoid

Making observations

verbalizing what is observed or perceived
- works better when you know the patient well

Encouraging

- Encouraging descriptions of perceptions

Voicing

- Voicing doubt and expressing uncertainty
- Invalidating their perception not their feelings

Formulating

- Formulate a plan of action
- Striving to prevent anger or anxiety from escalating
- Include them in the process and helps you figure out what works for them

Non-therapeutic communication

- asking irrelevant or personal questions
- offering personal opinions
- giving advice
- giving false reassurance
- minimizing feelings
- changing the topic
- "why" questions
- offering value judgments
- excessive questioning
- giving approval or disapproval
- rejecting
- agreement

Non-verbal communication

- attention
- posture
- gait
- facial expressions
- eye contact
- gestures
- sounds
- territoriality
- personal space
- silence
- these can vary between cultures and groups

Altruism

- defense mechanism
- reaching out to others

Sublimation

- defense mechanism
- dealing with unacceptable feelings/impulses by unconsciously substituting them with acceptable forms of expression
- ex: channeling anger into sports

Suppression

defense mechanism where we voluntarily deny unpleasant thoughts and feelings
- this is a choice
- ex: person having no recollection of childhood abuse

Repression

defense mechanism that unconsciously puts unacceptable ideas, thoughts, and emotions out of awareness
- ex: a man is jealous of his friend's success and is unaware of his own jealously

Regression

- defense mechanism
- sudden use of childlike/primitive behaviors that do not correlate with developmental level
- ex: adults throwing tantrums when upset

Displacement

- defense mechanism
- shifting feelings related to an object, person, or situation to another less threatening object, person, or situation

Reaction formation

- defense mechanism
- overcompensating or demonstrating the opposite behavior of what is felt

Undoing

- defense mechanism
- performing an act of make-up for prior behavior

Rationalization

- defense mechanism
- creating reasonable and acceptable explanations for unacceptable behavior

Dissociation

- defense mechanism
- creating a temporary compartmentalization or lack of connection between the person's identity, memory, or how they perceived the environment
- ex: blanking out

Denial

- defense mechanism
- pretending the truth is not reality to manage the anxiety of acknowledging what is real

Compensation

- defense mechanism
- emphasizing strengths to make up for weakness

Identification

- defense mechanism
- conscious or unconscious assumption of the characteristics of another individual or group

Intellectualization

- defense mechanism
- separation of emotions and logical facts when analyzing or coping with a situation

Conversion

- defense mechanism
- responding to stress through the unconscious development of physical manifestations not caused by a physical illness

Splitting

- defense mechanism
- demonstrating an inability to reconcile negative and positive attributes of self or others

Projection

- defense mechanism
- attributing one's unacceptable thoughts and feelings onto another who doesn't have them

Barriers to change

- ambivalence!
- shaming
- lecturing
- telling people what to do

Motivational interviewing techniques

- express empathy
- develop discrepancy
- roll with resistance
- support self-efficacy
- resist righting reflex
- understand motivations
- listen to your patient
- empower your patient

Stages of change

1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance

Principles of bioethics

1. beneficence
2. autonomy
3. fidelity/non-maleficence
4. justice
5. veracity

Beneficence

doing good or causing good to be done; kindly action

Autonomy

the right to make one's own decisions and respect for the rights of others to make their own decisions

Fidelity/non-maleficence

maintain loyalty and commitment doing no wrong to a client and being an advocate for your client and families

Justice

treating others fairly and equally also watching and correcting any discrepancies you see in care

Veracity

one's duty to always communicate truthfully

Voluntary admission

voluntary per guardian

Legal hold

temporary emergency admission

Involuntary admission or commitment

qn admission in which a person does not agree to the need for psychiatric treatment and admission and refuses to sign a voluntary admission form

Ed Thomas law

If a patient is brought to the hospital by police, as long as they have the correct paperwork filed, the patient will be discharged back to police custody

Tarasoff act

duty to warn of threatened suicide or harm to others

Mental health commitment law

allows judges and magistrates to order treatment for people who in the past have become dangerously ill due to lack of compliance with doctor's care
--Used to have to be an immediate threat
--Concern from opponents that this will violate civil liberties- Not an immediate risk but taking rights away because of their past

Use of benzodiazepines and non-benzodiazepines in treatment of anxiety

- Enhance GABA, causing sedation/muscle relaxation
- Risk for CNS depression

Important patient education for SSRIs

- Takes weeks to see a noticeable change
- Side effects: may impact blood sugar levels, nausea, dizziness, anxiety, trouble sleeping, loss of appetite, inability to orgasm, decreased sex drive, when combined with other anti-depressants can cause serotonin syndrome

Important patient education for MAOIs

- low tyramine diet is required or else go to hypertensive crisis
- side effects: lots of GI upset, muscle twitches/jerks, hypotension, paresthesia, serotonin syndrome

Serotonin syndrome

usually when two antidepressants that increase serotonin are combined they create high levels of serotonin

Symptoms of serotonin syndrome

- pyrexia/sweating
· Anxiety/agitation/confusion
· Tremors
· Ataxia
· Hypertension
· Tachycardia
· Seizures

Management of serotonin syndrome

· Usually recover within 24 hours
· If mild: discontinue medications and monitor until the medication wears off
· If moderate to severe: manage each symptom (antiseizure meds, antihypertensives, antipyretics/cooling blankets, benzodiazepines), can be ICU level management

Lithium toxicity

§ Early indications - <1.5 mEq/L
· Diarrhea, nausea, vomiting, thirst, polyuria, muscle weakness, fine hand tremors, slurred speech, lethargy
· Hold medication and notify provider
§ Advanced indications 1.5-2.0 mEq/L
· Confusion, sedation, poor coordination, course tremors, ongoing GI symptoms
· Hold meds, notify provider, and begin promoting excretion (increase fluid intake)
· Consider/prepare to move patient to medical floor
§ Severe 2-2.5 mEq/L
· Extreme polyuria of dilute urine, tinnitus, giddiness, jerking movements, blurred vision, ataxia, seizures, severe hypotension and stupor leading to coma, possible death d/t respiratory complications
· Admit to ICU
· Gastric lavage, use mannitol or aminophylline to increase excretions
§ >2.5 mEq/L
· Rapid progression of manifestations leading to coma and death
· Hemodialysis may be warranted

Extrapyramidal symptoms

- acute dystonia
- pseudo parkinsonism
- akathisia
- tardive dyskinesia

Acute dystonia

· Spasms or rigidity of tongue, neck, face, and back
· Usually 1-5 days after first dose
· Treat with antiparkinsonism medications

Pseudoparkinsonism

· Bradykinesia, rigidity, shuffling gait, drooling, tremors
· Usually within first month of starting medication (can occur as early as 5 hours after first dose)
· Treat with antiparkinsonism medications (like benztropine)

Akathisia

· Inability to sit or stand still, continual pacing, agitation
· Usually occurs within first 2 months (can be as fast as 2 hours)
· Treat with antiparkinsonian agents, beta blockers, or lorazepam/diazepam

Tardive dyskinesia

· Involuntary movements of tongue, face, legs, arms, or trunk
· Can develop at any time
· Considered untreatable
· Valbenazine (Ingrezza)first medication to come out recently

Neuroleptic malignant syndrome

§ Can occur within first week or treatment or anytime after
· Give oral medications for a week before doing injections to make sure they don't have severe side effects
§ Symptoms: sudden high fever, blood pressure fluctuations, diaphoresis, tachycardia, muscle rigidity, drooling, decreased LOC, coma, tachypnea
§ Treatment
· Control symptoms
· Requires ICU level care

Identify assumption according to CBT

o Basic rules for living
o Attitudes that tend to be global
o Judgmental
o "if then" statements
o Affective shift if violated
o Basic core beliefs people have that are harming

Illnesses that are treated better with CBT

- anxiety
- depression
- eating disorders

Illnesses that are treated better with DBT

- anxiety
- phobias
- substance use

Major components of CBT

§ We can change how we think and what we do can have an impact on how we feel
§ Automatic thoughts
§ Assumptions
§ Schemas
· Structure of how our thoughts move, way to look at patterns