-An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one
-Socially deviant behavior (i.e. political, religious, or sexual) and conflicts that are primarily between the individual and society (unless the behaviors are due to a dysfunction)
What is not considered a mental disorder?
-Associated with significant distress or disability in social, occupation, or other important activities
-Significant disturbance in cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning
What is considered a mental disorder per the DSM5?
-Define NP roles
-Identify competencies assumed to be held by all NPs who function in a particular role
-Varies broadly from state to state
Purpose of Scope of Practice?
-Authoritative statements regarding the quality and type of practice that should be provided
-Provide a way to judge the nature of care provided
-Reflect the expectation for the care that should be provided to clients with various illnesses
-Reflect professional agreement focused on the minimum levels of acceptable performance
-Can be used to legally describe the standard of care that must be met by a provider
-May be precise protocols that must be followed or more general guidelines that recommend actions
Purpose of Standard of Practice?
Understand the patient’s illness to evaluate the effect on their lives and create a beginning diagnosis and treatment plan
Purpose of Psychiatric Interview?
-Create a relationship with client by being calming, warm, understanding, kind, respectful, concerned and focused
-Able to help patient better if a therapeutic alliance was formed
What is a Therapeutic Alliance?
-Therapist and patient work collaboratively to create therapeutic change through an affectionate bond
-Agreement on goals of therapy
-The therapist’s ability to be empathetic and involved in therapy
-The ability of the patient to do the work of therapy
Important components of a therapeutic alliance?
Holistic treatment that relies on the nurse’s processing of that the patient is experiencing
What is Psychotherapy?
-Her application of Sullivan’s theory of anxiety to nursing practice
-Described the effects of different levels of anxiety (mild, moderate, severe, and panic) on perception and learning
-Promoted interventions to lower anxiety, with the aim of improving clients’ abilities to think and function at more satisfactory levels
Peplau’s most universal contribution to PMHNPs?
-Observation, interpretation, and intervention
(The PMHNP observes and listens to the client, developing impressions about the client’s situation)
Per Peplau, skills of a MH nurse?
-The processes by which the nurse helps clients make positive changes in their health care status and well-being
-Believed that illness offered a unique opportunity for experiential learning, personal growth, and improved coping strategies and that PMH-APRNs play a unique role in facilitating this growth
What is the main idea for Peplau’s Theory of Interpersonal Relationships?
-Silence
-Accepting
-Giving recognition
-Giving information
-Offering self
-Giving broad openings
-Offering general leads
-Placing the event in time or sequence
-Making observation
-Encouraging description of perceptions
-Encouraging comparison
-Reflection
-Exploring
-Seeking clarification
-Presenting reality
-Voicing doubt
-Verbalizing the implied
-Attempting to translate into feelings
-Encouraging formulation of a plan of action
-Summarizing
Therapeutic Communication Techniques?
-Reassuring
-Approving
-Disapproving
-Rejecting
-Advising
-Probing
-Challenging
-Defending
-Requesting an explanation
-Indication the existence of an external source
-Belittling feelings
-Making stereotypical comments
-Giving literal responses
-Introducing an unrelated topic
Non-Therapeutic Techniques?
-Orientation
-Identification
-Exploitation
-Resolution
Four Phases of the Nursing Model?
-The PMHNP addresses individual and family problems with the patient
-Assess identified problems during the orientation phase
-Determines the underlying healthcare issues with the patient
-Collects psychiatric data
-Establish a trusting relationship
Psychotherapy Process?
By applying core principles of psychotherapy, as well as, nursing theory
How does the patient recover through adaption?
Avoid taking patients with similar problems or put aside personal pathology
What does the PMHNP need to avoid?
-Focus on difficulties patient is experiencing in current relationships and the ways the relationships can be handled
-Change pattern of communication
-Alter expectations within relationships
-Use social supports to help patients deal with stressors and improve their environment
-Relieve symptoms
-Build social skills
Goals for Interpersonal Therapy?
-Complicated bereavement/grief
-Marital and interpersonal conflicts, such as role disputes
-Life events, such as role transitions
-Isolation, lack of support, interpersonal deficits
Indications for Interpersonal Therapy?
Therapist identifies depressive symptoms, evaluates patient, generates a diagnosis, obtain information on how the patient handles relationships
Early Phase of Interpersonal Therapy?
Patient and therapist derive more specific strategies to deal with stressors
Middle Phase of Interpersonal Therapy?
-Consolidate gains
-Foster independence in the person
-Review risk of relapse and reappearance of depressive symptoms
-To contract again for continuation of treatment as needed
Termination Phase of Interpersonal Therapy?
Facilitate changes by the patient in order to address identified problems
Purpose of Group Therapy?
Assure dominant members are brought to the attention of the group, so they are able to address issues within the process
Role of leader in group therapy?
A person explaining to the group ways that person is able to cope with things
Role of information giver in group therapy?
A technique where special favors or awards are given to assure patient participation and involvement in group therapy
Role of Reinforcement in group therapy?
Increase subjectivity about thoughts governing their behavior.
This is done by:
-homework assignments
-dream description
-looking at ideas and beliefs the patient has about themselves
Goal of Cognitive Behavioral Therapy (CBT)?
-Encouraging patient to analyze early parental relationships
-Underlying meaning of behavior
-Identification of negative thoughts
-Effect of thoughts on feelings and behaviors
CBT Interventions?
-Anxiety
-Bipolar Disorder
-Eating Disorders
-Borderline Personality Disorder
Interpersonal Therapy (IPT) is useful for?
- Infancy (birth to 18 months)
- Childhood (18 months to 6 yrs.)
- Juvenile (6 to 9 yrs.)
- Preadolescence (9-12 yrs.)
- Early Adolescence (12-14 yrs.)
- Late Adolescence (14-21 yrs.)
Stages of Development?
Gratification of needs
Characteristic of Infancy?
Delayed gratification
Characteristic of Childhood?
Formation of peer group
Characteristic of Juvenile?
Developing relationships within same gender
Characteristic of Preadolescence?
Identity
Characteristic of Early Adolescence?
Forming lasting and intimate relationships
Characteristic of Late Adolescence?
-Good me vs Bad me: based on social appraisal and the anxiety that results from negative feedback
-Not me: unknown, repressed component of self
What are the 3 types of self?
Measures that the individual employs to reduce anxiety and enhance security
How does Sullivan’s theory define security operation?
All of the security operations that an individual uses to defend against anxiety and ensure self-esteem
How does Sullivan’s theory define self system?
-Significant time spent in a home-like environment
-Interact with similar individuals
-Conduct different activities throughout the day
-May attend group or individual therapy sessions
-Establish treatment goals for themselves and community
-Learn new ways to respond from peers and counselors
What is Milieu Therapy?
Return to larger society when goals have been met
Goal of Milieu Therapy?
-Broad term referring to psychotherapy, behavior analytics, or a combination of the two
-Focus on behaviors or in combination with thoughts and feelings that might be causing them
What is Behavioral Therapy?
-Treatment method in which the client expresses all thoughts freely and without censoring self
-Freud concluded that talking about emotional issues had the potential to heal the wounds causing mental illness
What is Psychoanalysis?
-General appearance, attitude, behavior
-Speech
-Mood and Affect
-Thought content
-Thought process
-Impulse Control
-Cognition and Sensorium
Components of Mental Status Exam (MSE)?
-General description of what the patient talked about
-I.E. information and description related to symptoms or circumstances of depression, anxiety, compulsions, phobias, delusions, SI/SH/HI/AVH
How to describe thought content?
Clinical tool to determine suicide risk
-Sex
-Age
-Depression
-Previous Attempts
-Ethanol Abuse
-Relational Loss
-Social Supports Lacking
-Organized Plan
-No Souse
-Sickness
SAD PERSONs Scale?
The way in which a client thinks
What is Thought Process?
-Shifting of idea
-Illogical
-Difficulty to follow
What is Loose Association?
Wanders to a related topic but never makes it back to the original topic
What is Tangential Thinking?
Completely nonsensical combination of words
What is Word Salad?
Made up words
What is Neologisms?
Gets lost in details but eventually makes it make to the original topic
What is
Circumstantial Thought?
Thinking process stops and mind goes “blank”
What is Thought Blocking?
-Often seen in mania
-Pressured speech
-Rapid topic changes
-Topics may relate but in strange ways
What is Flight of Ideas?
-Often indicates dementia
-Fabrication of information to fill in missing gaps
What is Confabulation?
-Only understands things literally
-Common in schizophrenic patients
What is Concrete Thought Process?
-Able to think abstractly
-Can be determined by asking patient how a chair and table are similar or “why should people in glass houses not throw stones?”
What is Abstract Thought Processes?
Describes whether the patient is in good contact of their environment or is there is a distortion of reality (Typically presents as hallucinations)
What are Perceptual Disturbances?
-Misinterpretation of true stimuli
-I.E. a curtain in a dark room is mistaken for a person
What are Illusions?
-Sensations experienced by the client without real external stimuli
-Patient may not have intact reality testing, which is the ability to accept evidence that these perceptions re not real
What are Hallucinations?
-Visual
-Gustatory (taste)
-Olfactory (smell)
-Tactile
These hallucinations may indicate a medical illness , substance intoxication or withdrawal?
False sensory perceptions that occur while falling asleep and while awakening from sleep
What are Hypnagogic and Hypnopompic Hallucinations?
-Sensorium can be obtained while observing patient during the evaluation
-Memory can be tested by having the patient remember and repeat 3 objects
-Concentration can be tested by counting backwards from 100 by 7s
Ways to test Cognition and Abstraction?
Clinical disorders
-does not include personality disorders or mental retardation
DSM-5 Axis 1?
Personality Disorders and Mental Retardation
DSM-5 Axis 2?
General Medical Conditions
(medical issues that causes the mental disorder)
DSM-5 Axis 3?
Psychosocial and environmental problems
DSM-5 Axis 4
Global Assessment of Functioning (GAF)
DSM-5 Axis 5
-Scoring system that is used to assess how well an individual is functioning in their daily lives
-Scores range from 0 to 100
What is GAF?
100 – no symptoms
90 – minimal symptoms with good functioning
80 – transient symptoms that are expected reactions to psychosocial stressors
70 – mild symptoms or mild difficulty in social, occupation, school
60 – moderate symptoms or mild difficulty in social, occupation, school
50 – serious symptoms or mild difficulty in social, occupation, school
40 – some impairment in reality testing or communication or serious impairment in work, school, family relations, etc.
30 – behavior is considerably influence by delusions or hallucinations or serious impairment in judgement, communication or inability to function
20 – some danger of hurting self or others or occasionally fails to maintain minimal personal hygiene or gross impairment in communication
10 – persistent danger of severely hurting self or others or persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death
0 – inadequate information
GAF Scoring System?
-The idea that from the earliest ages, children possess sexual feelings and motivations
-sexual instinct or drive directs a person toward action
-sexual drives are oral, anal, or genital
-stages are associated with a characteristic psychosocial process
-stages have been organized according to hierarchy of dominant body zones
What is Freud’s Psychosexual stages of development?
-Freud believed that sexual instincts, together with the nature of nurturing relationships, play a role in the formation of psychiatric disorders
-Sexual stimulation exerts a predominant force on mental activity throughout the life
-force = libido
Relation between Freud’s theory and mental disorders?
-Birth to 18 months
-Focused on oral pleasures (sucking)
-Too much or too little can result in oral fixation or oral personality, which is evidence by preoccupation with oral activities
-May have stronger tendency to smoke, drink alcohol, over eat, or bite nails
- Potential personality: overly dependent, gullible, perpetual followers, pessimism, aggression
Psychosexual stage: Oral?
-18 months to 3 yrs
-Focused on eliminating and retaining feces
-Learn to control anal stimulation through pressure from society
-Potential personality: obsession with cleanliness, perfection, controlling (anal retentive), messy, disorganized (anal expulsive)
Psychosexual stage: Anal?
-3 yrs to 6 yrs
-Pleasure zone switches to genitals
-Boys may develop unconscious sexual desires for their mother, which can result in seeing father as competition. Will fight for mothers affection
-Oedipus complex: fear of castration as punishment for having these feelings (can be opposite with girls)
-When the boy identifies with father, they become masculine, identifies as males, repress sexual feelings towards mother
-A fixation in this stage can cause sexual deviancies, weak/confused sexual identity
Psychosocial stage: Phallic
-6 to 12 yrs
-sexual urges remain represses
-children interact and play mostly with same sex peers
Psychosocial stage: Latency?
-12yrs+
-begins at the start of puberty
-sexual urges are awakened
-through past lessons, adolescents direct their sexual urges onto opposite sex peers with the primary focus of pleasure in genitals
Psychsexual stage: Genital?
-only personality present at birth
-unconscious and includes instinctive and primitive behaviors
-driven by pleasure principle, which is the immediate gratification of all desires (anxiety if no instant gratification)
Freud’s ID?
-develops from the ID
-functions in the conscious, preconscious, and unconscious mind
-personality component responsible for dealing with reality
-ego represents one component of your full personality
-ego provides direction and guidance
Freud’s Ego?
-emerges around age 5
-holds the moral standards and ideals
-provides guidelines for making judgements
-has 2 parts (conscience and ego ideal)
Freud’s Superego?
-birth to 18 months
conflict: trust vs mistrust
-important events: feeding
-outcome: hope
Erikson’s Stage of Development: Infancy?
-2 to 3 years
-conflict: autonomy vs shame and doubt
-important events: toilet training
-outcome: will
Erikson’s Stage of Development: Early childhood?
-3 to 5 years
-conflict: initiative vs guilt
-important events: exploration
-outcome: purpose
Erikson’s Stage of Development: Preschool
-6 to 11 years
-conflict: industry vs inferiority
-important event: school
-outcome: confidence
Erikson’s Stage of Development: School Age?
-12 to 18 years
-conflict: identity vs role confusion
-important events: social relationships
-outcome: fidelity
Erikson’s Stage of Development: Adolescence?
-19 to 40 years
-conflict: intimacy vs isolation
-important events: relationships
-outcome: love
Erikson’s Stage of Development: Young Adult?
-40 to 65 years
-conflict: generativity vs stagnation
-important events: work and parenthood
-outcome: care
Erikson’s Stage of Development: Middle Adult?
-65 to death
-conflict: ego integrity vs despair
-important events: reflection on life
-outcome: wisdom
Erikson’s Stage of Development: Maturity?
-involves self awareness (introspection, physical and emotional sensation) and executive functions (focusing, planning, judgement, social functioning)
-regulate emotion and motor behavior
-associated with schizophrenia, attention disorders, OCD, mood disorders
Function of the frontal lobe?
-coordination of sensation and motor behavior (coordination of language functions)
-spatial orientation (knowing where your body is, physical sensation)
-recognition of people and objects
Function of Parietal lobe?
-memory formation: language (Wernicke’s area) and learning
-associated with euphoria, auditory hallucinations, and delusions (impaired left lobe)
-right lobe impairment: dysphoria, depression, irritability, inappropriate affect
Function of temporal lobe?
-vision and visual memory
-impairment can cause visual defects, blindness and visual hallucinations
Function of Occipital lobe?
-used in treatment planning to justify a level of care, specify treatment needs, provide rationale for legal adjudication, immediate safety measures and ensure reasonable cost containment
-hypothesis about the causes, precipitants and maintaining influence of a person’s psychological, interpersonal, and behavioral problems
-description of chief features
What is case formulation?
- Symptoms and problems
- Precipitating events or stressors
- Predisposing life events or stressors
- Mechanisms or causes of the problem
- Other contributing factors
5 Broad Categories of Case Formulation?
Biological
-genes
-physical health
-disabilities
Psychological/behavioral factors
-lifestyle
-stress
-health beliefs
-self esteem
-coping skills
Social Conditions
-cultural influences
-family relationships/circumstances
-social support
-peers
-school
What are the Biopsychosocial Assessment Domains?
-Family history of psychiatric illness
-Early loss of a nurturing relationship
-Stressful life events
-Low social support
What psychosocial factors influence depression?
-interviewer should know the reason the patient was brought in for an evaluation
-area should be secured for safety
-patient needs to know that the clinician cannot withhold any information from the team that will affect treatment or safety
Important things to communicate to the patient during an initial psychiatric assessment?
-allows the patient to answer in any way that he or she chooses
-do not force patient to follow one particular train of thought
-does not define the focus of interest
-useful to begin interview
Key points to Open Ended Questions?
-focuses on one particular problem
-gathers specific information
-limited responses (yes or no)
Key points to Closed Ended Questions?
A phenomenon that occurs when people redirect emotions or feelings about one person to an entirely separate individual
For example, displacement onto the PMHNP of feelings toward a parent/authoritative figure
Definition of Transference?
When the provider unconsciously displaces patterns of behaviors/emotional reactions onto the patient as if they were a significant figure from earlier in the provider’s life
Definition of Counter Transference?
-affect the thought processes and senses, which may distort or completely transform the interaction
-high levels of anxiety will cause the patient or provider to inaccurately process the information
How can perceptual differences affect the interview?
Involves providing the patient with a rational understanding of their disorder and options for treatment. The patient will then use that information to make a decision for themselves.
What is autonomy?
-healing with hands
-energy is believed to be transferred by laying the hands over specific parts of the body to aid in the process of healing
-should only be used if the patient’s culture, social, and moral views allow it
What is therapeutic use of touch?
-Poor
-Fair
-Good
-Intense
It is important that the provider takes in account the patient’s current condition, and past history to understand why the eye contact is the way it is.
Descriptors of lack of eye contact during the interview?
It adds 2 additional elements
I: Implementation consideration of the services provided
E: the evaluation of service provision
R: client’s response to the diagnostic process, treatment planning, and intervention efforts
How is a SOAPIER note different from a SOAP?
Orientation
-establish rapport
-set parameters
-purpose of meeting
-formal/informal contracts of responsibilities
-termination begins
Working
-maintain relationship
-gather further data
-promote clients problem solving skills, self esteem, use of language
-facilitate changes
-overcome resistance behaviors
-evaluate problems and goals
Termination
-deal with intense feelings regarding the experience
-summarize goals and objectives
-evaluate outcome attainment
-review patient’s plan for future
-finalize termination
Phases of the therapeutic patient/nurse relationship?
Building
-define the structure, size, composition, purpose and time of group
-task and maintenance functions may be discussed and demonstrated
Working
-facilitates communicate and ensures that meetings begin and end on time
Termination
-ensure each member summarized individual accomplishments
-gives positive and negative feedback regarding the group experience
The PMHNPs role in relationship building, maintaining and terminating?
-questionnaires, interviews, checklists, outcome assessments
-standardized assessments ensure consistent, comprehensive evaluations
-establish baseline for follow ups
(healthcare administrators and payors are increasingly requiring standardized assessments to justify services or quality of care)
What are the psychiatric symptoms measurement scales?
A social readjustment rating scale that lists 43 life events associated with varying amounts of disruption and stress in average people’s lives.
-Each event, called a life change unit (LCU), has a different “weight” for stress
-The more events the patient adds, the higher the score
-The higher the score, and the larger the weight of the event, the more likely the patient will become ill
-Each event has a dedicated number of LCUs (i.e. death of spouse is 100 LCUs)
-Accumulation of 200 or more LCUs in a single year increases the risk of developing a psychosomatic disorder in that year
What is the Holmes and Rahe Stress Scale?