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Mental Health, Spring 2021
Exam 1
Chp 1 – Historical Overview
Key Figures
- Florence Nightingale
o Holistic care (whole pt, family,
community)
o Sensitive to pt emotions, illness
anxiety
o Beginnings of therapeutic
communication
o Encouraged independence and selfcare
- Linda Richards
o 1st trained nurse in US
o Opened Boston City Hospital
Training Program for Nurses in 1882
 Provide physical care in
psych hospitals
- Harriet Baily
o 1st psych nurse textbook – Nursing
Mental Disease in 1920
- Hildegard Paplau
o Introduced interpersonal relations
and therapeutic relationship
o Use of self as a nursing tool outside
scope of physicians and hospital
admin
o Developed specialty training psych
nurses – 1st graduate nursing
program in 1954
Premoral Era, Ancient times 1700 AD
- Ancient times 800 BC
o Mental illness caused by sin or
displeasing a god
 Driven by society, ostracized
by families (asylums, death)
 Extraction of evil spirits
(removing part of skull,
exorcisms)
o Some mental illnesses viewed as
supernatural powers (revered by
society
- 800 BC – 1 AD
o Egyptian and Greek Period of Inquiry
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-
Hippocrates: abnormal
behavior due to brain
disturbances
 Aristotle: recognition of
interconnection betw
physical and mental health
 Mental illness viewed as
disease
o Treatments
 Counseling, music, relaxation
 Observation and
documentation
 Goal was to correct
imbalances
1 AD – 1300 AD
o Early Christianity: all diseases caused
by demons
o Spirit of inquiry dead in Western
Europe
o Theologians and witch doctors
providing care for mentally ill
o In middle east, mental disorders
viewed as illness
o Treatment
 Incarcerated, beaten, starved
 First asylums built by
Muslims
1300 AD – 1700 AD
o England: mental ill differentiated
from criminals
o Colonies: mental illness still believed
to be demon possession
o Mentally ill immune to normal
biological stressors (cold, heat,
hunger)
o Treatment
 Witch hunts
 Jail
 Wealthy could afford private
hospital care
 Pt exhibited and encouraged
to perform, viewed for small
fee
Moral Treatment Period, 1790-1900
- Moral treatment period
o Asylum: protection, social support,
or sanctuary from life stresses
-
o Moral treatment: kindness,
compassion, pleasant environment
o People w/ mental illness were
removed from their homes from
their safety/safety of others
Key Figures
o Philippe Pinel (1745-1826)
 People can get better
 Superintendent of Bicetre
(for men) and Salpetriere (for
women) institutions
 Ordered the removal of
chains, abolished the use of
whips and other tools of
torture
 Stopped blood-letting
 Put pt under care of
physicians
o William Tuke (1732-1822): Opened
York Retreat in 1796
 Creating retreat for indiv
with mental disorders
 Restraints abandoned
 Pt provided sympathetic care
in pleasant environment
 Encouraged to engage in
jobs/activities
o Dorthy Dix (1802-1887)
 Instrumental in developing
asylums in US
 Legislative activist to insure
states appropriated funds for
state hospitals to treat indiv
w/ mental illness
 Opened 32 state hospitals
 Motivated by a visit to Tuke’s
York Retreat
 Proposed alleviated suffering
with adequate shelter,
nutritious food, warm
clothes
 While Dix is credited as
national reformer, the 1st
asylum in the US was the
Eastern Lunatic Asylum in
Williamsburg VA founded in
1773
Asylums Over Time
- Asylums started as refuge and safe place for
mentally ill
- Over time, became a place of torture
o Overcrowding, under-funded,
isolation, misguided
treatments/experimentations,
women were at increased
vulnerability (held prisoner for years
and tortured)
Early Scientific Study
- Shift from sanctuary to treatment
- Sigmund Freud (1856-1939) personifies
beginning of mental health scientific
discovery
o Believed mental illnesses were
psychological, due to disturbed
personality dev and poor parenting
o Psychanalysis (treatment focused on
repaired trauma and psych injury)
o Writing and reporting outcomes of
treatment
Psychopharmacology
- 1930s: barbiturates were explored
- 1950s: chlorpromazine (antipsychotic),
lithium (antimanic), and imipramine
(antidepressant), were introduced
- Hospital stays became shorter
- Negative effects of hospitalization became
more evident
- New questions regarding ethical, moral,
legal use of psychopharmacology arose
Legislative Events that Changed Psych Care in US
- 1946: President Truman signed National
Mental Health Act
- 1947: Hill-Burton Act allocated funds for
general hospitals to develop psych units
- 1949: National Institutes of Mental Health
established
- 1961: President Kennedy est Joint
Commission on Mental Illness and Health
- 1963: Community Mental Health Centers
Act
Factors that Lead to Deinstitutionalization
- Lack of confidence in state hospital systems
- Treatment failures, inability to eliminate
mental illness
- Legislation focused on civil rights of
mentally ill
-
Psychotropic medications
All lead to Community Mental Health
Centers Act that virtually eliminated state
hospitals
Deinstitutionalization
- 1955: 558,922 resided in state hospitals (1
psych bed for every 300 Americans)
- 2010: 1 bed for every 3000 Americans
- Using 1955 #s, potentially 1 million people
would be hospitalized by today
o Nursing homes
o Prisons/jails
 Trans institutionalization –
LA county jail one of largest
mental health systems in
world
o Homeless
o Families, group homes, living alone
Community-Based Care
- Systemic changes in thinking
o Symptom stabilization -> recovery
and reintegration
o Clinicians have all the answers -> pt
centered care
o Med management -> holistic
thinking (housing, nutrition,
employment, sleep)
- In 1980, 2,000 community-based mental
health centers were projected to be needed
o Approx. 1300 in place
o Primary focus was substance abuse
treatment
o Lack of supports for serious mental
illness
o Deinstitutionalization considered a
failed initiative
- Ongoing need for a full continuum of care
Contemporary Mental Health Care
- 1999: Mental Health – a report of the
surgeon general
o Mental health treatment is effective
and well documented
o Treatment exists for most mental
disorders
- 2000: report of the surgeon general’s
conference on children’s mental health – a
national action agenda
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-
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o Recommendations for identifying
and referring children to mental
health services
o Increasing access for families
o Evidenced based practice
2003: Presidents new freedom commission
on mental health
o Recommended 6 goals to transform
mental healthcare in the US
 Mental health is essential to
overall health
 Mental health care is
consumer and family driven
 Eliminate disparities in
mental healthcare
 Common practice of early
mental health screening,
assessment, and referral for
services
 Deliver excellent mental
health care and accelerate
research
 Use technology to access
mental health care and info
2008: Mental Health Parity and Addiction
Equality Act
o Same coverage for mental health
and addiction care as physical health
treatments
o Prevents disparity in number of
visits approved for mental health
care and physical health care
2010: Pt Portability and Affordable Care Act
passed
o Increased access to mental health
care
o Prevented insurance companies
from denying coverage due to preexisting conditions
Healthy People 2020
o Improve mental health through
prevention and by improving access
to quality mental health services
 Physical and mental health
trauma experienced by
military and veterans
 Macro-level trauma to
communities caused by
violence and natural
disasters
 Treatment of older adults
with dementia and mood
disorders
o Nurses direct practice, advocacy,
improving social and physical
environments
Black Pioneers in Mental Health
- Solomon Carters Fuller, MD (1872-1953)
o Significant contributions to study of
Alzheimer’s
o Performed his ground-breaking
research on physical changes to
brains of Alzheimer’s pts
- Paul Bertau Cornely, MD DrPH (1906-2002)
o Work focused on dev of public
health initiatives aimed at reducing
healthcare disparities among
chronically underserved
o Desegregate health facilities across
US
o Published over 100 scientific and
popular articles
- Mamie Phipps Clark, PhD (1917-1983)
o Realize shortage of psych services
available to African Amer
community/other minorities
o Groundbreaking research on impact
of race on child dev helped end
segregation, was influential in deseg
efforts including Brown v. Board of
Education
o 1946: opened “Northside Center for
Child Development” in Harlem to
provide comprehensive psych
services to poor, blacks, and other
minority children and families
- Maxie Clarence Maultsby Jr MD (19322016)
o Founded of rational behavior
therapy (explored
emotional/behavioral self
management, comprehensive syst of
cognitive behavioral psych therapy
and counseling that included most
recent neuro psych facts about brain
function related to emotional and
behavioral self control)
o Made emotional self-help a
legitimate focus of scientific
research and clinical use
o Created is the first comprehensive,
short term, and drug free technique
of psych therapy that produces long
term therapeutic results
Chp 2 – DSM-5 Classification
Key Concepts
- Mental health = emotional and psych wellbeing of an indiv who has the capacity to
interact with others, deal with ordinary
stress, and perceive ones surroundings
realistically
- Wellness = purposeful process of indiv
growth, integration of experience,
meaningful connection w/ others, reflecting
personally valued goals and strengths,
results in being well and living values
- Mental disorders = clinically significant
disturbances in cognition, emotion
regulation, or behavior that reflect a
dysfunction in psych, biological, or dev
processes underlying mental dysfunction –
usually associated w/ distress or impaired
functioning
Duel Continuum Model of Mental Health
Mental Health Continuum Model
Diagnoses
8 Dimensions of Wellness
Diagnostic and Statistical Manual of Mental
Disorders = 5 (DSM-5)
- = a system for classifying and diagnosing
mental disorders
- No absolute boundaries betw disorders,
many fall onto a spectrum of disorders
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Contents
o DSM-5 Basics (introduction, using
the manual, cautionary statement)
o Diagnostic criteria and code
o Emerging measures and models
o Appendix
Diagnostic criteria and codes
Using the DSM-5
- Formal diagnoses name
- ICD-10 code (billing use)
- Specific criteria for diagnosis
- Additional clarifications and definitions
- Clear timeframes that must be met
- Additional specifiers
- Bulimia Nervosa, mild, partial remission
-
Diagnostic features = additional clarification
and description of disorder
Associated features supporting diagnosis =
key features of disorder (EX: normal weight
to over-weight, menstrual irreg, etc)
-
Prevalence = total # of people who have
disorder within a specific period of time
- Point prevalence = proportion of indiv in
population who have disorder at specific
point in time
- Dev and course = overview and highlights of
disease course
Stigma = the patient
- Significant barrier to pt seeking treatment
(remember our history)
- Public stigma = publicly marked as being
mentally ill and subject to prejudice and
discrimination
- Stereotyped = dangerous, unpredictable,
uncapable of indep function, weak or
immoral
- Stigma within healthcare
- Counteracting stigma =
o Use non-stigmatizing language
(person with ___)
o Recognize the symptoms are often
outside pt control
Stigma = the profession
- Psych hospitals = often portrayed as dark,
gloomy, dangerous places
- Psych health professionals = arrogant, coldhearted, apathic, manipulative
Stigma = impact to treatment
- Self-stigma = internalization of publics
negative POV of mental illness leading to
low self-esteem and low self concept
- Label avoidance = avoiding treatment or
care in order to avoid being labeled with
mental illness
Recovery
- 4 stages
o Crisis and diagnosis
o Dealing w/ agitation, symptoms,
burden
o Reorganization of life
o Meaningful life
- *most important = learning coping skills
- Implications for nursing
o Identification and prompt diagnosis
o Early start to medication
o Help accepting limitations
o Defining new goals for future
Chp 3 – Cultural and Spiritual Issues in Mental
Healthcare
Key Concepts
- Culture = way of life for people who identify
or associate w/ one another based on
common purpose, need, or similarity of
background. Totality of learned, socially
transmitted beliefs, values and behaviors
derived from interpersonal interactions
- Cultural identity = set of cultural beliefs one
looks to for standards of behavior, many
people consider themselves to have
multiple cultural identities
- Acculturation = socialization process where
minority groups learn and adopt selective
aspects of dominant culture
- Spirituality = dev over time and dynamic,
conscious process characterized by selfreflection and living according to one’s
values and/or feeling connectedness to
higher power
o Self-transcendence = self reflection
and living according to ones values
in est meaning to events and
purpose to life
o Transcendence beyond self = feeling
of connection and mutuality to
higher power
- Religiousness = participation in community
of people who gather around common ways
of worshipping
Cultural Competence
- Linguistic = capacity to communicate info in
a way easily understood by diverse pop and
address health literacy needs for pt and
families
o Adolescents, people w/ dev delays,
indiv w/ paranoia and delusions
- Cultural = set of academic and interpersonal
skills that are respectful of and responsive
to health beliefs, health care practices and
cultural and linguistic needs of diverse pt
groups to facilitate positive healthcare
outcomes
Poverty and Mental Health
- In US, 1/3 of people living in poverty are
single mothers and their children
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Living below the poverty level ($24, 300 for
family of 4)
o 24.1% African American
o 11.4% Hispanic American
o 9.7% Caucasian American
Added financial stress, decreased access to
healthcare, increased violence exposure
o Exacerbated mental illness
o Alcoholism/substance abuse
o Depression
o Anxiety
o Hopelessness
Hispanic Amer and Mental Health
o Largest minority group in US
o Heterogeneous group (variations in
beliefs betw indiv from Mexico,
Cuba, Puerto Rico, etc)
o Barriers to seeking treatment
 Mental health services not
meet cultural needs (EX:
language)
 Cost of care
 Immigration status
African Amer and Mental Health
o Approx. 13% of US pop
o Tend to have strong family supports,
large extended families
o Concern w/ bias in diagnosis and
treatment (disproportionally
diagnosed w/ schizophrenia)
o 46.8% AA youth experienced mental
health disorder before 18 y/o
o Black children ages 5-12yr have
suicide rate approx. double of white
Asian Amer, Polynesians, Pacific Islanders
o 4.4% of US pop – one of fastest
growing minority groups in US
(lowest rate of seeking mental
health treatment)
o Traditionally, mental health is
denied or hidden (disgrace to family)
o Asian cultures tend to emphasize
more holistic mind-body view (talk
therapies, emotional expression
may be viewed as less effective
when physical symptoms are
unaddressed)
o Several cultural bound syndromes
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
Hwabyung = suppressed
anger
Neurasthenia = fatigue,
weakness, poor
concentration, memory loss,
irritability, aches and pains,
sleep disturbances
Spirituality, Religion, and Mental Health
- Religion and spirituality can provide support
and strength when dealing with mental
illness and emotional problems
- Diff religions have diff beliefs regarding
mental illness
- People with mental illness benefit from
spiritual assessment and interventions
(meditation, guided imagery, prayer)
- Use caution, some religious beliefs can be
confused w/ psych illnesses
Nursing Spiritual Assessments
- FICA
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HOPE
Chp 11 – Psychopharmacology
Nurses roles
- Admin meds
- Monitor effectiveness
- Manage side effects
- Educate pt on meds, symptom
management, risks, benefits, adherence
- Nurses in non psych settings will likely be
responsible for psychotropic meds (for
mental instability associated w/ unplanned
discontinuation)
Nursing Psych Meds
- Target symptoms = specific measurable
symptom expected to improve w/
treatment
o Nurses are responsible for
monitoring and documenting effects
of med
- Side effects = unwanted effects of meds
o Nurses implement nursing
interventions for relief of side
effects
- Adverse effects = serious physiological
consequences
Neurotransmitters
- = chemicals that transmit signals across
junctions (synapses) betw neurons
- Vesicles = storage location of
neurotransmitters prior to being released
- Pre-synaptic neuron is activated, releases
neurotransmitters which travel across the
synapse and activate receptors on postsynaptic neuron = causes post-synaptic
neuron to depolarize a “fire”
-
Can’t remain in synapse or post-synaptic
neuron will continue to fire
o Neurotransmitter can diffuse away
o Broken down by an enzyme
 Common target for drugs
 MAO (monoamine oxidase)
required to breakdown
neurotransmitters associated
w/ depression
(norepinephrine, serotonin,
dopamine)
 MOAI antidepressants inhibit
enzyme leaving more
neurotransmitters in synapse
to impact receptors
o Pre-synaptic neuron can reabsorb
and reuse (reuptake)
 SSRIs target carrier proteins
designed to reuptake
serotonin into the presynaptic neuron, leave
serotonin in the synapse to
impact receptors
Post synaptic neurons can respond to
neurotransmitters
o Down-regulation = making itself less
receptive to stimulation
o Up-regulation = making itself more
receptive to stimulation
Clinical Concepts
- Efficacy = ability of a drug to produce a
response
- Potency = dose of a drug required to
produce a response
- Toxicity = point in which concentration of
the drug in the blood stream is high enough
to become harmful or poisonous to the
body
- Therapeutic index = ratio of the maximum
nontoxic dose to the minimum effective
dose
o High therapeutic index = wide range
betw where drug begins to take
effect and when it becomes toxic
o Low index = narrow range, potential
for greater risk
-
Rules of Neurotransmitters
1. What goes up, must come down. What goes
down, must come up.
2. With great power comes great
responsibility (the more effective a drug is,
usually the greater ADRs. Less effective
meds, less severe side effects, don’t always
work as well)
a. Clozapine – most effect anti-psych,
very high risk for agranulocytosis,
require weekly monitoring
b. Best to attempt to treat with the last
powerful option that provides the
good results
Pharmacokinetics – Absorption
- Absorption = movement of drug into
plasma (routes of admin table 11.3)
- First pass effect (oral meds) = metabolism
of drugs in GI tract or liver prior to entering
circulation (only a fraction of drug reaches
circulation)
- Bioavailability = amount of drug that
reaches systemic circulation unchanged
Pharmacokinetics – Distribution
- Distribution = amount of drug found in
various tissues (target tissues)
o Psychoactive drugs must be able to
cross BBB to CNS to be effective
- Solubility = ability for drug to dissolve
o Drugs that are lipid soluble more
easily cross BBB
o Most psycho pharm drugs are lipid
soluble, however this allows them to
cross the placenta
Protein binding = degree to which a drug
binds to plasma proteins
o Only unbound or “free” drugs act on
receptor sites
o High protein binding reduces the
concentration of the drug at the
receptor sites
o Bind is reversible, once the drug is
metabolized more drug can be
unbound
o Drugs can be stored in fat depots,
prolonging the duration of action
o Discontinuation of med is not always
immediately felt due to the drug
being released from storage sites
Pharmacokinetics – Excretion
- Excretion = removal of drugs from the body
- Half-life = time required for plasma
concentrations of a drug to reduce by 50%
o Takes 4 half-lives for more than 90%
of drug to be eliminated
- Majority of psychiatric meds rare excreted
through the liver
- Renal excretion (lithium, gabapentin, mood
stabilizers)
Phases of Drug Treatment
- Initiation phase = assessment, diagnosis,
baseline labs
o Nursing assessment
o Observes and monitors pt response
to med
o Pt education
o Plan for ongoing contact and
services
- Stabilization phase = prescriber adjusts
meds for max effect with min ADR
o When meds are increased quickly,
nurse monitors closely for ADRs
o Pt education
o Family support
o Meds can be augmented (adding
another drug)/caution with
polypharmacy
- Maintenance Phase = symptoms are
improving, meds are continued to prevent
relapse
o Assisting pt to monitor symptoms
o Ongoing education/motivation
-
Discontinuation phase
o Pt education on taper schedule
o Monitoring for reemergence of
symptoms
o Monitoring for withdrawal
symptoms
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Cultural and Spirituality
-
Cultural competence = set of academic and
interpersonal skills that are respectful
of/and responsive to the health beliefs,
health care practices, and cultural linguistic
needs of diverse pt to bring about positive
health care outcomes
- Demonstrated by valuing culture beliefs,
bridging any language gaps, and considering
pt literacy level when planning and
implementing care
Mental Illness Cultural Beliefs
- Hispanic Americans
o Tendency to use all other resources
before seeking help from mental
health professionals (many believe
that mental health facilities don’t
accommodate their cultural needs,
many still seek help through
supportive home care and
counseling from church)
o Care sought if bilingual and
bicultural mental health facilities are
available
- African Americans
o Extensive family networks relied on
for support
o Older adult members treated w/
great respect
o Double stigma = from cultural group
and longtime racial discrimination
o Diagnosis and treatment often
racially biased, leading to less access
to care because of lack of health
insurance
- Asian Americans
o Denial or disguise of existence of
mental illness
o Embarrassment if family member is
treated for mental illness
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o Culture bound syndromes =
Neurasthenia and Hwabyung
(suppressed anger)
Native Americans
o Emphasis on respect/reverence for
earth and nature
o Healers and healing treatments –
herbal meds, healing ceremonies
and feasts
o Varying views of mental illness
among tribes – supernatural
possession, stigmatization (degree
not the same for all disorders,
variable among tribes)
Minority Women
o Greater conflicting feelings and
psych stressors than men
o Adjustment to defined role in
culture versus diff role in larger
predominant society
o Compartmentalization of work and
family lives
Poverty
o Widespread among all cultural
groups
o Financial and emotional stress
triggering or exacerbating mental
problems – becoming trapped in
downward spiral with increasing
tension/stress, feelings of
powerlessness and low self esteem
o Homeless population most at risk for
being unable to escape poverty
Rural cultures
o Limited access to health care
o Problematic for children and older
people who have specialized needs
o Diverse geography and culture
o Treatment approaches possibly
accepted in one part of the country
but not another
Spirituality
- = ones self as part of spiritual force
- Connection to life, way of interpreting life
events
- Source of hope, joy, comfort, guidance on
life’s journey
-
= dynamic and intrinsic aspect of humanity
through which people seek ultimate
MEANING, PURPOSE, and
TRANSCENDENCE, and experience
RELATIONSHIP to self, family, and others,
community, society, nature, and significant
or sacred
- Expressed thru beliefs, values, traditions
and practices
Religiousness
- Participation in community of people
gathering around ways of worshipping
- Religious beliefs often defining one’s
relationship within a family and community
- Judeo-Christian thinking dominates
Western societies
- Islam, Hinduism, and Buddhism dominate
Eastern and Middle Eastern cultures
Spiritual Coping Process
Spiritual Assessment and Interventions = FICA
Spiritual Care
- Encourage/facilitate spiritual practices
- Compassionate presence
- Allow reminiscence
- Facilitate meaningful connections
-
Orient to positive and meaningful
Create opportunities for creative work and
patient to give
Facilitate contact w/ nature
Chaplaincy Referral
Psychiatric Nursing Process
Scope of Practice
- “the diagnosis and treatment of human
responses to actual or potential health
problems” – ANA
- Symptom management of patients with
mental disorders
Standards of Practice – 6 components
- Assessment
- Diagnosis
- Outcome ID
- Planning
- Implementation
- Evaluation
Standards of Professional Performance
- Quality of practice
- Education
- Professional practice eval
- Collegiality
- Collaboration
- Ethics
- Research
- Resource utilization
- Leadership
- Delegation
Education and Certification of P/MH Nurses
- Technical level
o Unlicensed personnel – psych aid
(PAs)
o Licensed practical nurse – LPN
- Professional level
o Generalist – associate degree,
diploma, or BSN (RNC certification)
o Specialist = MSN, DNP, or PhD
Basic Practice
- RN w/ baccalaureate education –
credentialed by American Nurses
Credentialing Center (ANCC)
- Use of nursing process to treat actual or
potential mental health problems or psych
disorders
- Promote and foster health and safety
-
Assess dysfunction, assist to regain or
improve coping abilities
- Maximize strengths, prevent further
disability
Advanced Practice
- Minimum entry master’s level prep
o Doctorate of nursing practice (DNP),
nursing science (DNS), philosophy
(PhD)
- Nationally certified by ANCC, licensed for
adv practice by state
o P/MH clinical nurse specialist and
nurse practitioner in primary care
Patient Interviews
- State the purpose
- Use open-ended questions to allow
observation of pt verbal and nonverbal
responses
- Use close-ended questions to elicit specific
info
- Clarify when words don’t have the same
meaning
- Summarize to allow the pt to correct the
nurses interpretation
- Motivational interviewing (OARS)
Philosophy of P/MHN
- Assist the person to change or cope w/
current or potential problems
o Therapeutic use of self
o Humanistic focus, belief in client’s
worth, dignity and human rights
o Holistic view of client as intellectual
bio-psycho-social-spiritual being
- Promote constructive coping mechanisms
- Maximize adaptive coping responses
Responsibilities of P/MHN
- Assess, identify outcomes and evaluate
responses
- Manage the therapeutic milieu 24/7
- Administer psychotropic meds (LPN/RN) or
prescribes them (APRN)
- Educate clients to resolve problems
- Support clients to improve recreational
occupational and social skills
- Performs counseling (generalist) or
psychotherapy (clinical specialist)
- Supervise and assist other staff members
Biopsychosocial Nursing Assessment
Assessment of Mental Status
- A snapshot of pt current mental status at
this point in time
- Baseline for future comparsion
- Objective, nonjudgmental observations and
factual info
o No interpretations or global
opinions
- Note the content as well as process of pt
communication
Categories of mental status exam
- General observations
o Physical appearance, speech,
attitude, motor activity
- Orientation = level of consciousness
- Mood and affect
- Cognition and thought process
o Attention, concentration, memory,
abstract reasoning
o Intellectual function, perceptions,
judgment, insight
Risk for Suicidal Ideation
- Have you ever tried to harm or kill yourself?
- Do you have thoughts of suicide at this
time? If yes, do you have a plan and can you
tell me the details of the plan?
- Do you have the means to carry out this
plan?
o If the plan requires a weapon, does
the pt have it available?
-
Have you made preparations for your
death?
o Writing a note to loved ones, putting
finances in order, giving away
possessions
- Has a significant episode in your life caused
you to think this way?
o Recent loss of spouse or job
Risk for Assaultive or Homicidal Ideation
- Do you intend to harm someone? If yes,
who?
- Do you have a plan? If yes, what are the
details of the plan?
- Do you have the means to carry out the
plan?
o If plan requires a weapon, is it
readily available
Mini-Mental State Exam
- Organic screening for differentiating
dementia from depression, etc
- Monitors changes in mental status
- Total score of 30 points
o Dementia – avg 9.7
o Depression w/ cog impairment – avg
19
o Uncomplicated depression – avg 25
o Normal subjects – avg 27.6
o Score of 9-12 indicates a high
likelihood of organic illness
Intelligence Testing
- Wechsler Adult Intelligence Scale (WAIS)
o Ages 17+
o Verbal and performance scores
- Wechsler Intelligence Scale for Children
Revised (WISC-R)
o Ages 6-17
- Stanford Binet
o Ages 2-18
o 1st formal IQ test used, introduced in
1905
o Most useful for children under age 6
Behavioral Rating Scales
- Personality
o Minnesota Multiphasic Personality
o 566 questions w/ true/false answers
o 10 clinical dimensions w/ 3 validity
scales
- Mania
o Young mania rating scale
-
Schizophrenia
o Positive and Negative Symptoms of
Schizophrenia (PANSS)
o Abnormal involuntary movement
scale (AIMS)
Depression Scales
- Beck Depression Inventory (BDI)
o 21 questions, screens for behavioral,
cognitive, and affective symptoms of
depression
- Hamilton Rating Scale for Depression (HAMD)
o 21 items on a Likert scale, max score
of 52
o Score of 14 or more indicates clinical
depression
- Geriatric Depression Scale (GDS)
o 30 questions w/ yes/no answers
o Score of 21-30 severe depression
o 15 questions – short version
Psychological Diagnosis
- According to DSM-5
o Axis 1 (DSM-IV)
o Seldom changes during admission
- According to NANDA
o Changes according to client
responses
o Prioritize
o Problem oriented
o Evaluate daily, weekly, or monthly
Outcome Identification
- Goals and actions that are
o Specific = client will sleep 8 hr/night
by 3rd night
o Individualized = client will
demonstrate improved self-esteem
by initiating conversations, making
eye contact, verbalizing positive
statements about self
o Collaborate = client will agree to a
safety contract and seek out staff
member on each shift when thinking
self-destructive thoughts
Nursing Interventions
- Counseling interventions
- Conflict resolution
- Bibliotherapy and webotherapy
- Reminiscence
-
-
-
Behavior therapy – behavior modification,
token economy
Psychoeducation
Health teaching
Spiritual interventions
Therapeutic interaction
o Talking, poetry, writing, journaling,
social skills training, cooking,
modeling assertiveness, expression
of feelings
Health teaching
o About med, stress management,
coping skills, nutrition, sleep,
hygiene
Therapeutic environment (Milieu)
Self-care activities
o Relaxation, exercise, spirituality
Somatic therapies
o Nursing care of clients receiving ECT
Psychotherapy
Evaluating Outcomes
- Demonstrates clinical effectiveness and
promotes rational clinical decision making
o Cognition = giving up irrational
beliefs, making positive selfstatements, improving ability to
problem solve
o Affect = decreased anxiety,
depression, loneliness
o Behavior = improved coping skills
and social skills
- Patient benefits
- Patient level of satisfaction
Nursing Interventions – Social Domain
- Social behavior and privilege systems
- Milieu therapy
o Containment
o Validation
o Structured interaction
o Open communication
- Promotion of pt safety
o Observation
o De-escalation
o Seclusion
o Restraints
- Home visits
- Community action
Therapeutic Interventions
Communication and Therapeutic Relationship
Nurse-Client relationship
- = a dynamic, collaborative, therapeutic
interactive process betw nurse and client
- Purpose = to create a safe climate wherein
clients
- Goal = facilitate change in clients feelings,
attitudes, and behaviors
Therapeutic Use of Self
- Application of nurses own personality
characteristics within the interaction to
facilitate healing
- Open-ended process, continues to develop
throughout life as we learn new ways to
relate to others
- Basic concept involves understanding of self
and others
Self-Awareness
- The process of understanding one’s own
beliefs, thoughts, motivations, biases, and
limitations and recognizing how they affect
others
- Self-examination = willingness to be
introspective
- Avoidance of bias if self-examination
involves another’s perspective
- “Know thyself”
Johari’s Window
Goal of Self-Awareness
Steps to increase self-awareness
- Listen to yourself – experience emotions,
explore thoughts, feelings, impulses
- Listen and learn from others, be open to
feedback
- Reveal to others important aspects about
self (self-disclosure)
Culturally Competent Care
- Be aware of one’s own values, beliefs and
behaviors
- Have knowledge of cultural differences
- Perform a cultural assessment
- Show respect and acceptance to clients in
ways they understand
Orientation Phase
- Client
o Seeks or is brought in for help,
communicates needs and
expectations
- Nurse
o Explains parameters of relationship
o Gathers data and establishes
rapport
o Negotiates contract, lays
groundwork for termination
Identification Phase
- Client
o Explores deeper feelings
o Identifies with nurse
- Nurse
o Structures relationship to focus on
client
o Facilitates expression of problems
and feelings
o Encourages self-care, avoids
fostering dependency
Working Phase
-
Client
o More independent in working to
interpret behaviors
o Begins to try out new behaviors
- Nurse
o Supports client, explores feelings
and problems at client’s pace
o Deals with resistance
o Encourages risk taking and facilitates
achievement of goals
Termination (Resolution) Phase
- Client
o Engages in new problem-solving
skills and coping behaviors
o Views self positively and plans for
future
o May decompensate when
anticipating separation
- Nurse
o Review goals and accomplishments
o Shares own feelings and assists
client to express feelings about
relationship and separation
Attributes of Therapist (Carl Rogers)
- Congruence (genuineness)
- Unconditional positive regard
- Empathic understanding
- Concreteness
Communication
- All behavior communicates some message
- It’s not WHAT you say but HOW you say it
- Culture influences perceptions and values
influence how communication is
transmitted and received
Therapeutic Communication
- Ongoing process of interaction in which
meaning emerges
- Professional, nonjudgmental attitude w/ pt
as primary focus
- Self-disclosure only for therapeutic
purposes
- No advice or social relationships with pt
- Pt confidentiality
- Assess pt intellectual competence
- Guide pt to reinterpret experiences
rationally
- Clarify to track the pt verbal interaction
Nonverbal Messages
- Positive or negative
- Mirror or enhance verbal messages
- Varies from culture to culture
- Gestures
- Facial expression, eye contact
- Body language
Body Space Zones
- Boundaries and body space zones
o Personal boundaries (4 body zones)
o Professional boundaries and ethics
Therapeutic Actions
- Timing and judgement of when best to use
- Nurse self-disclosure = only personal
statements about self that help client
- Confrontation = subtly point in incongruent
behaviors
- Evaluate relationship betw teherapist and
client
- Role play – try out new behaviors
Therapeutic Communication techniques Table (9.2)
Nontherapeutic Communication techniques Table
(9.3)
-
-
Normal response to anxiety provoking
thoughts and feelings – afraid of selfexploration
Client = avoidance, acting out, forgetting,
silence, lateness
Nurse = make observations, support client
to deal with anxiety
Defense Mechanisms
- Mediate the indiv reaction to emotional
conflicts and to external stressors
- Evaluate purpose of a defense mechanism,
determine whether or not to discuss with pt
- Some are conscious (helpful), some are
unconscious (not helpful)
- Maladaptive (harmful) or adaptive
(beneficial)
Communication Considerations
- Specific mental health issues involved
o Develop insight, identify feelings,
analyze behavior, help pt function
effectively
- Process recordings to retrospectively
analyze your interactions
Ethical Aspects
Therapeutic Obstacles
- Transference
- Countertransference
Resistance
Code of Ethics for Nurses – purpose:
- Informs nurse and society of professions
ethical expectations and requirement
- Provides framework for ethical decision
making
Guiding Ethical Principles
- Autonomy = concept of self-determination,
most people are capable of making their
own decisions and should be allowed to
make decisions without interference
- Beneficence = doing good/acting in the best
interest of our clients
o Can conflict w/ autonomy at times
Other ethical principles
- Nonmaleficence = to do no harm, not
intentionally hurting others
- Justice = fair and equitable distribution of
resources
- Fidelity = faithfulness to obligations/duties,
follow thru explicitly (“I’ll see you in 20
minutes) or implicitly (unspoken but
understood)
- Veracity = have a duty to tell the truth
o Doesn’t mean we have to tell clients
everything all the time, can withhold
some info for a therapeutic purpose
- Paternalism = health professionals are
authorized to make decisions for the good
of the pt – can break autonomy when
needed for benefit of pt
Dangerousness
- Most mentally ill pt are no more violent
than the general population
- Mentally ill and dangerous can be confined
indefinitely
- Predicting danger is subjection – try to error
on the side of caution
Forcing medications
- Pt delusions or denial may lead to refusal of
meds
- Conflicts with nurses desire to act in best
interest of pt
- Nurses options
o Offer a lower dose or not give med
o Pt can discharge against medical
advice
o Involuntary commit pt because they
are unsafe to themselves
Patient Rights/Legal Issues
Self Determinism
-
Empowerment or free will to make moral
judgements
- Internal motivation to make choices based
on personal goals
- Right to choose one’s own health-related
behaviors
- Possibly different from those recommended
by health professionals
Protection of Pt Rights
- Patient self-determination act = requires
that we give pt education on advanced
care, give info about their rights to
complete advanced care documents
o Required by law to ask it pt has
advanced care directive
o If they don’t have one, ask if they
would like to complete one in the
hospital with us
- Advance care directives in mental health
o Living will
o Durable power of attorney
o May have psychiatric advanced
directive = decisions/declarations
about kinds of things they would
want in their care should their
mental health capacity deteriorate
to a point where they can no longer
make decisions
Competency = degree to which pt can understand
and appreciate the info given during consent
process
- Cognitive ability to process info at specific
time
o Different from rationality
- Determining competency – can the pt:
o Communicate their choices (verbally
or written)
o Understand relevant info
o Appreciate situation and
consequences of decision vs
decision
o Use logical thought processes
Informed Consent
- Legal procedure to ensure patient knows
benefits and costs of treatment
- Mandate of state laws
- Complicated in mental health treatment
Right to Informed Consent
-
Must be able to give consent
o Not a minor
o Not legally declared incompetent
- Sign forms on admission which cover psych
treatment
- Commitment procedure gives hospital right
to treat involuntary pts
- Psychosis or mental illness is not a reason
to bypass informed consent
- Written consent necessary for ECT,
psychosurgery, experimental drugs
Least Restrictive Environment
- Larger concept underlying pt right to refuse
treatment
o Retaining pt independence and self
determination
- A person can’t be restricted to an institution
when he/she can be successfully treated in
the community
- Med can’t be given unnecessarily
- Use of restraints or locked room only if all
other “less restrictive” interventions have
been tried first
- Right to treatment in Least Restrictive
o Mentally ill client can’t be
committed if other alternatives are
more appropriate and available
o Clients who aren’t dangerous can’t
be hospitalized against their will
o Clients can’t be restricted in
freedom any more than necessary to
provide adequate treatment
Privacy = part of persons life that isn’t governed by
society’s laws or intrusion
Confidentiality = ethical duty and nondisclosure
(provider can’t disclose pt info)
- Breach of Confidentiality = release info
without pt consent
Right to Privacy
- Confidentiality
o We don’t share any info about client
including fact that they’re
hospitalized
o High degree of stigma around
mental illness
- Privileged communication
-
Exceptions
o If we believe with reasonable
certainty that a client is going to
harm someone else = law
 EX: murder my ex wife
o Possible child/elder abuse =
mandatory reporters
o Private confidential info during
guardianship/court cases
Right to Treatment
- Pt can’t be held against will without an
individualized treatment plan and certain
other standards of care specified by law
o Food, clothing, etc
- State hospitals must provide “adequate”
treatment for involuntary committed pt
Right to Refuse Treatment
- Right is lost only after client is declared
incompetent (guardian can give permission)
o Court ordered 21 day commitments
- Non emergencies
- Emergencies
Other rights
- Right to habeas corpus = can petition courts
that they are sane
- Right to independent psych exam = can
request exam by another physician of their
choice
- Right to outside communication
o Phone calls, letters, visitors
Legal Aspects – Types of Treatment
- Voluntary
o Competent adult seeking and willing
to accept inpatient treatment for
mental illness
o Pt may leave at any reasonable time
OR if they have become
incompetent/are presenting as a
treat – can involuntary admit them
 Can reach out to court and
have them involuntary
committed
o Retains all civil rights
 Vote, drive, buy or sell
property, manage personal
affairs
- Involuntary (civil commitment)
-
-
-
o Court ordered, without person’s
consent
o Probate judge reviews petition and
court orders involuntary eval and
treatment
o Emergency short-term
hospitalization of 48 to 92 hours
 In MO – 96 hour, 21 days, 90
days, or 1 year
o Grounds for involuntary
commitment
 3 common elements =
mentally disordered/obvious
need of mental health
treatment, danger to
themselves/others, unable to
provide for basic needs
o Retains all civil rights as voluntary pt
o Right to receive treatment and
possible right to refuse treatment
o Loses right to leave hospital at any
time
Circuit court commitment
o Pre-trial eval/forensic commitment
 Within absence of all mind
altering drugs (psych meds,
illicit drugs, nicotine,
caffeine, etc)
o Incompetent to stand trial (IST)
o Not guilty by reason of insanity
(NGRI)
Voluntary by Guardian
o Incompetency hearing
 Must show that all 3 of these
exist: person is mentally
disordered, have impaired
judgment, incapable of
handling personal affairs
 Have to do additional
hearing to reverse
o Loses all civil rights and have no
power to consent to/refuse
treatment
 Guardian makes all decision
for them
Juvenile Admissions
o Voluntary admission by guardian,
have to show legal guardianship
o Juvenile court amy order minor
placed in custody of DMH for eval
and treatment
Discharge
- Voluntary may leave at any reasonable time
unless pt meets criteria for involuntary
commitment
- Conditional release (CR) allows for civilly
committed pt to leave before expiration of
court under certain conditions
o Can be readmitted without another
hearing if there is an issue/don’t
meet criteria
Legal Liability in Nursing
- Malpractice = failure of professional to
provide proper care, resulting in pt harm
- Negligence = result in injury
- Battery/medical battery =
harmful/offensive touching of another
person
- Assault = treat to use force without bodily
contact (needle)
- False imprisonment = detained w/o lawful
basis
- Common areas for lawsuits – pt who are
suicidal or violent
Mandates to inform
- Legal obligation to breach confidentiality
- Duty to warn
- Reporting STDs
- Reporting abuse
HIPAA
- pt authorization necessary for release of
info w/ exception of that required for
treatment, payment, and health care admin
operations
- American recovery and reinvestment act
2009
Documentation
- Pt record = primary documentation of pt
problems, verifies behavior and describes
care provided
- Meaningful, accurate, objective
descriptions – no general or stereotypical
- Electronic held to same standards as nonelectronic
-
Can be used in court, pt can view their
records
Nursing documentation based on nursing
standards
Observations of subjective and objective
physical, psych, and social responses
Interventions implemented and pt response
Observations of med – therapeutic and side
effects
Eval of outcomes of interventions
-
-
-
Chapter 23: Depressive Disorders
Mood = pervasive and sustained emotion that
influences one’s perceptions of world/how one
functions
Depression = mental state characterized by
sadness, loss of interest or pleasure (anhedonia),
feelings of guilt/low self-worth, disturbed sleep or
appetite, low energy, poor concentration
- In adolescents = anger, agitation, aggression
are common
Depressive Disorders
- Disruptive Mood Dysregulation Disorder
(DMDD) = temper outbursts and/or
aggression
o 3+ times per week for 12 months
o In at least 2 settings
o Diagnoses shouldn’t be made before
age 6 or after age 18 – symptoms
must be observed prior to age 10
- Major depressive disorder = 5 or more of
the following, present for 2+ weeks and
impact functioning
o Depressed mood (irritability in
children)
o Loss of interest or pleasure
o Weight loss/gain (5%)
o Sleeping too much or not enough
o Psychomotor agitation or
retardation
o Fatigue or loss of energy
o Feelings of worthlessness or guilt
o Poor concentration
o Recurrent thoughts of death or
suicidal ideation
-
-
-
-
Persistent Depressive Disorder (dysthymia)
= depressed mood (criteria for major
depressive disorder) for at least 2 years (1
year for children)
Premenstrual dysphoric disorder =
depressive symptoms (at least 5) present 1
week before menses and becomes
minimal/absent in week post-menses
Substance/med induced depressive
disorder = symptoms are experienced while
intoxicated/withdrawing from a med or
substance
o Substance is capable of producing
symptoms
Depressive disorder due to another medical
condition = symptoms caused by patho of
another med condition
o Not exclusively part of delirium
o Not better explained by adjustment
disorder with depressed mood
Other specified depressive disorder
o Recurrent brief depression
o Short duration depressive episode
o Depressive episode with insufficient
symptoms
Unspecified depressive disorder = clinician
chooses not to specify
o Insufficient info
o Setting (ED)
ALL depressive disorders require
o Clinically significant distress and
impairment in social, occupation, or
other important areas of functioning
o Can’t be caused by substance use or
other med condition
Depressive Disorder Specifiers
- Severity
o Mild
o Moderate
o Severe
o With psychotic features
o In partial remission
o In full remission
o Unspecified
- Additional specifiers
o With anxious distress
o With mixed features
o With atypical features
o With mood congruent psych
features
o With mood incongruent psych
features
o With catatonia
o With peripartum onset
o With seasonal pattern
Differential Diagnosis
- Mood disorders (including bipolar)
- ADHD, ODD, autism spectrum
- Medical conditions
- Normal development
- Adjustment disorders
- Grief/loss
Epidemiology
- Risk factors
o Prior episodes of depression
o Family history
o Lack of supports
o Lack of coping abilities
o Life stressors
o Substance use
o Med/mental health comorbidities
- Age
o Mean age of onset = 30 yrs
- Gender
o Twice as common in adolescent and
adult women
- Ethnicity and culture
o Prevalence unrelated to race
o Cultural variations to symptom
description
o Somatic symptoms vs sadness
common in some cultures
Biological Theories
- Genetics = more common among 1st degree
biological relatives
- Neurobiological hypothesis = deficiency or
dysregulation of neurotransmitters (norepi,
dopamine, serotonin) or receptor function
in CNS
o All antidepressants pharm agents
currently target these
neurotransmitters or receptors
- Neuroendocrine and neuropeptide
hypothesis = alterations in multiple
-
endocrine syst contribute to depressive
symptoms
Psychoimmunology = chemical messengers
(cytokines) influence immune responses
and can result in changes in brain activity
o High cytokine levels are associated
with depression and cognitive
impairment and inflamm is liked to
development of some mental
disorders
Psych Theories
- Psychodynamic factors = early lack of love,
care, warmth, and protection resulting in
anger, guilt, helplessness, and fear
- Behavioral factors = severe reduction in
rewarding activities and an increase in
unpleasant events in life
- Cognitive factors = irrational beliefs and
negative distortions about self,
environment and future lead to depressive
effects
o Cognitive processes can be learned
or developed through poor coping
- Developmental factors = depression results
from loss (emotionally or physically) of
parents at an early age
Social Theories
- Family factors = maladaptive patterns of
family interaction, unhealthy interactions
can negatively impact 1 or more family
member, especially those with poor coping
- Environmental factors = depressive
symptoms in one person is associated w/
similar symptoms in friends, co-workers,
siblings, spouses, and neighbors
Assessing for Depression
- Physical Health
o Appetite, weight changes
o Sleep issues
o Fatigue, decreased energy
- Med assessment
o OTC meds
o Herbal supplements
 St John’s wort
- Substance use
- Psychosocial assessment
-
-
o Mental status (mood, affect,
thought content, cognition,
memory)
o Coping skills
o Developmental history
o Family psychiatric history
o Relationships
o Support systems
o Education
o Work history
o Abuse history
o Interpersonal functioning
Behavioral assessment
o Changes
o Patterns
Self concept
Stress and coping
Suicidal behavior
Nursing Diagnosis
- Disturbed thought process
- Low self-esteem
- Ineffective indiv coping
- Ineffective family coping
- Hopelessness
- Self-care deficient
- Insomnia
- Sexual dysfunction
- Caregiver role strain
Nursing Interventions
- Establishing recovery and wellness goals
- Physical care (sleeping, eating, hygiene,
activity)
- Pharm intervention
o Admin meds
o Monitoring meds
o Managing side effects
o Managing ADR
o Monitoring drug interactions
o Teaching
- Cognitive interventions
o Thought stopping
o Positive self talk
o Affirmations
- Behavioral interventions
o Activity scheduling
o Social skills training
o Problem solving
- Group intervention
-
o Grief
o Chronic med conditions
o Pt/family education about diagnosis
and treatment
Psychoeducation
Milieu therapy
Safety
Family interventions
Support groups
Alternative Therapies
- Electroconvulsive therapy = effective for
severe depression, unresolved by other
treatments
o Nursing interventions
 Education
 Emotional support
 Assess and monitor pre and
post intervention
- Light therapy = effective for mild to
moderate seasonal, nonpsychotic
depression
o Appropriate for children and
adolescents
o Can also address sleep disturbance
issue
- Repetitive Transcranial Magnetic
Stimulation (rTMS) = effective for mild
treatment-resistant depression
o Magnetic coil placed on the scalp to
release small electrical pulses to
depolarize neurons and exert effects
across synapses
o Less electricity than ECT
o Patient is awake, reclined in a chair
and sedation is not required
o 20-30 session, approx. 30 min each
over 4-6 weeks
Chapter 24: Bipolar Disorders
Mania = abnormally and persistently elevated,
expansive or irritable mood
Mood lability = rapid shifts in mood that often
occur in bipolar disorders
Rapid cycling = extreme form of mood lability
Bipolar Disorders DSM-5
Manic episode
- At least 1 week of elevated, expansive, or
irritable mood (any duration if requiring
hospitalization)
- 3 or more (mist be a change from “usual”
behavior
o Inflated self-esteem or grandiosity
o Decreased need for sleep
o More talkative or pressured speech
o Flight of ideas or racing thoughts
o Distractibility
o Increased goal-directed activities or
psychomotor agitation
o Risk taking behaviors (buying sprees,
sexual indiscretions, foolish business
investments)
- Impairment to functioning
- Not caused by substance or med condition
Hypomanic episode
- Mania criteria for 4 days
- Does NOT cause impairment to functioning
Major Depressive Episode
- 5 or more of the following
o Depressed mood (irritability in
children)
o Loss of interest or pleasure
o Weight loss or gain (5%)
o Sleeping too much or not enough
o Psychomotor agitation or
retardation
o Fatigue or loss of energy
o Feelings of worthlessness or guilt
o Poor concentration
o Recurrent thoughts of death or
suicidal ideation
- Present for at least 2 weeks and impaired
functioning
Bipolar 1 Disorder
- Meet criteria for at least one lifetime manic
episode
- Mania can be preceded or followed by
hypomania episode or major depressive
episode
Bipolar 2 Disorder
- Must meet criteria for at least 1 hypomanic
episode (past or current)
- Must meet criteria for major depressive
episode (past or current)
- Can NOT have a manic episode
Cyclothymic Disorder
- Must occur for at least 2 years (1 in children
and adolescents)
- Symptoms must be present at least half the
time with no period of more than 2 months
without symptoms
- Numerous periods of hypomanic and
depressive SYMPTOMS
- Can NOT meet full criteria for manic
episode, hypomanic episode or major
depressive episode
Substance/Med Induced Bipolar
- Manic/hypomanic disturbance in mood
(with or without depressed mood) case by
substance intoxication or withdraw
Bipolar due to another med condition
- Manic/hypomanic disturbance in mood
directly linked to patho of another med
condition
- Can’t occur exclusively during delirium
- Cushing’s disease, MS, stroke, traumatic
brain injury
Other specified bipolar disorders
-
Short-duration hypomanic episodes (2-3
days) and major depressive episodes
- Hypomanic episodes
o With insufficient symptoms and
major depressive episodes
o Without prior major depressive
episode
- Short-duration cyclothymia (less than 24
months)
Unspecified Bipolar Disorder
- Insufficient info
- Setting (ED)
-
-
Bipolar Disorders Specifiers
- Specifiers
o Mild
o Moderate
o Severe
- With…
o Anxious features
o Mixed features
o Rapid cycling
o Melancholic feature
o Atypical features
o Psychotic features
o Catatonia
o Peripartum onset
o Seasonal pattern
- Remission
o Partial
o Full
Epidemiology
- Age
o Most experience symptoms before
25
o 20% have symptoms before 19
- Gender
o No significant gender differences
o Women at greater risk for
depressive episodes and rapid
cycling
- Comorbidities
o Anxiety
o Substance use (decreased chance of
remission, poor treatment
compliance)
Biological theories
Chronobiological theories = circadian
dysregulation underlies the sleep
disturbance of bipolar disorder
o Seasonal changes in light exposure
can trigger affective episodes in
some pt
Genetic factors
o in twin studies, 40-90% risk of
acquiring bipolar disorder if the
identical twin has the disorder
o genetic etiology of bipolar and
schizophrenia overlap
Chronic stress, inflamm and kindling
o The greater and allostatic load, the
number of episodes increase,
increasing physical/mental health
risk
o Kindling = smaller stresses
compound to increase a pt
vulnerability to a future stress
response, stress response is
triggered by smaller and smaller,
stimuli, eventually no stimuli needed
Psychological and Social Theories
- Behavioral approach syst dysregulation =
indiv w/ bipolar overreact or underreact to
cues when approaching a reward
- Social rhythm disruption theory = social
cues or rhythm structure the day (wake up,
eat, go to bed), indiv with bipolar have
fewer social rhythms, disrupted social
rhythms lead to increased mood swings
Treatment
- Goal
o Minimize manic and depressive
episodes
o Fewer episodes = more productive
life
- 3 barriers to treatment
o Stressful life events
o Med non-adherence
o Disruption of social rhythms (job
loss, relationship dysfunction, lack of
routine)
- Treatment modalities
o Medication
o Psychotherapy
o Education
o Support
Nursing Assessment
- Physical health
o Activity (energy)
o Eating
o Sleeping
o Sexual practices
o Current meds/discontinuation
- Psychosocial
o Mood
o Cognition
o Thought disturbances (psychosis)
o Stress and coping
o Risk assessment
 23-26% attempted suicide
 Substance use
o Social/occupational functioning
o Strengths assessment
Nursing Diagnosis
- Sleep deprivation
- Imbalanced nutrition – less than body
requires
- Disturbed personal identity
- Defensive coping
- Risk of suicide
- Risk-prone health behavior
- Ineffective coping
- Ineffective role performance
- Interrupted family processes
- Impaired social interaction
- Impaired parenting
- Compromised family coping
- Readiness for enhanced coping/resilience
Interventions
- Therapeutic relationship
- Recovery and wellness goals
- Self-care
o Rest, hydration, nutrition, sleep
hygiene
- Medications
o Admin and monitoring meds
o Managing ADRS
o Monitoring drug interactions
o Promoting adherence
o Teaching points
 Salt intake can effect
therapeutic blood levels


Med induced weight gain
Potential risk of OTC med,
herbal supplements,
alternative meds
Psychosocial interventions
- Identifying risk factors
o Stress
o Med non-adherence
o Marital status
o Poor sleep
- Identifying intervention strategies
o Stress reduction, meditation,
conflict reduction, radical
acceptance
o Indiv therapy
o Med accountability/education
o Family support, martial counseling
o Sleep hygiene, rhythm therapy
Intervention – warning signs of relapse
- Stop cooking, cleaning, chores
- Missing work
- Sleeping more
- Avoiding people
- Headaches/stomach aches
- Not caring about people
- Sleeping less
- Lack of concentration
- Talking fast
- Feeling irritable
- More energy than usual
- Risk thoughts/choices
- Friends seeing modo change
Continuum of Care
- Inpatient
o Safety
o Stabilization
o Initiation of treatment
- Intensive outpatient
o Close med monitoring
o Intensive therapy
o Crisis services
- Community care
- Non-psychiatric hospitalization
Medications for Depression and Bipolar
Antidepressant Med
-
-
-
Also used for anxiety disorders, eating
disorders, and other mental health
conditions
Avoid (or used w/ extreme caution) in ot w/
bipolar disorder
Can have some effect in 7 days but take 4-6
weeks for full effect
Require a slow taper for discontinuation
Most are metabolized by CYP450 enzyme
system = can have inducer/inhibitor effects
w/ other drugs
All carry a black box warning for suicidal
behavior in children, adolescents and young
adults
Tricyclic Antidepressants
Monoamine Oxidase Inhibitors (MAOIs)
Selective Serotonin Reuptake Inhibitors
MAOIs
Serotonin Norepi Reuptake Inhibitors
Norepi Dopamine Reuptake Inhibitors
Other Antidepressants/new agents
A2 Antagonist
Antidepressants and Medical Emergencies
Mood Stabilizers
- Antimanic meds
-
Anticonvulsants
-
Antipsychotics
Cognitive Behavior Interventions
Cycle of Cognition
Cognitive Processes in Mental Disorders
- Involved in development of mental
disorders
o Cognitive triad = thoughts about
oneself, the world, the future
o Cognitive distortions = “twisted
thinking”
o Schema = indiv life rules acting as a
filter, dev in early childhood and
fixed by middle childhood
Dev of Cognitive Therapies
- Albert Ellis
o First to dev and implement cognitive
therapy
o Continued refinement and dev of
theory and therapeutic approach
called rational emotive behavior
therapy (REBT)
- Aaron Beck = cognitive behavioral therapy
(CBT)
- Steven de Shazer and Insoo Kim Berg –
solution-focused brief therapy (SFBT)
Cognitive Behavioral Therapy
= used to alter distorted beliefs and problem
behaviors, negative and inaccurate thoughts
identified and replaced, rewards for behavior
changed
- Assumptions
o People disturbed by the perception
of event, not by the event
o Whenever or however the belief
develops, the indiv beliefs it
o Work and practice can modify
beliefs, creating difficulties
Guiding principles of CBT
- Behavior is learned, therefore it can be
unlearned
- Identification of core beliefs
o Both positive and negative
- Negative core beliefs are usually unrealistic
and fall into 2 broad categories
o Helpless
o Unloveability
Core Irrational Beliefs
- Helpless = I am
powerless/weak/trapped/incompetent/fail
ure
-
Unlovable = I am
undesirable/unattractice/unworthy/bound
to be rejected/to be alone
Implementing CBT
- Engagement and assessment
- Interventions
o Identify the underlying belief
o Explore the evidence that supports
or refutes the belief about the event
o Identify alternative explanations for
the event
o Examine the real implications if the
belief is true
- Evaluation and termination
Cognitive Restructuring
- Understand that core beliefs are ideas and
not necessarily the truth
- Identify core beliefs, automatic thoughts,
cognitive distortions and/or thinking errors
- Change negative core beliefs
- Reframe core beliefs in a more realistic and
positive way
- Clients who decide for themselves and
devise their own systematic procedures to
change are more apt to be successful
Cognitive Techniques
- Socratic dialogue = specific questioning to
identify automatic thoughts and
assumptions
- Listen for clients “core messages”
o Guide the client to question and
evaluate reactions in a nonthreatening manner
- Consider alternate ways of dealing with
their issues
- Set goals
Thought Stopping
- Learn to stop negative or maladaptive
thinking
- Associates the stoppage of a negative
thought
o “I’ll never amount to anything”
o “I can’t do this”
- With a visual image, sensation, or
circumstance
o A traffic stop sign
o Hearing the word “stop”
o Learning against a closed door
o Snaps a rubber band on the wrist
Other Cognitive Strategies
- Rational coping statements
- Positive imagery = visualize that you can do
better = self efficacy theory (Bandura)
- Reframing = see things in a good light
- Cognitive homework
- Psycho-educational resources, self-help
(bibliotherapy)
- Use humor
Dialectical Behavior Therapy (DBT) – Marsha
Linehan
= outpatient treatment of chronically suicidal
people w/ borderline personality disorder (BPD)
- Assumes dysregulation of emotions and
intolerance to stress
o Manifested in self-mutilation
(cutting), poor impulse control,
dissociated behavior
o Alexithymic = unable to find words
to express feelings
o Dysfunctional attempts to express
feelings and problem solve
- Accepting maladaptive behavior patterns
(cognitively) while working to change them
(behaviorally)
Goals and Skills of DBT
- Therapeutic goals focus on 4 main skills
o Mindfulness (attention to one’s
experiences)
o Interpersonal effectiveness
o Emotional regulation
o Distress tolerance
Rational Emotive Behavior Therapy – Albert Ellis
- Identify irrational beliefs (false
assumptions)
o Something should, out, must be
different
o Something is awful, terrible, or
horrible
o One cannot bear, stand, or tolerate
something
o Something is damned, as a louse,
rotten person
- Dispute irrational beliefs
-
Reframe into rational thoughts = positive
self talk
Assumptions
- Based on premise that one’s values and
beliefs control one’s behavior
- People are born w/ potential to be rational
(self-constructive) and irrational (selfdefeating)
- Irrational thinking, self-damaging
habituations, wishful thinking, and
intolerance are exacerbated by culture and
family groups
Framework
- A = activating event that triggers automatic
thoughts and emotions
- B = beliefs that underlie the thoughts and
emotions
- C = consequences of this automatic process
- D = dispute or challenge unreasonable
expectations
- E = effective outlook dev by disputing or
challenging negative belief syst
Interventions
- Role-playing, assertion training,
desensitization, humor, operant
conditioning, suggestion, support
- Focus = dev rational beliefs to replace those
that are irrational and interfere with quality
of life
Learning New Behaviors
- Modeling = vicarious learning, imitation
- Shaping = token economy, prompting,
fading, time out, revoking privileges
- Social skills training = assertiveness,
communication, skills, problem-solving
- Role-playing = rehearse new responses
- Contracting = verbal or written agreement
outlining expected behaviors and
consequences of undesirable behaviors
Conditioning
- Classic conditioning = Pavlov
o Stimulus-response
o Process by which involuntary
behavior is learned
o Useful in treating phobias
 Systemic desensitization to
stimulus
-
Operant conditioning = Skinner
o Use of reinforcement
o Process by which voluntary behavior
is learned
o Activity is strengthened or
weakened by its consequences
(under control of the indiv)
Increasing Behavior
Use of reinforcement – to INCREASE desired
behavior (social, material, activity)
- Positive reinforcer = reward given, added
(+)
- Negative reinforcer = removal of stimulus ()
Candy, video games, computer time, money,
praise, tokens, level increases, ground passes are
all examples of reinforcements to shape/treat
behaviors
Reinforcement Schedules
- Timing is important for adaptive change to
occur
- Fixed ratio = every expected response is
reinforced
- Variable ratio = behaviors are rewarded
randomly, most effective in producing long
term change
- Fixed interval = rewarded at specific time
intervals
- Random interval = behaviors rewarded at
random time intervals
Decreasing Behavior
- Punishment =aversive stimulus decreases
future undesirable behavior
o NOT a negative reinforcer
- Response cost = penalty for undesirable
behavior
o Losing allowance, dropping a level,
assessing a fine
- Extinction = eliminate behavior by ignoring
or not rewarding it
Behavioral Techniques
- Stress management
o Progressive muscle relaxation
o Positive imagery
o Meditation
-
o Deep breathing
Bibliotherapy
Assertive training
o Use of “I” statements
o Behavioral rehearsal (role playing)
o Assigning homework
Solution-Focused Brief Therapy
- Focus = solutions rather than problems,
problems best understood in relation to
solutions
- Emphasis on what is functional and
healthful rather than on problems or
symptoms
- View of pt as an indiv with a collection of
strengths and successes rather than as a
diagnosis and collection of symptoms
- Emphasis on the uniqueness of the indiv
and the capacity to make changes or deal
w/ day to day lives
Assumptions
- People have strengths and resources for
problem solving
- Not necessary to know a lot about problem
to resolve it
- Problem defined and dissected from pt POV
- Resolution of even long standing issues
- No right or wrong way to see things
- Change most likely when focused on what is
changeable
- Expectation of change and movement
- Identify and amplify change – co create
reality
Interventions
- Therapist in position of curiosity– asks
questions
- Interventions focus on achievement of
specific, concrete, and achievable goals
- Techniques utilized
o Miracle question
o Exception questions
o Scaling questions
o Relationship questions
o Compliments