Psych Exam Study Guide with my book notes

Here it is: it is a work in progress. I will keep updating.

PMH study guide, Exam 1

Chapter 1

Significance of National Mental Health Act of 1946 to nursing: page 9

Consequence of WW2: men disqualified from service b/c of mental instability, men returning from war w/ nuttiness. 1946, Truman signs act. Act started the 6 member mental health advisory panel [now the NIMH], supported research, training, and devel of clinics and treatment centers. The money: Hill-Burton act for hosp building, and bigger psych wards. Clinics popped up everywhere. Also created grants for fellowships for specially trained psych nurses. First grad-level RN program at Rutgers, developed by H Peplau. There are still many grad programs in psych RNing.

PMH nursing’s unique influence on development of nursing in general: Peplau’s work developed concept of therapeutic relationship, the value of interpersonal relationships, RN’s self as a healing tool, and creating the RN as separate from the MD hierarchy.

Chapter 2

Mental disorders are classified as clusters of symptoms with many likely causes, not by their origins like pathophysiology.

DSM–IV-TR: the dictionary of classifying MI’s. Provides criteria for diagnosis but without perfect boundaries btwn disorders.

Drawbacks: Some people think that diagnosis leads to labeling and makes pts into their illness rather than a whole person with treatable diagnoses. This is bullshit: doctors of all sorts treat patients as their diseases and not as people; psych docs aren’t unique. The DSM-4 is also a list of western disorders, and does not contain other culture specific disorders.

Multiaxial Diagnosis: DSM4 Dx critera are based on 5 axes:

1. Clinical disorder: focus of psych clinical attention
2. Personality disorders and Mental Retardation
3. General medical conditions: physical conditions
4. PsychSoc/environmental problems
5. Overall functioning in social, psych, and professional areas. Uses the GAF [global assessment functioning] Scale. Scored from low [0-10] to high [90-100.]

Contribution of epidemiology to understanding MI: epidemiology meaning ‘how prevalent is the disorder.’ Examine associations of disorder with the region of study [Marin: highest breast cancer rates], rather than etiology. CDC tracks this data.

• “Rate”: proportion of cases compared to the total pop.
• “prevalence”: total # of people w/ disorder in pop
• ‘Point prevalence’: # of people in pop at a certain time.
• ‘Incidence’: rate of only new cases in a defined time period.

Contribution is: helps understand the distribution of an illness. Helps with EBP. Knowing how this book harps on stigma, epidemiology probably helps remind people that these diseases can happen to anyone. Don’t hate!

Characteristics of MI diagnoses

Is that a part of this chapter? Things I know about MI Dx’es: they are usually wrong, if you put 5 MD’s together on one case they claim 5 different diagnoses between them. Few patients actually present ‘textbook’ symptoms, therefore no patient quite fits the mold, and often pt’s have multiple diagnoses in order to cover ‘all the bases’ of the symptoms they present. Just because we have the diagnosis doesn’t mean the treatment fits perfectly either: it’s not like staph and antibiotics. Also, several diagnoses have the same ‘symptom lists’ so one person may fit well under several diagnoses. It’s not exactly science.

Chapter 4 (accidently left this chapter off the list of chapters for exam 1 in syllabus)

Tx options for those with MI:

· Continuum of care: various options for treatment, varied treatment levels

· Least restrictive enviro: avoids enabling, creates enviro for pt independence

· Coordination of Care: what a case manager might do: to refer pt to the best care facilities/treatments, to create individualized plan

· Case management: care coordinator or team, meets w/ patient and other providers, works as a ‘broker’

· RN as case mgr: this actually requires the RN to have a lot of training.

· Crisis intervention: 6 hour short term intervention to stabilize pt. Found in ER of hospitals or psych hospitals. RNs must be expert in these settings: meds are usually administered to ‘bring down’ the patient. RNs also make referrals to other care providers

Where pts go to get care:

· 23 hour observation: Admits pts to inpatient setting [hosp] for 23 hours for rapid stabilization, but not ‘acute care.’ The problem is a major deviation from normal that is expected to improve fast; like drug induced psychosis, acute trauma from rape, or psych pts that stop taking their meds.

· Crisis stabilization: where you go if 23 hour observation didn’t fix you. Less than 7 days of treatment for ‘symptom management,’ coordination of after-care.

· Acute inpatient care: most intensive, and most restrictive intervention. You have to be so sick that: you will harm self or others, unable to care for basic needs. Where; in psych hosp, in psych unit of hosp, or state mental hospital. Admit is voluntary or involuntary. LOS is usually 24 hrs to a couple days if involuntary, if voluntary they will keep you based on degrees of symptoms and ability to pay. You are discharged when: you are non violent and can manage your needs w/ help of willing/able family/friends.

· Partial hospitalization [PHP’s: partial hosp programs]: a response to better outcomes in terms of price/benefit of outpatient care. Day hosp service; you go home at night. Intensive therapy, highly structured. Who goes: you have acute symptoms and decline in self care, but not a threat to self or others. Provide therapy and training for ADL’s.

· Residential services: rehab and therapy for people w/ chronic and serious MI. Treatment lasts from 24 hours to 6 months to several years. Some have more staffing than others: ‘intensive residential services.’ Funding for these programs is very tricky. Serves education, psych therapy, and training in ADL’s.

· Respite residential care: gives the family who tend to an MI pt a vacation: for short-term care.

· In-Home MH care: best cost/benefit option is always to have MI pts live at home. This is the alternative if outpatient care doesn’t work out. Case mgr and RN care help avoid hospital time and increase pt independence. RN needs to assess and create plan of care, ensure med compliance and lab tests, coordination of services.

· Outpatient care: often the step down from inpatient care. You need less than in home care, or residential care. Offers med management, ADL training, therapy/counseling, case management.

· Intensive outpatient programs: pt goes back to normal life, this is in place to prevent relapse. Few hours per day, few days per week: focus on med and stress management rather than social skills.

· Supportive employment: getting people w/ chronic MI, especially retardation, jobs. Job coaches get the pt the job and teach them on-site.

· Outpatient detox: most drug/ETOH rehab is now outpatient, except for those pts with need for severe withdrawal treatment needs or complicated Hx [seizure, pregnancy, etc.] Initially a 24 hour bed may be provided, follwed by 4-5 day/week rehab program until fully rehabbed. Uses the 12 step model of AA.

· In home detox: RN visits for the first week sober to assess and ensure med compliance.

· Assertive community Tx [ACT]: 24 hour services to allow serious MI pts live in the community, and prevent costly hospital visits. Provide 24 hour emergency hotlines, mobile treatment, and other services to help re-integration of severly ill pts.

· Psych Rehab programs: put people back into workforce and community with access to therapy and training in ADL’s and social skills. Promote high function with minimal intervention.

· Clubhouse Model: Run by MI pts. Offer ‘membership’ and ‘belonging’ and daytime support and opportunities for paid work. Pts are voluntary members and are expected to contribute to the household. Not a place to sleep usually. People start with work training around the clubhouse and move on to connect with outside part-time employment, and then competitive employment.

· Relapse prevention after-care: prevents re-hospitalization. Teaches family and pt about illness, coping, warning symptoms, etc.

· Technology based care: talk to the psych RN through your phone or computer [telemedicine] because you live way out in the boonies where there are no care facilities.

Alternative housing: places for the homeless, 40% of whom have severe MI, and pts who cannot be cared for by willing/able family. RNs are usually not involved with these services, but may do referrals or visit these settings for in-home treatment:

· Personal Care Homes: 6-10 pts with 24 hour supervision, assistance with meals, meds, ADL’s, transportation.

· Board-and-Care-Homes: 24 hour supervision, assistance with meals, meds, not so much self-care/ADL skills. 50-150 pts. Shared rooms: 4-6 people per room.

· Therapeutic foster care: for children and adults. Placement in family situation, where family members are trained for MI situations. Family provides structure and supervision. Pt is an active member of the family, may attend outpatient care during the day.

· Supervised apartments: pts live in their own apartments alone or with 1 flatmate. Staff stop by as little or as much as needed to ensure med compliance, self-care, etc.

Chapter 6

2 – differences between the various major forms of psychosocial interventions

A “duh” question

Knowledge of basic Peplau theory

Knowledge of Carl Roger’s approach

Psychodynamic theories: study of unconscious

Psychoanalytic: Freud’s

• Conscious vs unconscious
• Personality made of: id [primitive/selfish], ego [contact w/ reality, cognition, defense], superego [manages looking good inside of culture]
• Object relations: obsessions and imitations of mommy, daddy, etc.
• Anxiety and ‘defense mechanisms’: protecting what our attachments and object relations
• Sexuality: libido lives inside the id. Sexuality is the end product of devel into adulthood
• Psychoanalysis: couch session to change personality
• “transference:” projecting mommy/daddy onto therapist. “countertransference;” therapist projects onto patient.

Neo-Freudians:

• Adler: freud’s student, theory: we avoid feeling inferior
• Jung: analytical psych. Concepts of persona, and introvert/extroverted people
• Karen Horney: intro to fem psych—women are not sad about their substandard genitalia; it’s not penis envy. Stated that women’s angst stemmed from submissive cultural position/male dominated culture.
• Otto Rank: student of freud. Stated primary source of pain was from pain of birth, underscored devel as freedom from need of mother, then from society, and that “will” is the primary goal of human devel
• Fromm: Sociological interaction focused. Bring harmony btwn indiv and society
• Klein: play therapy to reveal early childhood fears and desires. “early identity: meaning early object relations.”
• Harry Stack Sullivan: your health is derived from interpersonal relations; how well you play w/ others

Humanistic Theories: all about the goodness of the human, develop worth, positive outlook on life

Carl Rogers client-centered therapy, Gestalt, and Maslow

• Rogers: empathy w/ client via indirect non judgemental questioning
• Gestalt: modern world makes people nuts; remind them of their drives and needs via indiv and group actions like catharsis, etc
• Maslow’s: used to prioritize and needs

Behavioral theories: forget why you act so weird, let’s define “normal behavior”

• Pavlov: dog and food and bell. Classical conditioning
• Watson and “behaviorists”: “frequency vs recency,” likelihood of responses is increased by how often [frequent] or how recently the stim is responded to. No separation btwn mind/body

Reinforcement Theories

• Thorndike: Our problem solving/learning is through trial and error: we maintain the ‘winning formula’ after it works a few times.
• BF Skinner: respondent vs operational: respondent is like Pavlov, operant is like Thorndike

Cognitive theories: getting into thinking processes

• Al bandura: Social Cognitive Theory: we learn by mimicry, modeling. Disinhibition means changing one modeled behavior based on the model of another, new person.
• Aaron Beck: distorted viewpoints are the basis for depression—poor cognition makes disappointment.

Developmental theories:

• Erikson: 8 stages w/ different conflicts and resolutions to be ‘met:’
• Stages Infancy • Childhood • Preadolescence • Adolescence • Adulthood - Early adulthood • Middle adulthood • Late adulthood

Erikson also contributed: theory of turbulent teenage-dom, identity formation, identity crisis.

• Jean Piaget: Learning in children; cognition devel in children. Applied to psych RNing: you can identify what cognitive level a client is at, which cognitive skills, as defined by Piaget, the client can perform
• Carol Gilligan: gender differentiation. Boys’ development cognitively and socially vs girls’. Points out that devel theories that underscore detachment as the highest goal leave feminine bonding tendencies out of the loop of ‘successful.’
• Jean Baker Miller: connection/bonding patterns of females again.

Social theories

• Family Dynamics: the psychology of each family member has its influence on the otehrs’--little research on these
• Balance Theory and Social Distance [litwak]: about caregiving in social groups. “formal support systems:” hospitals, etc. “Informal support system”=fam, friends, neighbors. People w/o informal support are found to have more accidental deaths and suicides. Social distance means how different are the group’s values from the dominant culture’s values—how much ‘outsiders’ are they? [The notion includes all differences such as social class, race/ethnicity or sexuality, but also the fact that the different groups do not mix.-- wikipedia]

Role Theories:

• “role” meaning a person’s position or function inside an environment. In psych, we’re talking about the person’s role being in conflict with the ‘self’ or the ‘id.’

Sociocultural Perspectives:

• Margaret Mead: culture and gender: are gender behaviors ‘nature’ or ‘nuture’? She puts her money on ‘nuture.’
• Madeline Leininger: Transcultural Nursing. Caring and thereby nursing care are different between cultures.

Nursing Theories:

Interpersonal models:

• Hildegard Peplau: a nursing theorist who…emphasized the nurse-client relationship as the foundation of nursing practice. At the time, her research and emphasis on the give-and-take of nurse-client relationships was seen by many as revolutionary. Peplau went on to form an interpersonal model emphasizing the need for a partnership between nurse and client as opposed to the client passively receiving treatment. Empathic linkage=empathy, self-system=lends framework of anxiety
• Ida Jean Orlando: dynamic-RN-pt-relationship. Focuses on the needs of the pt, the rxns of the RN, and any factor that is inhibiting the pts’ needs being met. Pt distress is about inability to have their needs met.

Existential and Humanistic Theories

• Joyce Travelbee: RNs helping pts find ‘meaning’ in their situation. Defined concepts of ‘suffering’ and ‘hope’
• Jean Watson: all about caring as the essence of Nursing.
• Imogene King: defines RNing as caring for the pt, creating goals and navigating the challenges. Addresses systems theories.
• Dorothea Orem: self-care focused: self-care, self-care-deficit. Meaning self-care in pts when healthy and the need for RNs when not so healthy.

Chapter 7

Basic psychoneuroimmunology

Neurotransmitter-related activity

Chapter 8

SE’s of benzos

2 - Physiological responses to drugs

3 - SE’s of antipsychotics

Implications for psychotropic use in elderly

Phases of drug therapy

Complications with lithium

2 - Complications with antidepressants

Chapter 9

5 - Therapeutic communication

Defense mechanisms

2 - Self awareness

Chapter 10

Phases of a therapeutic relationship

Communication to enhance assessment

Outcome indicators

Chapter 11

Cognitive triad

CBT

SFBT

bibliotherapy

Chapter 17

• Suicide: successfully killing oneself. 11^th leading cause of death.
• Suicidality: all suicide related behaviors and thoughts
• Suicidal ideation: thinking about and planning one’s own death
• Suicide attempt: well, it didn’t work. Women make 3x the attempts that men do. Estimated 5% of all US pop have attempted. 20% of men and 40% of women die by suicide within a year of their 1^st suicide attempt; it is one of the best predictors for suicide. Adolescents also make more attempts than adults.
• Parasuicide: voluntary apparent attempt at suicide, in which the real aim is not death. “Faking it” for reasons of sending a message or numbing out for a time. More common in younger age groups.
• Lethality: probability that the person will complete the suicide; a combo of the person’s commitment and the chosen method.

Assessing and intervening with suicidal ideation and intent

Assessing:

• Goals: identify ideation, determine the severity of the intent, what the suicide plan is, and assess pt access to the means to the end.
• Assess: related events that are risk factors [loss, divorce, etc], warning behaviors [recklessness, giving things away, getting affairs in order legally and interpersonally]. Assess ETOH and drug consumption recently.
• Assess pt access to overdose-able drugs and firearms.
• Once you know the pt plan, assess its lethality.

Document: this is the time to cover your ass. It also helps provide a trail of breadcrumbs in the ‘continuum of care.’

Intervention:

• RN intervention: We no longer hospitalize patients; only if the patient is acute. Don’t leave the pt for a second, until the interventions are started. Later RN role is to coach patients with coping skills and find resources.
• Meds: antidepressants are used to raise serotonin and avert suicide risk: prozac, Zoloft, Paxil, Wellbutrin, Effexor, Celexa, Lexapro.
• ECT: for pts w/ severe depression and suicidality that cannot be treated otherwise.
• Therapy: to reverse negative thinking about oneself
• No-suicide contract: to not kill yourself, and to get help when you need it. Dismantling of the plan happens: guns and meds are locked away, etc. Not a decent intervention with high risk pts [previous attempts, etc.] Not as effective for isolated pts: they need to be with family or friends.
• Commitment to treatment statement: like a no-suicide contract, but the pt commits to living and going through the treatment course. Getting access to guns, etc, away from the patient is a ‘priority commitment.’ Family needs to be involved in enforcing the course of treatment including meds.
• Create a plan for what the pt will do when they start considering suicide again
• Psychoeducation: the pt and family learn more about the underlying MI and the precipitating thoughts and behaviors.
• Social skills training
• Develop support networks: family, friends, and support groups need to be identified to support the pt through recovery, so that no one person is burdened. Choose a MH professional who the pt can call when things get too difficult.
• Reduce feelings of stigma

Risk factors: MI, esp depression, is top of the list.

Vulnerability: close family member suicide, MI, previous attempt, Loss [deaths, job, divorce], chronic illness

Risk: white man, elderly man, adolescent man, LGB sexual orientation, access to gun

Intent: plan and means to execute it

Dis-inhibition: drugs/ETOH, impulsivity, isolation, psychotic thoughts

Antidepressants and suicide

• Meds: antidepressants are used to raise serotonin and avert suicide risk: prozac, Zoloft, Paxil, Wellbutrin, Effexor, Celexa, Lexapro.

Advance directives

• Also known as a: Commitment to treatment statement: like a no-suicide contract, but the pt commits to living and going through the treatment course. Getting access to guns, etc, away from the patient is a ‘priority commitment.’ Family needs to be involved in enforcing the course of treatment including meds.

Chapter 20

Interventions for clients with mania

Mania: abnormal and elevated, expansive, or irritable mood for at least 1 week.

Elevated mood: euphoria, or feeling “high.”

Expansive mood: poor control of emotions: inappropriately expressive, overly enthusiastic about all sorts of things, and thinking oneself is overly important.

Irritable mood: easily annoyed or angered, esp when they cannot get what they want

Lability of mood: a tendency of mania to oscillate between irritable and euphoric

Intervention:

• Need interdisciplinary treatment
• Safety for the pt: mania can cause recklessness and delusion. Both physical and fiscal safety.
• Help out the family
• Pt forgets their needs: food, water, rest.
• Monitor and encourage adequate sleep cycles: pts need to report lack of sleep which can be a precursor to manic episode.
• Meds: lithium, depakote, tegretol, zyprexa, risperdal are all ‘mood stabilizers.’
• Acute phase: In acute illness these are combined with antipsychotics to bring down major symptoms, otherwise they are increased gradually.
• Continuum phase: Therapy continues under close supervision, maintenance: then independently.
• Discontinuation: Prophylaxis with mood stabilizers are recommended lifelong to prevent acute symptoms.

Pt ed with lithium: most used mood stabilizer. But not usually adequate alone—needs to be in a cocktail—especially during acute phase. Lots of side effects, and narrowest therapeutic range. Because it is a salt, it is sensitive to sodium levels in the body: the more sodium you have the worse the lithium works. Similarly, lithium effects/side effects increase without enough fluid volume. African Americans are more at risk for these sodium-related sensitivities. Start dose low and slow and increase slowly due to narrow therapeutic range. If signs of toxicity: get a blood sample, push fluids, call the MD. Moderate tox= 1.5-2.5, high tox= >2.5 mEq/L. Pt ed: no ETOH or drugs [CNS depressants]. Pregnancy/breastfeeding risks. Avoid driving. Do not abruptly discontinue.

2 -Timeline of and assessing antidepressant effectiveness

“Duh”

1 extra credit