3180 week 1

psychoeducational groups

Milieu (mil′y ) is a word of French origin (mi "middle" + lieu "place") and refers to surroundings and physical environment. In a therapeutic context, it refers to the overall environment and interactions within that environment. Peplau (1989) referred to this as the therapeutic milieu. It is an all-inclusive term that recognizes the people (patients and staff), the setting, the structure, and the emotional climate as important to healing. Regardless of whether the setting involves treatment of psychotic children, adult patients in a psychiatric hospital, substance users in a residential treatment center, or psychiatric patients in a day treatment program, a well-managed milieu offers patients a sense of security and promotes healing. Structured aspects of the milieu include activities, rules, reality orientation practices, and environment. Managing Behavioral Crises Behavioral crises can lead to patient violence toward self or others and usually, but not always, escalate through fairly predictable stages. Staff members in most mental health facilities practice crisis prevention and management techniques. Training generally consists of a full-day course learning the skills to recognize and avoid crisis and de-escalate behavioral emergencies. Hands-on techniques, which are only used as a last resort, are also taught. At minimum, annual training is recommended to maintain competency. Some facilities have special teams of nurses, psychiatric technicians, mental health specialists, and other professionals who respond to psychiatric emergencies called codes. Each member of the team takes part in the team effort to defuse a crisis in its early stages. If preventive measures fail and imminent risk of harm to self or others persists, each member of the team participates in a rapid, organized plan to safely manage the situation. The nurse is most often this team's leader not only in organizing the plan but also in timing the actions and managing the concurrent administration of medications. Seclusion, restraint, and emergency medication are actions of last resort. The trend is to reduce or completely eliminate these practices whenever safely possible. The nurse can initiate such an 168 intervention in the absence of a physician in most places, but must secure a physician's order for restraint or seclusion within a specified time. Refer to Chapters 6 and 27 for further discussions and protocols for use of restraints and seclusion. The concept of trauma-informed care is a guiding principle for clinical interventions and unit philosophy and is addressed more comprehensively in Chapter 16. Safety A safe environment is an essential component of any inpatient setting. Protecting the patient is essential, but equally impor-tant is the safety of the staff and other patients. Safety needs are identified, and individualized interventions begin on admission. Staff members check all personal property and clothing to prevent any potentially harmful items (e.g., medication, alcohol, or sharp objects) from being taken onto the unit or left in their immediate possession. Some patients are at greater risk for suicide than others, and psychiatric-mental health nurses are skillful in evaluating this risk through questions and observations. The Joint Commission, an agency that accredits hospitals, developed National Patient Safety Goals (2015) specific to specialty areas within hospitals to promote patient safety. Table 4.3 lists safety goals specific to behavioral healthcare. Centers for Medicare and Medicaid Services also emphasize safety and have identified several preventable hospital-acquired injuries for which they will not provide reimbursement. For example, they will not compensate healthcare organizations when a patient falls and fractures a hip as nearly all falls are preventable. It is likely that other health insurance providers will also begin to limit payment for preventable injuries under the regulatory concept of pay for performance. TABLE 4.3 National Patient Safety Goals in Behavioral Healthcare Goal Process Example Identify patients correctly Use at least two identifiers when providing care, treatment, or services. Use the patient's name and date of birth for identification before drawing blood. Use medicines safely Maintain and communicate accurate medication information for the individual served. Find out what medications the patient is taking and compare them to newly ordered medications. Prevent infection Use the hand cleaning guidelines from either the Centers for Disease Control and Prevention or the World Health Organization. Wet hands first; apply an amount of product recommended by the manufacturer to hands, and rub hands together for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Identify patient safety risk Determine which patients are most likely to attempt suicide Routinely administer a screening tool such as the Beck Scale for Suicidal Ideation, a 21-item tool that takes 5-10 minutes to complete. From the Joint Commission. (2015). Behavioral health care: 2016 national patient safety goals. Retrieved from http://www.jointcommission.org/assets/1/6/2016_NPSG_BHC.pdf. Tracking patients' whereabouts and activities is done periodically or continuously, depending upon patients' risk for harming themselves or others. For patients with active suicidal thoughts, continuous in-person observation is essential because even checking on a patient every 15 minutes may not prevent a suicide that takes only several minutes. Monitoring visitation is an important aspect of patient wellbeing and safety. Although visitors can contribute to patients' healing, visits may be overwhelming or distressing. Also, visitors may unwittingly or purposefully provide patients with unsafe items. Staff should inspect bags and packages. Sometimes, the unsafe items take the form of comfort foods from home or a favorite restaurant and should be monitored because they may be incompatible with diets or medications. Intimate relationships between patients are prohibited. There are risks for sexually transmitted diseases, pregnancy, and emotional distress at a time when patients are vulnerable and may lack the capacity for consent.

cognitive development

ch 2

future challenges and roles

ch 1 -aging population many nurses are retiring -may feel discriminated - Educational Challenges -As with other specialty areas in a hospital setting, psychiatric nurses are caring for more acutely ill patients. In the 1980s, it was common for patients who were depressed and suicidal to have insurance coverage for about 2 weeks. Now patients are lucky to be covered for 3 days, if they are covered at all. This means that nurses need to be more skilled and be prepared to discharge patients for whom the benefit of their care will not always be evident. Providing educational experiences for nursing students is challenging as a result of this level of acute care and also due to the declining inpatient populations. Clinical rotations in general medical centers are becoming more difficult to obtain. Faculty are fortunate to secure rotations in state psychiatric hospitals, veterans administration facilities, and community settings. Community psychiatric settings also provide students with valuable experience, but the logistics of placing and supervising students in multiple sites has required creativity on the part of nursing educators. Some schools have established integrated rotations that, theoretically, allow students to work outside the psychiatric setting with patients who have mental health issues—for example, caring for a person with major depressive disorder on an orthopedic floor. Some faculty are concerned that without serious commitment, this type of specialty integration may water down a previously rich experience. Nurse-led medical/health homes and clinics are becoming increasingly common. Community nursing centers that can secure funding serve low-income and uninsured people. In this model, psychiatric-mental health nurses work with primary care nurses to provide comprehensive care, usually funded by scarce grants from academic centers. These centers use a nontraditional approach of combining primary care and health promotion interventions. Advanced practice psychiatric nurses have also been extremely successful in setting up private practices where they provide both psychotherapy and medication management. An Aging Population -As the number of older adults grows, the prevalence of Alzheimer's disease and other dementias requiring skilled nursing care in inpatient settings is likely to increase. Healthier older adults will need more services at home, in retirement communities, or in assisted living facilities. For more information on the needs of older adults, refer to Chapters 23, 28, and 31. Cultural Diversity -Cultural diversity is steadily increasing in the United States. The United States Census Bureau (2015) notes that the United States will have a majority minority population by 2044. Psychiatricmental health nurses will need to increase their cultural competence. Simply put, cultural competence means that nurses adjust their practices to meet their patients' cultural beliefs, practices, needs, and preferences. Science, Technology, and Electronic Healthcare -Genetic mapping from the Human Genome Project has resulted in a steady stream of research discoveries concerning genetic markers implicated in a variety of psychiatric illnesses. This information could be helpful in identifying at-risk individuals and in targeting medications specific to certain genetic variants and profiles. However, the legal and ethical implications of responsibly using this technology are staggering. For example: • Would you want to know you were at risk for a psychiatric illness such as bipolar disorder? • Who should have access to this information—your primary care provider, insurer, future spouse, or a lawyer in a child-custody battle? 62 • Who will regulate genetic testing centers to protect privacy and prevent 21st-century problems such as identity theft and fraud? Despite these concerns, the next decade holds great promise in the diagnosis and treatment of psychiatric disorders, and nurses will be central as educators and caregivers. Scientific advances through research and technology are certain to shape psychiatric-mental health nursing practice. Magnetic resonance imaging research, in addition to comparing healthy people to people diagnosed with mental illness, is now focusing on the development of preclinical profiles of children and adolescents. The hope of this type of research is to identify people at risk for developing mental illness, which allows earlier interventions to try to decrease impairment. Electronic healthcare services provided from a distance are gaining wide acceptance. In the early days of the internet, consumers were cautioned against the questionable wisdom of seeking advice through an unregulated medium. However, the internet has transformed the way we approach healthcare needs and allows people to be their own advocates. Telepsychiatry through audio and visual media is an effective way to reach underserved populations and those who are homebound. This allows for assessment and diagnosis, medication management, and even group therapy. Psychiatric nurses may become more active in developing websites for mental health education, screening, or support, especially to reach geographically isolated areas. Many health agencies hire nurses to staff help lines or hotlines, and as provision of these cost-effective services increases, so too will the need for bilingual resources. 63 Advocacy and Legislative Involvement -Through direct care and indirect action, nurses advocate for the psychiatric patient. As a patient advocate, the nurse reports incidents of abuse or neglect to the appropriate authorities for immediate action. The nurse also upholds patient confidentiality, which has become more of a challenge as the use of electronic medical records increases. Another form of nursing advocacy is supporting the patient's right to make decisions regarding treatment. On an indirect level, the nurse may choose to be active in consumer mental health groups (such as NAMI) and state and local mental health associations to support consumers of mental healthcare. The nurse can also be vigilant about reviewing local and national legislation affecting healthcare to identify potential detrimental effects on the mentally ill. Especially during times of fiscal crisis, lawmakers are inclined to decrease or eliminate funding for vulnerable populations who do not have a strong political voice. The APNA devotes significant energy to monitoring legislative, regulatory, and policy matters affecting psychiatric nursing and mental health. As the 24-hours-a-day, 7-days-a-week caregivers and members of the largest group of healthcare professionals, nurses have the potential to exert tremendous influence on legislation. However, when commissions and task forces are developed, nurses are not usually the first group to be considered to provide input and expertise for national, state, and local decision makers. In fact, nursing presence is often absent at the policymaking table. Consider the President's New Freedom Commission for Mental Health, which included psychiatrists (medical doctors), psychologists (PhDs), academics, and policymakers—but no nurses. It is difficult to understand how the largest contingent of mental healthcare providers in the United States could be excluded from a group that would determine the future of mental healthcare. It is in the best interest of consumers of mental healthcare that all members of the collaborative healthcare team, including nurses, be involved in decisions and legislation that will affect their care. Current political issues that need monitoring and support include mental health parity, discriminatory media portrayal, standardized language and practices, and advanced practice issues, such as prescriptive authority over schedule II drugs and government and insurance reimbursement for nursing care.

cognitive theory

-changing thoughts -effective for depression, anxiety, ocd, firstline treatment Aaron T. Beck (see Fig. 2.4) was originally trained in psychoanalysis. He noticed that people with depression thought differently than people who were not depressed. They had stereotypical patterns of negative and self-critical thinking that seemed to distort their ability to think and process information. To challenge these negative patterns, he developed cognitive-behavioral therapy (CBT), which is based on both cognitive psychology and behavioral theory. Beck's method (Beck et al., 1979), the basis for CBT, is an active, directive, time-limited, structured approach. This evidence-based therapy is used to treat a variety of psychiatric disorders such as depression, anxiety, phobias, and pain. It is based on the underlying theoretical principle that feelings and behaviors are largely determined by the way people think about the world and their place in it (Beck, 1967). Their cognitions (verbal or pictorial events in their streams of consciousness) are based on attitudes or assumptions developed from previous experiences. These cognitions may be fairly accurate or distorted. According to Beck, people have schemas, or unique assumptions about themselves, others, and the world in general. For example, if a man has the schema, "The only person I can trust is myself," he will have expectations that everyone else has questionable motives, are dishonest, and will eventually hurt him. Other negative schemas include incompetence, abandonment, evilness, and vulnerability. People are typically not aware of such cognitive biases. Rapid, unthinking responses based on schemas are known as automatic thoughts. These responses are particularly intense and frequent in psychiatric disorders such as depression and anxiety. Often automatic thoughts, or cognitive distortions, are irrational and lead to false assumptions and misinterpretations. For example, if a woman interprets all experiences in terms of 87 whether she is competent and adequate, thinking may be dominated by the cognitive distortion, "Unless I do everything perfectly, I'm a failure." Consequently, the person reacts to situations in terms of adequacy, even when these situations are unrelated to whether she is personally competent. Table 2.3 describes common cognitive distortions. Therapeutic techniques are designed to identify, reality test, and correct distorted conceptualizations and the dysfunctional beliefs underlying them. Patients are taught to challenge their own negative thinking and substitute it with positive, rational thoughts. They learn to recognize when thinking is based on distortions and misconceptions. Homework assignments play an important role in CBT. A particularly useful technique is the use of a four-column format to record the precipitating event or situation, the resulting automatic thought, and the proceeding feeling(s) and behavior(s). Finally, a challenge to the negative thoughts based on rational evidence and thinking is listed in the last column. The following is an example of the type of analysis done by a patient receiving CBT. A 24-year-old nurse who was recently discharged from the hospital for severe depression presented this record (Beck, 1979): Table 2.4 compares and contrasts psychodynamic, interpersonal, cognitive-behavioral, and behavioral therapies. Implications of Cognitive Theories for Nursing Recognizing the interplay between events, negative thinking, and negative responses can be beneficial from both a patient-care standpoint and a personal one. As a supportive therapeutic measure, helping the patient identify negative thought patterns is a worthwhile intervention. Workbooks are available to aid in the process of identifying cognitive distortions. The cognitive approach can also help nurses understand their own responses to a variety of difficult situations. One example might be the anxiety that some students feel regarding the psychiatric nursing clinical rotation. Students may overgeneralize ("All psychiatric patients are dangerous.") or personalize ("My patient doesn't seem to be better. I'm probably not doing him any good.") the situation. The key to effectively using this approach in clinical situations is to challenge the negative thoughts not based on facts then replace them with more realistic appraisals.

mood stabilizers

,3 Lithium Although lithium (Eskalith, Lithobid) has been used as a mood stabilizer in patients with bipolar (manic-depressive) disorder for many years, we do not understand its mechanism of action. As a positively charged cation, similar in structure to sodium and potassium, lithium may well act by affecting electrical conductivity in neurons. As discussed earlier, an electrical impulse consists of the inward, depolarizing flow of sodium followed by an outward, repolarizing flow of potassium. These electrical charges are propagated along the neuron so that, if they are initiated at one end of the neuron, they will pass to the other end. Once they reach the end of a neuron, a neurotransmitter is released. It may be that an overexcitement of neurons in the brain underlies bipolar disorder and lithium interacts in some complex way with sodium and potassium at the cell membrane to stabilize electrical activity. Furthermore, lithium may reduce the excitatory neurotransmitter glutamate and exert an antimanic effect. Another mechanism by which lithium functions to regulate mood includes the noncompetitive inhibition of the enzyme inositol monophosphatase. Inhibition of 5-HT autoreceptors by lithium is more related to lithium's antidepressant effects rather than its antimanic effects. While we do not know exactly how lithium works, we are certain that its influence on electrical conductivity results in adverse effects and toxicity. By altering electrical conductivity, lithium represents a potential threat to all body functions regulated by electrical currents, especially cardiac contraction. Lithium can induce, although not commonly, sinus bradycardia. Extreme alteration of cerebral conductivity with overdose can lead to convulsions. Alteration in nerve and muscle conduction can commonly lead to tremor at therapeutic doses or more extreme motor dysfunction with overdose. Sodium and potassium play a strong role in regulating fluid balance, and the distribution of fluid in various body compartments explains the disturbances in fluid balance that lithium can cause. These include polyuria (the output of large volumes of urine) and edema (the accumulation of fluid in the interstitial space). Long-term use of lithium can cause hypothyroidism in some patients, which is secondary to interfering with the iodine molecules affecting the formation and conversion to its active form (T3) thyroid hormone. In addition, hyponatremia can increase the risk of lithium toxicity because increased renal reabsorption of sodium leads to increased reabsorption of lithium as well. Primarily because of its effects on electrical conductivity, lithium has a low therapeutic index. The therapeutic index represents the ratio of the lethal dose to the effective dose and is a measure of overall drug safety in regard to the possibility of overdose or toxicity. A low therapeutic index means that the blood level of a drug that can cause death is not far above the blood level required for drug effectiveness. Lithium blood levels need to be monitored on a regular basis to ensure that the drug is not accumulating and rising to dangerous levels. Table 3.3 lists some of the adverse 135 effects of lithium. Chapter 13 considers lithium treatment in more depth and discusses specific dosage-related adverse and toxic effects, nursing implications, and the patient teaching plan. Anticonvulsant Drugs Valproate (available as divalproex sodium [Depakote] and valproic acid [Depakene]), carbamazepine (Tegretol), and lamotrigine (Lamictal) are useful in the treatment of bipolar disorders. Their anticonvulsant properties derive from the alteration of electrical conductivity in membranes. In particular, they reduce the firing rate of very-high-frequency neurons in the brain. It is possible that this membrane-stabilizing effect accounts for the ability of these drugs to reduce the mood swings that occur in patients with bipolar disorders. Other proposed mechanisms as mood stabilizers are glutamate antagonists and GABA agonist. Valproate Valproate (Depakote, Depakene) is structurally different from other anticonvulsants and psychiatric drugs that show efficacy in the treatment of bipolar disorder. Valproate is recommended for mixed episodes and has been found useful for rapid cycling. Common side effects include tremor, weight gain, and sedation. Occasional serious side effects are thrombocytopenia, pancreatitis, hepatic failure, and birth defects. Baseline levels are measured for liver function tests and complete blood count (CBC) before an individual is initiated on this medication and laboratory monitoring is repeated periodically. In addition, the therapeutic blood level of the drug is monitored. Carbamazepine Carbamazepine (Equetro, Tegretol) is useful in treating acute mania. It reduces the firing rate of overexcited neurons by reducing the activity of sodium channels. Baseline liver function tests, CBC, electrocardiogram, and electrolyte levels should be obtained. Blood levels are monitored to avoid toxicity (>12 mcg/mL), but there are no established therapeutic blood levels for carbamazepine in the treatment of bipolar disorder. Common effects include anticholinergic side effects (e.g., dry mouth, constipation, urinary retention, blurred vision), orthostasis, sedation, and ataxia. A rash may occur in about 10% of patients during the first 20 weeks of treatment. This potentially serious side effect should be reported immediately because it could progress to a life-threatening exfoliative dermatitis or Stevens-Johnson syndrome. The FDA requires genetic testing before this drug is used in people of Asian descent. Lamotrigine The FDA approved lamotrigine (Lamictal) for maintenance therapy in bipolar disorder, but it is not effective in acute mania. Lamotrigine works well in treating the depression of bipolar disorder. It modulates the release of glutamate and aspartate. Patients should promptly report any rashes which could be a sign of life-threatening Stevens-Johnson syndrome. This adverse drug reaction can be minimized by slowly increasing to therapeutic doses. Concurrent use with valproate may double the blood levels of lamotrigine and increase the risk of Stevens-Johnson syndrome. Refer to Chapter 13 for more detailed discussion on mood stabilizers.

social influences on mental health care

organizations help with different illnesses Consumer Movement and Mental Health Recovery Over 100 years ago, tremendous energy was directed toward improving equality in the United States. Black men were given the right to vote in 1870 as were women, finally, in 1920. Treating people fairly and challenging labels became a focus of the American culture. With regard to treatment of people with mental illness, decades of institutionalization had created significant political and social concerns. Groups of people with mental illnesses—frequently called mental health consumers—began to advocate for their rights and fought against discrimination and forced treatment. In 1979 people with mental illnesses and their families formed a nationwide advocacy group, the National Alliance on Mental Illness (NAMI). In the 1980s, individuals in the consumer movement organized by NAMI began to resist the traditional arrangement of mental healthcare providers dictating treatment without the input of the patient. This paternalistic relationship was demoralizing, and it also implied that patients were not competent to make their own decisions. Consumers demanded increased involvement in decisions concerning their treatment. The consumer movement also promoted the concept of recovery, a new and an old idea. On one hand, it represents a concept that has been around a long time: that some people—even those with the most serious illnesses such as schizophrenia—recover. One recovery was depicted in the movie A Beautiful Mind. In this film, a brilliant mathematician, John Nash, seems to have emerged from a continuous cycle of devastating psychotic relapses to a state of stabilization and recovery (Howard, 2001). A newer conceptualization of recovery evolved into a consumer-focused process. According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2012), recovery is "a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential." The focus is on the consumer and what he or she can do. A real-life example of recovery follows: Surgeon General's Report on Mental Health The first Surgeon General's report on the topic of mental health was published in 1999 (HHS). This landmark document was based on an extensive review of the scientific literature in consultation with mental health providers and consumers. The two most important messages from this report were that (1) mental health is fundamental to overall health, and (2) there are effective treatments. The report is reader-friendly and a good introduction to mental health and illness. You can review the report at http://www.surgeongeneral.gov/library/mentalhealth/home.html. Human Genome Project The Human Genome Project was a 13-year project that lasted from 1990-2003 and was completed on the 50th anniversary of the discovery of the DNA double helix. The project has strengthened biological and genetic explanations for psychiatric conditions. The goals of the project (US Department of Energy, 2008) were to do the following: • Identify the approximately 20,000 to 25,000 genes in human DNA. • Determine the sequences of the 3 billion chemical base pairs that make up human DNA. • Store this information in databases. • Improve tools for data analysis. • Address the ethical, legal, and social issues that may arise from the project. Researchers are continuing to make progress in understanding genetic underpinnings of diseases and disorders. You will be learning about these advances in the clinical chapters that follow. President's New Freedom Commission on Mental Health The President's New Freedom Commission on Mental Health chaired by Michael Hogan released its recommendations for mental healthcare in America in 2003. This was the first commission since First Lady Rosalyn Carter's (wife of President Jimmy Carter) in 1978. The report stated that the system of delivering mental healthcare in America was in a shambles. It called for a streamlined system with less fragmentation in the delivery of care. The commission advocated for early diagnosis and treatment, adoption of principles of recovery, and increased assistance in helping people find housing and work. Box 1.2 describes the goals necessary for such a transformation of mental healthcare in the United States. Institute of Medicine The Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series was released in 2005 by the Health and Medicine Division (HMD) of the National Academies of Medicine, formerly the Institute of Medicine (IOM). It highlighted effective treatments for mental illness and addressed the huge gap between the best care and the worst. It focused on such issues as the problem of coerced (forced) treatment, a system that treats mental health issues separately from physical health problems, and lack of quality control. The report encouraged healthcare workers to focus on safe, effective, patient-centered, timely, efficient, and equitable care.Another important and related publication issued by the Institute of Medicine in 2011 is The Future of Nursing: Focus on Education. This report contends that the old way of training nurses is not adequate for the 21st century's complex requirements. It calls for highly educated nurses who are prepared to care for an aging and diverse population with an increasing incidence of chronic disease. They recommended that nurses be trained in leadership, health policy, system improvement, research, and teamwork. Quality and safety education for nurses Recommendations from both documents were addressed by a group called Quality and Safety Education for Nurses (QSEN; pronounced Q-sen) and were funded by the Robert Wood Johnson Foundation. They have developed a structure to support the education of future nurses who possess the knowledge, skills, and attitudes to continuously improve the safety and quality of healthcare. Consider this tragic story: Betsy Lehman was a health reporter for the Boston Globe who was married to a cancer researcher. When she herself was diagnosed with cancer she was prescribed an incorrect, extremely high dose of an anticancer drug. Ms. Lehman sensed something was wrong and appealed to the healthcare providers who did not respond to her concerns. The day before she died, she begged others to help because the professionals were not listening (Robert Wood Johnson Foundation, 2011). How could her death have been prevented? Consider the key areas of care promoted by QSEN and how they could have prevented Ms. Lehman's death: 1. Patient-centered care: Care should be given in an atmosphere of respect and responsiveness, and the patient's values, preferences, and needs should guide care. 2. Teamwork and collaboration: Nurses and interprofessional teams need to maintain open communication, respect, and shared decision making. 3. Evidence-based practice: Optimal healthcare is the result of integrating the best current evidence while considering the patient/family values and preferences. 4. Quality improvement: Nurses should be involved in monitoring the outcomes of the care that they give. They should also be care designers and test changes that will result in quality improvement. 5. Safety: The care provided should not add further injury (e.g., nosocomial infections). Harm to patients and providers are minimized through both system effectiveness and individual performance. 6. Informatics: Information and technology are used to communicate, manage knowledge, mitigate error, and support decision making. Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative In 2013 President Barack Obama announced that $300 million in public and private funding would 51 be devoted to the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative. This money would be used to develop innovative techniques and technologies to unravel the mystery of how the brain functions. The goal is to uncover news ways to prevent, treat, and cure psychiatric disorders, epilepsy, and traumatic brain injury. According to the National Institutes of Health (2016) more than $70 million is going to over 170 researchers working at 60 different institutions. These researchers are examining such topics as: • Developing computer programs that may help researchers detect and diagnose autism and Alzheimer's disease from brain scans • Building a cap that uses ultrasound waves to precisely stimulate brain cells • Creating a "neural dust" system made of tiny electric sensors for wirelessly recording brain activity • Improving current rehabilitation technologies for helping the lives of stroke patients • Studying how the brain reads and speaks Research Domain Criteria (RDoC) Initiative In other specialty areas, symptom-based classification has been replaced by more scientific understanding of the problem. For example, physicians do not make a cardiac diagnosis depending on the type of chest pain a person is having but rather on diagnosing the specific problem such as myocarditis. Psychiatry continues to rely heavily on symptoms in the absence of objective and measurable data. In 2013 the National Institute of Mental Health (NIMH) announced that it would no longer fund DSM diagnosis-based studies. Instead it would put all of its time, effort, and money into something called the Research Domain Criteria (RDoC) Initiative. This promising initiative challenges researchers to seek causes for mental disorders at the molecular level. NIMH hopes to transform the current diagnostic procedure by using genetics, imaging, and fresh information to create a new classification system.

psychotropic drugs

.alter chemistry of brain bipolar, schizophrenia

case study 1

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ch 5 objectives

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function of cerebellum

2 slides

epidemiology of mental disorders

2 slides -numbers before covid Epidemiology, as it applies to psychiatric-mental health, is the quantitative study of the distribution of mental disorders in human populations. Understanding this distribution helps identify high-risk groups and risk factors associated with illness onset, duration, and recurrence. According to SAMHSA (2014), nearly 44 million adults in the United States experienced a diagnosable mental illness in 2013. In fact, neuropsychiatric disorders are the leading category of disease with twice the disability as the next category, cardiovascular diseases. More than a third of this disability is caused by depression. Individuals may have more than one mental disorder or another medical disorder. The simultaneous existence of two or more disorders is known as a comorbid condition. For example, schizophrenia is frequently comorbid with diabetes. Two different but related words used in epidemiology are incidence and prevalence. Incidence conveys information about the risk of contracting a disease. It refers to the number of new cases of mental disorders in a healthy population within a given period of time, usually annually. An example of incidence is the number of Atlanta adolescents who were diagnosed with major depression between 2000 and 2001. Prevalence describes the total number of cases, new and existing, in a given population during a specific period of time, regardless of when they became ill. An example of prevalence is the number of adolescents who screened positive for major depression in New York City schools between 2000 and 2010. A disease with a short duration such as the common cold tends to have a high incidence (many new cases in a given year) and a low prevalence (not many people suffering from a cold at any given time). Conversely, a chronic disease such as diabetes will have a low incidence because the person will be dropped from the list of new cases after the first year (or whatever time increment is being used). Lifetime risk data, or the risk that one will develop a disease in the course of a lifetime, will be higher than both incidence and prevalence. According to Kessler, Berglund, and colleagues (2005), 46.4% of all Americans will meet the criteria for a psychiatric disorder in their lifetimes. Table 1.1 shows the prevalence of some psychiatric disorders in the United States. Originally, epidemiology meant the study of epidemics. Clinical epidemiology is a broad field that examines health and illness at the population level. Studies use traditional epidemiological methods and are conducted in groups usually defined by the illness or symptoms or by the diagnostic procedures or treatments given for the illness or symptoms. Clinical epidemiology includes the following: • Studies of the natural history—what happens if there is no treatment and the problem is left to run its course—of an illness • Studies of diagnostic screening tests • Observational and experimental studies of interventions used to treat people with the illness or symptoms Analysis of epidemiological studies can reveal the frequency with which psychological symptoms appear together with physical illness. For example, epidemiological studies demonstrate that depression is a significant risk factor for death in people with cardiovascular disease and premature death in people with breast cancer.

cultural competence for psychiatric mental health nurses

3 slides

audience respose questions highest annual prevalnece

c

risk and protective factors

call for a sitter if they are suicidal. -5150 can help make sure they are safe -to protect patients from self harm: support groups, family support, level of resilience. -someone who fels hopeless, family history of suicide, previous attempts may have high risk. -therapy is another protetvite factr Individual attributes and behaviors refer to characteristics that are both inborn and learned that make us who we are. We all have unique ways of managing thoughts and feelings and navigating the everyday pressures of life. The ability to respond to social cues and participate in social activities influences our view of ourselves and how others view us. Biological and genetic factors can also influence mental health. Prenatal exposure to alcohol and oxygen deprivation at birth are two examples of biological factors. Genetic factors are huge predictors of mental health and are implicated in nearly every psychiatric disorder. What makes some people adapt to tragedy, loss, trauma, and severe stress better than others? The answer may be the individual attribute of resilience. Resilience is the ability and capacity for people to secure the resources they need to support their well-being. It is a quality found in some children of poverty and abuse who seek out trusted adults. These adults provide them with the psychological and physical resources that allow them to excel. A score higher than 13 is rated as above average in emotional regulation. A score between 6 and 13 is inconclusive. A score lower than 6 is rated as below average in emotional regulation. If your emotional regulation is below average, you may need to master some calming skills. Here are a few tips: • When anxiety strikes, your breathing may become shallow and quick. You can help control the anxiety by controlling your breathing. Inhale slowly through your nose, breathing deeply from your belly, not your chest. • Stress will make your body tight and stiff. Again, you can counter the effects of stress on the body and brain if you relax your muscles. • Try positive imagery; create an image that is relaxing such as visualizing yourself on a secluded beach. • Resilience is within your reach. From Reivich, K., & Shatte, A. (2002). The resilience factor: 7 essential skills for overcoming life's obstacles. New York, NY: Broadway Books. Any third party use of this material, outside of this publication, is prohibited. Interested parties must apply directly to Random House, Inc. for permission. Being resilient does not mean being unaffected by stressors. People who are resilient are effective at regulating their emotions and not falling victim to negative, self-defeating thoughts. You can get an idea of how good you are at regulating your emotions by taking the Resilience Factor Test in Box 1.1. Social and Economic Circumstances Your immediate social surroundings impact personal attributes. The earliest social group, the family, has tremendous effects on developing and vulnerable humans. The family sets the stage in promoting confidence and coping skills or for instilling anxiety and feelings of inadequacy. The social environment extends to schools and peer groups. Again, this environment has the ability to affect mental health positively and negatively. For example, socioeconomic status dictates the sort of resources available to support mental health and reduce concerns over basic needs such as food, clothing, and shelter. Educational advancement is a tremendous supporter of mental health by providing opportunities for a satisfying career, security, and economic benefits. Social and Economic Circumstances Your immediate social surroundings impact personal attributes. The earliest social group, the family, has tremendous effects on developing and vulnerable humans. The family sets the stage in promoting confidence and coping skills or for instilling anxiety and feelings of inadequacy. The social environment extends to schools and peer groups. Again, this environment has the ability to affect mental health positively and negatively. For example, socioeconomic status dictates the sort of resources available to support mental health and reduce concerns over basic needs such as food, clothing, and shelter. Educational advancement is a tremendous supporter of mental health by providing opportunities for a satisfying career, security, and economic benefits. Environmental Factors The overall environment that affects mental health relates to the political climate and cultural 46 considerations. Access and lack of access to basic needs and commodities such as healthcare, water, safety services, and a strong highway system have a profound effect on community mental health. Social and economic policies, which are formed at the global, national, state, and local government levels, also impact mental health. For example, in the United States, laws have been gradually shifting toward better reimbursement for mental health services. This shift makes it easier to access and improve mental healthcare. Predominant cultural beliefs, attitudes, and practices influence mental health. There is no standard measure for mental health, partly because it is culturally defined. One approach to differentiating mental health from mental illness is to consider what a particular culture regards as acceptable or unacceptable. In this view, those with mental illness are those who violate social norms and thus threaten (or make anxious) those observing them. For example, traditional Japanese culture may consider suicide to be an act of honor, and Middle Eastern "suicide bombers" are considered holy warriors or martyrs. Contrast these viewpoints with Western culture where people who attempt or complete suicides are nearly always considered mentally ill. Throughout history, people have interpreted health or sickness according to their own current views. A striking example of how cultural change influences the interpretation of mental illness is an old definition of hysteria. According to Webster's Dictionary (Porter, 1913), hysteria was: A nervous af ection...in women, in which the emotional and reflex excitability is exaggerated, and the will power correspondingly diminished, so that the patient loses control over the emotions, becomes the victim of imaginary sensations, and often falls into paroxysm or fits. Treatment for this condition, thought to be the result of sexual deprivation, often involved sexual activity. Thankfully, this diagnosis fell into disuse as women's rights improved, the family atmosphere became less restrictive, and societal tolerance of sexual practices increased. Cultures differ not only in their views regarding mental illness but also the types of behavior categorized as mental illness. Culture-bound syndromes seem to occur in specific sociocultural contexts, and people in those cultures easily recognized them. For example, one syndrome recognized in parts of Southeast Asia is running amok, in which a person (usually a male) runs around engaging in almost indiscriminate violent behavior. In the United States, anorexia nervosa is recognized as a disorder characterized by voluntary starvation. The disorder is well known in Europe, North America, and Australia but unheard of in many other parts of the world.

personality structure

-

nursing model

- Hildegard Peplau (1909-1999; Fig. 2.2), influenced by the work of Sullivan and learning theory, developed the first systematic theoretical framework for psychiatric nursing in her groundbreaking book Interpersonal Relations in Nursing (1952). Peplau not only established the foundation for the professional practice of psychiatric nursing but also continued to enrich psychiatric nursing theory and work for the advancement of nursing practice throughout her career. Peplau was the first nurse to identify psychiatric-mental health nursing both as an essential element of general nursing and as a specialty area that embraces specific governing principles. She was also the first nurse theorist to describe the nurse-patient relationship as the foundation of nursing practice. She also shifted the focus from what nurses do to patients to what nurses do with patients. Her theory is mainly concerned with the processes by which the nurse helps patients make positive changes in their healthcare status and well-being. She believed that illness offered a unique opportunity for experiential learning, personal growth, and improved coping strategies. Psychiatric nurses play a central role in facilitating this growth. Peplau proposed an approach in which nurses are both participants and observers in therapeutic conversations. She believed it was essential for nurses to observe the behavior not only of the patient but also of themselves. This self-awareness on the part of the nurse is essential in keeping the focus on the patient and in keeping the social and personal needs of the nurse out of the nursepatient conversation. Perhaps Peplau's most universal contribution to the everyday practice of psychiatric-mental health nursing is her application of Sullivan's theory of anxiety to nursing practice. She described the effects of different levels of anxiety (mild, moderate, severe, and panic) on perception and learning. She promoted interventions to lower anxiety with the aim of improving patients' abilities to think and function at more satisfactory levels. Chapter 15 presents more on the application of Peplau's theory of anxiety and interventions. Table 2.2 lists selected nursing theorists and summarizes their major contributions and the impact of these contributions on psychiatric-mental health nursing.

biologic model

-A biological model, or medical model, of mental illness assumes that abnormal behavior is the result of a physical problem. It focuses on neurological, chemical, biological, and genetic issues. Adherents of this dominant model seek to understand how the body and brain interact to create emotions, memories, and perceptual experiences. The biological model locates the illness or disease in the body—usually in the limbic system of the brain and the synapse receptor sites of the central nervous system—and targets the site of the illness using physical interventions such as drugs, diet, or surgery. BOX 2.1 Some Characteristics of Self-Actualized Persons • Accurate perception of reality. Not defensive in their perceptions of the world. • Acceptance of themselves, others, and nature. • Spontaneity, simplicity, and naturalness. Self-actualized individuals do not live programmed lives. • Problem-centered rather than self-centered orientation. Possibly the most important characteristic. Possibly the most important characteristic is a sense of a mission to which they dedicate their lives. • Pleasure in being alone and in ability to reflect on events. • Active social interest. • People who are self-actualized don't take life for granted. • Mystical or peak experiences. A peak experience is a moment of intense ecstasy, similar to a religious or mystical experience, during which the self is transcended. • Self-actualized people may become so involved in what they are doing that they lose all sense of time and awareness of self (flow experience). • Lighthearted sense of humor that indicates "we're in it together" and lacks sarcasm or hostility. • Fairness and respect for people of different races, ethnicities, religions, and political views. • Creativity, especially in managing their lives. • Resistance to conformity (enculturation). Self-actualization results in autonomous, independent, and self-sufficient individuals. Adapted from Maslow, A. H. (1970). Motivation and personality. New York, NY: Harper & Row. The recognition that psychiatric illnesses are as physical in origin as diabetes and coronary heart disease serves to decrease the stigma surrounding them. Just as someone with diabetes or heart disease cannot be held responsible for being ill, patients with schizophrenia or bipolar affective disorder are no more to blame. Biological Therapies Psychopharmacology therapy In 1950 a French drug firm synthesized chlorpromazine—a powerful antipsychotic medication— and psychiatry experienced a revolution. The advent of psychopharmacology—the use of medications to treat mental illness—presented a strong alternative to psychological approaches for mental illness. The dramatic experience of observing patients freed from the bondage of psychosis and mania by powerful drugs such as chlorpromazine and lithium left witnesses convinced of the critical role of the brain in psychiatric illness. Since the discovery of chlorpromazine (later sold under the trade name Thorazine), many other medications have proven effective in controlling psychosis, mania, depression, and anxiety. These medications greatly reduce the need for hospitalization and dramatically improve the lives of people suffering from serious psychiatric difficulties. Today, psychoactive medications exert differential effects on different neurotransmitters and help restore brain function, allowing patients with mental illness to continue living productive lives with greater satisfaction and far less 92 emotional pain. Brain stimulation therapies In addition to psychotherapy and psychopharmacology as treatment for mental illness are the brain stimulation therapies. The oldest of these therapies is electroconvulsive therapy (ECT). All of these methods involve focused electrical stimulation of the brain. In addition to treating psychiatric disorders, they also treat traditional neurological disorders such as Parkinson's disease, epilepsy, and pain conditions. Table 2.5 provides a summary of Food and Drug Administration-approved brain stimulation treatments and their use. Implications of the Biological Model for Nursing Historically, psychiatric-mental health nurses always have attended to the physical needs of psychiatric patients. Nurses administer medications. They also monitor sleep, activity, nutrition, hydration, elimination, and other functions. Nurses are responsible for preparing patients for somatic therapies such as electroconvulsive therapy. Physical needs and physical care in psychiatric nursing are provided as part of a holistic approach to healthcare. Basic nursing strategies such as focusing on the qualities of a therapeutic relationship, understanding the patient's perspective, and communicating in a way that facilitates the patient's recovery take place alongside physical care.

behavioral theory

-recondition brain to perceive things differently

group therapy (2)

-self care groups, arts and crafts, be productive, feel productive, exercise groups, we are group leaders most of the time. -pay attntion to setting -consistency of group -chance of fighting -5 stages

nanda-i,noc, and nic

-DSM-5 and NANDA-I-Approved Nursing Diagnoses Psychiatric-mental health nursing includes the diagnosis and treatment of human responses to actual or potential mental health problems. "A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, group, or community" (Herdman & Kamitsuru, 2014, p. 25). While the DSM-5 is used to diagnose a psychiatric disorder, a well-defined nursing diagnosis provides the framework for identifying appropriate nursing interventions for dealing with the patient's reaction to the disorder. Nursing Outcomes Classification (NOC) The Nursing Outcomes Classification (NOC) is a comprehensive source for standardized outcomes and definitions of these outcomes (Moorhead et al., 2013). A five-point Likert scale is used with all outcomes and indicators. A rating of 5 is always the best possible score and a rating of 1 is always the worst possible scale. Words used in the scales include 1 = Extremely compromised to 5 = Not compromised and 1=Never demonstrated to 5 = Consistently demonstrated. The 490 outcomes are listed in alphabetical order. Outcomes are organized into seven domains: functional health, physiological health, psychosocial health, health knowledge and behavior, perceived health, family health, and community health. The psychosocial health domain includes four classes: psychological well-being, psychosocial adaptation, self-control, and social interaction. Nursing Interventions Classification (NIC) The Nursing Interventions Classification (NIC) is another book used to standardize, define, and measure nursing care. The NIC (Bulechek et al., 2013) defines a nursing intervention as "any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes" (p. xv) including direct and indirect care through a series of nursing activities. There are seven domains: basic physiological, complex physiological, behavioral, safety, family, health system, and community. Two domains relate specifically to psychiatric nursing: behavioral, including communication, coping, and education, and safety, covering crisis and risk management.

clinical epidemiology

-Originally, epidemiology meant the study of epidemics. Clinical epidemiology is a broad field that examines health and illness at the population level. Studies use traditional epidemiological methods and are conducted in groups usually defined by the illness or symptoms or by the diagnostic procedures or treatments given for the illness or symptoms. Clinical epidemiology includes the following: • Studies of the natural history—what happens if there is no treatment and the problem is left to run its course—of an illness • Studies of diagnostic screening tests • Observational and experimental studies of interventions used to treat people with the illness or symptoms Analysis of epidemiological studies can reveal the frequency with which psychological symptoms appear together with physical illness. For example, epidemiological studies demonstrate that depression is a significant risk factor for death in people with cardiovascular disease and premature death in people with breast cancer.

levels of psychiatric nursing practice

-Psychiatric-mental health nurses are registered nurses educated in nursing and licensed to practice in their individual states. Psychiatric nurses are qualified to practice at two levels, basic and advanced, depending on educational preparation. Table 1.2 describes basic and advanced psychiatric nursing interventions. 59 TABLE 1.2 Basic Level and Advanced Practice Psychiatric-Mental Health Nursing Interventions Basic Level Intervention Description Coordination of care =Coordinates implementation of the nursing care plan and documents coordination of care Health teaching and health maintenance -individualized anticipatory guidance to prevent or reduce mental illness or enhance mental health (e.g., community screenings, parenting classes, stress management) Milieu therapy -Provides, structures, and maintains a safe and therapeutic environment in collaboration with patients, families, and other healthcare clinicians Pharmacological, biological, and integrative therapies -Applies current knowledge to assessing patient's response to medication, provides medication teaching, and communicates observations to other members of the healthcare team Basic Level -Basic level registered nurses are professionals who have completed a nursing program, passed the state licensure examination, and are qualified to work in most any general or specialty area. The psychiatric-mental health registered nurse (PMH-RN) is a nursing graduate who possesses a diploma, an associate degree, or a baccalaureate degree and chooses to work in the specialty of psychiatric-mental health nursing. At the basic level, nurses work in various supervised settings and perform multiple roles such as staff nurse, case manager, home care nurse, and so on. After 2 years of full-time work as a registered nurse, 2,000 clinical hours in a psychiatric setting, and 30 hours of continuing education in psychiatric nursing, a baccalaureate-prepared nurse may take a certification examination administered by the American Nurses Credentialing Center (the credentialing arm of the ANA) to demonstrate clinical competence in psychiatric-mental health nursing. After passing the examination, a board-certified credential is added to the RN title resulting in RN-BC. Certification gives nurses a sense of mastery and accomplishment, identifies them as competent clinicians, and satisfies a requirement for reimbursement by employers in some states. Advanced Practice - One of the first advanced practice nursing roles in the United States was the psychiatric clinical nurse specialist in the 1950s. These expert nurses were originally trained to provide individual therapy and group therapy in state psychiatric hospitals and to provide training for other staff. Eventually they, along with psychiatric nurse practitioners who were introduced in the mid-1960s, gained diagnostic privileges, prescriptive authority, and the ability to provide psychotherapy. Currently, the psychiatric-mental health advanced practice registered nurse (PMH-APRN) is a licensed registered nurse with a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) in psychiatric nursing. This DNP is not to be confused with a doctoral degree in nursing (PhD), which is a research degree, whereas the DNP is a practice doctorate. The PMH-APRN may function autonomously depending on the state and is eligible for specialty privileges. Some advanced practice nurses continue their education to the PhD level. Unlike other specialty areas, there is no significant difference between a psychiatric nurse practitioner (NP) and a clinical nurse specialist (CNS) as long as the CNS has achieved prescriptive authority. Certification is required and is obtained through the American Nurses Credentialing Center. Only one examination—the Psychiatric-Mental Health Nurse Practitioner—Board Certified (PMHNP-BC)—is currently available. Three other examinations have been discontinued: • Adult Psychiatric-Mental Health Nurse Practitioner—Board Certified (PMHNP-BC) • Adult Psychiatric-Mental Health Clinical Nurse Specialist—Board Certified (PMHCNS-BC) • Child/Adolescent Psychiatric-Mental Health Clinical Nurse Specialist—Board Certified (PMHCNS-BC) While these examinations are no longer given, you will still find many nurses who practice in these roles. Their credentials will continue to be renewed if professional development and practice hour requirements are met

psychoanalytical theory

-Sigmund Freud (1856-1939), an Austrian neurologist, revolutionized thinking about mental health disorders. He introduced a groundbreaking theory of personality structure, levels of awareness, anxiety, the role of defense mechanisms, and the stages of psychosexual development. Originally, he was searching for biological treatments for psychological disturbances and even experimented with using cocaine as medication. He soon abandoned this physiological approach and focused on psychological treatments. Freud came to believe that the vast majority of mental disorders resulted from unresolved issues that originated in childhood. Levels of Awareness Freud believed that there were three levels of psychological awareness in operation. He used the image of an iceberg to describe these levels of awareness (Fig. 2.1). Conscious The conscious part of the mind is the tip of the iceberg. It contains all the material a person is aware of at any one time including perceptions, memories, thoughts, fantasies, and feelings Preconscious Just below the surface of awareness is the preconscious, which contains material that can be retrieved rather easily through conscious effort. Unconscious The unconscious includes all repressed memories, passions, and unacceptable urges lying deep below the surface. Memories and emotions associated with trauma may be stored in the unconscious because the individual finds it too painful to deal with them. The unconscious exerts a powerful yet unseen effect on the conscious thoughts and feelings of the individual. The individual is usually unable to retrieve unconscious material without the assistance of a trained therapist. Personality Structure Freud (1960) delineated three major and distinct but interactive systems of the personality: the id, the ego, and the superego. 74 Id At birth we are all id. The id is totally unconscious and impulsive. It is the source of all drives, instincts, reflexes, and needs. The id cannot tolerate frustration and seeks to discharge tension and return to a more comfortable level of energy. The id lacks the ability to problem solve and is illogical. A hungry, screaming infant is the perfect example of id. Ego Within the first few years of life as the child begins to interact with others, the ego develops. The ego resides in the conscious, preconscious, and unconscious levels of awareness. The problem solver and reality tester, the ego attempts to navigate the outside world. It is able to differentiate subjective experiences, memory images, and objective reality. The ego follows the reality principle, which says to the id, "You have to delay gratification for right now," then sets a course of action. For example, a hungry man feels tension arising from the id that wants to be fed. His ego allows him not only to think about his hunger but also to plan where he can eat and to seek that destination. This process is known as reality testing because the individual is factoring in reality to implement a plan to decrease tension. Superego The superego, which develops between the ages of 3 and 5, represents the moral component of personality. The superego resides in the conscious, preconscious, and unconscious levels of awareness. The superego consists of the conscience (all the "should nots" internalized from parents and society) and the ego ideal (all the "shoulds" internalized from parents and society). When behavior falls short of ideal, the superego may induce guilt. Likewise, when behavior is ideal, the superego may allow a sense of pride. In a mature and well-adjusted individual, the three systems of the personality—the id, the ego, and the superego—work together as a team under the administrative leadership of the ego. If the id is too powerful, the person will lack control over impulses. If the superego is too powerful, the person may be self-critical and suffer from feelings of inferiority. Defense Mechanisms and Anxiety Freud (1969) believed that anxiety is an inevitable part of living. The environment in which we live presents dangers and insecurities, threats and satisfactions. It can produce pain and increase tension or produce pleasure and decrease tension. The ego develops defenses, or defense mechanisms, to ward off anxiety by preventing conscious awareness of threatening feelings. Defense mechanisms share two common features: (1) they all (except suppression) operate on an unconscious level and (2) they deny, falsify, or distort reality to make it less threatening. Although we cannot survive without defense mechanisms, it is possible for our defense mechanisms to distort reality to such a degree that we experience difficulty with healthy adjustment and personal growth. Chapter 15 provides a full list and description of defense mechanisms. Psychosexual Stages of Development Freud believed that human development proceeds through five stages from infancy to adulthood. He believed that experiences during the first 5 years determined an individual's lifetime adjustment pattern and personality traits. By the time a child enters school, subsequent growth consists of elaborating on this basic structure. Freud's psychosexual stages of development are in Table 2.1. Psychoanalytic Therapy Classical psychoanalysis, as developed by Sigmund Freud, is seldom used today. Freud's premise that early intrapsychic conflict as the cause for all mental illness is no longer widely thought to be valid. Such therapy requires an unrealistically lengthy period of treatment (i.e., three to five times a week for many years), making it prohibitively expensive and uncovered by insurance. The purpose of these sessions is to uncover unconscious conflicts. Free association, dream and fantasy analysis, defense mechanism recognition, and interpretation are tools used by the analyst. Two concepts from classic psychoanalysis that are impor-tant for nurses to know are transference and countertransference (Freud, 1969). Transference refers to unconscious feelings that the patient has toward a healthcare worker that were originally felt in childhood for a significant other. The 75 patient may say something like, "You remind me exactly of my sister." The transference may be positive (affectionate) or negative (hostile). Psychoanalysis actually encourages transference as a way to understand original relationships. Such exploration helps the patient to better understand certain feelings and behaviors. Countertransference refers to unconscious feelings that the healthcare worker has toward the patient. For instance, if the patient reminds you of someone you do not like, you may unconsciously react as if the patient were that individual. Strong negative or positive feelings toward the patient could be a red flag for countertransference. Such responses underscore the importance of maintaining self-awareness and seeking supervisory guidance as therapeutic relationships progress. Chapter 8 talks more about countertransference and the nurse-patient relationship.

dsm-v

-The Diagnostic and Statistical Manual (DSM) is a publication of the American Psychiatric Association (APA). First published in 1952, the latest 2013 edition describes criteria for 157 disorders. The development of the DSM-5 was influenced by clinical field trials conducted by psychiatrists, psychiatric-mental health advanced practice registered nurses, psychologists, licensed clinical social workers, licensed counselors, and licensed marriage and family therapists. The DSM identifies disorders based on specific criteria. It is used in inpatient, outpatient, partial hospitalization, consultation-liaison, clinics, private practice, primary care, and community settings. The DSM also serves as a tool for collecting epidemiological statistics about the diagnosis of psychiatric disorders. The following is a list of disorder categories in the DSM-5. You may notice that the order of the list is similar to the way the chapters are organized in this textbook. 1. Neurodevelopmental Disorders 2. Schizophrenia Spectrum Disorders 3. Bipolar and Related Disorders 4. Depressive Disorders 5. Anxiety Disorders 6. Obsessive-Compulsive Disorders 7. Trauma and Stressor-Related Disorders 8. Dissociative Disorders 9. Somatic Symptom Disorders 10. Feeding and Eating Disorders 11. Elimination Disorders 56 12. Sleep-Wake Disorders 13. Sexual Dysfunctions 14. Gender Dysphoria 15. Disruptive, Impulse Control, and Conduct Disorders 16. Substance-Related and Addictive Disorders 17. Neurocognitive Disorders 18. Personality Disorders 19. Paraphilic Disorders 20. Other Disorders A common misconception is that a classification of mental disorders classifies people, when the DSM actually classifies disorders. For this reason, the DSM and this textbook avoid the use of labels such as "a schizophrenic" or "an alcoholic." Viewing the person as a person and not an illness requires more accurate terms such as "an individual with schizophrenia" or "my patient has major depression."

icd-10-cm

-The ICD-10-CM In an increasingly global society, it is important to view the United States' diagnosis and treatment of mental illness as part of a bigger picture. The international standard of disease classification is the International Classification of Diseases, Tenth Revision (ICD-10) (WHO, 2016). The United States has adapted this resource with a "clinical modification," hence its title of ICD-10-CM.

defense mechanisms and anxiety

-believed that anxiety is an inevitable part of living. The environment in which we live presents dangers and insecurities, threats and satisfactions. It can produce pain and increase tension or produce pleasure and decrease tension. The ego develops defenses, or defense mechanisms, to ward off anxiety by preventing conscious awareness of threatening feelings. Defense mechanisms share two common features: (1) they all (except suppression) operate on an unconscious level and (2) they deny, falsify, or distort reality to make it less threatening. Although we cannot survive without defense mechanisms, it is possible for our defense mechanisms to distort reality to such a degree that we experience difficulty with healthy adjustment and personal growth. Chapter 15 provides a full list and description of defense mechanisms.

interpersonal theory

-emphasizes previous expeirence tha influence how you behave

psychiatric mental health nurses

-even nurses in genral should promote mental health -clinic support sychiatric-mental health nursing is the nursing specialty that is dedicated to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and comorbid conditions across the lifespan (American Nurses Association et al., 2014). Psychiatricmental health nurses work with people throughout their life span: children, adolescents, adults, and the elderly. Psychiatric-mental health nurses assist people who are in crisis or who are experiencing life problems, as well as those with long-term mental illness. These nurses work with patients with dual diagnoses (e.g., a mental disorder and a comorbid substance disorder), homeless persons and families, forensic patients (i.e., people in jail), and individuals who have survived abusive situations. Psychiatric-mental health nurses work with individuals, couples, families, and groups in every nursing setting. They work with patients in hospitals, in their homes, in halfway houses, in shelters, in clinics, in storefronts, on the street—virtually everywhere. BOX 1.3 Phenomena of Concern for Psychiatric-Mental Health Nurses Phenomena of concern for psychiatric-mental health nurses include: • Promotion of optimal mental and physical health and well-being • Prevention of mental and behavioral distress and illness • Promotion of social inclusion of mentally and behaviorally fragile individuals • Co-occurring mental health and substance use disorders • Co-occurring mental health and physical disorders • Alterations in thinking, perceiving, communicating, and functioning related to psychological and physiological distress • Psychological and physiological distress resulting from physical, interpersonal, and/or environment trauma or neglect • Psychogenesis and individual vulnerability • Complex clinical presentations confounded by poverty and poor, inconsistent, or toxic environmental factors • Alterations in self-concept related to loss of physical organs and/or limbs, psychic trauma, developmental conflicts, or injury • Individual, family, or group isolation and difficulty with interpersonal relations • Self-harm and self-destructive behaviors including mutilation and suicide • Violent behavior including physical abuse, sexual abuse, and bullying • Low health literacy rates contributing to treatment nonadherence From American Psychiatric Nurses Association, International Society of Psychiatric-Mental Health Nurses, & American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: NursesBooks.org. The Psychiatric-Mental Health Nursing: Scope and Standards of Practice defines the specific activities 58 of the psychiatric-mental health nurse. This publication—jointly written in 2014 by the American Nurses Association (ANA), the American Psychiatric Nurses Association (APNA), and the International Society of Psychiatric-Mental Health Nurses (ISPN)—defines the focus of psychiatricmental health nursing as "promoting mental health through the assessment, diagnosis, and treatment of human responses to mental health problems and psychiatric disorders" (p. 14). The psychiatric-mental health nurse uses the same nursing process you have already learned to assess and diagnose patients' illnesses, identify outcomes, and plan, implement, and evaluate nursing care. Box 1.3 describes phenomena of concern—human experiences and responses—for psychiatric-mental health nurses.

legislaton and mental health funding

-many plans do not form enough coverage -la county spends lots of money on treatments Mental Health Parity Imagine insurance companies singling out a group of disorders such as digestive diseases for reduced reimbursement. Imagine people with colon cancer being assigned higher co-pays than other cancers. Imagine limiting the number of treatments for which patients could be reimbursed for Crohn's disease over a lifetime. People would be outraged by such discrimination. Yet this is exactly what has happened with psychiatric disorders. Too often, insurance companies: • Did not cover mental healthcare at all • Identified yearly or lifetime limits on mental health coverage • Limited hospital days or outpatient treatment sessions • Assigned higher co-payments or deductibles In response to this problem, advocates fought for parity. This term means equivalence or equal treatment. The Mental Health Parity Act was passed in 1996. This legislation required insurers that provide mental health coverage to offer annual and lifetime benefits at the same level provided for medical/surgical coverage. Unfortunately, by the year 2000, the Government Accounting Office found that although 86% of health plans complied with the 1996 law, 87% of those plans actually imposed new limits on mental health coverage. The Wellstone-Domenici Parity Act was enacted in 2008 for group health plans with more than 50 employees. The law required that any plan providing mental health coverage must do so in a manner that is functionally equivalent or on par with coverage of other health conditions. This parity pertains to deductibles, co-payments, coinsurance, and out-of-pocket expenses, as well as treatment limitations (e.g., frequency of treatment and number/frequency of visits). Patient Protection and Affordable Care Act of 2010 Parity laws were a good first step in providing more equitable coverage for mental healthcare. However, parity laws do not require health plans to cover psychiatric care. Furthermore, the parity laws only applied to large insurers. The Patient Protection and Affordable Care of 2010 (ACA) improves coverage for most Americans who are uninsured through a combination of expanded Medicaid eligibility (for the very poor), creation of Health Insurance Exchanges in the states (to serve as a broker to help uninsured consumers choose among various plans), and the so-called "insurance mandate," a requirement that people without coverage obtain it. The ACA improves mental healthcare coverage in several ways (Norris, 2016): • Eliminates medical underwriting in the individual and small group markets, so medical history no longer results in enrollment denials for preexisting conditions or higher premiums. • Requires all individual and small group health plans to cover 10 essential health benefits with no annual or lifetime dollar limits. Mental health and addiction treatment are among the essential benefits. • Makes health insurance with mental health benefits available for many individuals who previously had been uninsured. Significant numbers of these (mostly low-income) persons had untreated mental health problems. • Provides for prescription coverage for all new individual and small group health plans, including medications to treat behavioral health problems. • Requires all non-grandfathered health plans—including large group plans—to cover a range of preventive care at no cost to the patient. • Allows young adults to remain on their parents' health plans until age 26. This is important to mental health since most psychiatric disorders emerge in adolescence or early 20s. Although the ACA has dramatically improved mental healthcare coverage, there are still problems. Problems include finding a mental health professional for care within certain plans and limited coverage for some brand-name drugs, especially antipsychotics. Also, health insurance companies may be more than twice as likely to deny authorization for mental healthcare compared with authorization for general medical care (NAMI, 2015). Hopefully, these deficiencies will be addressed as the ACA continues to be evaluated and evolves.

Freudian theory and nursing

-transference and countertransference -transference: perceive you and have emotions towards you. feeling like you are like a mom to them. look like a relative, and project this emotion towards you. -countertransference: opposite. nurse is projecting feelings towards the patients, may look like someone you know. can request a change of assignemnt. - Freud believed that human development proceeds through five stages from infancy to adulthood. He believed that experiences during the first 5 years determined an individual's lifetime adjustment pattern and personality traits. By the time a child enters school, subsequent growth consists of elaborating on this basic structure. Freud's psychosexual stages of development are in Table 2.1. Psychoanalytic Therapy Classical psychoanalysis, as developed by Sigmund Freud, is seldom used today. Freud's premise that early intrapsychic conflict as the cause for all mental illness is no longer widely thought to be valid. Such therapy requires an unrealistically lengthy period of treatment (i.e., three to five times a week for many years), making it prohibitively expensive and uncovered by insurance. The purpose of these sessions is to uncover unconscious conflicts. Free association, dream and fantasy analysis, defense mechanism recognition, and interpretation are tools used by the analyst. Two concepts from classic psychoanalysis that are impor-tant for nurses to know are transference and countertransference (Freud, 1969). Transference refers to unconscious feelings that the patient has toward a healthcare worker that were originally felt in childhood for a significant others The patient may say something like, "You remind me exactly of my sister." The transference may be positive (affectionate) or negative (hostile). Psychoanalysis actually encourages transference as a way to understand original relationships. Such exploration helps the patient to better understand certain feelings and behaviors. Countertransference refers to unconscious feelings that the healthcare worker has toward the patient. For instance, if the patient reminds you of someone you do not like, you may unconsciously react as if the patient were that individual. Strong negative or positive feelings toward the patient could be a red flag for countertransference. Such responses underscore the importance of maintaining self-awareness and seeking supervisory guidance as therapeutic relationships progress. Chapter 8 talks more about countertransference and the nurse-patient relationship.

cultural competence for psychiatric mental health nurses

.

demographic shifts in the us

.

eastern tradition

.

family therapy

.

function and activities of the brain

.

function of brainstem

.

impact of culture on mental health

.

indigenous culture

.

measuring race and ethnicity in the US

.

mental dysfunction and altered activity of neurons

.

mental illness

.

objectives

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populations at risk of mental illness and inadequate care

.

therapeutic milieu

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traits of mental health ability to..

.

visualizing the brain

.

western tradition

.

neurotransmitter destruction

. destroys in synaptic cleft -

factors that can affect mental health

. hyper: panic attacks, anxiety hypo: depression

Antidepressants

.-

anxiolytics/antianxiety medications

.-adavan is the most popular benzodiazapene. worls on gabba receptors. long period of time may develop tolerance and will stop working. benzodizapines causes more tolerance. -gabba agonist Buspirone Buspirone (BuSpar) is a drug that reduces anxiety without having strong sedative-hypnotic properties. Because this agent does not leave the patient sleepy or sluggish, patients tolerate it better than the benzodiazepines. It is not a CNS depressant and, therefore, does not have as great a danger of interaction with other CNS depressants such as alcohol. Although the mechanism of action of buspirone is not clear, one possibility is illustrated in Fig. 3.11. Buspirone seems to act as a partial serotonin-1A agonist (booster). It also has a moderate affinity for D2 receptors, and side effects include dizziness and insomnia. Refer to Chapter 15 on anxiety disorders for a discussion of the adverse reactions, dosages, nursing implications, and patient and family teaching points for the antianxiety drugs. Refer to Chapter 19 on sleep disorders for a more detailed discussion on medications to promote sleep Benzodiazepines Benzodiazepines potentiate, or promote, the activity of GABA by binding to a specific receptor on the GABA receptor complex. This binding results in an increased frequency of chloride channel opening causing membrane hyperpolarization, which reduces the cellular excitation. If cellular excitation is decreased, the result is a calming effect. Fig. 3.10 shows that benzodiazepines, such as diazepam (Valium), clonazepam (Klonopin), and alprazolam (Xanax), enhance the effects of GABA. All benzodiazepines can cause sedation at higher therapeutic doses. There are five benzodiazepines approved by the FDA for treatment of insomnia with a predominantly hypnotic (sleep-inducing) effect: flurazepam (Dalmane), temazepam (Restoril), triazolam (Halcion), estazolam (ProSom), and quazepam (Doral). Other benzodiazepines, such as lorazepam (Ativan) and alprazolam (Xanax), reduce anxiety without being as sleep-producing when used at lower therapeutic doses. The fact that the benzodiazepines inhibit neurons probably accounts for their usefulness as anticonvulsants and for their ability to reduce the neuronal overexcitement of alcohol withdrawal. When used alone, even at high dosages, these drugs rarely inhibit the brain to the degree of respiratory depression, coma, and death. However, when combined with other CNS depressants, such as alcohol, opiates, or tricyclic antidepressants, the inhibitory actions of the benzodiazepines can lead to life-threatening CNS depression. Any drug that inhibits electrical activity in the brain can interfere with motor ability, attention, and judgment. Healthcare providers must caution a patient taking benzodiazepines about engaging in activities that could be dangerous if reflexes and attention are impaired, including specialized activities, such as working in construction, and more common activities, such as driving a car. In older adults, the use of benzodiazepines may contribute to falls and bone fractures. Ataxia is a common side effect secondary to the abundance of GABA receptors in the cerebellum. Melatonin Receptor Agonists Melatonin is a naturally occurring hormone that is only excreted at night as part of the normal circadian rhythm. Ramelteon (Rozerem) is a melatonin (MT) receptor agonist and acts much the same way as endogenous melatonin. It has a high selectivity and potency at the MT1 receptor site— which regulates sleepiness—and at the MT2 receptor site—which regulates circadian rhythms. This is one of two hypnotic medications approved for the treatment of insomnia not classified as a scheduled substance, lacking abuse potential, by the DEA. Side effects include headache and dizziness. Long-term use of ramelteon above therapeutic doses can lead to increased prolactin and associated side effects (e.g., sexual dysfunction). Short-Acting Sedative-Hypnotic Sleep Agents The Z-hypnotics include zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). They have sedative effects without the antianxiety, anticonvulsant, or muscle relaxant effects of benzodiazepines. They are selective for GABAA receptors containing alpha-1 subunits. The drugs' affinity to alpha-1 subunits confers the potential for amnestic and ataxic side effects, and their onset of action is faster than that of most benzodiazepines. It is important to inform patients taking nonbenzodiazepine hypnotic agents about the quick onset of action and to take them when they are ready to go to sleep. Most of these drugs have short half-lives, which determine the duration of action. Eszopiclone has the longest duration of action (an average of 7 to 8 hours of sleep per therapeutic dose) while the other two are much shorter. Eszopiclone also has a unique side effect of an unpleasant bitter taste upon awakening. Although tolerance and dependence are reportedly less than with benzodiazepines, the Z-hypnotics are categorized as schedule IV, similar to the benzodiazepines, by the US Drug Enforcement Administration (DEA). There have been reports of sleepwalking, eating, and even driving after the use of Z-hypnotics. These CNS adverse effects have been reported with other hypnotics as well. Doses for immediate-release zolpidem are now lower for women and the elderly.

action of psychotropic drugs

.-know thre are enzymes that are responsible to metabolize most medications -different in each person because of differences in amount enzymes -ex: prozac may not be fully metabolized leaving to side effects -cyp system

minority status, race, ethnicity and culture

.1st lecture

antipsychotic drugs

.3 -approved to treat schizophrenia and bipolar -benzo and atavan are not used long turn -know major side effects -know meds can have interactions with others antipsychotic Drugs First-Generation Antipsychotics First-generation antipsychotics are also referred to as conventional antipsychotics and typical antipsychotics. An overactivity of the dopamine system in the mesolimbic system may be responsible for at least some of the symptoms of schizophrenia. These drugs are strong antagonists (blocking the action) of the D2 receptors for dopamine. By binding to these receptors and blocking the attachment of dopamine, they reduce dopaminergic stimulation. These drugs may be most effective on the "positive" symptoms of schizophrenia, such as delusions (e.g., paranoid and grandiose ideas) and hallucinations (e.g., hearing or seeing things not present in reality). Refer to Chapter 12 for a more detailed discussion of schizophrenia and its symptoms. These drugs are also antagonists—to varying degrees—of the muscarinic receptors for acetylcholine, α1 receptors for norepinephrine, and (H1) receptors for histamine. Although it is unclear if this antagonism plays a role in the beneficial effects of the drugs, it is certain that antagonism is responsible for some of their major side effects. Fig. 3.17 illustrates the proposed mechanism of action of the first-generation antipsychotics, which include the phenothiazines, thioxanthenes, butyrophenones, and pharmacologically related agents. As summarized in Fig. 3.18, many of the unpleasant side effects are logical given their receptor-blocking activity. For example, because dopamine (D2) in the basal ganglia plays a major role in the regulation of movement, it is not surprising that dopamine blockade can lead to motor abnormalities known as extrapyramidal symptoms (EPS). These EPS include acute dystonic reactions, parkinsonism, akathisia, and tardive dyskinesia. Nurses and physicians often monitor patients for evidence of involuntary movements after administration of the first-generation antipsychotic agents. One popular scale is called the Abnormal Involuntary Movement Scale (AIMS). Refer to Chapter 12 for an example of AIMS and a discussion of the clinical use of antipsychotic drugs, side effects, specific nursing interventions, and patient teaching strategies. An important physiological function of dopamine is that it acts as the hypothalamic factor that inhibits the release of prolactin from the anterior pituitary gland. Therefore blockade of dopamine transmission can lead to increased pituitary secretion of prolactin. In women, this hyperprolactinemia can result in amenorrhea (absence of the menses) or galactorrhea (excessive or inappropriate breast milk production), and in men, it can lead to gynecomastia (development of the male mammary glands) and galactorrhea. Acetylcholine is a neurotransmitter that attaches to muscarinic receptors and helps regulate internal function. Blockade of the muscarinic receptors by phenothiazines and a wide variety of other psychiatric drugs can lead to a constellation of adverse effects. These side effects usually involve blurred vision, dry mouth, constipation, and urinary hesitancy. These drugs can also impair memory since acetylcholine is important for memory function. 137 FIG. 3.18 Adverse effects of receptor blockage of antipsychotic agents. From Varcarolis, E. [2004]. Manual of psychiatric nursing care plans [2nd ed.]. St. Louis, MO: Elsevier. Many of the first-generation antipsychotic drugs also act as antagonists for norepinephrine. These receptors are found on smooth muscle cells that contract in response to norepinephrine from sympathetic nerves. For example, the ability of sympathetic nerves to constrict blood vessels is dependent on the attachment of norepinephrine to α1 receptors. Therefore blockade of these receptors can bring about vasodilatation and a consequent drop in blood pressure. Vasoconstriction mediated by the sympathetic nervous system is essential for maintaining normal blood pressure when the body is in the upright position; blockade of the α1 receptors can lead to orthostatic hypotension. Finally, many of these first-generation antipsychotic agents, as well as a variety of other psychiatric drugs, block the H1 receptors for histamine. The two most significant side effects of blocking these receptors are sedation and substantial weight gain. Sedation may be beneficial in severely agitated patients. Nonadherence to the medication regimen is a significant issue because of these troublesome side effects. Second-Generation Antipsychotics Second-generation antipsychotics are also known as atypical antipsychotics. These drugs produce fewer EPS and target both the negative and positive symptoms of schizophrenia (Chapter 12). These newer agents are often chosen as first-line treatments over the first-generation antipsychotics due a more favorable side effect profile. Most of the available second-generation antipsychotics, however, can increase the risk of metabolic syndrome with increased weight, blood glucose, and triglycerides. The simultaneous blockade of receptors 5-HT2C and H1 is associated with weight gain from increased appetite stimulation via the hypothalamic eating centers. Strong anti-muscarinic properties at the M3 receptor on the pancreatic beta cells can cause insulin resistance leading to hyperglycemia. The receptor responsible for elevated triglycerides is currently unknown (Stahl, 2013). Clozapine and olanzapine have the highest risk of causing metabolic syndrome, while aripiprazole and ziprasidone are among the lowest risk in this classification. The second-generation antipsychotics are predominantly D2 (dopamine) and 5-HT2A (serotonin) antagonists (blockers). The blockade at the mesolimbic dopamine pathway decreases psychosis, similar to the way the first-generation antipsychotics work. Decreasing D2 stimulation can decrease psychosis, but cause adverse effects in the: • Nigrostriatal area, which can cause the movement side effects of EPS. • Mesocortical area, which can worsen cognitive and negative symptoms of schizophrenia. • Tuberoinfundibular area, which can increase the hormone prolactin leading to gynecomastia, 138 galactorrhea, amenorrhea, and low libido. Most second-generation antipsychotics have more 5-HT2A than D2 antagonist effects. Blocking the 5-HT2A receptors increases dopamine and norepinephrine. This may explain why the secondgeneration antipsychotics have less effect on causing EPS, cognitive impairment, and prolactin effects. Clozapine Clozapine (Clozaril) is an antipsychotic drug that is relatively free of the motor side effects of the phenothiazines and other second-generation antipsychotics. Clozapine preferentially blocks the D1 and D2 receptors in the mesolimbic system rather than those in the nigrostriatal area. This allows it to exert an antipsychotic action without leading to difficulties with EPS. However, it can cause a potentially fatal side effect. Clozapine has the potential to suppress bone marrow and induce agranulocytosis. Any deficiency in white blood cells renders a person prone to serious infection. Therefore regular measurement of absolute neutrophil count (ANC) is necessary. Typically, the count is measured weekly for the first 6 months. If results are normal, counts will be measured every other week for the next 6 months and every month thereafter. Clozapine has the potential for inducing convulsions, a dose-related side effect, in 3.5% of patients. Patients should use caution with other drugs that can increase the concentration of clozapine. Note that smoking cessation reduces CYP 1A2 enzymes and can increase clozapine's concentration. Risperidone Risperidone (Risperdal) has a low potential for inducing agranulocytosis or convulsions. However, high therapeutic dosages (>6 mg/day) may lead to motor difficulties. As a potent D2 antagonist, it has the highest risk of EPS among the second-generation antipsychotics and may increase prolactin, which may lead to sexual dysfunction. Because risperidone blocks α1 and H1 receptors, it can cause orthostatic hypotension and sedation, respectively. Keep in mind that orthostatic hypotension can lead to falls, which are a serious problem among older adults. Weight gain, sedation, and sexual dysfunction are adverse effects that may affect adherence to the medication regimen and should be discussed with patients. Risperdal Consta is an injectable form of the drug that is administered every 2 weeks, providing an alternative to the depot form of first-generation antipsychotics. Quetiapine Quetiapine (Seroquel) has a broad receptor-binding profile. Its strong blockade of H1 receptors accounts for the high sedation. The combination of H1 and 5-HT2C blockade leads to the weight gain associated with use of this drug and also to a moderate risk for metabolic syndrome. It causes moderate blockade of α1 receptors and associated orthostasis. Quetiapine has a low risk for EPS or prolactin elevation from low D2 binding due to rapid dissociation at D2 receptors. This drug is too commonly prescribed for sleep problems when other drugs should be considered. Olanzapine Olanzapine (Zyprexa) is similar to clozapine in chemical structure. It is an antagonist of 5-HT2 , D2 , H1 , alpha-1, and muscarinic receptors. Side effects include sedation, weight gain, hyperglycemia with new-onset type 2 diabetes, and higher risk for metabolic syndrome. Olanzapine is also available in a long-acting intramuscular agent under the trade name of Zyprexa Relprevv. Ziprasidone Ziprasidone (Geodon) is a serotonin-norepinephrine reuptake inhibitor at multiple receptors: 5-HT2 , D2 , alpha-1, and H1D . Ziprasidone is contraindicated in patients with a known history of QT interval prolongation, recent acute myocardial infarction, or uncompensated heart failure. Each dose should be taken with food to enable absorption. Aripiprazole 139 Aripiprazole (Abilify) is a unique second-generation antipsychotic known as a dopamine modulator in addition to its 5-HT2A antagonist activity. Depending on endogenous dopamine levels and signaling status, aripiprazole has varying effects on the D2 receptor due to its partial agonist properties. In areas of the brain with excess dopamine, it lowers the dopamine level by acting as a receptor antagonist. However, in regions with low dopamine, it stimulates receptors to raise the dopamine level (De Bartolomeis et al., 2015). Aripiprazole lacks H1 and 5-HT2C properties, which explains its lack of sedation and weight gain, respectively. Paliperidone Paliperidone (Invega) is the major active metabolite of risperidone. It has similar side effects with regard to prolactin elevation. Other than the D2 and 5-HT2A antagonistic properties as an antipsychotic, paliperidone is also an antagonist at alpha-1 receptors and H1 receptors, which explains the side effects of orthostasis and sedation, respectively. The Osmotic Release Oral System (OROS) provides consistent 24-hour release of the medication, leading to minimal peaks and troughs in plasma concentrations. It also has two long-acting injectable formulations: Invega Sustenna (every month) and Invega Trinza (every 3 months). Iloperidone Iloperidone (Fanapt) possesses minimal binding affinity for H1 receptors and has minimal affinity for cholinergic muscarinic receptors. A common adverse effect is orthostatic hypotension from the α1 blockade, which necessitates a slow dosage titration over the first few days to minimize orthostatic hypotension. There was a significant increase in the mean QT interval, although no deaths or serious arrhythmias were noted in the clinical trials. Another limitation of this medication is the risk of orthostatic hypotension (Holmes & Zacher, 2012). Lurasidone Lurasidone (Latuda) has high affinity for 5-HT2A and D2 receptors in addition to other serotonergic receptors such as 5-HT1A . Lurasidone has similar pharmacological properties to the tetracyclic antidepressant mirtazapine. Lurasidone has high affinity for serotonergic (such as 5HT2A and 5HT2C ), noradrenergic, and dopaminergic receptors (D3 and D4). There is minimal muscarinic receptor activity. Each dose must be taken with 350 calories to ensure optimal absorption. Asenapine Asenapine (Saphris) is unique among the antipsychotics as being administered in a sublingual formulation, which enhances its direct absorption. Therefore it avoids much of the hepatic metabolism that restricts its availability when administered orally. Bioavailability of asenapine is reduced from 35% with sublingual administration to less than 2% with oral administration. Patients should avoid food and water for 10 minutes after sublingual administration (Holmes & Zacher, 2012). It has a higher affinity for 5-HT2A receptors than D2 receptors. It also has antagonistic activity at alpha-1 receptor that accounts for the orthostatic hypotension, and H1 antagonistic activity, which causes sedation. Chapter 12 discusses the first- and second-generation antipsychotic drugs in detail including the indications for use, adverse reactions, nursing implications, and patient and family teaching.

organization of the brain

.Brainstem The most primitive area of the brain is the brainstem. It connects directly to the spinal cord and is central to the survival of all animals by controlling such functions as heart rate, breathing, digestion, and sleeping. Ascending pathways in the brainstem, referred to as mesolimbic and mesocortical pathways, seem to play a strong role in modulating the emotional value of sensory material. These pathways project to areas of the cerebrum collectively known as the limbic system. The limbic system plays a crucial role in emotional status and psychological function using norepinephrine, serotonin, and dopamine as their neurotransmitters. The role of these pathways in normal and abnormal mental activity is significant. For example, experts believe that the release of dopamine from the mesolimbic pathway plays a role in psychological reward and drug addiction. The neurotransmitters released by these neurons are major targets of the drugs used to treat psychiatric disorders. Hypothalamus In a small area above the brainstem lies the hypothalamus, which plays a vital role in: • Controlling basic drives such as hunger, thirst, and sex • Linking higher brain activities, such as thought, emotion, and the functioning of the internal organs • Processing sensory information that is then sent to the cerebral cortex • Regulating the entire cycle of sleep and wakefulness and the ability of the cerebrum to carry out conscious mental activity Cerebellum Located behind the brainstem where the spinal cord meets the brain, the cerebellum (Fig. 3.4) receives information from the sensory systems, the spinal cord, and other parts of the brain and then regulates voluntary motor movements. It plays a crucial role in coordinating contractions so that movement is accomplished in a smooth and directed manner. It is also involved in balance and the maintenance of equilibrium. Cerebrum The human brainstem and cerebellum are similar in both structure and function to these same structures in other mammals. The development of a much larger and more elaborate cerebrum is what distinguishes human beings from the rest of the animal kingdom. The cerebrum, situated on top of and surrounding the brainstem, is responsible for mental activities and a conscious sense of being. This is responsible for our conscious perception of the external world and our own body, emotional status, memory, and control of skeletal muscles that allow willful direction of movement. The cerebrum is also responsible for language and the ability to communicate. The surface of the cerebrum is called the cerebral cortex. There are four major lobes of the cortex, each responsible for specific functions. For example, conscious sensation and the initiation of movement reside in the frontal lobe, the sensation of touch resides in the parietal lobe, sounds are based in the temporal lobe, and vision is housed in the occipital lobe. Likewise, a specific area of the frontal cortex controls the initiation of skeletal muscle contraction. Of course, all areas of the cortex are interconnected so that you can form an appropriate picture of the world and, if necessary, link it to a proper response (Fig. 3.5). Both sensory and motor aspects of language reside in specialized areas of the cerebral cortex. Sensory language functions include the ability to read, understand spoken language, and know the names of objects perceived by the senses. Motor functions involve the physical ability to use muscles properly for speech and writing. In both neurological and psychological dysfunction, the use of language may become compromised or distorted. The change in language ability may be a factor in determining a diagnosis. Underneath the cerebral cortex are pockets of gray matter deep within the cerebrum. Some of these, the basal ganglia, are involved in the regulation of movement. Others, the amygdala and hippocampus in the limbic system, are involved in emotions, learning, memory, and basic drives. Anxiety disorders can be associated with abnormalities in the amygdala, which cause intense fear such as in panic disorder. Significantly, there is an overlap of these areas both anatomically and in the types of neurotransmitters involved. One important consequence is that drugs used to treat emotional disturbances may cause movement disorders, and drugs used to treat movement disorders may cause emotional changes.

cultural barriers to quality mental health services

.Communication Barriers Communication is a key aspect of caring for patients, yet healthcare providers and patients may not even speak the same language. The US Department of Health and Human Services (HHS) Office of Minority Health (2013) states that healthcare organizations should offer and provide language assistance services, including an interpreter, at all points of contact and in a timely manner during all hours of operation and service. These services should be provided at no cost to each patient who has limited English proficiency. Patients with limited English proficiency are those who cannot speak English or do not speak English well enough to meet their communication needs. The HHS asserts that providing language services benefits patients, providers, and facilities alike. A professional interpreter should match the patient as closely as possible in gender, age, social status, and religion. In addition to interpreting the language, the interpreter can provide information regarding nonverbal communication patterns and cultural norms that are relevant to the encounter. In this way, the interpreter acts as a cultural broker, interpreting not only the language but also the culture. Especially important in psychiatric settings, interpreters should not be relatives or friends of the patient. The stigma of mental illness may prevent the openness needed during the encounter. Also, those close to the patient may not have the language skills necessary to meet the demands of interpretation, which is a complex task. Languages frequently cannot be translated word for word. The literal translations of words in one language can carry many different connotations in the other language, and certain concepts are so culturally linked that an adequate translation is difficult. Even people who speak English well may have difficulty communicating emotional nuances in English. Certain terms may be more accessible to patients in their own languages. Idioms and figures of speech can be extremely confusing. For instance the terms feeling blue or feeling down may have no meaning at all in the patient's literal understanding of English. In addition to interpreters, translators can be critically important in the healthcare setting, since a translation error can be a matter of life and death. Translators can provide patients with materials written in the language that they understand. Stigma of Mental Illness Mental illnesses are stigmatized disorders, and this stigma presents significant barriers to treatment. Many people in all sectors of society in the United States associate mental illness with moral weakness. Others express fear of, or bias against, those with mental health problems. However, in many cultural groups, the stigma of mental illness is more severe and prevalent than it generally is in the United States. In cultural groups that emphasize the interdependence and harmony of the family, mental illness is perceived as a failure of the family. In such groups, the pressures on both the individual with the mental illness and the family are increased. Both the individual and the whole family are ill, and the illness reflects badly on the character of all family members. Stigma and shame can lead to reluctance to seek help, so members of these cultural groups may enter the mental healthcare system at an advanced stage when the family has exhausted its ability to cope with the problem. Misdiagnosis Another barrier to mental healthcare is misdiagnosis. Studies indicate that blacks and African Americans, Afro-Caribbean, and Latino-Hispanic Americans run a significant risk of being misdiagnosed with schizophrenia when the true diagnosis is bipolar disease or an affective disorder (Schwartz et al., 2014). Why does this happen? One reason for misdiagnosis is the use of culturally inappropriate assessment tools. Experts have validated most of the available tools using subjects of European origin. Marsella (2011) asserts that the use of standardized Western assessment instruments may result in inaccuracy of diagnosis when applied to non-Western patients. In cultures where the body and mind are considered one entity, or in cultures in which there is a high degree of stigma associated with mental health problems, individuals frequently somatize their feelings of psychological distress. In somatization, psychological distress is experienced as physical problems. For example, a Cambodian woman may describe feelings of back pain, fatigue, and dizziness and say nothing about feelings of sadness or hopelessness (Henderson et al., 2016). Somatization is just one example of how psychological distress is manifested in a way that seems different. Because of this, using psychiatric diagnostic criteria that were developed based on studies with predominantly white American samples are often invalid when applied to other cultures. The impact of cultural concepts on a psychiatric diagnosis has been included in the American Psychiatric Association's (APA, 2013a) diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Furthermore, the DSM-5 includes a standardized tool for taking into account cultural variations during the assessment phase of patient care. The Cultural Formulation Interview (APA, 2013b) is a 14-question inventory that helps clinicians plan for care based on orientation, values, and assumptions that originate from particular cultures. It takes into consideration the meaning of the 191 illness for the patient, the role of family and others as support, the patient's attempts to cope with previous illness, and expectations of current care. Cultural Concepts of Distress Cultural concepts of distress take into account the way that groups experience, understand, and communicate problematic behaviors, suffering, or troubling emotions and thoughts (APA, 2013a). All forms of distress are local constructs including the disorders described in the DSM-5. There are three specific types of cultural concepts: 1. Cultural syndromes, or culture-bound syndromes, exist when clusters of symptoms occur in specific groups and are recognized by these groups as a known pattern of experience. These syndromes are typically given a distinct name. 2. Cultural idioms of distress are specific ways of expressing distress that people in particular cultures understand. In the United States, saying, "I am depressed" or "I'm a nervous wreck" may refer to a variety of problems and not a specific disorder. 3. Cultural explanations refer to explanations for symptoms, illness, or distress understood within the context of the particular culture. Cultural syndromes may seem exotic or irrational to nurses who have been trained within a Western medical framework. The symptoms may be shocking, and other-culture explanations regarding causation and treatment may be mystifying. These illnesses, however, are usually well understood by the people within the cultural group. They know the name of the problem, its etiology, its course, and the way it should be treated. Frequently, when these illnesses are treated in culturally prescribed ways, the remedies are quite effective. There are many cultural syndromes. Some of these syndromes seem to be mental health problems manifested in somatic ways. Hwa-byung and neurasthenia have many similarities to depression and do not carry the degree of stigma associated with a mental disorder. Because the somatic complaints are so prominent, and because patients frequently deny feelings of sadness or depression, they may not fit the DSM-5 diagnostic criteria for depression. Ataque de nervios and ghost sickness belong to another group of culture-based illnesses characterized by abnormal behaviors. These types of illnesses seem to be culturally acceptable ways for patients to express that they can no longer endure the stressors in their lives. People in the culture understand the patient is ill and provide support using culturally prescribed treatments, which often relieve the symptoms. A list of some of the syndromes that psychiatric nurses may see is provided in Box 5.2. We tend to think of cultural syndromes as strange or exotic, yet there are disorders listed in the DSM-5 that may seem unusual to others. Consider anorexia nervosa, bulimia nervosa, and bingeeating disorder. These problems are bound to Western culture apparently because other cultures do not value the thinness so prized by European and North American cultural groups. When we consider culture in diagnosis and treatment, we are more likely to see culturally different behavior as normal. For example, in African American churches, it is common to refer to spiritual experiences in terms such as "I was talking to Jesus this morning." Rather than considering the speaker to be delusional, the care provider understands that he was praying. If a Vietnamese father says he tried to take the wind illness out of his child by vigorously rubbing a coin down her back, the care provider realizes that the father is not a potential threat to the child. Genetic Variation in Pharmacodynamics Another clinical practice issue that presents a barrier to quality mental health services for some groups is genetic variation in drug responses. There is a growing realization that many drugs vary in their action and effects along genetic and psychosocial lines (Lehne, 2013). In most clinical trials a high percentage of participants are white while other racial subgroups are underrepresented. This is a real problem since what is found true in drug studies primarily performed with subjects of European origin may not be true in racially and ethnically diverse populations. The relatively new field of pharmacogenetics focuses on how genes affect individual responses to medicines (National Institutes of Health, 2014). Genes carry "recipes" for making specific protein molecules. Medications interact with thousands of proteins, and the smallest difference in the quantities or composition of these molecules can make a big difference in how they work. By understanding how genes influence drug responses, we hope to one day prescribe drugs that are Genetic variations in drug metabolism have been documented for several classifications of drugs, including antidepressants and antipsychotics. An important variation that impacts the ability to metabolize drugs relates to the more than 20 cytochrome P-450 (CYP) enzymes present in human beings (Henderson et al., 2016). Genetic variations in these enzymes may alter drug metabolism, and these variations tend to be propagated through racial/ethnic populations. CYP enzymes metabolize most antidepressants and antipsychotics. Some genetic variations result in rapid metabolism, and if the body metabolizes medications too quickly, serum levels become too low, minimizing therapeutic effects. Other variations may result in poor metabolism. If the body metabolizes medications too slowly, serum levels become too high, increasing the risk of intolerable side effects. Care providers are utilizing genetic testing to determine correct medications and dosages with fairly good success (Brennan et al., 2015).

humanistic theory

.In the 1950s humanistic theories arose as a protest against both the behavioral and psychoanalytic schools, which were thought to be pessimistic, deterministic, and dehumanizing. Humanistic theories focus on human potential and free will to choose life patterns supportive of personal growth. Humanistic frameworks emphasize a person's capacity for self-actualization. This approach focuses on understanding the patient's perspective as he or she subjectively experiences it. There are a number of humanistic theorists, and this text will explore Abraham Maslow and his theory of self-actualization. Maslow believed that human beings are motivated by unmet needs. Maslow (1968) focused on human need fulfillment, which he categorized into six incremental stages, beginning with physiological survival needs and ending with self-transcendent needs (Fig. 2.5). The hierarchy of needs is conceptualized as a pyramid with the strongest, most fundamental needs placed on the lower levels. The higher levels—the more distinctly human needs—occupy the top sections of the pyramid. When lower-level needs are met, higher needs are able to emerge. • Physiological needs: The most basic needs are the physiological drives—needing food, oxygen, water, sleep, sex, and a constant body temperature. If all needs were deprived, this level would take priority over the rest. • Safety needs: Once physiological needs are met, safety needs emerge. They include security; protection; freedom from fear, anxiety, and chaos; and the need for law, order, and limits. Adults in a stable society usually feel safe, but they may feel threatened by debt, job insecurity, or lack of insurance. It is during times of crisis, such as war, disasters, assaults, and social breakdown, when safety needs take precedence. Children, who are more vulnerable and dependent, respond far more readily and intensely to safety threats. • Belonging and love needs: People have a need for intimate relationships, love, affection, and belonging and will seek to overcome feelings of loneliness and alienation. Maslow stresses the importance of having a family and a home and being part of identifiable groups. TABLE 2.3 Common Cognitive Distortions Distortion Definition Example All-or-nothing thinking Thinking in black and white, reducing complex outcomes into absolutes Although Lindsey earned the second highest score in the state's cheerleading competition, she consistently referred to herself as "a loser." Overgeneralization Using a bad outcome (or a few bad outcomes) as evidence that nothing will ever go right again Andrew had a minor traffic accident. He is reluctant to drive and says, "I shouldn't be allowed on the road." Labeling A form of generalization in which a characteristic or event becomes definitive and results in an overly harsh label for self or others "Because I failed the advanced statistics exam, I am a failure. I might as well give up. I may as well quit and look for an easier major." Mental filter Focusing on a negative detail or bad event and allowing it to taint everything else Anne's boss evaluated her work as exemplary and gave her a few suggestions for improvement. She obsessed about the suggestions and ignored the rest. Disqualifying the positive Maintaining a negative view by rejecting information that supports a positive view as being irrelevant, inaccurate, or accidental "I've just been offered the job I thought I always wanted. There must have been no other applicants." Jumping to conclusions Making a negative interpretation despite the fact that there is little or no supporting evidence "My fiancé, Juan, didn't call me for 3 hours, which just proves he doesn't love me anymore." a. Mind-reading Inferring negative thoughts, responses, and motives of others Isabel is giving a presentation and a man in the audience is sleeping. She panics, "I must be boring." b. Fortune-telling error Anticipating that things will turn out badly as an established fact "I'll ask her out, but I know she won't have a good time." Magnification or minimization Exaggerating the importance of something (such as a personal failure or the success of others) or reducing the importance of something (such as a personal success or the failure of others) "I'm alone on a Saturday night because no one likes me. When other people are alone, it's because they want to be." a. Catastrophizing Catastrophizing is an extreme form of magnification in which the very worst is assumed to be a probable outcome "If I don't make a good impression on the boss at the company picnic, she will fire me." Emotional reasoning Drawing a conclusion based on an emotional state "I'm nervous about the exam. I must not be prepared. If I were, I wouldn't be afraid." "Should" and "must" statements Rigid self-directives that presume an unrealistic amount of control over external events Renee believes that a patient with diabetes has high blood sugar today because she's not a very good nurse and that her patients should always get better. Personalization Assuming responsibility for an external event or situation that was likely outside personal control "I'm sorry your party wasn't more fun. It's probably because I was there." 89 Modified from Burns, D. D. (1989). The feeling good handbook. New York, NY: William Morrow. • Esteem needs: People need to have a high self-regard and have it reflected to them from others. If self-esteem needs are met, they feel confident, valued, and valuable. When self-esteem is compromised, they feel inferior, worthless, and helpless. • Self-actualization: Human beings are preset to strive to be everything they are capable of becoming. Maslow said, "What a man can be, he must be." What people are capable of becoming is highly individual—an artist must paint, a writer must write, and a healer must heal. The drive to satisfy this need is felt as a sort of restlessness, a sense that something is missing. It is up to each person to choose a path that will bring about inner peace and fulfillment. Although Maslow's early work included only five levels of needs, he later took into account two additional factors: (1) cognitive needs (the desire to know and understand) and (2) aesthetic needs (Maslow, 1970). He describes the acquisition of knowledge (our first priority) and the need to understand (our second priority) as being hard-wired and essential. The aesthetic need for beauty and symmetry is universal. You may be interested to know that Maslow (1970) developed his theory by investigating people whom he believed were self-actualized. Among these people were historical figures such as Abraham Lincoln, Thomas Jefferson, Harriet Tubman, Walt Whitman, Ludwig van Beethoven, William James, and Franklin D. Roosevelt. Other people he investigated were living at the time of his studies. They include Albert Einstein, Eleanor Roosevelt, and Albert Schweitzer. Box 2.1 identifies basic personality characteristics that distinguish self-actualizing people. The value of Maslow's model in nursing practice is twofold. First, an emphasis on human potential and the patient's strengths is key to successful nurse-patient relationships. Second, the model helps establish what is most important in the sequencing of nursing actions. For example, to collect any but the most essential information when a patient is struggling with drug withdrawal may be dangerous. Following Maslow's model as a way of prioritizing actions, the nurse meets the patient's physiological need for stable vital signs and pain relief before collecting general information for a nursing database.

diathesis stress model

.Nature Versus Nurture For centuries, people believed that extremely unusual behaviors resulted from supernatural (usually evil) forces. In the late 1800s, the mental health pendulum swung briefly to a biological focus with the "germ theory of diseases." Germ theory explained mental illness in the same way other illnesses were being described—that is, a specific agent in the environment caused them. This theory was abandoned rather quickly because clinicians and researchers could not identify causative factors for mental illnesses. There was no "mania germ" that could be viewed under a microscope and subsequently treated. Although biological treatments for mental illness continued to be explored, psychological theories dominated and focused on the science of the mind and behavior. These theories explained the origin of mental illness as faulty psychological processes that could be corrected by increasing personal insight and understanding. For example, a patient experiencing depression and apathy could be assisted to explore feelings from childhood when overly protective parents strictly discouraged attempts at independence. This psychological focus was challenged in 1952 when chlorpromazine (Thorazine) was found to have a calming effect on agitated, out-of-control patients. Imagine what this discovery must have been like for clinicians. Out of desperation they had resorted to every biological treatment imaginable including wet wraps, insulin shock therapy, and psychosurgery (in which holes were drilled in the head of a patient and probes inserted into the brain) as attempts to change behavior. The scientific community began to believe that if psychiatric problems respond to medications that alter neurochemistry, then a disruption of intercellular components must already be present. A diathesis-stress model—in which diathesis represents biological predisposition and stress represents environmental stress or trauma—is the most accepted explanation for mental illness. This nature-plus-nurture argument asserts that most psychiatric disorders result from a combination of genetic vulnerability and negative environmental stressors. One person may develop major depression largely as the result of an inherited and biological vulnerability that alters brain chemistry. Another person with little vulnerability may develop depression as a result of a stressful environment that causes changes in brain chemistry.

limbic system

.The most primitive area of the brain is the brainstem. It connects directly to the spinal cord and is central to the survival of all animals by controlling such functions as heart rate, breathing, digestion, and sleeping. Ascending pathways in the brainstem, referred to as mesolimbic and mesocortical pathways, seem to play a strong role in modulating the emotional value of sensory material. These pathways project to areas of the cerebrum collectively known as the limbic system. The limbic system plays a crucial role in emotional status and psychological function using norepinephrine, serotonin, and dopamine as their neurotransmitters. The role of these pathways in normal and abnormal mental activity is significant. For example, experts believe that the release of dopamine from the mesolimbic pathway plays a role in psychological reward and drug addiction. The neurotransmitters released by these neurons are major targets of the drugs used to treat psychiatric disorders Hypothalamus In a small area above the brainstem lies the hypothalamus, which plays a vital role in: • Controlling basic drives such as hunger, thirst, and sex • Linking higher brain activities, such as thought, emotion, and the functioning of the internal organs • Processing sensory information that is then sent to the cerebral cortex • Regulating the entire cycle of sleep and wakefulness and the ability of the cerebrum to carry out conscious mental activity Cerebellum Located behind the brainstem where the spinal cord meets the brain, the cerebellum (Fig. 3.4) receives information from the sensory systems, the spinal cord, and other parts of the brain and then regulates voluntary motor movements. It plays a crucial role in coordinating contractions so that movement is accomplished in a smooth and directed manner. It is also involved in balance and the maintenance of equilibrium. Cerebrum The human brainstem and cerebellum are similar in both structure and function to these same structures in other mammals. The development of a much larger and more elaborate cerebrum is what distinguishes human beings from the rest of the animal kingdom. The cerebrum, situated on top of and surrounding the brainstem, is responsible for mental activities and a conscious sense of being. This is responsible for our conscious perception of the external world and our own body, emotional status, memory, and control of skeletal muscles that allow willful direction of movement. The cerebrum is also responsible for language and the ability to communicate. The surface of the cerebrum is called the cerebral cortex. There are four major lobes of the cortex, each responsible for specific functions. For example, conscious sensation and the initiation of movement reside in the frontal lobe, the sensation of touch resides in the parietal lobe, sounds are based in the temporal lobe, and vision is housed in the occipital lobe. Likewise, a specific area of the frontal cortex controls the initiation of skeletal muscle contraction. Of course, all areas of the cortex are interconnected so that you can form an appropriate picture of the world and, if necessary, link it to a proper response (Fig. 3.5). Both sensory and motor aspects of language reside in specialized areas of the cerebral cortex. Sensory language functions include the ability to read, understand spoken language, and know the names of objects perceived by the senses. Motor functions involve the physical ability to use muscles properly for speech and writing. In both neurological and psychological dysfunction, the use of language may become compromised or distorted. The change in language ability may be factor in determining a diagnosis. Underneath the cerebral cortex are pockets of gray matter deep within the cerebrum. Some of these, the basal ganglia, are involved in the regulation of movement. Others, the amygdala and hippocampus in the limbic system, are involved in emotions, learning, memory, and basic drives. Anxiety disorders can be associated with abnormalities in the amygdala, which cause intense fear such as in panic disorder. Significantly, there is an overlap of these areas both anatomically and in the types of neurotransmitters involved. One important consequence is that drugs used to treat emotional disturbances may cause movement disorders, and drugs used to treat movement disorders may cause emotional changes.

resilience

.What makes some people adapt to tragedy, loss, trauma, and severe stress better than others? The answer may be the individual attribute of resilience. Resilience is the ability and capacity for people to secure the resources they need to support their well-being. It is a quality found in some children of poverty and abuse who seek out trusted adults. These adults provide them with the psychological and physical resources that allow them to excel. BOX 1.1 The Resilience Factor Test Use the following scale to rate each item listed below: A score higher than 13 is rated as above average in emotional regulation. A score between 6 and 13 is inconclusive. A score lower than 6 is rated as below average in emotional regulation. If your emotional regulation is below average, you may need to master some calming skills. Here are a few tips: • When anxiety strikes, your breathing may become shallow and quick. You can help control the anxiety by controlling your breathing. Inhale slowly through your nose, breathing deeply from your belly, not your chest. • Stress will make your body tight and stiff. Again, you can counter the effects of stress on the body and brain if you relax your muscles. • Try positive imagery; create an image that is relaxing such as visualizing yourself on a secluded beach. • Resilience is within your reach. From Reivich, K., & Shatte, A. (2002). The resilience factor: 7 essential skills for overcoming life's obstacles. New York, NY: Broadway Books. Any third party use of this material, outside of this publication, is prohibited. Interested parties must apply directly to Random House, Inc. for permission. Being resilient does not mean being unaffected by stressors. People who are resilient are effective at regulating their emotions and not falling victim to negative, self-defeating thoughts. You can get an idea of how good you are at regulating your emotions by taking the Resilience Factor Test in Box 1.1

disturbances of mental function

.pos itive symptoms: paranoia, -gabba can contribute to anxiety - Most origins of mental dysfunction are unknown. Some known causes include drugs (e.g., lysergic acid diethylamide [LSD]), long-term use of high daily doses of prednisone, excess levels of hormones (e.g., thyroxine, cortisol), infection (e.g., encephalitis, acquired immunodeficiency syndrome [AIDS]), and physical trauma. Even when the cause is known, the link between the causative factor and the mental dysfunction is difficult to understand. Genetics There is often a genetic predisposition for psychiatric disorders. The incidence of both thought and mood disorders are higher in relatives of people who have these diseases than in the general population. Monozygotic (identical) twins provide us with an understanding of inheritance of a disorder through a concept known as concordance rate. Concordance refers to how often an illness will affect both twins even when they are raised apart. A 100% concordance rate would mean that if one twin has a disorder, the other one would also have it. For schizophrenia, the concordance rate is 50%, meaning that inheritance is half of the equation and that other factors are involved. Neurotransmitters Major components in the brain's chemical stew are the monoamine neurotransmitters (norepinephrine, dopamine, and serotonin), the amino acid neurotransmitters (glutamate and γaminobutyric acid [GABA]), the neuropeptides (CRH and endorphin), and acetylcholine. Alteration of these chemicals is the basis of psychiatric illness and is the target for pharmacological treatment. Understanding alterations in neurotransmitters will lead to better treatments and possibly prevent mental disorders. Research interest is focused on certain neurotransmitters and their receptors, particularly in the limbic system, which links the frontal cortex, basal ganglia, and upper brainstem. Let us consider major depression. We believe that a deficiency of norepinephrine, serotonin, dopamine, or a combination of these is the biological basis of depression. How this deficiency happens is illustrated in Fig. 3.8. Fig. 3.8A shows normal transmission of neurotransmitters. In Fig. 3.8B we see a deficiency in the amount of neurotransmitter in the presynaptic cell. Fig. 3.8C shows a deficiency or loss of the ability of postsynaptic receptors to respond to the neurotransmitters. Changes in neurotransmitter release and receptor response can be both a cause and a consequence of intracellular changes in the neurons involved. Thought disorders such as schizophrenia are associated with excess transmission of dopamine from the presynaptic neuron. As illustrated in Fig. 3.9, this may be caused by excessive release of the neurotransmitter or to an increase in receptor responsiveness. Besides dopamine, the neurotransmitter glutamate may have a role in schizophrenia's pathology. Glutamate may have a direct influence on the activity of dopamine-releasing cells (Howes et al., 2015). First, glutamate activity increases in the hippocampus, then hippocampus metabolism is increased, and then the hippocampus begins to atrophy or shrink the brain's memory center. This process happens early in the disease and may become a primary tool for early diagnosis and a target for treatment. The neurotransmitter GABA seems to play a role in modulating neuronal excitability and anxiety. Not surprisingly, many antianxiety (anxiolytic) drugs act by increasing the effectiveness of this neurotransmitter. This is accomplished primarily by increasing receptor responsiveness It is important to keep in mind that a vast network of neurons interconnects the various areas of the brain. This network serves to integrate the many activities of the brain. A limited number of neurotransmitters are used in the brain and, thus, a particular neurotransmitter is often used by different neurons to carry out quite different activities. For example, dopamine is not only involved in thought processes but also the regulation of movement. As a result, alterations in neurotransmitter activity, resulting from a mental disturbance or to the drugs used to treat the disturbance, can affect both thinking and movement. Basic body processes such as sleep patterns, body movement, and autonomic functions can be affected by alterations in mental status whether arising from disease or from medication.

pet scans

.used to control normal brains

cellular composition of the brain

The brain is composed of approximately 100 billion neurons, nerve cells that conduct electrical impulses. Most functions of the brain, from regulation of blood pressure to the conscious sense of self, result from the actions of individual neurons and the interconnections between them. Although neurons come in a great variety of shapes and sizes, all carry out the same three types of physiological actions: 1. Responding to stimuli 2. Conducting electrical impulses 3. Releasing chemicals called neurotransmitters Neurons have the ability to communicate by conducting an electrical impulse from one end of the cell to the other. All cellular membranes are electrically charged due to ions inside and outside the cell. Communication between neurons occurs mainly through sodium (Na +) and potassium (K+) ions. In a resting state, there is an unequal distribution of these two on the inside of the cell membrane and the outside. There are lots of positively charged potassium ions just inside the membrane and lots of sodium ions (along with some potassium ions) on the outside. The intracellular space is more negative when compared with the extracellular space. Stimulation of the nerve cell membrane changes this resting state within milliseconds. First, the stimulus causes the sodium gates to open. Sodium ions flow into the nerve cell and potassium ions flow out. The entry of positively charged ions into the cell actually reverses the electrical potential from a negative one to a positive one. The current at the end of the cell is conducted along the membrane until it reaches the other end (Fig. 3.3). Once an electrical impulse reaches the end of a neuron, a neurotransmitter is released. A neurotransmitter is a chemical substance that functions as a neuromessenger. Neurotransmitters are released from the axon terminal at the presynaptic neuron on excitation. The neurotransmitter then crosses the space, or synapse, to an adjacent postsynaptic neuron where it attaches to receptors on the neuron's surface. It is this interaction from one neuron to another, by way of a neurotransmitter and receptor that allows the activity of one neuron to influence the activity of other neurons. It is the interaction between neurotransmitter and receptor that is a major target of the drugs used to treat psychiatric disease. Table 3.1 lists important neurotransmitters and the types of receptors to which they attach. Also listed are the mental disorders associated with an increase or decrease in these neurotransmitters. After attaching to a receptor and exerting its influence on the postsynaptic cell, the neurotransmitter separates from the receptor and is destroyed. Box 3.2 describes the process of neurotransmitter destruction. Neurotransmitters can be destroyed two ways. Specific enzymes destroy some neurotransmitters (e.g., acetylcholine) at the postsynaptic cell. The enzyme that 111 destroys acetylcholine is called acetylcholinesterase (referred to as cholinesterase from here on). Most enzymes start with the name of the neurotransmitter they destroy and end with the suffix - ase. Other neurotransmitters (e.g., norepinephrine) are taken back into the presynaptic cell from which they were originally released by a process called cellular reuptake. These neurotransmitters are either reused or destroyed by intracellular enzymes. In the case of the monoamine neurotransmitters (e.g., norepinephrine, dopamine, serotonin), the destructive enzyme is called monoamine oxidase (MAO).

theory of psyhosocial developmet

ch 2 erikson believes if u had any triggrs that would affect the future Erik Erikson (1902-1994), an American psychoanalyst, began as a follower of Freud. Erikson (1963) came to believe that Freudian theory was restrictive and negative in its approach. He also stressed that more than the limited mother-child-father triangle influences an individual's development. He emphasized the role of culture and society on personality development. According to Erikson, personality was not set in stone at age 5, as Freud suggested, but continued to evolve throughout the life span. Erikson described development as occurring in eight predetermined and consecutive life stages (psychosocial crises), each of which results in a positive or negative outcome. The successful or unsuccessful completion of each stage will affect the individual's progression to the next (Table 2.6). For example, Erikson's crisis of industry versus inferiority occurs from the ages of 7 to 12. During this stage, the child's task is to gain a sense of personal abilities and competence and to expand 94 relationships beyond the immediate family to include peers. The attainment of this task (industry) brings with it the virtue of confidence. The child who fails to navigate this stage successfully is unable to master age-appropriate tasks, cannot make a connection with peers, and will feel like a failure (inferiority)

mental health and illness

ch2 People often make a distinction between mental illnesses and physical illnesses. This is a peculiar distinction. Mental refers to the brain, the most complex part of the body, responsible for the higher thought processes that set us apart from all other creatures. Surely the workings of the brain—the synaptic connections, the areas of functioning, the spinal innervations and connections—are physical. One problem with this distinction is that it implies that psychiatric disorders are "all in the head." Most damaging is the belief that these disorders are under personal control and indistinguishable from a choice to engage in bad behavior. These beliefs support the stigma to which people with mental illness are often subjected. Stigma, the belief that the overall person is flawed, is characterized by social shunning, disgrace, and shame. Perhaps the difference between mental and physical illness lies in the tradition of explaining the unexplainable through superstition. Consider that the frightening convulsions of epilepsy were once explained as demon possession or a curse. Unfortunate individuals with epilepsy were subjected to horrible treatment including shunning, imprisonment, and exorcisms. Today, people recognize that seizures are part of a disorder and not under personal control. How do we know? Because we can see epilepsy on brain scans as areas of overactivity and excitability. There are no specific biological tests to diagnose most psychiatric disorders—no cranium culture for depression and no magnetic resonance imaging (MRI) for obsessive-compulsive disorder (OCD). However, researchers are convinced that the root of most mental disorders lies in intercellular abnormalities. We can now see clear signs of altered brain function in several mental disorders including schizophrenia, OCD, stress disorders, and depression.

audience response question mrs m's comlaints

d

reasons for admission

dsm is publication of American psychiatric association, reviewed every few years and constantly changing. -

mental health attributes

good things happen in life but cannot enjoy it. -able to control emotions to day with day to day stressors -patients may not recognize the consequences of their own actions (personality disorders)

mental health

same diagnosis with different treatment. individualized treatment plans. assess each need. -can be untrustworthy -build trust relationship -different presentations -work productively: being able to accomplish tasks . First, overall health is not possible without good mental health. The World Health Organization (WHO, 2014) describes health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." There is a strong relationship between physical health and mental health: Poor physical health can lead to mental distress and disorders, and poor mental health can lead to physical problems. What does it mean to be mentally healthy? Mental health is a state of well-being in which each individual is able to realize his or her own potential, cope with the normal stresses of life, work productively, and make a contribution to the community. Mental health provides people with the capacity for rational thinking, communication skills, learning, emotional growth, resilience, and self-esteem. Some of the attributes of mentally healthy people are shown in Fig. 1.1. Society's definition of mental illness evolves over time. It is a definition shaped by the prevailing culture and societal values, and it reflects changes in cultural norms, social expectations, political climates, and even reimbursement criteria by third-party payers. In the past,

mental health ranking

symptoms severe can take more time and medications to treat these symptoms. always adress it early. On one end of the continuum is mental health. Well-being describes the general condition of people in this category. Well-being is characterized by adequate to high-level functioning. While individuals at this end of the continuum may experience stress and discomfort resulting from problems of everyday life, they experience no serious impairments in daily functioning. For example, you may spend a day or two in a gray cloud of self-doubt and recrimination over a failed exam, a sleepless night filled with worry about trivial concerns, or months of genuine sadness and mourning after the death of a loved one. During those low times, you are fully or vaguely aware that you are not functioning well. However, time, exercise, a balanced diet, rest, interaction with others, and mental reframing may alleviate these problems or concerns. At the opposite end of the continuum is mental illness. Individuals may have emotional problems or concerns and experience mild to moderate discomfort and distress. Mild impairment in functioning such as insomnia, lack of concentration, or loss of appetite may be felt. If the distress increases or persists, individuals might seek professional help. Problems in this category tend to be temporary, but individuals with mild depression, generalized anxiety disorder, and attentiondeficit disorder may fit into this group. The most severely affected individuals fall into the mental illness portion of the continuum. At this point, individuals experience altered thinking, mood, and behavior. It may include relatively common disorders such as depression and anxiety, as well as major disorders such as schizophrenia. The distinguishing factor in mental illness is typically chronic or long-term impairments that range from moderate to disabling. All of us fall somewhere on the mental health-mental illness continuum and shift gradually or suddenly. Many people will never move into the mental illness stage. On the other hand, many people who do reach a more severe level of impairment can experience recovery that ranges from a glimmer of hope to leading a satisfying life. People who have experienced mental illness can testify to the existence of changes in functioning. The following comments of a 40-year-old woman illustrate the continuum between illness and health as her condition ranged from deep depression to mania to well-being (recovery):