Muddy points discussion 1
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After studying Module 2: Lecture Materials & Resources, (SEE ATTACHED) submit one QUESTION for the week.
Instructions
- Each student should post a QUESTION regarding the content designed for the Muddy Point assignment by Thursday at 11:59 pm.
- The muddy point question must be UNIQUE and ASSOCIATED WITH THE CONTENT PROVIDED AS ATTACHMENT . Questions SHOULD NOT BE EASILY FOUND with an internet search or clearly defined in your textbook or other course resources. The best muddy point question asks to DESCRIBE, DISTINGUISH, EXPLAIN, SUMMARIZE AND TRANSLATE CONTENT THAT NEED FURTHER CLASSIFICATION.
- The student may use the required course materials or another scholarly resource. However, the PAGE NUMBER to any textbook MUST BE INCLUDED to receive full credit.
REQUIREMENTS:
at least 500 words ( 2 pages of content) formatted and cited in current APA style 7 ed with support from at least 3 academic sources which need to be journal articles or books from 2019 up to now. NO WEBSITES allowed for reference entry. Include doi, page numbers, etc. Plagiarism must be less than 10%.
EVOLUTION OF THE
DIAGNOSTIC STATISTICAL MANUAL OF MENTAL ILLNESS (DSM)
NUR 620: Psychiatric Management I
History of the DSM
Prior to 1980, diagnoses were made based on biological or psychoanalytic theory
Introduction of DSM-III in 1980 revolutionized classification
Classification newly relied on specific lists of symptoms, improving reliability and validity
Diagnoses classified along five “Axes” describing types of problems (e.g. disorder categories, health problems, life stressors)
DSM-IV introduced in 1994
Eliminated previous distinction between psychological vs. organic mental disorders
Reflected appreciation that all disorders are influenced by both psychological and biological factors
DSM-IV-TR (“text revision” of DSM-IV) incorporated new research and slightly altered criteria accordingly
Previously, psychopathology was categorized along five axes. Axis I = Clinical syndromes (most psychological disorders). Axis II = personality disorders and mental retardation (more pervasive), Axis III = relevant medical conditions. Axis IV = Relevant life stressors. Axis V = Global assessment of functioning (0-100 rating). DSM-5 no longer uses the axis system. This information is still taken into account by clinicians, but it’s not discussed in terms of axes.
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The DSM-5
Basic characteristics
Removed axial system
Clear inclusion and exclusion criteria for disorders
Disorders are categorized under broad headings
Empirically-grounded, prototypic approach to classification
New disorder labels are created when groups of individuals are identified whose symptoms are not adequately explained by existing labels
Example: Premenstrual dysphoric disorder
New disorder in DSM-5
Relatively rare and severe emotional disturbance present during the majority of premenstrual phases
Example of new disorder that did not make it into the DSM-5: Mixed anxiety-depression
Insufficient research to justify the creation
DSM-5 represented some changes to classification. One major change is that the Axis system used in DSM-IV-TR was eliminated. NOTE: PMDD is not the same as the colloquial term “PMS”; rather, it is much more persistent, severe and interfering.
For a detailed outline of all changes in DSM-5, see Boettcher et al. 2013 – A Student’s Guide to Important Changes in DSM-5, part of the instructor resources for Barlow/Durand Abnormal Psychology and Durand/Barlow Essentials of Abnormal Psychology.
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Issues with Classifying and Diagnosing Psychological Disorders
Widely used classification systems
Diagnostic and Statistical Manual of Mental Disorders (DSM)
Updated every 10 to 20 years
Current edition (released May 2013): DSM-5
Previous edition called DSM-IV-TR
ICD-10
International Classification of Diseases (ICD-10)
Published by the World Health Organization (WHO)
Unresolved Issues in DSM-5
The problem of comorbidity
Defined as two or more disorders for the same person
High comorbidity is extremely common
Emphasizes reliability, maybe at the expense of validity (i.e., may artificially “split” diagnoses that are very similar)
Dimensional classification:
DSM was intended to move toward a more dimensional approach, but critics say it does not improve much from DSM-IV
Labeling issues and stigmatization
Some labels have negative connotations and may make patients less likely to seek treatment
Discussion Tip: Have students discuss how these problems have changed over time and across diagnoses. Are there differences within this culture in terms of demographic factors (i.e., SES, ethnicity, geography, age)?
THE PSYCHIATRIC INTERVIEW
NUR 620| Psychiatric Management I| Module 2
NOTE:
To change the image on this slide, select the picture and delete it. Then click the Pictures icon in the placeholder to insert your own image.
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Preparing For the Interview
NUR 448
Meet with patients during a consistent time of day, week
Make you space comfortable for you and the patient
Arrange your chair so you can see the clock
Align your chair higher than the patient’s
Signs of an engaged interviewer:
Relaxed
Unhurried
Good eye contact,
Alert to verbal and non-verbal cues
Chief Complaint
What brought the patient in (Why now)? Patient’s own words
OLDCARTS
Onset
Location
Duration
Character
Aggravating Factors
Relieving Factors
Timing Severity
Is there an emergency that should be addressed immediately?
Physical aggression
Self harm or suicide attempt
Alcohol or benzodiazepine withdrawal
Failure to eat or sleep deprivation
Social Versus Therapeutic Communication
Social
Disclosure can be equal
Spontaneous
Meets personal needs of both
Confidentiality might or might not be observed.
Listener could be biased
Therapeutic
Patient-centered
Planned
Directed by professional
Meets patient’s needs
Guides the patient to explore personal issues
Listener objective
Information shared with health team
Techniques
Therapeutic Techniques
Offering self
Active listening
Silence
Empathy
Questioning
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Therapeutic Use of Self
Verbal and nonverbal communication
Silence and therapeutic listening
Components
Being actively alert
Using eye contact
Attending posture
Concentrating
Being patient
Displaying openness
Silence and Therapeutic Listening
Offering empathy/support
Asking questions
Assimilating information
Organizing, synthesizing, and interpreting information
Validating and clarifying information
Responding verbally and nonverbally
Summarizing
Giving feedback
Categories of Communication
Words
Written reports on patient behaviors, statements and corroborated reports
Must comply with the HIPAA standards to protect health information
Speech and Behavior
Body language and tone of speech must match.
Verbal and nonverbal communication must match.
Facial expressions
Body posture
Movements
Eye glaze
Gestures
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Ineffective and Inappropriate Behaviors
Not fully listening, not paying attention
Looking too busy, ignoring the patient
Seeming uncomfortable with silence, fidgeting
Being opinionated, arguing with the patient
Avoiding sensitive topics, changing the topic
Being superficial or using clichés
Having a closed posture, avoiding eye contact
Ineffective and Inappropriate Behaviors
Making false promises or reassurances
Giving advice or talking too much
Laughing or smiling inappropriately
Showing disapproval or being judgmental
Belittling feeling or minimizing problems
Being defensive or avoiding the patient
Making flippant or sarcastic remarks
Lying or being insincere
Therapeutic Techniques (Cont.)
General leads
Restating
Verbalizing the implied
Clarification
Making observations
Presenting reality
Encouraging description of perceptions
Voicing doubt
Therapeutic Techniques (Cont.)
Placing an event in time or sequence
Encouraging comparisons
Identifying themes
Summarizing
Focusing
Interpreting
Encouraging evaluation
Physical Examination
Physical examinations can be helpful in diagnosing mental health problems
Understand and rule out physical etiologies
Toxicities
Medication side effects
Allergic reactions
Metabolic conditions
NOTE: Physical exams are often the “first pit stop” in assessing mental health, because many patients visit a primary care physician first. For example, a PMHNP might ascertain whether panic attacks are the result of a heart or respiratory condition, or whether depression could be due to the side effects of a medication. Physical exams are not typically conducted in outpatient clinics. They are more common in inpatient or hospital settings, or in the case of mental illnesses that are likely to affect physical functioning (e.g., substance use disorders, eating disorders, somatic symptom disorders, disorders in which a patient is taking meds with a lot of side effects, e.g., schizophrenia).
Teaching Tip: Have students generate a list of possible medical problems that could cause symptoms of psychological disorders (e.g., diabetes, anemia, vitamin deficiencies, etc.). Use this as a basis for a discussion about the differences in perception, stigma and treatment between “medical” vs. “psychological” problems.
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Behavioral Assessment
Behavioral observation
Identification and observation of target behaviors
Target behavior: Behavior of interest (e.g., something that needs to be increased or decreased)
Direct observation conducted by assessor (e.g., therapist) or by individual or loved one
Goal: Determine the factors that are influencing target behaviors
The ABCs of observation
Antecedents
Behavior
Consequences
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Behavioral Assessment (Cont.)
Behavioral observation
When individual observes self, it is called self-monitoring
May be informal or formal (e.g., using established rating scales)
The problem of reactivity
Simply observing a behavior may cause it to change due to the individual’s knowledge of being observed
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Psychological Testing
Psychological testing
Specific tools for assessment of:
Cognition
Emotion
Behavior
Include specialized areas like personality and intelligence
Technology Tip: This APA website contains information and useful links related to psychological testing, including the ethics of testing.
http://www.apa.org/science/testing.html
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Neuroimaging and Brain Structure
Neuroimaging: Pictures of the brain
Two objectives:
Understand brain structure
Understand brain function
Imaging brain structure
Computerized axial tomography (CAT or
CT scan)
Utilizes X-rays
Magnetic resonance imaging (MRI)
Utilizes strong magnetic fields
Better resolution than CT scan
Technology Tip: This site contains a series of excellent links to resources related to neuroimaging, neuroanatomy, and their relation to psychopathology: http://www.neuropsychologycentral.com/interface/content/links/page_material/imaging/imaging_links.html#a
Neuroimaging and Brain Function
Imaging brain function
Positron emission tomography (PET)
Single photon emission computed tomography (SPECT)
Both involve injection of radioactive isotopes
Isotopes react with oxygen, blood, and glucose in the brain
Functional MRI (fMRI) – brief changes in brain activity
Neuroimaging Advantages and Disadvantages
Advantages:
Yield detailed information
Lead to better understanding of brain structure and function
Disadvantages:
Still not well understood
Expense
Lack adequate norms
Limited clinical utility
Psychophysiological Assessment
Purpose
Assess brain structure, function, and activity of the nervous system
Psychophysiological assessment domains
Electroencephalogram (EEG) – brain wave activity.
ERP – Event related potentials = brain response to a specific experience (e.g., hearing a tone)
Heart rate and respiration – cardiorespiratory activity
Electrodermal response and levels – sweat gland activity
Uses of routine psychophysiological assessment
Disorders involving a strong physiological component
Examples
PTSD, sexual dysfunctions, sleep disorders
Headache and hypertension
EEG = Electroencephalogram
Alpha waves – awake, resting patterns
Delta waves – asleep, relaxed patterns
Panic attacks – delta wave activity during wakefulness may indicate localized dysfunction
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First degree relatives
Parents
Full siblings
Children
Second degree relatives
Grand parents
Half siblings
Grandchildren
Aunts, uncles, nephews or nieces
3. History of Neurological or mental disorders
Neurological disorders: Seizures, Intellectual disabilities
Mental illness: Bipolar disorder, Schizophrenia
Substance abuse: Alcoholism, opioid abuse
Suicide: Completed or attempted
Family History
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Pregnancy and Childbirth
Early Childhood
Adolescent and Childhood
Educational history
Occupational history
Menstrual history
Sexual history
Marital history
Alcohol, drug and tobacco history
Past medical history
Psychiatric history
Personal History
The Mental Status Examination
Describes the mental state and behaviors of the person being seen.
It includes both objective observations of the clinician and subjective descriptions given by the client.
Show patient’s baseline and response to treatment
Education, cultural norms, psychosocial factors affect client’s presentation.
Components of the Mental Status Exam
Appearance
Behavior
Speech
Mood
Affect
Thought process
Thought content
Cognition
Insight/Judgment
Intelligence
Components of Mental Status Exam
FIGURE 3.2 Components of the mental status exam.
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Appearance: What do you see?
Build, posture, dress, grooming, prominent physical abnormalities
Level of alertness: Somnolent, alert, lethargic
Emotional facial expression
Attitude toward the examiner: Cooperative, uncooperative
Eye contact: ex. poor, good, piercing, downcast
Psychomotor Behavior
Psychomotor activity: Retardation or agitation
Movements: tremor, abnormal movements
Handshake: firm, refused, heavy, weak
Coordination: clumsy, awkward
Gait: ataxia, unsteady, shuffled
Speech
Rate: increased, pressured, decreased, monosyllabic, latency
Rhythm: articulation, prosody, dysarthria, monotone, slurred
Volume: loud, soft, mute
Content: fluent, loquacious, paucity of speech, impoverished
Quantity: Verbose, scant, responds only to questions
Mood
How the client describes their feelings
Often placed in “quotes” or as the patient states
Examples: “Happy, depressed, anxious, sad, angry, irritable, good.”
Affect
The emotional state we observe
Type:
euthymic (normal mood),
dysphoric (depressed, irritable, angry)
euphoric (elevated, elated) anxious
Range:
full (normal)
restricted, blunted, flat, labile
Congruency: does it match the mood
mood congruent vs. mood incongruent
Stability: stable vs. labile
Thought Process
Describes the rate of thoughts, how they flow and are connected.
Normal: tight, logical and linear, coherent and goal directed
Abnormal: associations are not clear, organized, coherent. Examples include circumstantial, tangential, loose, flight of ideas, word salad, clanging, thought blocking.
Thought Process: Descriptions
Circumstantial: Provide unnecessary detail but eventually get to the point
Tangential: Move from one thought to another but never get to the point
Loose: Illogical shifting between unrelated topics
Flight of ideas: Quickly moving from one idea to another
Thought blocking: thoughts are suddenly interrupted. Parts of ideas or phases expressed. Also called pausity of thought.
Thought Process: Descriptions (cont.)
Mutism – refusal to speak.
Echolalia – meaningless repetition of words.
Echopraxia-imitation of the movements of another
Neologisms – new words formed to express ideas
Circumstantiality – being incidental and irrelevant in stating details.
Perseveration: Repetition of words, phrases or ideas
Word Salad: Randomly spoken words
Thought Content
Refers to the themes that occupy the patient’s thoughts and perceptual disturbances
Examples: preoccupations, illusions, ideas of reference, hallucinations, derealization, depersonalization, delusions
Abstraction
Concrete
Normal: Intellectual and emotional Awareness of one’s own illness and/or situation
Abnormal: Complete denial. Recognizes there is a problem but projects blame
Abstract
Able to intepret a proverb
Able to tell a joke
Able to recognize similarities in groups
Must be soically and culturally relevant
Should be based on the patient’s level of education
Thought Content: Descriptions
Preoccupations: Suicidal or homicidal ideation (SI or HI), perseverations, obsessions or compulsions
Illusions: Misinterpretations of environment
Hallucinations: False sensory perceptions.
auditory (AH), visual (VH), tactile or olfactory
Ideas of Reference: Misinterpretation of incidents and events in the outside world having direct personal reference to the patient
Derealization: Feelings the outer environment feels unreal
Depersonalization: Sensation of unreality concerning oneself or parts of oneself
Confabulation: Creating stories to make up for gaps in memory
Delusions
Fixed, false beliefs firmly held in spite of contradictory evidence
Control: outside forces are control client’s actions
Erotomanic: a person, usually of higher status, is in love with the patient
Grandiose: unrealistic, inflated sense of self-worth, power or wealth
Somatic: patient has a physical defect
Reference: unrelated events apply to them
Persecutory: others are trying to attack or harm client
Somatic – total misinterpretation of physical symptoms
Nihilistic – belief in non-existence of self, others and the world
Influential (active)- belief that one is able to control others through one’s thoughts
Influence (passive)- belief that others are able to control the person
Cognition
Level of consciousness
Alert, lethargy, stupor, obtunded
Attention and concentration:
Ability to focus, sustain and appropriately shift mental attention
Memory: immediate, short and long term
Abstraction: proverb interpretation or joke
Mini-Mental State Exam or clock drawing test
Insight and Judgment
Insight: Perception of the illness
Normal: Intellectual and emotional Awareness of one’s own illness and/or situation
Abnormal: Complete denial. Recognizes there is a problem, but projects blame
Judgment: the ability to anticipate the consequences of one’s behavior and make decisions to safeguard your well being and that of others
Psychotherapeutic Management
Relevant guidelines for providing care to all disorders
Provide support for patients.
Strengthen patients’ self-esteem.
Treat adult patients as adults.
Prevent failure or embarrassment.
Treat patients as individuals.
Provide reality testing.
Handle hostility therapeutically.
Be calm and straightforward about norms and limits.
TREATING THE VIOLENT PATIENT
Stay out of striking distance at least 3 arms length.
Avoid touching patients without approval.
Change the topic if the behavior escalates.
Avoid entering a room alone when a patient is out of control.
Leave the area if the patient is agitated.
Another person should know when and where is the interview
Ensure that help can be called if needed (emergency call button)
Ensure that neither the patient or any obstruction is between the interviewer and the exit
Remove from sight any object that can be used as a weapon
TREATING THE VIOLENT PATIENT
Another person should know when and where is the interview
Ensure that help can be called if needed (emergency call button)
Ensure that neither the patient or any obstruction is between the interviewer and the exit
Remove from sight any object that can be used as a weapon
TREATING THE HALLUCINATING PATIENT
Comment on the patient’s behavior i.e. looking up at the ceiling, self talk, suspicion.
If the patient acknowledges hearing something, probe for more information.
Assess if the hallucinations have themes of powerlessness, hatred, guilt, or loneliness.
After the content is known, focusing on the hallucinations is unnecessary.
Distract the patient, and teach the patient to distract himself or herself from the hallucinations.
TREATED THE SUICIDAL/HOMICIDAL CLIENT
When patients have hallucinations that are commanding them to harm themselves or others:
Implement a one to one observation protocol
Inform your preceptor and/or psychiatrist
Anticipate transferring patient to an inpatient unit
TREATING THE DELUSIONAL CLIENT
Clarify meaning of the delusion.
Do not argue with the patient about the delusions
Assess for violent behavior.
For patients with dementia or severe cognitive impairments, “ignore and distraction” may be more effective.
TREATING CLIENTS WITH NON-TRADITIONAL VALUES
Understand the patient’s point of view as the patient sees it.
Encourage patients to examine the effects or outcomes of their beliefs on their lives.
Be supportive and non judgmental.
TREATING THE ANXIOUS CLIENT
Clarify the meaning of the communication.
Key into their feelings and underlying themes rather than to make sense of incoherent speech.
Spend frequent and brief time intervals to offer support, and build trust.
TREATING THE MANIPULATIVE CLIENT
Address what is happening or had happened in the patient-provider relationship.
Set limits to the behavior.
A power struggle is useless.
TREATING THE TEARFUL CLIENT
Allow and encourage verbally and nonverbally.
Crying can relieve tension.
Provide privacy.
Your stance should be quiet and unobtrusive.
Encourage discussion of the circumstance that precipitated the tears.
TREATING THE SEXUALLYINAPPROPRIATE CLIENT
Remind the patient that the action is inappropriate.
Discuss the underlying need.
Set limits.
The PMHNP should refrain from touching the patient with sexual and boundary issues.
TREATING THE NON-COOPERATIVE CLIENT
Actively listen.
Clarify client’s thoughts.
Verbalize thoughts to identify the underlying causes of the lack of cooperation.
Discuss the causes, fears, and outcomes of the client’s behavior.
Use therapeutic communication to increase trust.
TREATING THE DEPRESSED CLIENT
Improvement in personal hygiene, proper nutrition. and gradual increase in activities are encouraged
Use patience, frequent contact, and empathy to assist the patient to recognize the need for change.
TREATING THE PARANOID CLIENT
Communicate clearly, simply, and congruently.
Clarify misinterpretations.
Offer rationale for treatment plan.
Encourage participation but do not force patients to participate.
TREATING THE HYPERSTIMULATED CLIENT
Place client in a quiet area with minimal auditory and visual stimulation. (inpatient)
Remain calm, speaks slowly and softly.
Maintain personal space.
Anticipate transfer to a higher level of care
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