Muddy points discussion 1

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After studying Module 2: Lecture Materials & Resources, (SEE ATTACHED) submit one QUESTION  for the week.  


  1. Each student should post a QUESTION regarding the  content designed for the Muddy Point assignment by Thursday at 11:59 pm.
  2. 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. 
  3. 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.


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%.


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.


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.


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


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)?


NUR 620| Psychiatric Management I| Module 2


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.


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:



Good eye contact,

Alert to verbal and non-verbal cues

Chief Complaint

What brought the patient in (Why now)? Patient’s own words






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


Disclosure can be equal


Meets personal needs of both

Confidentiality might or might not be observed.

Listener could be biased




Directed by professional

Meets patient’s needs

Guides the patient to explore personal issues

Listener objective

Information shared with health team


Therapeutic Techniques

Offering self

Active listening





Therapeutic Use of Self

Verbal and nonverbal communication

Silence and therapeutic listening


Being actively alert

Using eye contact

Attending posture


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


Giving feedback

Categories of Communication


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


Eye glaze



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


Verbalizing the implied


Making observations

Presenting reality

Encouraging description of perceptions

Voicing doubt

Therapeutic Techniques (Cont.)

Placing an event in time or sequence

Encouraging comparisons

Identifying themes




Encouraging evaluation

Physical Examination

Physical examinations can be helpful in diagnosing mental health problems

Understand and rule out physical etiologies


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.


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





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


Psychological Testing

Psychological testing

Specific tools for assessment of:




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.


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:

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


Yield detailed information

Lead to better understanding of brain structure and function


Still not well understood


Lack adequate norms

Limited clinical utility

Psychophysiological Assessment


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


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


First degree relatives


Full siblings


Second degree relatives

Grand parents

Half siblings


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


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






Thought process

Thought content




Components of Mental Status Exam

FIGURE 3.2  Components of the mental status exam.


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


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


How the client describes their feelings

Often placed in “quotes” or as the patient states

Examples: “Happy, depressed, anxious, sad, angry, irritable, good.”


The emotional state we observe


euthymic (normal mood),

dysphoric (depressed, irritable, angry)

euphoric (elevated, elated) anxious


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



Normal: Intellectual and emotional Awareness of one’s own illness and/or situation

Abnormal: Complete denial. Recognizes there is a problem but projects blame


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


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


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.


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


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


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.


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


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.


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.


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.


Address what is happening or had happened in the patient-provider relationship.

Set limits to the behavior.

A power struggle is useless.


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.


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.


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.


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.


Communicate clearly, simply, and congruently.

Clarify misinterpretations.

Offer rationale for treatment plan.

Encourage participation but do not force patients to participate.


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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