Week 1 STUDY GUIDE: N129 PSYCHIATRIC/MENTAL HEALTH NURSING

Chapter 1: Mental Health and Mental Illness

●​ Objectives:
○​ Define mental health and mental illness.
○​ Describe the continuum of mental health and mental illness.
○​ Discuss risk and protective factors for mental illness and mental health.
○​ Explore the role of resilience in the prevention of and recovery from mental illness and consider resilience in response to stress.
○​ Identify how culture influences the view of mental illnesses and behaviors associated with them.
○​ Discuss the nature/nurture origins of psychiatric conditions.
○​ Summarize the social influences of mental healthcare in the United States.
○​ Discuss the role of public policy on mental health funding.
○​ Explain how epidemiological knowledge supports mental healthcare.
○​ Identify how the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) is used for diagnosing psychiatric conditions.
○​ Describe the specialty of psychiatric-mental health nursing.
○​ Discuss future challenges and opportunities for psychiatric-mental health nursing.
●​ Attributes of Mental Health:
○​ Good mental health is characterized by a person's ability to fulfill a number of key functions and activities:
■​ The ability to learn.
■​ The ability to feel, express, and manage a range of positive and negative emotions.
■​ The ability to form and maintain good relationships with others.
○​ Other attributes include:
■​ Rational thinking.
■​ Effective coping.
■​ Resiliency.
■​ Self-control.
■​ Self-awareness.
■​ Developmentally on task.
■​ Spiritual satisfaction.
■​ Happiness and joy.
■​ Self-care.
■​ Positive self-concept.
■​ Learning and productivity.
■​ Effective communication.
■​ Meaningful relationships.
●​ Mental Health – Mental Illness Continuum:​
This continuum ranges from Health and Well-being (least impairment, occasional stress) to Mental Health Problems (emotional problems, mild to
moderate distress, mild or temporary impairment) to Mental Illness (marked distress, moderate to disabling or chronic impairment).
●​ Mental Illness:
○​ Refers to all psychiatric disorders that have definable diagnoses.
○​ Manifested in significant dysfunctions that may be related to developmental, biological, or psychological disturbances in mental functioning.
○​ The ability to think may be impaired.
●​ Diagnostic and Statistical Manual, Fifth Edition (DSM-5):
○​ Purpose: The current official guidebook for categorizing and diagnosing psychiatric mental health disorders in the United States.
○​ Usage: Provides clinicians, researchers, regulatory agencies, health insurance companies, pharmacological companies, and policy makers with a
standard language and criteria for the classification of mental disorders.
○​ Example (Major Depressive Disorder - MDD):
■​ Diagnosis requires five (or more) symptoms present during the same 2-week period, representing a change from previous functioning,
with at least one symptom being either depressed mood or loss of interest/pleasure.
■​ Symptoms include:
■​ Depressed mood most of the day, nearly every day (subjective report or observation).
■​ Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
■​ Significant weight loss (not dieting) or weight gain (e.g., >5% body weight change in a month), or decrease/increase in
appetite nearly every day.
■​ Insomnia or hypersomnia nearly every day.
■​ Psychomotor agitation or retardation nearly every day (observable by others).
■​ Fatigue or loss of energy nearly every day.
■​ Feelings of worthlessness or excessive/inappropriate guilt nearly every day.
■​ Diminished ability to think or concentrate, or indecisiveness, nearly every day.
■​ Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan.
●​ Multi-Axial System (Historical DSM-IV-TR Context):
○​ Axis I: Clinical disorders (e.g., mood, anxiety, psychotic disorders).
○​ Axis II: Personality disorders and mental retardation (e.g., borderline personality disorder).
 ○​ Axis III: General medical conditions impacting mental disorder or its management (e.g., hypothyroidism).
○​ Axis IV: Psychosocial and environmental factors (e.g., education, housing, economic problems).
○​ Axis V: Global Assessment of Functioning (GAF), a number from 0 to 100 summarizing overall functioning.
■​ GAF Scale Examples:
■​ 100: No symptoms.
■​ 90: Minimal symptoms with good functioning.
■​ 80: Transient symptoms, expected reactions to psychosocial stressors.
■​ 70: Mild symptoms or some difficulty in social, occupational, or school functioning.
■​ 60: Moderate symptoms or moderate difficulty in social, occupation, or school functioning.
■​ 50: Serious symptoms or serious impairment in social, occupational, or school functioning.
■​ 40: Some impairment in reality testing or communication; major impairment in several areas (e.g., work, school, family
relations, judgment, thinking, mood).
■​ 30: Behavior considerably influenced by delusions or hallucinations; serious impairment in communication or judgment;
inability to function in almost all areas.
■​ 20: Some danger of hurting self or others; occasionally fails to maintain minimal personal hygiene; gross impairment in
communication.
■​ 10: Persistent danger of severely hurting self or others; persistent inability to maintain minimal personal hygiene; serious
suicidal ideation.
●​ Mental Disorders with Strong Biological Influences:​
Schizophrenia.
○​ Bipolar disorder.
○​ Major depression.
○​ Obsessive-compulsive and panic disorders.
○​ Posttraumatic stress disorder.
○​ Autism.
○​ Anorexia nervosa.
○​ Attention deficit/hyperactivity disorder.
●​ Factors That Can Affect Mental Health:
○​ Biological (hormones, genetics).
○​ Spirituality/Religion.
○​ Culture/Regional differences.
○​ Family, friends, community.
○​ Personality traits.
○​ Health practices and beliefs.
○​ Environmental experiences.
○​ Economics.
○​ Other social conditions: interpersonal, family, and community dynamics, housing quality, social support, employment opportunities, and work
and school conditions.
●​ Dynamic Factors of Mental Health and Mental Illness:
○​ Mental illness is plagued by myths and misconceptions.
○​ No consistent line exists between mental illness and mental health.
○​ Psychiatry’s definition of mental health changes and reflects:
■​ Changes in cultural norms and society’s expectations.
■​ Values and professional biases.
■​ Individual differences and political climate.
■​ Historically, women who worked outside the home and homosexuals were considered mentally ill.
○​ No single definition of mental health fits all, as people have different backgrounds, cultures, grow intellectually and emotionally at different
rates, make different decisions, choose to or not to evaluate behaviors, grow within themselves, and have or do not have spiritual beliefs.
●​ Stigma and Mental Health:
○​ Stigma: A negative stereotype that leads to an attitude or belief causing one to view a person with mental illness as inferior, dangerous, or
unstable.
○​ Impact: A major barrier to mental health treatment and recovery. Stigmatizing attitudes have harmful effects on the individual and family.
○​ Psychosocial Processes Leading to Stigmatization: Stereotyping, labeling, separating, and status loss or discrimination in a context of power
imbalance, social isolation, and reduced opportunities.
Chapter 2: Theories and Therapies
●​ Objectives:
○​ Describe the evolution of theories of psychiatric disorders and conditions.
○​ Distinguish between dominant theories and associated therapies for psychiatric alterations.
○​ Identify how psychiatric theories and therapies are applied in nursing care.
○​ Discuss the major components of Peplau’s Theory of Interpersonal Relationships.
○​ Describe the biological model and its impact on the treatment of psychiatric disorders.
○​ Explain the value of developmental theories to patients across the lifespan.
●​ Psychoanalytic Theories and Therapies (Sigmund Freud):
○​ Personality Structure:
■​ Id: Unconscious, impulsive, instincts (sex and aggression), seeking immediate gratification, irrational and impulsive.
■​ Ego: Conscious, preconscious, and unconscious; problem solver and reality tester; executive mediating between id impulses and
superego inhibitions; rational; tests reality.
■​ Superego: Conscious, preconscious, and unconscious; ideal; ideals and morals; striving for perfection; incorporated from parents;
becomes a person's conscience.
○​ Levels of Awareness: Conscious, Preconscious, Unconscious.
○​ Anxiety.
○​ Role of Defense Mechanisms.
○​ Stages of Psychosexual Development:
■​ Oral Stage (0-1 year old): Pleasure from oral activities, including sucking and tasting.
■​ Anal Stage (2-3 years old): Children begin potty training.
■​ Phallic Stage (3-6 years old): Boys are more attached to their mother, while girls are more attached to their father.
■​ Latency Stage (6 years old to puberty): Children spend more time and interact mostly with same-sex peers.
■​ Genital Stage (Beyond puberty): Individuals are attracted to opposite-sex peers.
○​ Psychodynamic Therapy:
■​ Rooted in psychoanalysis.
■​ Explores how a person's past experiences and unconscious thoughts influence their current behavior.
■​ Concepts include: Free Association, Dream Analysis, Transference, and Countertransference.
■​ Best candidates are relatively healthy and well-functioning individuals.
●​ Interpersonal Theories and Therapies:
○​ Core Idea: The purpose of all behavior is to get needs met through interpersonal interactions and to reduce or avoid anxiety.
○​ Effectiveness: Effective in grief and loss, interpersonal disputes, and role transition.
○​ Nurse-Patient Relationship Phases:
■​ Preorientation Phase: Preparing for assignment – chart review.
■​ Orientation Phase: First encounter – conducts interview (express thoughts, identify problems, and discuss realistic goals).
■​ Working Phase: Nurse and patient identify and explore areas causing problems in the patient’s life.
■​ Termination Phase: Discuss patient’s plan for the future.
●​ Behavioral Theories and Therapies:​
Core Idea: All behaviors are learned through conditioning and can be observed without considering thoughts or feelings.
○​ Key Theories:
■​ Classical Conditioning Theory (Ivan Pavlov): A learning process that associates a neutral stimulus with a stimulus that produces a
natural response.
■​ Operant Conditioning Theory (B.F. Skinner): A method of learning that occurs through rewards and punishment for voluntary
behavior.
○​ Behavioral Therapy Methods:
■​ Modeling: Learning by imitation (e.g., role playing).
■​ Operant Conditioning: Application of rewards vs. punishment.
■​ Exposure Therapy: Exposing to fear in a safe environment.
■​ Aversion Therapy: Pairing a target (bad behavior) with a negative stimulus.
■​ Biofeedback: A non-invasive technique that helps people control involuntary bodily functions (e.g., heart rate, breathing, blood
pressure).
●​ Cognitive Theory and Therapies:
○​ Core Idea: Focus on thoughts and cognition. Thoughts come before feelings and actions. Thoughts about the world are based on unique
perspectives.
○​ Types of Therapies:
■​ Rational-Emotive Therapy (RET):
■​ Aims to remove core irrational beliefs by helping people recognize thoughts that are not accurate, sensible, or useful.
■​ Focuses on present attitude, painful feelings, and dysfunctional behaviors.
■​ ABC Framework:
■​ A: Activating Event (e.g., being passed over for a promotion).
■​ B: Beliefs (irrational, e.g., "I must be perfect to be valued, so this means I'm a failure").
■​ C: Emotional Consequence (e.g., feeling deeply discouraged and unmotivated).
■​ Cognitive Behavioral Therapy (CBT):
■​ A structured, goal-oriented type of talk therapy that helps with mental health conditions and stress.
■​ Helps identify, reality test, and correct distorted conceptualizations and dysfunctional beliefs.
■​ Emphasizes the interaction between Thoughts, Emotions, and Behaviors.
■​ Dialectical Behavior Therapy (DBT):
■​ A structured therapy that helps people learn to manage difficult emotions and behaviors.
■​ Aims to avoid extreme ways of thinking.
■​ Strategies:
 ■​ Mindfulness: Practice of being fully aware and present in the moment.
■​ Distress Tolerance: How to tolerate pain in difficult situations, not change it.
■​ Interpersonal Effectiveness: How to ask for what you want and say no while maintaining self-respect and
relationships with others.
■​ Emotional Regulation: How to change emotions that you want to change.
●​ Humanistic Theories (Maslow's Hierarchy of Needs):
○​ Core Idea: Focused on human need fulfillment.
○​ Rather than concentrating on dysfunction, humanistic psychology strives to help people fulfill their potential and maximize their well-being.
○​ Maslow's Hierarchy:
■​ Physiological needs: Food, water, warmth, rest (Basic needs).
■​ Safety needs: Security, safety (Basic needs).
■​ Belongingness and love needs: Intimate relationships, friends (Psychological needs).
■​ Esteem needs: Prestige and feeling of accomplishment (Psychological needs).
■​ Self-actualization: Achieving one's full potential, including creative activities (Self-fulfillment needs).
●​ Biological Theories and Therapies:
○​ Core Idea: Assumes that abnormal behavior is the result of a physical problem.
○​ Therapies:
■​ Pharmacotherapy.
■​ Brain Stimulation Therapies (e.g., Electroconvulsive Therapy - ECT).
●​ Developmental Theories:
○​ Lawrence Kohlberg's Theory of Moral Development:
■​ Level I: Obedience/Punishment (Infancy): No difference between doing the right thing and avoiding punishment.
■​ Level I: Self-Interest (Pre-school): Interest shifts to rewards rather than punishment; effort to secure greatest benefit for oneself.
■​ Level II: Conformity and Interpersonal Accord (School-age): Effort made to secure approval and maintain friendly relations with
others ("good boy/girl" level).
■​ Level II: Authority and Social Order (School-age): Orientation toward fixed rules; purpose of morality is maintaining social order;
interpersonal accord expanded to include entire society.
■​ Level III: Social Contract (Teens): Mutual benefit, reciprocity; morally right and legally right are not always the same; utilitarian rules
that make life better for everyone.
■​ Level III: Universal Principles (Adulthood): Morality based on principles that transcend mutual benefit.
○​ Erikson’s Eight Stages of Development:
■​ Stage 1 (0-1 year): Hope: Trust vs. Mistrust (Trust that basic needs like nourishment and affection will be met).
■​ Stage 2 (1-3 years): Will: Autonomy vs. Shame (Sense of independence in many tasks develops).
■​ Stage 3 (3-6 years): Purpose: Initiative vs. Guilt (Take initiative on some activities, may develop guilt when success not met or
boundaries overstepped).
■​ Stage 4 (7-11 years): Competence: Industry vs. Inferiority (Develop self-confidence in abilities when competent or sense of inferiority
when not).
■​ Stage 5 (12-18 years): Fidelity: Identity vs. Role Confusion (Experiment with and develop identity and roles).
■​ Stage 6 (19-39 years): Love: Intimacy vs. Isolation (Establish intimacy and relationships with others).
■​ Stage 7 (40-64 years): Care: Generativity vs. Stagnation (Contribute to society and be part of a family).
■​ Stage 8 (65+ years): Wisdom: Integrity vs. Despair (Assess and make sense of life and meaning of contributions).
Chapter 3: Neurobiology and Pharmacotherapy
●​ Objectives:​
Discuss the structure and major functions of the brain and how psychotropic medications can alter these functions.
○​ Identify how specific brain functions are altered in certain psychiatric disorders (e.g., major depressive disorder, anxiety, schizophrenia).
○​ Describe how a neurotransmitter functions as a chemical messenger.
○​ Describe how the use of imaging techniques can be helpful for understanding mental illness.
○​ Differentiate pharmacodynamics and pharmacokinetics.
○​ Identify the main neurotransmitters affected by various psychotropic medications and their subgroups (antianxiety, antidepressant, mood
stabilizers, antipsychotics, psychostimulants, cholinesterase inhibitors).
○​ Identify cautions for medication teaching plans regarding herbal supplements.
●​ Functions and Activities of the Brain:
○​ The brain's major functions include:
■​ Control basic drives: hunger, thirst, sex, aggressive self-protection.
■​ Mediate conscious sensation.
■​ Store and retrieve memories.
■​ Regulate mood (affect) and emotions.
■​ Think and perform intellectual functions.
■​ Regulate sleep cycle.
■​ Produce and interpret language.
■​ Process visual and auditory data.
○​ Brain Regions and Functions:
 ■​ Cerebral Cortex (gray matter).
■​ White matter.
■​ Frontal Lobe: Thought processes, formulate and select goals, plan, terminate actions, decision making, insight, motivation, social
judgment, voluntary motor ability.
■​ Parietal Lobe (Sensory and Motor): Receive and identify sensory information, concept formation and abstraction, proprioception and
body awareness, reading, mathematics, right and left orientation.
■​ Temporal Lobe (Auditory): Language comprehension, stores sounds into memory (language, speech), connects with limbic system to
allow expression of emotions (sexual, aggressive, fear, etc.).
■​ Occipital Lobe (Vision): Interprets visual images, visual association, involved with language formation.
■​ Brainstem: Connects to other brain regions.
■​ Cerebellum: Involved in movement and balance.
●​ Neurotransmitters:
○​ Definition: Chemical messengers that carry chemical signals ("messages") from one neuron (nerve cell) to the next target cell (another nerve cell,
muscle cell, or gland).
○​ Specific Neurotransmitters and their Associations:
■​ Dopamine (DA):
■​ Effects: Involved in fine motor movement, integration of emotions and thoughts, decision making, stimulates hypothalamus
to release hormones.
■​ Mental Illness Association: Decrease in Parkinson’s disease and depression; Increase in schizophrenia and mania.
■​ Norepinephrine (NE):
■​ Effects: Level in brain affects mood, attention and arousal, stimulates sympathetic system for “fight or flight” in response to
stress.
■​ Mental Illness Association: Decrease in depression; Increase in mania, anxiety states, and schizophrenia.
■​ Serotonin:
■​ Effects: Plays a role in sleep regulation, hunger, mood states, pain perception, hormonal activity, and aggression and sexual
behavior.
■​ Mental Illness Association: Decrease in depression.
■​ Histamine:
■​ Effects: Involved in alertness, inflammatory response, stimulates gastric secretion.
■​ Mental Illness Association: Decrease causes sedation and weight gain.
■​ γ-aminobutyric acid (GABA):
■​ Effects: Plays a role in inhibition; reduces aggression, excitation, and anxiety; may play a role in pain perception; has
anticonvulsant and muscle-relaxing properties; may impair cognition and psychomotor functioning.
■​ Mental Illness Association: Decrease in anxiety, schizophrenia, mania, and Huntington’s disease; Increase leads to
reduction of anxiety.
■​ Glutamate:
■​ Effects: Excitatory; AMPA plays a role in learning and memory.
■​ Mental Illness Association: Decrease (NMDA) in psychosis; Increase (NMDA) in Alzheimer's disease; Increase (AMPA) can
improve cognition.
■​ Acetylcholine (Ach):
■​ Effects: Plays a role in learning and memory; stimulates parasympathetic branch of autonomic nervous system for "resting
and digesting" actions; affects sexual and aggressive behavior.
■​ Mental Illness Association: Decrease in Alzheimer’s disease, Huntington’s disease, and Parkinson’s disease; Increase in
depression.
Chapter 4: Treatment Settings
●​ Objectives:
○​ Discuss the unique challenges in accessing and navigating care for psychiatric disorders.
○​ Analyze the continuum of psychiatric care and the variety of care options available.
○​ Describe the role of the primary care provider and the psychiatric specialist in treating psychiatric disorders.
○​ Explain the purpose of patient-centered medical homes and implications for holistically treating individuals with psychiatric disorders.
○​ Identify key components and benefits of community-based care, such as psychiatric home care.
○​ Discuss other community-based care providers, including assertive community treatment teams, partial hospitalization programs, and alternate
delivery of care methods such as telepsychiatry.
○​ Describe the role of the nurse as it pertains to outpatient psychiatric settings.
○​ Identify the main types of inpatient care and the functions of each.
○​ Discuss the purpose of identifying the rights of hospitalized psychiatric patients.
○​ Define the therapeutic milieu.
○​ Describe the role of the nurse as it pertains to inpatient psychiatric settings.
●​ Background of Psychiatric Care:
○​ Origins: Rooted in asylums established before the Civil War, with states assuming responsibility for the "insane" due to a lack of effective
treatments and community care.
 ○​ Mid-20th Century Developments (Early 1950s): Limited options (private psychiatrists or mental hospitals); state hospitals housed 550,000
patients compared to ~40,000 today.
○​ Impact of Medicare and Medicaid (1960s): Shifted psychiatric care to general hospitals and nursing homes; Medicaid incentivized community
care but excluded most psychiatric hospital care.
○​ 1999 Olmstead Decision: Supreme Court ruled psychiatric hospitalizations as "unjustified isolation," deeming institutionalization a violation of
the Americans with Disabilities Act, emphasizing the right to live in the community.
○​ Shift to Community Care: Decline in state psychiatric hospitals (322 in 1950 to ~195 in 2019); state- and county-financed systems replaced many
hospital functions.
○​ Pharmacological Advances (1950s): Introduction of antipsychotic medication (e.g., chlorpromazine/Thorazine) led to expansion of
psychopharmacology and increased involvement of general practitioners in psychiatric care.
○​ Current System: Includes outpatient and inpatient settings, with level of care determined by condition severity, comorbidities, social supports,
and relapse potential.
●​ Continuum of Care:
○​ Focuses on providing treatment in the least restrictive environment possible.
○​ Emphasizes community-based care over institutionalization.
○​ Promotes patient autonomy, integration into society, and adherence to the Americans with Disabilities Act.
○​ Tailors care to individual needs while ensuring safety and effective treatment.
○​ Levels from Least to Most Restrictive:
■​ Primary Care.
■​ Specialty Care.
■​ Patient-Centered Medical Homes.
■​ Community Mental Health Centers.
■​ Psychiatric Home Care.
■​ Assertive Community Treatment.
■​ Intensive Outpatient Programs.
■​ Partial Hospitalization Programs.
■​ Emergency Care.
■​ Crisis Stabilization/Observation Units.
■​ General and Private Hospitals.
■​ State Hospital.
○​ Professional Support (Inpatient vs. Outpatient):
■​ Inpatient Care: Intensive Care Team, around the clock access, frequent interactions, higher staff availability.
■​ Outpatient Care: Flexible Care Team, scheduled meetings, limited interactions, lower staff availability.
●​ Prevention in Outpatient Care:
○​ Primary Prevention:
■​ Aim: Prevent the onset of mental health disorders.
■​ Focus: Education, awareness, and reducing risk factors.
■​ Examples: Stress management workshops, promoting healthy coping mechanisms, anti-stigma campaigns.
○​ Secondary Prevention:
■​ Aim: Early identification and intervention for mental health issues.
■​ Focus: Screening and treating conditions at an early stage to prevent progression.
■​ Examples: Depression screenings, crisis hotlines, short-term counseling services.
○​ Tertiary Prevention:
■​ Aim: Manage and reduce the impact of chronic mental health disorders.
■​ Focus: Rehabilitation, relapse prevention, and improving quality of life.
■​ Examples: Long-term therapy, medication management, community support programs.