Mental Health and Mental illness

Mental Health and Mental illness 150 150 Tony Guo

Mental Health and Mental illness

  • Mental health is defined as “Successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms.”
  • Mental illness is defined as “maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms, and interfere with the individual’s social, occupational, and/or physical functioning.”
  • Mental health and mental illness are culturally defined
  • Maslow’s hierarchy of needs:- Physiological (food, water, rest, health), Security (shelter and safety), Social (love), Ego (Self-esteem), Self-actualization (need for development)

 

Physical Response to stress

General Adaptation Syndrome (GAS) stages:

  1. Alarm
  2. Resistance
  3. Exhaustion

 

  • Biological responses associated with fight-or-flight syndrome:- Immediate response (Acute) and Sustained response (Chronic)
  • However, it also occurs in response to psychological or emotional stimuli.
  • These stressors are often not resolved as rapidly as some physical stressors.
  • Modern stress has been described as a psychosocial state that is pervasive, chronic, and relentless.
  • This promotes susceptibility to diseases of adaptation.
  • Adaptation is determined by the extent to which the thoughts, feelings, and behaviors interfere with an individual’s functioning

 

Anxiety

  • A feeling of discomfort and apprehension related to fear of impending danger. The individual may be unaware of the source of their anxiety, but it is often accompanied by feelings of uncertainty and helplessness.
  • Anxiety is common, and it can be both positive or negative

 

Peplau’s four levels of Anxiety

  • Mild anxiety- It is associated with the tension experienced in response to the events of day-to-day living.
  • Moderate anxiety- an individual is less alert to events occurring within the environment. The individual’s attention span and ability to concentrate decrease, although he or she may still attend to needs with direction.
  • Severe anxiety- Attention span is extremely limited, and the individual has difficulties completing even the simplest task. Physical symptoms (e.g., headaches, palpitations, insomnia) and emotional symptoms (e.g., confusion, dread, horror) may be evident
  • Panic anxiety- Associated with a feeling of terror, and individuals may be convinced that they have a life-threatening illness or fear that they are “going crazy,” are losing control, or are emotionally weak. Behavior may be characterized by wild and desperate actions or extreme withdrawal.

 

Ego Defense Mechanism

Definition Example
Compensation Covering up a real or perceived weakness by emphasizing a trait one considers more desirable Individuals with poor family lives may direct their energy into excelling above and beyond what is required at work.
Denial Refusing to acknowledge the existence of a real situation or the feelings associated with it An alcoholic can’t stop drinking and doesn’t acknowledge that they have a problem
Displacement The transfer of feelings from one target to another that is considered less threatening or that is neutral An employee who is angry with their boss but expresses their emotions to their partner
Identification An attempt to increase self-worth by acquiring certain attributes and characteristics of an individual one admires A girl dresses like her friends, as much because she desires to be like them
Intellectualization An attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis Jane’s partner job transfers him to another city and they hide the anxiety from their kids explaining the benefits associated with the move.
Introjection Integrating the beliefs and values of another individual into one’s ego structure “boys don’t cry”
Isolation Separating a thought or memory from the feeling, tone, or emotion associated with it A person with a particularly stressful job may use isolation to separate their work life from their family life, avoiding the stress affecting their relationships.
Projection Attributing feelings or impulses unacceptable to one’s self to another person A boy who has a secret attraction to a girl he likes, tells his friends that, “she is in love with me”
Rationalization Attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors I drink because it’s the only way I can deal with my bad job.
Reaction formation Preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors An individual attends medical school although they don’t want to be a doctor to please their parents
Regression Responding to stress by retreating to an earlier level of development and the comfort measures associated with that level of functioning A ten-year-old is in the hospital to get his tonsils removed and begins sucking his thumb like he did when he was a toddler
Repression Involuntarily blocking unpleasant feelings and experiences from one’s awareness An adult who was sexually abused as a child tries to block the memory of the experience.
Sublimation Rechanneling of drives or impulses that are personally or socially unacceptable into constructive activities After years of alcohol addiction, John joins an alcohol anonymous group and helps spread awareness of alcohol addiction.
Suppression The voluntary blocking of unpleasant feelings and experiences from one’s awareness “I don’t have money for the bills, but I will deal with tomorrow”
Undoing Symbolically negating or canceling out an experience that one finds intolerable Mary yells at her colleagues at school about a late turned-in assignment but buys coffee for them  

 

5 stages of grief

  • Denial- “No, it can’t be true!”
  • Anger- “It’s not fair!”
  • Bargaining- “If God will help me through this, I promise I will go to church every Sunday and volunteer my time to help others.”
  • Depression- At this stage, the individual becomes disengaged from all association with the lost entity
  • Acceptance- Brings a feeling of peace after the loss

 

  • The resolution of the grief response is thought to occur when an individual can look back on the relationship with the lost entity and accept both pleasure and disappointments of the association.

 

Maladaptive Grief responses

  • This occurs when an individual is unable to progress satisfactorily through the stages of grieving to achieve resolution and usually gets stuck with the denial or anger stages.
    1. Prolonged response- preoccupation with memories of the lost entity for many years. May experience functional disorganization and intense emotional pain.
    2. Delayed/inhibited response- the individual becomes fixed in the denial stage of the grieving process. May experience anxiety disorders such as phobias, sleeping, and eating disorders.
    3. Distorted response- Fixed in the anger stage of grieving and all normal behaviors associated with grieving like helplessness, sadness, anger, guilt, etc., are exaggerated.

 

Biological Implications

  • Greater emphasis has been placed on the study of the biological foundations of cognitive processes, emotional processes, and behavioral processes

 

  • Review of the Brain
  1. Forebrain
    1. Cerebrum
      1. Consists of right and left hemispheres separated by corpus callosum
      2. Each hemisphere contains frontal, parietal, temporal, and occipital lobes
    2. Diencephalon
      1. Connects cerebrum with lower structures of the brain
      2. Consists of thalamus and hypothalamus, which are part of a loop of structures known as the limbic system
  2. Midbrain
    1. Mesencephalon
      1. Extends from the pons to the hypothalamus
      2. Responsible for integration of visual, auditory, and righting reflexes
  3. Hindbrain
    1. Pons
      1. Part of the brainstem
      2. Contains centers for respiration and is associated with sleep
    2. Medulla
      1. Connects the spinal cord and pons
      2. Responsible for heart rate, respiration, and reflexes like sneezing
    3. Cerebellum
      1. Connects to the brainstem through bundles of fiber tracts
      2. Concerned with involuntary movement

 

  • Autonomic nervous system is divided into the sympathetic (dominant in stressful situations) and parasympathetic systems (dominant in relaxed situations) 
  • Synapse are junctions between the neurons while neurotransmitters are chemical messengers that convey information across synaptic clefts to neighboring target cells 

 

Neurotransmitters Functions Implications in mental illness
Acetylcholine Sleep, arousal, pain perception, motor control, learning, and memory  Motor and memory disorders such as Alzheimer’s disease, Parkinson’s disease, and Huntington’s disease
Norepinephrine Regulation of mood, cognition, perception, attention, vigilance, memory, cardiovascular functioning, and sleep-wake cycles Mood disorders such as depression, schizophrenia, and mania
Dopamine Regulation of movements and coordination, emotions, reward signals, learning, voluntary decision-making ability, and inhibits release of prolactin High levels = mania and schizophrenia

Low levels = Parkinson’s disease and depression

Serotonin Sleep-wake cycle, sexual behavior, appetite, anxiety, aggression, and pain perception Depression and schizophrenia
Histamine Circadian rhythms, psychomotor activity, learning, cognition, appetite, and eating disorders Epilepsy, depression, psychosis, stroke, anxiety, neuroinflammatory process, and neurodegeneration
Gamma-Aminobutyric Acid Prevent postsynaptic excitation, interrupting the progression of the electrical impulse at the synaptic junction Alterations may lead to anxiety disorders, movement disorders, and epilepsy 
Glycine Regulation of spinal and brainstem reflexes Glycine encephalopathy
Glutamate and Aspartate Relay of sensory information and in the regulation of various motor and spinal reflexes Huntington’s disease, temporal lobe epilepsy, and spinal cerebellar degeneration.

 

  • Neuroendocrinology is the study of the interaction between the nervous system and the endocrine system, and the effects of various hormones on cognitive, emotional, and behavioral functioning.
  • Studies have been conducted to determine genetic and environmental contributions to psychiatric disorders. 
  • Possible genetic links to various psychological disorders have been discovered through these studies.
  • Psychoneuroimmunology is the study of the relationship between the immune system, the nervous system, and psychological processes.
  • Psychiatric nurses must have a specialized knowledge about, neuroanatomy and neurophysiology, neuronal processes, neuroendocrinology, circadian rhythms, genetic influences, PNI (psychoneuroimmunology), trauma, psychopharmacology, and diagnostic technology.

 

Legal and Ethical issues

  • Ethics: A branch of philosophy that deals with distinguishing right from wrong
  • Bioethics: Term applied to ethics when they refer to concepts within the scope of medicine, nursing, and allied health
  • Moral behavior: Conduct that results from serious critical thinking about how individuals should treat others
  • Values: Personal beliefs about what is important and desirable
  • Values clarification: A process of self-exploration by which people identify and rank their own personal values
  • Right: A valid, legally recognized claim or entitlement, encompassing both freedom from government interference or discriminatory treatment and entitlement to a benefit or service

 

  • Utilitarianism states that actions are right if they are useful or for the benefit of the majority.
    • The organ transplant team prioritized the patients selected to receive an organ donation. Thus, a person who has a good chance of surviving the surgery and living for several years will be chosen for the organ transplant while a client who is critically ill, who may not survive the surgery, does not receive the organ donation.
  • Kantianism states that decisions and actions are bound by a sense of duty; and that moral judgements are based on law and avoids pleasure/emotions.
  • Natural law theories: Do good and avoid evil. Human knowledge of the difference between good and evil directs decision-making.
  • Ethical egoism are decisions based on what is best for the individual making the decision.
  • Ethical dilemmas are situations that require individuals to make a choice between two equally unfavorable alternatives
    • Patient that had signed a DNR, during a crisis tells the nurse that they change their mind.

 

Ethical principles

  • Autonomy emphasizes the status of persons as autonomous moral agents whose rights to determine their destinies should always be respected.
  • Beneficence refers to one’s duty to benefit or promote the good of others.
  • Nonmaleficence is abstaining from negative acts toward another; includes acting carefully to avoid harm.
  • Justice: Principle based on the notion of a hypothetical social contract between free, equal, and rational persons. The concept of justice reflects a duty to treat all individuals equally and fairly.
  • Veracity: Principle that refers to one’s duty to always be truthful and not intentionally deceive or mislead clients.

Patient right’s

  1. The right to treatment- Anyone admitted into the hospital has a right to be treated 
  2. The right to refuse treatment (including medication), however this right is put aside if the treatment requires immediate intervention to prevent self-harm or harm to others, or death.
  3. The right to the least restrictive treatment alternative where the clients who can be adequately treated in an outpatient setting should not be hospitalized, but if they need hospitalization they should not be sedated, restrained, or secluded unless less restrictive measures where not successful.

 

  • Types of laws include 
    • Statutory law- passed by the legislature body
    • Common law- decisions developed from previous cases

 

  • Civil law: Protects the private and property rights of individuals and businesses

Torts- violations of civil law where individual has been wronged 

Contracts- a party asserts that the other party is failing to fulfil an obligation or breached the contract, or either compensation.

  • Criminal law: Provides protection from conduct deemed injurious to the public welfare

 

Legal Issues in Psychiatric/Mental Health Nursing

  • Confidentiality and right to privacy
  • Health Insurance Portability and Accountability Act (H I P A A) 
    • Individuals have the rights to access their medical records, to have corrections made to their medical records, and to decide with whom their medical information may be shared
    • If information is released in an emergency, the following information must be recorded in the client’s record: date of disclosure, person to whom information was disclosed, reason for disclosure, reason written consent could not be obtained, and the specific information disclosed.
  • Doctrine of privileged communication
  • Exceptions: A duty to warn; suspected child or elder abuse
    • Assessment of a threat of violence by a client toward another individual
    • Identification of the intended victim 
    • Ability to intervene in a feasible, meaningful way to protect the intended victim
  • Informed consent
    • This is the permission granted to a physician to perform a therapeutic procedure 
    • Individuals have the right to decide whether to accept or reject treatment.
    • Healthcare provider can be charged with assault and battery for providing life-sustaining treatment to a client when the client has not agreed to it.
  • Restraints and seclusion
    • Restraint refers not only to leather restraints but also to any manual method or medication used to restrict a person’s freedom of movement.
    • Seclusion is a type of physical restraint in which the client is confined alone in a room from which he or she is unable to leave.
    • Injuries and deaths have been associated with restraint and seclusion, this treatment requires careful attention whenever it is used.
  • False imprisonment
    • deliberate and unauthorized confinement of a person within fixed limits by the use of verbal or physical means

 

Hospitalization

  • Voluntary admissions
  • Involuntary commitments- where the client is in imminent danger to themselves or other, or unable to perform ADL (activities of daily living)
    • Emergency commitments (Mostly because they are a danger to themselves/others)
    • A mentally ill person in need of treatment (Typically longer and meant for clients who have been affected severely by mental illness)
    • Involuntary outpatient commitment (This is court ordered used to oblige the client with mental illness to submit to treatment on an outpatient basis)
      • Client records shows repeated deteriorate to the point requiring inpatient commitment
      • Presence of severe and persistent mental illness and have limited awareness of the condition or that has could contribute to incarceration, homelessness, violence, or suicide 
      • Existence of an individual treatment plan that could effective and service provider who has agreed to provide the treatment.

 

  • A gravely disabled client

Nursing Liability

  • Negligence- failure to exercise the care toward others that a reasonable or prudent person would do in the circumstances, or taking action that such a reasonable person would not.
  • Failure to exercise the care toward others that a reasonable or prudent person would do in the circumstances.
  • Malpractice- an act or continuing conduct of a professional that does not meet the standard of professional competence and results in provable damages to his or her client or patient
  • Act or continuing conduct of a professional that does not meet the standard of competence and results in provable damages to the patient

Types of Lawsuits

  • Breach of confidentiality
  • Defamation of character- sharing information that would be detrimental to the client’s reputation 
    • Libel (written)
    • Slander (Oral)
  • Invasion of privacy- searching a client without probable cause 
  • Assault and battery where in a person’s genuine fear and apprehension that the client would be touched without their consent and unconsented touching respectively.
  • False imprisonment

Avoiding Liability

  • Effective communication- using SBAR (Situation, Background, Assessment, and Recommendation) to other healthcare providers and also establish rapport with clients that will encourage open and honest communication.
  • Accurate and complete documentation in the medical record- Since the development of new technology that has encouraged healthcare systems to adopt electronic health records that are the best sources for informatics due to standard of quality and safety in nursing.
  • Complying with standards of care- ANA standards and hospital polies
  • Knowing the client- allowing and helping the clients be involved in their own care 
  • Practicing within the nurse’s level of competence and scope of practice- not only adhering to professional standards but also keeping knowledge and skills current through evidence-based literature, in-service, and continuing education.

 

Interpersonal Techniques

Therapeutic Communication Techniques (Recommended to use when interacting with a patient)

Examples Rationale
Silence  

-Absence of verbal communication

1. Interested, expectant silences often encourage the patient to verbalize.2. Silence allows the patient an opportunity to take the initiative in communication that, which is most pressing.

3. Silence reduces the pace of the interview.

4. Silence allows time to consider alternatives and to weigh questions.

5. Nonverbal communications occur during silences.

Accepting

-Giving indication of reception.

“Yes”

“Nodding”

“I follow what you said.”

1. Such responses signify that the nurse is attuned to the patient.

2. Accepting does not indicate agreement, but is nonjudgmental in nature.

3. Facial expression, inflection, posture, etc. must convey acceptance as well as verbal acceptance.

Giving recognition 

-Acknowledging, indicating awareness.

“Good morning, Miss Jones.”

“I notice you’ve combed your hair.”

1. Such recognition indicates perception of the patient as an individual.

2. Recognition carries no value judgments of “good” or “bad”, etc., thus does not burden the patient with expected behaviors.

Offering self

-Making one’s self available

“I’ll sit with you awhile.”

“I’ll stay here with you.”

1. The presence and interest of the nurse may be therapeutic when verbal communications are not timely.

2. To be therapeutic, this offer must be un-conditional, not contingent on patient behavior.

3. Conditions, which are applicable, should be stated, as time available, etc.

Giving broad openings

-Allowing the patient to take the initiative in introducing the topic.

“Where would you like to begin?”

“Is there something you’d like to talk about?”

1. Such comments help the patient to identify his role in the interaction.

2. The nurse should avoid conventional “small talk” when greeting the patient.

Offering general leads 

-Giving encouragement to continue

“Go on…”

“Tell me about it.”

1. Leads encourage the patient to talk.

2. Following the patient’s lead involves taking cues from the patient rather than the nurse directing the discussion.

Placing the events in time or in sequence   

-Clarifying the relationships of events in time.

“Was this before or after…?”

“When did this happen?”

1. Sequence helps the nurse and patient view events in perspective.

2. Objectivity is enhanced when chronologic order is established. 

3. Cause and effect relationships can be better studied.

4. Recurring patterns of interpersonal difficulties may be identified.

Making observations  

-Verbalizing what is perceived.

“You appear tense.”

“I noticed you’re biting your lips.”

1. Observations can be called to the attention of the patient, who may be unaware of them.

2. Stating observations encourages the patient’s noticing for himself so he can describe the same.

3. The nurse and patient can compare observations

Encouraging descriptions of perceptions 

-Asking the patient to verbalize what he perceives.

“Tell me when you feel anxious.”

“What is happening?”

1. Patient descriptions allow the nurse to see things as they seem to the patient. 

2. Descriptions of behavior are necessary for understanding reasons for behavior.

3. Talking may make it unnecessary to act out harmful behavior.

Restating   

-Repeating the main idea expressed.

Pt:  “I can’t sleep.  I stay awake all night.”

Nurse:  “You have difficulty sleeping.”

1. Restatement gives evidence that the idea has been communicated.

2. The patient is encouraged of continue.

3. An opportunity to restate for clarity is provided.

4. Restatement may bring out related aspects, which have been omitted.

Reflecting   

-Directing back to the patient questions, feelings, and ideas.

Pt:  “Do you think I should tell the doctor?”

Nurse:  “Do you think you should tell the doctor?”

1. Refection encourages acceptance of one’s own ideas and feelings.

2. The patient’s point of view is given value.

3. Reflection makes obvious the nurse’s interest in hearing as much as the patient needs to tell.

Giving information

-Making available the facts the patient needs.

“My purpose in being here is…”

“Visiting hours are…”

1. Providing needed facts builds trust and enhances knowledge for decision making.

2. When the nurse does not have knowledge required, she should state she does not know, but seek such information or make proper referrals.

3. Misleading or vague explanations should be avoided.

Seeking clarification

-Seeking to make clear that which is not meaningful or which is vague.

“I’m not sure that I understand.”

“Have I heard you correctly, you said…?”

1. Patients are often aware of not being understood, and will eventually cease to try to communicate.

2. It is not necessary to understand everything said, but pretenses of understanding should be avoided.

3. Attempts to clarify communications for others may enhance self-understanding.

 

Nontherapeutic Communication

Example Rationale
Reassuring   

-Indicting there is not cause for anxiety.

“Everything will be all right.”

“I wouldn’t worry about that!”

1. Attempts to dispel the anxiety of the patient by implying there is not sufficient reason for it devalues the patient’s judgment, and communicated the nurse’s lack of understanding and empathy.

2. Concrete examples of patient progress can be commented on rather than general reassurances.

3. Reassurance makes the nurse feel better at the time but is meaningless to the patient.

4. The person giving the reassurance cannot be sure that the predicted favorable outcome will occur.  

5. Reassurances block expression of feelings.

Giving approval   

-Sanctioning the patient’s ideas or behaviors.

“That’s good.”

“I’m glad that you…”

1. Statement of the “good” implies the opposite is “bad”.

2. Approval limits the freedom of the patient to act in a way that displeases the nurse.

3. Approval leads the patient to strive for praise rather that progress.

4. Approval arouses undue ambition, competitiveness, and a sense of superiority. 

5. Approval blocks learning.

6. Approval and disapproval may alter undesirable behavior, but usually only temporarily. 

Rejecting “Let’s not discuss . . .”

“I don’t want to hear about . . .”

Correction: “Let’s look at that a little closer.”

1. Refusing to consider or showing contempt for the client’s ideas or behavior.  

2. This may cause the client to discontinue interaction with the nurse for fear of further rejection.

Sanctioning or denouncing “That’s good. I’m glad that you . . .”

“That’s bad.  I’d rather you wouldn’t . . .”

Correction: “Let’s talk about how your behavior invoked anger in the other clients at dinner.”

1. The client’s ideas or behavior; implies that the nurse has the right to pass judgment on whether the client’s ideas or behaviors are “good” or “bad” and the client is expected to please the nurse. 

2. The nurse’s acceptance of the client is then seen as conditional, depending on the client’s behavior

Agreeing/disagreeing “That’s right.  I agree.”

“That’s wrong.  I disagree.” 

“I don’t believe that.”

Correction: “Let’s discuss what you feel is unfair about the new community rules.”

1. Indicating accord with or opposition to the client’s ideas or opinions; implies that the nurse has the right to pass judgment on whether the client’s ideas or opinions are “right” or “wrong”.  

2. Agreement prevents the client from later modifying his or her point of view without admitting error.  Disagreement implies inaccuracy, provoking the need for defensiveness on the part of the client.

Giving advice “I think you should . . .”

“Why don’t you . . .”

Correction: “What do you think you should do?”

1. Telling the client what to do or how to behave implies that the nurse knows what is best and that the client is incapable of any self-direction.  

2. It nurtures the client in the dependent role by discouraging independent thinking.

Probing “Tell me how your mother abused you when you were a child.”

“Tell me how you feel toward your mother now that she is dead.”

“Now tell me about . . .”

Correction: The nurse should be aware of the client’s response and discontinue the interaction at the first sign of discomfort.

1. Persistent questioning of the client; pushing for answers to issues the client does not wish to discuss.  

2. This causes the client to feel used and valued only for what is shared with the nurse and places the client in the defensive.

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