Exam 1 Flashcards
Important DSM-5 TR updates
recognizes the increased importance of culture for both clinical care and research applications
culture, as well as age and gender, warranted separate discussion of variances in symptom expression, risk, course, prevalence, and other aspects of diagnosis, where evidence was available
The DSM-5 TR differs from the previous DSM-IV-TR in recognizing boundaries between disorders are more fluid over the course of life. Symptoms usually seen in one disorder may also appear in other disorders and be of various severity and intensity.
The DSM-5 manual (APA, 2022) deletes the requirement from the former DSM IV-TR five-axial diagnostic system in favor of nonaxial documentation of diagnosis.
DSM-5 TR conceptualizes each of the mental disorders as …
a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and is associated with present distress (e.g., a painful symptom), disability (i.e., impairment in one or more important areas of functioning), or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom
*must not be merely an expected and transient response to a particular event
Are deviant behaviors mental disorders?
Deviant behaviors (e.g., political, religious, or sexual) and conflicts between the individual ad society are not considered mental orders per se, but if the deviance or conflict is a symptom of dysfunction in the individual, then it may be considered a symptom of the illness.
10 disease classifications of of mental and behavioral disorders (The ICD-10)
- Organic – including symptomatic – mental disorders
- Mental and behavioral disorders due to psychoactive substance abuse
- Schizophrenia, schizotypal, and delusional disorders
- Mood (affective) disorders
- Neurotic, stress-related, and somatoform disorders
- Behavioral syndromes associated with physiological disturbances and physical factors
- Disorders of adult personality and behavior
- Mental retardation
- Disorders of psychological development
- Behavioral and emotional disorders with onset usually occurring in childhood and adolescence
What’s Current Procedural Terminology (CPT) coding
CPT coding is a standard, universal code that is applied to medical procedures and services for the purpose of client records.
Aside from professional responsibility, 3 reasons why documentation is important
Legal Protection
Regulatory Standards
Reimbursement
CPT definition of counseling
CPT® defines counseling as including one or more of the following:
Diagnostic results, impressions, and/or recommended diagnostic studies
Prognosis
Risks and benefits of management (treatment) options
Instructions for management (treatment) options
Importance of compliance with chosen management (treatment) options
Risk factor reduction
Client and family education
Progress note of psychotherapy vs psychotherapy note
Progress notes for documentation of psychotherapy (with or without E/M) are not the same as psychotherapy notes. If providers choose to create specific psychotherapy notes, they need to carefully review the requirements and note the requirement to create a second set of records constituting the client’s medical record. The point is to protect specific health information, not prevent the provider from being appropriately reviewed and reimbursed for work done. Please note that the guideline for the psychotherapy note requires information about what the provider did, not client-specific history.
SOAP, SOAPIE, SOAPIER notes
A SOAPIE = SOAP note plus I = implementation consideration of the services to be provided and E = the evaluation of service provision.
A SOAPIER = plus R, which is the client’s response to the diagnostic process, treatment planning and intervention efforts
Purpose of the Psychiatric Interview
to gather information necessary to understand, diagnose, and treat the client
what does the psychiatric interview focus on
focuses on the client’s biopsychosocial history and current mental status
What is the Biopsychosocial history
a comprehensive assessment of the client’s lifetime biologic, psychological, and social functioning
Chief complaint
The client’s chief complaint is the reason for current contact with the mental health system. The chief complaint should be obtained in the client’s own words.
(Because of the nature of the illness, the client’s statement may differ greatly from the family’s or evaluator’s assessment of the situation (e.g., an inpatient insists that she is in the hospital for a medical checkup following her abduction by aliens). The chief complaint provided valuable data concerning the client’s illness.)
History of present illness
a chronological account of the events leading up to the current contact with the mental health professional. Description of evolution of symptoms (onset, duration, and change over time). Exacerbating and ameliorating factors of the current psychological distress; what factors may have precipitated the current episode? Attendant changes in somatic functioning (sleep pattern, appetite, cognitive ability, sexual functioning) should also be noted.
Right hemisphere of brain
non-dominant hemisphere (usually the right brain in right-handed people) processes information in a visual-spatial, emotional, gestalt, holistic manner
Left hemisphere of brain
dominant hemisphere (usually the so-called left brain in right-handed people) processes information in an analytic, sequential, linear fashion
Frontal lobe
The frontal lobes are generally involved in self–awareness (introspection, physical and emotional sensation) and executive functions (focusing, planning, judgment, decision making, and social functioning). The frontal lobes regulate the expression of emotion and of motor behavior.
implicated in such clinical psychiatric syndromes as schizophrenia, disorders of attention (i.e., ADD), obsessive compulsive disorder, and mood disorders.
The parietal lobes
generally associated with the coordination of sensation and motor behavior (such as the coordination of language functions), spatial orientation (knowing where your body is, in a physical sense), and recognition of people and objects.
The temporal lobes
intimately involved in memory formation: language, and learning. Clinically, euphoria, auditory hallucinations, and delusions are usually associated with impaired function of the dominant (usually left) temporal lobe, while dysphoria, depression, irritability, and inappropriate affect are associated with abnormalities of the non-dominant (usually right) temporal lobe.
The occipital lobes
associated with vision and visual memory
The Corpus Callosum
Bridge between Hemispheres – As a body (corpus) of nerve fibers of colossal proportions, this tract allows each hemisphere of the brain to receive and send information to the other hemisphere, so that functions can be coordinated between the left and right sides of the brain. It has been implicated as abnormal in schizophrenia and attention deficit hyperactivity disorder (ADHD).
The Cingulum
Emotional Superhighway – On the same level as the corpus callosum is the main information highway of emotion, the cingulum. This central highway seems to be involved with the summation and integration of emotion and thinking in preparation for final input to the hypothalamus, a central integrating station. Thus, in contrast with the corpus callosum, which facilitates an integrative function of the left and right sides of the brain, the cingulum facilitates an integration from higher (thinking and emotion) to lower (the hypothalamic nuclei) brain regions. The cingulum is larger in women, whereas structures controlling aggression seem to be larger in men.
The Median Forebrain Bundle
Reward – The various tracts (mesocortical and mesolimbic tracts) involved in the processing of pleasurable experience and reward come together in a pathway called the median forebrain bundle. This bundle of reward fibers interconnects areas of the brain involved in the mediation of emotion, learning, arousal, memory, and hormonal control. It runs between the hypothalamus and the septal region. This tract has clinical importance in depression, mania, and schizophrenia. Researchers have postulated that there is a fundamental imbalance of activity between the median forebrain bundle reward system and the inhibitory (punishment) center of the brain. In mania the pleasure centers are hypothesized to be overactive and/or the inhibitory centers, underactive. In depression the reverse would be so.
The Periventricular System
Punishment – This tract follows a path around (peri) the fluid-filled spaces within the interior parts of the brain (the ventricles), connecting the emotional, thinking, and hormonal functions of the brain. This is the primary inhibitory or punishment pathway in the brain; activation of this pathway seems to initiate avoidance behaviors. This tract is in balance with the reward tract, mentioned above. Together they modulate varying degrees of excitation and inhibition of behavior in various areas of the brain involved in learning, emotion, arousal, and hormonal activation.
Mesolimbic and Mesocortical Tracts
Reinforcement – These two pathways carry information between a part of the brain stem called the mid (meso) brain and the limbic system and frontal lobes of the brain, respectively. The pathways that appear most involved in reinforcement are the mesolimbic and mesocortical pathways. These two pathways join to pass through the median forebrain bundle. Abnormal function of nerve cells in these two tracts has been implicated in the positive symptoms of schizophrenia, such as hallucinations (mesolimbic tract), and the deficit symptoms, such as flat affect (mesocortical).
Nuclei
Nuclei are kernel-like aggregates of nerve cells, which are the hub of specialized functions. One way of understanding a nucleus is to think of the map an airline might use to show all of its routes across the country. The larger cities, such as New York and Boston are the destination or transfer points of many routes; as such they are analogous to the nuclei of the brain. The brain has numerous nuclei, all of which are involved in a complex network of communication. Certain nuclei have been identified as having a clear role in specific clinical states. Table 2.1 contains some nuclei of interest, along with their locations and clinical relevance.
hippocampus
The hippocampus is a critical area in biological psychiatry. The hippocampus is essential for learning and the consolidation of new memories. Cells of the hippocampus (and its neighbor, the amygdale) are exquisitely sensitive to the environment. States of extreme stress can actually destroy the cells of the hippocampus.
Neurotransmitters are separated into three groups:
cholinergics, amino acids, and biogenic amines
Cholinergics –
Acetylcholine was the first of the neurotransmitters to be identified in the brain. Acetylcholine is synthesized in the axon. Choline is required for the synthesis of acetylcholine and can be found in the fluid surrounding the axon. An enzyme, choline acetyltransferase, aids in the synthesis of acetylcholine. Another enzyme, acetylcholinesterase, breaks down acetylcholine into choline and acetate. Both of these enzymes are present inside the axon. Acetylcholinesterase is also found in the synapse where it breaks down acetylcholine released from receptors into choline and acetate, making choline available to be taken back into the axon for further synthesis of acetylcholine. The neurons that produce acetylcholine, particularly in the peripheral nervous system, are called “cholinergic.” Acetylcholine, as it functions in the PNS, is especially important in causing side effects of antipsychotic medications. Anticholinergic medications (i.e., Cogentin, Artane, and Symmetryl) are used to counteract such side effects. A decrease in acetylcholine in the CNS is implicated in some of the dementias.
Amino Acids –
Included in this group are L-tryptophan, glutamate, gamma-aminobutyric acid (GABA), glycine, tyrosine, and tyramine. The major excitatory amino acid neurotransmitters are glutamate and aspartate, and the major inhibitory amino acid neurotransmitters are glycine and GABA (which is derived from the excitatory amino acid glutamate). Most amino acids can be made in the body. Some, called essential amino acids (such as L-tryptophan), can only be obtained through the diet (like turkey – GOBBLE! GOBBLE!). For this reason serious dietary imbalances, as in severe depression, psychosis, bulimia, anorexia, and carbohydrate addiction, can affect the functioning of the nervous system. Amino acid deficiencies can impair the ability of antidepressants to act effectively.
feduciary duty
the legal responsibility to act solely in the best interest of another party
Beneficence
is defined as an act of charity, mercy, and kindness with a strong connotation of doing good to others including moral obligation.
Nonmaleficence
is the obligation of a physician not to harm the patient
therapeutic alliance/communication techniques
medical mimics of psych disorders
THINC MED
T = Tumors
H = Hormones (thyroid, parathyroid, adrenal, gonad, pancreas)
I = Infection
N = Nutrition
C = CNS
M = Miscellaneous
E = Electrolyte Imbalances & Environmental Toxins
D = Drugs
General overview of Hildegard Peplau’s Interpersonal relations in nursing
change from what nurses do TO pts to what they do WITH pts
viewed nursing as an educative instrument to help individuals and communities use their capacities in living more productively
theory is mainly re processes the nurse helps clients make positive changes in their health care status and well-being.
Illness offered a unique opportunity for experiential learning, personal growth, and improved coping strategies and that PMH-APRNs play a unique role in facilitating this growth
Skills of MH nurse per Peplau
The skills of the psychiatric mental health nurse include observation, interpretation, and intervention
Peplau proposed an approach in which nurses are both _____ and _____ in therapeutic conversations.
participants and observers
