Introduction The DSM-5has modified previous classifications, as well as added new classifica- tionssuch as Neurocognitive Disorders, Neurodevelopmental Disorders, and Trauma and Stressor-Related Disorders, based on new scientific research and evidence- based practice. New Disordershave also been added including Hoarding Disorder, Binge Eating Disorder, and Disruptive Mood Dysregulation Disorderto name a few. The Bereavement Exclusionfor Major Depressive Disorder (MDD) has been eliminat- ed. This exclusion did not allow for a diagnosis of MDD for two months after the loss of a loved one. Now a grieving client can be diagnosed with MDD and treated for major depression before the two-month exclusionary period is up. The American Psychiatric Associationwants to focus on and is moving toward a better understanding of cultural factorsand a cultural understanding of mental ill- ness. It wants to focus on the patient’s understandingof the illness, the influence of othersin the family, a cultural definitionof the problem, and factors affecting coping and help seeking, using the Cultural Formulation Interview (CFI). The CFI will be included in DSM-5’s Section III: Emerging Measures and Models. Severity scaleswill prove of greater importance. Using severity scales will allow for a way to demonstrate improvement or worsening on a continuum over time. Severity scales will be used for evaluating disorders such as Autism Spectrum Disorder and Gambling Disorder. Primary care professionalsmay screen for disor- ders/severity using self-administered Patient Health Questionnaires (phqscreen- ers.com) or use the many Psychiatric Rating Scales available in the AssessTab. Dimensional/Cross-cutting Assessments– DSM-5 aimed to focus on all symptoms as well as symptoms that show up in many diagnoses(e.g., depression, anxiety, anger/irritability, sleep, and substance-use issues) and is leaning away from a pure criteria-based approach(e.g., 3 or more of the following) and single diagnosis approach, though this is just the beginning. These Assessment Measureswill be included in DSM-5’s Section III: Emerging Measures and Models. The APA also wanted to change the personality disordersto a “hybrid-dimensional” approach, eliminating 4 of the 10 PDs, but decided to retain the PDs as they existed in the DSM-IV-TR, believing such a change was too drastic and required more time and research. The alternative DSM-5 modelfor personality disorders will be included in Section III of the DSM-5. The Multiaxial System (Axes I-V)and Global Assessment of Functioning (GAF)scale have been eliminated from the DSM-5. Further discussion of the DSM-5 changes can be found in the Disorders/ InterventionsTab. Dedication PsychNotes 4eis especially dedicated to my son Jorgen David Pedersen, Jessica, and Isaac. Special thanks to Christina Snyder; also thanks to William Welsh, Lisa Thompson, Sam Rondinelli, Ellen Thomas, and of course Bob Martone and Julia Carp. PsychNoteshas been translated into Chinese, Portugese, Turkish, and Hungarian languages. 4th Edition PPssyycchh NNootteess Clinical Pocket Guide Darlene D. Pedersen, MSN, APRN, PMHCNS Purchase additional copies of this book at your health science bookstore or directly from F. A. Davis by shopping online at www.fadavis.com or by calling 800-323-3555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2014 by F. A. Davis Company All rights reserved. This book is protected by copyright. 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The fee code for users of the Transactional Reporting Service is: 978-0-8036-3922- 5/14 0 +$.25. Place 27⁄8×27⁄8Sticky Noteshere for a convenient and refillable note pad ✓HIPAA compliant ✓OSHA compliant Waterproof and Reusable Wipe-Free Pages Write directly onto any page of Psych Notes: Clinical Pocket Guide with a ballpoint pen. Wipe old entries off with an alcohol pad and reuse. DISORDERS/ DRUGS/ TOOLS/ BASICS ASSESS DRUGS A-Z CRISIS GERI INTERV LABS INDEX Look for other titles! Davis’s Notes Pocket Psych Drugs Point-of-Care Clinical Guide RNotes® Nurse’s Clinical Pocket Guide MedSurg Notes Nurse’s Clinical Pocket Guide NCLEX-RN® Notes Content Review & Exam Prep For a complete list of Davis’s Notes and other titles for health care providers, visit www.FADavis.com. 1 Mental Health and Mental Illness: Basics Autonomic Nervous System 12 Biological Aspects of Mental Illness 9 Brain 10 Central and Peripheral Nervous System 9 Confidentiality 14 Confidentiality, Do’s and Don’ts 14 Diathesis-Stress Model 4 Erikson’s Psychosocial Theory 7 Fight-or-Flight Response 4 Freud’s Psychosexual Development 6 General Adaptation Syndrome 3 Health Care Reform and Behavioral Health 17 Health Insurance Portability and Accountability Act (HIPAA) (1996) 15 Informed Consent 17 Key Defense Mechanisms 5 Legal Definition of Mental Illness 2 Legal-Ethical Issues 14 Limbic System 11 Mahler’s Theory of Object Relations 8 Maslow’s Hierarchy of Needs 3 Mental Health 2 Mental Illness/Disorder 2 Mind-Body Dualism to Brain and Behavior 9 Neurotransmitter Functions and Effects 13 Neurotransmitters 13 Patient’s Bill of Rights 16 Patient Care Partnership 16 Peplau’s Interpersonal Theory 8 Positive Mental Health: Jahoda’s Six Major Categories 2 Psychoanalytic Theory 4 Quality and Safety Education for Nurses (QSEN) 17 Restraints and Seclusion for an Adult – Behavioral Health Care 15 Right to Refuse Treatment/Medication 17 Stages of Personality Development 6 Sullivan’s Interpersonal Theory 6 Sympathetic and Parasympathetic Effects 12 Synapse Transmission 13 Theories of Personality Development 4 Topographic Model of the Mind 5 Types of Commitment 15 When Confidentiality Must Be Breached 14 BASICS BASICS Mental Health and Mental Illness: Basics Mental health and mental illness have been defined in many ways but should always be viewed in the context of ethnocultural factors and influence. Mental Illness/Disorder The DSM-5 defines mental illness/disorder (paraphrased) as: characterized by significant dysfunction in an individual's cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning. A mental disorder is not merely an expectable or culturally sanctioned response to a specific event, such as the death of a loved one. The deviation from the norm is not political, religious, or sexual, but results from dysfunction in the individual (APA 2013). Mental Health Mental healthis defined as: a state of successful performance of mental func- tion, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and cope with adversity (US Surgeon General Report, Dec 1999). Wellness-illness continuum– Dunn’s 1961 text, High Level Wellness,altered our concept of health and illness, viewing both as on a continuum that was dynamic and changing, focusing on levels of wellness.Concepts include: to- tality, uniqueness, energy, self-integration, energy use, and inner/outer worlds. Legal Definition of Mental Illness The legal definition of insanity/mental illness applies the M’Naghten Rule, for- mulated in 1843 and derived from English law. It says that: a person is innocent by reason of insanity if at the time of committing the act, [the person] was labor- ing under a defect of reason from disease of the mind as not to know the nature and quality of the act being done, or if he did know it, he did not know that what he was doing was wrong.There are variations of this legal definition by state, and some states have abolished the insanity defense. Positive Mental Health: Jahoda’s Six Major Categories In 1958, Marie Jahoda developed six major categories of positive mental health: ■ Attitudes of individual toward self ■ Presence of growth and development, or actualization ■ Personality integration 2 3 ■ Autonomy and independence ■ Perception of reality, and ■ Environmental mastery The mentally healthy person accepts the self, is self-reliant, and is self- confident. Maslow’s Hierarchy of Needs Maslow developed a hierarchy of needs based on attainment of self- actualization, where one becomes highly evolved and attains his or her full potential. The basic belief is that lower-level needs must be met first in order to advance to the next level of needs. Therefore, physiological and safety needs must be met before issues related to love and belonging can be addressed, through to self-actualization. Maslow’s Hierarchy of Needs Self-Actualization Self-fulfillment/reach highest potential Self-Esteem Seek self-respect, achieve recognition Love/Belonging Giving/receiving affection, companionship Safety and Security Avoiding harm; order, structure, protection Physiological Air, water, food, shelter, sleep, elimination General Adaptation Syndrome (Stress-Adaptation Syndrome) Hans Selye (1976) divided his stress syndromeinto three stages and, in doing so, pointed out the seriousness of prolonged stress on the body and the need for identification and intervention. 1. Alarm stage– This is the immediate physiological (fight or flight) response to a threat or perceived threat. 2. Resistance – If the stress continues, the body adapts to the levels of stress and attempts to return to homeostasis. 3. Exhaustion– With prolonged exposure and adaptation, the body eventually becomes depleted. There are no more reserves to draw upon, and serious illness may now develop (e.g., hypertension, mental disorders, cancer). Selye teaches us that without intervention, even death is a possibility at this stage. BASICS BASICS CLINICAL PEARL: Identification and treatment of chronic, posttraumatic stress disorder (PTSD) and unresolved grief, including multiple (compound- ing) losses, are critical in an attempt to prevent serious illness and improve quality of life. (See PTSD table and PTSD Treatments in Disorders/ Interventions tab and Military, Families, and PTSD in Crisis tab.) Fight-or-Flight Response In the fight-or-flight response, if a person is presented with a stressful situation (danger), a physiological response (sympathetic nervous system) activates the adrenal glands and cardiovascular system, allowing a person to adjust rapidly to the need to fight or flee a situation. ■ Such physiological response is beneficial in the short term: for instance, in an emergency situation. ■ However, with ongoing, chronic psychological stressors, a person continues to experience the same physiological response as if there were a real danger, which eventually physically and emotionally depletes the body. Diathesis-Stress Model The diathesis-stress model views behavior as the result of geneticand biological factors. A genetic predisposition results in a mental disorder (e.g., mood disorder or schizophrenia) when precipitated by environmental factors. Theories of Personality Development Psychoanalytic Theory Sigmund Freud, who introduced us to the Oedipus complex, hysteria, free asso- ciation, and dream interpretation, is considered the “Father of Psychiatry.” He was concerned with both the dynamics and structure of the psyche. He divided the personality into three parts: ■ Id – The id developed out of Freud’s concept of the pleasure principle. The id comprises primitive, instinctual drives (hunger, sex, aggression). The id says, “I want.” ■ Ego – It is the ego, or rational mind, that is called upon to control the instinctual impulses of the self-indulgent id. The ego says, “I think/I evaluate.” ■ Superego – The superego is the conscience of the psyche and monitors the ego. The superego says “I should/I ought” (Hunt 1994). 4