Exam 1

Question 1

Important DSM-5 TR updates

Answer 1

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.

Question 2

DSM-5 TR conceptualizes each of the mental disorders as …

Answer 2

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

Question 3

Are deviant behaviors mental disorders?

Answer 3

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.

Question 4

10 disease classifications of of mental and behavioral disorders (The ICD-10)

Answer 4

1. Organic – including symptomatic – mental disorders
2. Mental and behavioral disorders due to psychoactive substance abuse
3. Schizophrenia, schizotypal, and delusional disorders
4. Mood (affective) disorders
5. Neurotic, stress-related, and somatoform disorders
6. Behavioral syndromes associated with physiological disturbances and physical factors
7. Disorders of adult personality and behavior
8. Mental retardation
9. Disorders of psychological development
10. Behavioral and emotional disorders with onset usually occurring in childhood and adolescence

Question 5

What’s Current Procedural Terminology (CPT) coding

Answer 5

CPT coding is a standard, universal code that is applied to medical procedures and services for the purpose of client records.

Question 6

Aside from professional responsibility, 3 reasons why documentation is important

Answer 6

Legal Protection
Regulatory Standards
Reimbursement

Question 7

CPT definition of counseling

Answer 7

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

Question 8

Progress note of psychotherapy vs psychotherapy note

Answer 8

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.

Question 9

SOAP, SOAPIE, SOAPIER notes

Answer 9

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

Question 10

Purpose of the Psychiatric Interview

Answer 10

to gather information necessary to understand, diagnose, and treat the client

Question 11

what does the psychiatric interview focus on

Answer 11

focuses on the client’s biopsychosocial history and current mental status

Question 12

What is the Biopsychosocial history

Answer 12

a comprehensive assessment of the client’s lifetime biologic, psychological, and social functioning

Question 13

Chief complaint

Answer 13

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.)

Question 14

History of present illness

Answer 14

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.

Question 15

Right hemisphere of brain

Answer 15

non-dominant hemisphere (usually the right brain in right-handed people) processes information in a visual-spatial, emotional, gestalt, holistic manner

Question 16

Left hemisphere of brain

Answer 16

dominant hemisphere (usually the so-called left brain in right-handed people) processes information in an analytic, sequential, linear fashion

Question 17

Frontal lobe

Answer 17

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.

Question 18

The parietal lobes

Answer 18

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.

Question 19

The temporal lobes

Answer 19

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.

Question 20

The occipital lobes

Answer 20

associated with vision and visual memory

Question 21

The Corpus Callosum

Answer 21

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).

Question 22

The Cingulum

Answer 22

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.

Question 23

The Median Forebrain Bundle

Answer 23

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.

Question 24

The Periventricular System

Answer 24

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.

Question 25

Mesolimbic and Mesocortical Tracts

Answer 25

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).

Question 26

Nuclei

Answer 26

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.

Question 27

hippocampus

Answer 27

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.

Question 28

Neurotransmitters are separated into three groups:

Answer 28

cholinergics, amino acids, and biogenic amines

Question 29

Cholinergics –

Answer 29

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.

Question 30

Amino Acids –

Answer 30

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.

Question 31

feduciary duty

Answer 31

the legal responsibility to act solely in the best interest of another party

Question 32

Beneficence

Answer 32

is defined as an act of charity, mercy, and kindness with a strong connotation of doing good to others including moral obligation.

Question 33

Nonmaleficence

Answer 33

is the obligation of a physician not to harm the patient

Question 34

therapeutic alliance/communication techniques

Question 35

medical mimics of psych disorders

Answer 35

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

Question 36

General overview of Hildegard Peplau's Interpersonal relations in nursing

Answer 36

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

Question 37

Skills of MH nurse per Peplau

Answer 37

The skills of the psychiatric mental health nurse include observation, interpretation, and intervention

Question 38

Peplau proposed an approach in which nurses are both _____ and _____ in therapeutic conversations.

Answer 38

participants and observers

Question 39

Peplau feels psych nurse should observe...

Answer 39

the behavior not only of the client but of themselves. This self-awareness on the part of the nurse is essential in keeping the focus on the client, as well as keeping the social and personal needs of the nurse out of the nurse-client relationship.

Question 40

Peplau’s most universal contribution to the everyday practice of PMH-APRNs was...

Answer 40

...her application of Sullivan’s theory of anxiety to nursing practice. She described the effects of different levels of anxiety (mild, moderate, severe, and panic) on perception and learning. She promoted interventions to lower anxiety, with the aim of improving clients’ abilities to think and function at more satisfactory levels.

Question 41

Peplau's phases of therapeutic nurse/pt relationship

Answer 41

1. Orientation (problem defining) 2. Identification (select appropriate prof. assistance; pt starts to feel belonging & capability 3. Exploitation (interview techniques; pt integral part of plan) 4. Resolution (terminate prof. relationship)

Question 42

Harry Stack Sullivan’s Interpersonal Theory

Answer 42

The purpose of all behavior is to get needs met through interpersonal interactions and to decrease or avoid anxiety. He defined anxiety as any painful feeling or emotion that arises from social insecurity or prevents biological needs from being satisfied. Coined the term security operations to describe measures the individual employs to reduce anxiety and enhance security. Collectively, all of the security operations an individual uses to defend against anxiety and ensure self-esteem make up the self-system.

Question 43

Sullivan definition of personality

Answer 43

Sullivan (1953) defined personality as behavior that can be observed within interpersonal relationships. This premise led to the development of his interpersonal theory.

Question 44

Sullivan vs Freud

Answer 44

There are many parallels between Sullivan’s notion of security operations and Freud’s concept of defense mechanisms. Both are processes of which we are unaware, and both are ways in which we reduce anxiety. However, Freud’s defense mechanism of repression is an intrapsychic activity, whereas, Sullivan’s security operations are interpersonal relationship activities that can be observed.

Question 45

What treatment is Sullivan's interpersonal theory good for?

Answer 45

Sullivan's interpersonal theory provides the theoretical basis for interpersonal psychotherapy (IPT) for depression and schizophrenia. Interpersonal theory proposes that depression develops most often in the context of adverse events, particularly interpersonal loss. (Tasman 2008) He also wrote on techniques and approaches on psychiatric interview.

Question 46

What's interpersonal psychotherapy?

Answer 46

Sullivan & Meyer an effective short –term therapy he assumption is that psychiatric disorders are influenced by interpersonal interactions and the social context. The goal of interpersonal psychotherapy is to reduce or eliminate psychiatric symptoms (particularly depression) by improving interpersonal functioning and satisfaction with social relationships

Question 47

What does the PMH-APRN/therapist do in interpersonal psychotherapy?

Answer 47

Treatment is predicated on the notion that disturbances in important interpersonal relationships (or a deficit in one’s capacity to form those relationships) can play a role in initiating or maintaining clinical depression identifies the nature of the problem to be resolved and then selects strategies consistent with that problem area.

Question 48

3 phases of interpersonal therapy

Answer 48

beginning, middle, & end

Question 49

4 problem areas in interpersonal therapy

Answer 49

grief, role transition, role dispute, or interpersonal deficits

Question 50

Beginning stage of interpersonal therapy

Answer 50

1-3 sessions focuses on identifying the interpersonal challenge area to work on relationships/medical/therapy hx

Question 51

Middle stage of interpersonal therapy

Answer 51

session 4-14 focus on addressing the challenge area: grief, role transition, role dispute, or interpersonal deficits Find link between this challenging area and your mood symptoms alternative ways to handle interpersonal challenges, identify new ones communication and decision analysis practice in real life

Question 52

End stage of interpersonal therapy

Answer 52

final 2-3 sessions reviewing your progress, focusing on role transitioning related to the end of therapy

Question 53

touch as a therapeutic communication technique

Answer 53

The use of touch may only be considered after taking in the client's social, cultural, and moral views into account. It should not be the first approach taken by the PMH-APRN in clinical situations.

Question 54

therapeutic communication techniques

Answer 54

1. silence 2. accepting (ex. nod head) 3. give recognition (ex. "I noticed you combed your hair) 4. give information (tell schedule) 5. offer self (I'll sit w/ you x15 min) 6. broad openings (where would you like to start) 7. general leads (and then?) 8. place event in sequence (Was that before or after...?) 9. observations (I sense that you...) 10. describe perceptions (Describe what you are hearing) 11. comparison (Has this happened before?) 12. reflection (Are you wondering if...?) 13. exploring (Tell me more about that.) 14. seek clarification 15. present reality (I am your nurse, this is a hospital) 16. voice doubt (I find that hard to believe. ) 17. verbalize the implied 18. attempt to translate into feelings (Client: I might as well be dead. Nurse: Is it your feeling that no one cares?) 19. encourage action plan (How might you handle this next time?) 20. summarize

Question 55

Transference

Answer 55

Transference is a phenomenon in psychology characterised by unconscious “redirection of feelings” between people. It can occur both in everyday life and also in the therapy room. One example of how it can happen is when a person mistrusts another because the other resembles, say, an ex-spouse, in manners, appearance, or demeanour. Ex Amanda was undoubtedly transferring feelings of nervousness and fear of disapproval to her relationship with her partner when she responded to him as if he were her father, with whom she is likely to have had unresolved issues.

Question 56

projection

Answer 56

Projection, also an unconscious process like transference, is considered a defence mechanism whereby intolerable feelings or thoughts are externalised and attributed to others

Question 57

countertransference

Answer 57

countertransference is constituted by the therapist’s emotional reactions in response to the client’s transference and projective identifications. More generally, it can refer to a therapist’s emotional entanglement with a client ex when a therapist thinks their client has a similar personality to someone from their personal life, and in response to that thought, they treat them like they might treat the person they know.

Question 58

peplaus model of nurse-client relationship

Answer 58

alleviate suffering, find solutions to problems, explore ways to increase quality of life, and advocate

Question 59

how does peplaus model of nurse-client relationship facilitate forward movement for the relationship

Answer 59

boundary management, independent problem solving, and decision making that promotes autonomy

Question 60

Erik Erikson Ego Theory: Central theme development of ego identity

Answer 60

8 stages of life throughout lifespan, results in success or unsuccessful outcomes and can affect your progression to the next stage of life. Children in the initiative vs guilt respond best if they actively ask questions and participate, older adults respond to a life review strategy that focuses on integrity of their life. Individual responsibility and capacity to improve ones function are addressed. At each stage people experience a conflict that serves as a turning point

Question 61

Erik Erikson Trust vs Mistrust 0-1 year

Answer 61

ability to trust, gain confidence and security and feel secure even when threatened. Unsuccessful develops inability to trust, sense of fear, can heighten insecurities and lead to mistrust. Hope vs fear, suspicion.

Question 62

Erik Erikson Autonomy vs shame/doubt 1-3 year

Answer 62

Assert independence by walking away from mother, picking what to wear, dressing self, what toy to play with. If encouraged and supported increased independence, helps them feel confident, learn why they need to ask for help. If criticized or not given the opportunity they lead to feeling inadequate in ability to survive, lack independence and self confidence/esteem, dependent on others, feel shame or doubt in their abilities. Will vs shame.

Question 63

Erik Erikson Initiative vs guilt 3-6 years

Answer 63

assert themselves more, plan activities, make up games, plan activities with others. If supported they feel secure in leading others and develop sense of initiative. If criticized or controlled they develop sense of guilt and shame, feel like a nuisance to others and be a follower. Purpose vs inadequacy

Question 64

Erik Erikson Industry vs inferiority 6-puberty

Answer 64

sense of pride in accomplishments. Initiate projects, see them through until completion, and feel good about what accomplished. Teachers at this time play increased role in childs development. If encouraged they feel confident, if restricted they feel inferior, doubting their abilities. Competence vs inferiority

Question 65

Erik Erikson Identity role vs confusion: Adolescents

Answer 65

more independent, looking more into future toward career, housing, relationships. Being to explore possibilities and form own identity. If hindered this leads to confusion on sense of who they are. Fidelity vs rebellion

Question 66

Erik Erikson Intimacy vs isolation: young adulthood

Answer 66

being to share ourselves more intimately w/ others. explore relationships leading towards long term commitments, leads to comfortable relationships and sense of commitment, safety and care within relationship. Avoiding intimacy leads to isolation, loneliness, and even depression. Love vs isolation.

Question 67

Erik Erikson Generativity vs stagnation: Middle adulthood

Answer 67

establish careers, settle down, begin a family, sense of being part of bigger picture. Give back to society by raising children, involved in community/work. If failed feels stagnant. Care vs unproductive.

Question 68

Erik Erikson Ego integrity vs Despair: late adulthood

Answer 68

slow down on productivity, explore life as retired person, contemplate accomplishments and ability to develop integrity if we see ourselves leading successful life. If see life unproductive, feel guilt about past or life goals not met, become dissatisfied and develop despair, leads to hopelessness and depression. Wisdom vs dissatisfaction

Question 69

justice & example

Answer 69

tx everyone equally ex: blind pt a consent form in Braille or verbally read aloud

Question 70

nonmaleficence ex

Answer 70

if pt having rxn to med, stop it to prevent further harm

Question 71

fidelity and ex

Answer 71

loyal, faithful, honor commitments ex: not covering up errors, stay w/ pt in time of need as stated

Question 72

veracity and ex

Answer 72

honest if pt asks about SE, be open about all potential SE

Question 73

SAD PERSONS suicide risk scale

Answer 73

S- sex (male) A- Age (<20 or > 44 yrs) D- depression P - previous SA E- ETOH use R- rational thinking loss (psychosis) S- social support lacking O- organized suicide plan N- no spouse S- sickness 1 point each 3-4 pt = closely monitor 6-5 pt= strongly consider hospital 7-10= hospital

Question 74

loose associations

Answer 74

thought process illogical difficult to follow shifting of ideas

Question 75

tangential

Answer 75

thought process client wanders from subject to unrelated topic and unable to come back to original topic

Question 76

word salad

Answer 76

completely nonsensical combo of words

Question 77

neologisms

Answer 77

made up words

Question 78

thought processes that usually indicate schizophrenic disorders

Answer 78

loose associations, tangential, word salad, neologisms

Question 79

circumstantial thought

Answer 79

get lost in details but eventually return back to original topic

Question 80

flight of ideas

Answer 80

often in mania pressure speech, rapid topic changes; topics may be associated but in strange way

Question 81

confabulation

Answer 81

thought process often in dementia fabrication of info to fill in for memory gaps

Question 82

concrete thought is common in which clients

Answer 82

schizophrenic disorders not pathological when in children who may develop abstract thought in early adolescence

Question 83

illusion

Answer 83

common in delirium, misinterpretations of true stimuli

Question 84

most common type hallucination

Answer 84

auditory

Question 85

what do more unusual hallucinations (visual, gustatory, olfactory, tactile) often indicate

Answer 85

medical illness or substance intox/withdrawal

Question 86

hypnagogic and hypnopompic hallucinations

Answer 86

false sensory perceptions while falling sleep and while awakening from sleep respectively

Question 87

perceptual disturbances that are considered within normal range of experience and not pathological unless cause undue distress or problems w/ ADLs

Answer 87

hypnagogic & hypnopompic hallucinations, derealization, & depersonalization

Question 88

reaction formation (defense mechanism)

Answer 88

attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts/behaviors ex: boy teases girl he likes

Question 89

DMS-5 definition of mental health disorder

Answer 89

a health condition characterized by significant dysfunction in an individuals cognitions or behaviors that reflect a disturbance in psychological, biological, or developmental process underlying mental functioning

Question 90

Freud's Id

Answer 90

seeks pleasure, avoids pain. Drives wishes, desires, fantasies. No real perception of reality. Uses primary process.. seeks to satisfy needs

Question 91

Two major instincts of Freud's Id

Answer 91

Eros- pleasure-seeking urges (ex sexual) Thanatos- motivates people to use aggressive urges to destroy

Question 92

Freud's ego

Answer 92

aware of reality & understands behaviors have consequences. uses secondary processes - perception, recognition, judgment, memory, reasoning, problem-solving, impulse control, and formation of relationships

Question 93

Freud's superego

Answer 93

contains morals and values and is developed from our parents through childhood and society. contains rules of right and wrong

Question 94

Freud's Id vs ego vs superego

Answer 94

the id is the impulsive part of your personality that is driven by pleasure and repulsed by pain, the superego is the judgmental and morally correct part of your personality, and the ego is the conscious part of your personality that mediates between the id and the superego and makes decisions.