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Summary

Learning OutcomeAnalyse concepts of neuroscience and psychopathology in relation to mental health and illness/wellnessCriteria for disorders DSM5:Schizophrenia + Psychotic DisordersDefining Schizophrenia:Schizophrenia is one of the most severe mental disorders and is characterised by a major disturb...

Description

Learning Outcome Analyse concepts of neuroscience and psychopathology in relation to mental health and illness/wellness

Criteria for disorders DSM5:

Schizophrenia + Psychotic Disorders Defining Schizophrenia: Schizophrenia is one of the most severe mental disorders and is characterised by a major disturbance in: ● ● ● ●

Thought Perception Cognition Psychological functioning

Diagnosing Schizophrenia: The schizophrenia spectrum is defined by abnormalities in one or more of the following 5 domains: • Delusions: o False beliefs that are inconsistent with one’s social/cultural/religious beliefs and thoughts cannot change despite evidence • Hallucinations: o Vivid involuntary perceptions that are experiences as “normal” o Usually experienced as voices – are perceived as distinct from the person's own thoughts • Disorganised thinking (speech) o Person switches topic erotically o Response to question are unrelated o Speech incoherent or disorganised • Grossly disorganised or abnormal motor behaviour o Range of agitation to childlike “silliness” o Can leads to difficulties in performing activities of daily living • Negative symptoms o Diminished emotional expression or avolition Two or more of these need to be present for a significant period of time for one month within 6 months – At LEAST one symptom must be one of the first 3.

Depression Defining Depression: Depression is a mood disorder which can be classified into to two sub categories: Major depression (major depressive disorder) or persistent depressive disorder. Major Depressive disorder: • Is when someone is experiencing persistent symptoms which interfere with: ○ Work ○ School ○ Home Life ○ Daily Activities Persistent Depressive Disorder • Expressing milder symptoms • Symptoms have lasted for at least 2 years. • More common than major depression disorder. • It is seen as an exaggeration of ordinary happiness – the person may feel/complain of: o Feeling low o Feeling hopeless o Fatigue o Decreased concentration o Decrease/increase of sleep or appetite

Diagnosing A Major Depressive Episode Five or more of the symptoms listed have been present during the same 2 week period. The patient also must experience a change from previous functioning. At least one of the symptoms is either 1. Depressed mood 2. Loss of interest of pleasure. ● ●

● ● ● ● ● ● ●

Depressed mood most of the day – nearly every day ○ Indicated by subjective admission from individual or seen by others Noticeable decrease in interest or pleasure in all/most of all activities most of the day – nearly everyday ○ Indicated by subjective admission from individual or seen by others Significant weight loss when not dieting or weight gain. Or decrease or increase in appetite nearly every day Insomnia (inability to sleep) or Hypersomnia (excessive sleeping) Psychomotor agitation (engage in movements that serve no purpose) or retardation nearly every day Fatigue or loss of energy everyday Feelings of worthlessness or excessive or inappropriate guilt (may be delusional) nearly everyday Diminished ability to think or concentrate or inductiveness Recurrent thoughts of death/suicidal ideation without specific plan or a suicide attempt or a specific plan for committing suicide.

Diagnosing a Major Depressive Episode With Mixed Features Full criteria met for a major depressive episode and at least three of the following manic/hypomanic symptoms are present during the majority of days of the current or most recent episode of depression: ● ● ● ● ● ● ●

Elevated/expansive mood Inflated self-esteem or grandiosity More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Increased energy/goal directed activity Increased or excessive involvement in activities that may cause harm Decreased need for sleep/feeling rested without sleep

Features of Major Depressive Disorder – Appearance/behaviours: • •

Characterised by at least two features: o  Depressed mood/loss of interest/loss of pleasure  And 5 other symptoms: o o o o o o o o ●

Fatigue/lack  of energy Anhedonia  - i nability to feel pleasure in normally pleasurable activities. Negative  thinking Psychomotor  agitation/retardation Disturbed  sleep Feelings  of worthlessness/excessive guilt Difficulty  concentrating Recurring  thoughts of death/suicide

May have alterations in:

Appearance:

● ●

Wears soiled clothes/unwashed hair/ lost interest Possible significant weightless

Behaviour/mood:

● ● ● ● ●

Move slowly Less effort in tasks Mood worse in morning Pessimistic thoughts about the day Withdraw from socially and emotionally from contact with others

Thinking

● ● ● ● ● ● ●

Think slowly Focus more on themselves than others (selfish) – EGOCENTRIC Think are incompetent/unlovable/failure/uncaring/unhelpful Inappropriate guilt Poor concentration/poor memory – difficulty reading or focusing on problem Focuses on negative thoughts and ideas of exclusion Delusions/Hallucinations – usually manifest as negative. Voices telling people they are a failure/incompetent/evil etc

Sleep:

● ●

May appear tired/older looking Difficulty getting to sleep/wake up too soon/difficulty sleeping/hypersomnia

BIPOLAR: DSM 5 Manic Episode: •

Abnormally

& persistently elevated/expansive/irritable mood

•

Abnormally

& persistently increased goal directed activity lasting one week

•

Present

most of the day/nearly everyday o I nflated self-esteemed o P  sychomotor agitation o D  ecreased need for sleep

•

Impairment

•

This

in social or occupational functioning

episode is not attributable to the effects of substances (drugs/alcohol)

Characteristics of Mania:

Characterised by four factors:

● ● ● ●

Increased activity Impulsivity Disinhibition – self conscious Inflated ideas

People with mania may display:

● ● ● ● ●

Wear colourful clothing Euphoric – High feeling/excited Sexually hyperactive Tendency to start and leave unfinished activities Become disorganised – incapable in performing tasks Mood can change between optimistic/light hearted to irritable/aggressive Thoughts become rapid and varied – speech may contain puns/jokes/rhymes and irrelevancies

● ●

Thoughts/ideas are lost and become unable to concentrate

●

●

●

Hypomanic Episode:

● ●

Auditory and visual hallucinations – negative voices in negative mood vs positive voices in positive mood Delusions – Persons thinks they are novel/opinions right/outstanding genius – believe extremely wealthy/powerful and become irritable if thoughts challenge Exhaustion

As above but 4 days only Not marked impairment or occupational functioning

Bipolar 1: •

Defined

•

Mixed

by one or more manic or mixed episode

episode has features of mania and depression happening simultaneously o A  gitation o A  nxiety o F  atigue o I rritability

•

More

serious than 2

•

Cortisol

and thyroid hormone levels have been found to be elevated in clients during manic episodes and circadian rhythm

Bipolar 2: •

Characterised

•

Less

by hypomania and a depressive episode

common

Psychopathology: Trauma: Definition: Adopts a principle that only a consumer who has experienced trauma can truly understand the journey of healing- unique skills of resilience have helped patients survive trauma are emphasised within a strengths based framework. Traumatic incidents and their influence on mental health ● Crisis ● Loss ● Grief Often result in significant destabilisation and chaos for many people. Events such as: ● Loss of life ● Serious injury ● Relationship breakdown ● Sudden unemployment All may overwhelm a person, particularly if someone already lives with challenges of mental illness. Events such as these may result in the individual being profoundly affected and require skilled support to negotiate the days, weeks and months that may follow. Developmental crisis:

Major transitions between life stages, cause periods of significant and prolonged stress e.g. adolescence, marriage, retirement.

Situational crisis:

Situation specific or culturally specific e.g. loss of employment, loss of home, accidents, divorce.

Social crisis:

Arising from abuse of drugs or alcohol, criminal activity or violence.

Complex crises:

not a part of everyday experience or shared accumulated knowledge ● Severe mental illness ● Diagnosis of life threatening physical illness ● Needing to seek asylum from civil war, ethnic cleansing or religious persecution

A nurses role in a crisis: A person reaches crisis when their coping and resilience fails and have been overwhelmed. As nurses we can help at a time of increased vulnerability and need. Skills: -

Ability to remain calm Regulate own emotions Think carefully about how you would settle yourself in distress Speaking gently and softly Bringing your attention to your breath Speak in slow measured tones Put aside prejudice and unconscious bias

Neuroscience: Monoamine hypothesis: Mood disorders ● Related to serotonin levels and other neurotransmitters ● Low serotonin and noradrenaline ● Rate of serotonin synthesis in depressed people can be explained by reduction of serotonin synthesis ● SNRIs and SSRIs increase the monoamines available Brain derived neurotrophic factors: Mood disorders ● Supports the survival of existing neurons and encourages growth and differentiation of new neurons and synapses ○ Dysfunction of BDNF may affect monoamine systems through loss of neuron synapses Dopamine hypothesis: Schizophrenia Suggests that schizophrenia results from excess activity at the dopamine synapses in certain areas of the brain ● People with schizophrenia have a greater number of D2 receptors occupied at the prefrontal cortex. The more receptors occupied, the greater the cognitive impairment ○ D2 antagonist drugs can be effective as antipsychotics e.g. haloperidol and clozapine Glutamate hypothesis: Schizophrenia Dopamine inhibits glutamate release OR glutamate stimulates neurons that inhibit dopamine release ● Increased dopamine produces the same effect as decreased glutamate Serotonin Hypothesis: Schizophrenia ● Antagonism at serotonin 5ht2 receptors is important to reduce psychotic symptoms and mitigate the development of extrapyramidal effects

Evaluate legal issues which impact on clients and service providers within the context of mental health

Chapter 4 : Professional, legal and ethical issues

Standards of Practice For Mental Health Nursing: 1. Acknowledges

Maori as tangata whenau of Aotearoa New Zealand is knowledge of the place of Te Tiriti o Waitangi in nursing care and acknowledges the diversity of values, belief systems and practices of people and cultural groups in New Zealand society

2. Establishes

Collaborative partnerships as the basis for therapeutic relationships. Involves building on strengths, holding hope and enhancing resilience to promote recovery + wellbeing

3. Provides

Nursing care that reflects contemporary mental healthcare and standards

4. Promotes

Mental health and well-being in the context of their practice.

5. Is committed to ongoing

And contributes to the continuing development of theory and practice in mental health nursing.

education 6. Undertakes practice

But reflects relevant policies/legislation/ethical stands and codes of conduct.

Protective mechanism in mental health legislation: ●

●

● ●

Mental health acts included measures aimed at counterbalancing the power of legislation to detain individuals and impose compulsory treatment to not completely strip all health and human rights. Protective mechanisms include: ○ Right to legal advocacy ○ Processes of appeal/review ○ Appointment of statutory officials to oversee the operation of legislation ○ Complaints procedures/access to review tribunals A person subject to an assessment should be advised of the assessment in the presence of a member of family/caregiver/person concerned of welfare. 3 times this did not happen. As a result nurses acting in the duly authorised officer (DAO) role must now be vigilant that a third party is an appropriate person.

Definition of Mental disorder as defined by section 2 of the Mental Health Act: ●

●

●

An abnormal state of mind (whether of a continuous or intermittent nature), characterised by delusions, or by disorders of mood or perception of volition or cognition of such a degree that it: a. Poses a serious danger to the health and safety of that person or of others… OR b. Seriously diminished the capacity of that person to take care of himself or herself Section 4 of the Act specifies that Act cannot be invoked solely by reason of the persons: ○ Political, religious or personal beliefs ○ Sexual preferences ○ Criminal or delinquent behaviour ○ Intellectual disability Section 5 of the Act requires powers be exercised under the act with respect for the cultural identity of the client

Human rights and mental legislation: ●

Clients with mental illness have been historically subject to discriminatory laws, systemic loss of rights in legislation and breaches of those rights granted to them under mental health and other legislation.

Law and Mental Health Legislation: Mental Health (complementary Assessment and Treatment) Act 1992 Guidelines:

Civil Commitment/Committal: ● ● ●

●

Civil commitment is based on ethical justification of paternalism – means that the harm of restraining clients autonomy is justified buy the benefits to the person restrained. Civil commitment provides states with two powers to restrain the autonomy of individuals first is Parents patriae and second is police power Parens Patraie Power: ○ Autonomy is restrained out of protective concern for the individual ○ Eg person who is suicidal or is severe self neglect. Parens patriae allows the state to act “like a parent” Police Power: ○ Power of the state is able to restrain autonomy of individuals if their behaviour is considered a risk to others. ○ Eg. Person who might harm another because of a false belief that others mean to harm them. Both parens patriae and police powers may apply if the individual is considered to be a risk to both themselves and to others

Consequences of civil commitment: Individual either physically removed from society by being hospitalised Or conditions placed on their choices as a member of society – conditions are mental healthcare(medication) or living at a particular location

Assessment and Treatment

Section 8a: Application for assessment

●

● ●

Anyone may fill the assessment who believes an individual may be suffering from a mental health disorder and fill in an application requesting the Director of Area Mental Health services for an assessment Person who fills out form is called Applicant Person who is subject to application is called person Conditions must be met: ● Applicant is 18 years + ● Applicant has seen in the past 3 days ● States the grounds of reason why that individual is suffering from a mental disorder

Section 8b: Medical practitioner certificate to accompany application for assessment

● ●

Health professional must examine the person Identify reasonable grounds for believing that the person may be suffering from a mental disorder, issue the certificate.

Section 9: Assessment and examination to be arranged and conducted. Information of patient rights (DAO)

●

If the DAO believes an individual may be mentally disordered and may benefit from a compulsory assessment, they have the power to arrange assessment and examination. The DAO provides information to the individual and family of time and place of assessment and the psychiatrist name. They may also assist with transport to and from the examination.

Section 10: Certificate of preliminary assessment (record of findings)

●

Section 11: Further assessment and treatment for 5 days

Section 12: Certificate of further assessment (14 days)

●

It should state: he or she carefully considered the statutory definition of mental disorder + the patient is not mentally disordered or there are reasonable grounds for believing the proposed patient is mentally disordered and it is desired the patient undergo further assessment and treatment.

The psychiatrist concludes from his assessment (S10) the individual has a mental disorder and must remain under the MHA for a further 5 days for assessment and treatment. ● This may be done at the patients residence or at a nominated place ● If the health practitioner believes that further assessment cannot be treated as outpatient direct the patient be admitted and detained in a specified hospital for assessment throughout 5 days ● The patient may be granted absence from hospital

●

Section 16 of the MHA allows the patient to request a judge to review the individuals condition while the assessment process is in progress. If the judge is ‘satisfied’ that the

individual is fit to be released from compulsory status, the judge discharges the person forthwith and brings the process to an end. If not, the process of assessment continues.

Section 13: Further assessment and treatment for 14 days

●

Fit or not fit

Section 16: Review of patient’s condition by Judge

●

Section 16 of the MHA allows the patient to request a judge to review the individuals condition while the assessment process is in progress. If the judge is ‘satisfied’ that the individual is fit to be released from compulsory status, the judge discharges the person forthwith and brings the process to an end. If not, the process of assessment continues.

Section 29: Community Treatment Orders:

●

Community treatment order shall require the patient to attend at the patients place of residence or at some other place specified in order. If for whatever reason the clinician believes the patient cannot be in community, they: ○ Be treated as an inpatient for a period of 14 days

Section 14: Certificate of final assessment

●

Section 30: Inpatient Orders

● ●

Requires that every inpatient shall require the continued detention of the patient in the hospital specified in the order. If by any reason the clinician decides the patient may be treated as community then: ○ First that the patient be discharged from hospital and: ○ Direct the patient to attend at the patients place of residence

Legislative patient rights: ● ● ● ● ● ● ● ● ● ● ● ●

General rights to information (S64) Respect for cultural identity, etc. (S65) Right to treatment (S66) (Not right to refuse under the MHA) Right to be informed about treatment (S67) Further rights in case of visual impairment or audio recording (S68) Right to independent psychiatrist advice (S69) Right ...