Psychiatric mental health nursing videbeck 7th edition pdf

1. 200 words-- Elaborate on the mental illness of schizophrenia. State how this disease related to the book and The Hate You Give and the assigned character Starr.

2. 150 words-- What is the epidemiology of this disease? Speak on the population distribution, health determinants, risk factors, and specific population that is impacted.

3. 150 words--What is the prevalence rate of the disease within the US?

4. 150 words--What is the etiology of the disease?

5. 200 words--What pharmacological treatments are available for this disease? Provide specific instructions for the patient and provider for this medication. Is there a risk associated with each medication?

6. 150 words-- What adverse effects are associated with each individual medication?

7. 150 words-- What nonpharmacological treatment options are available?

8. 150 words-- What primary secondary and tertiary prevention are available for patients who diagnosed with schizophrenia?

9. 200 words-- Locate a research article pertaining to bipolar disorder as it pertains to public and community health nursing summarize this article in 200 words or more.

10. 200 words---Locate a research article pertaining to schizophrenia disorder as it pertains to the medias perception of this disease, what role do community and public health nurses play in minimizing the negative stigma surrounding this mental illness, provide examples?

Please respond to the questions in APA 7th format. The attached textbook MUST be used to formulate a response. In addition to the textbook please include 5 scholarly articles. Each section Must have subheadings.

Psychiatric–Mental Health Nursing

Seventh Edition

SHEILA L. VIDEBECK, PhD, RN Professor Emeritus

Des Moines Area Community College Ankeny, Iowa

Illustrations by Cathy J. Miller

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7th edition Copyright © 2017 Wolters Kluwer

Copyright © 2014, 2011, 2008 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2006, 2004, 2001 by Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via e-mail at permissions@lww.com, or via our website at lww.com (products and services).

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Library of Congress Cataloging-in-Publication Data Names: Videbeck, Sheila L., author. | Miller, C. J. (Cathy J.), illustrator. Title: Psychiatric-mental health nursing / Sheila L. Videbeck ; illustrations by Cathy J. Miller. Description: Seventh edition. | Philadelphia, PA : Wolters Kluwer, [2017] | Includes bibliographical references and index. Identifiers: LCCN 2016018623 | eISBN 9781496355911 Subjects: | MESH: Psychiatric Nursing | Mental Disorders—nursing | Nurse-Patient Relations Classification: LCC RC440 | NLM WY 160 | DDC 616.89/0231—dc23 LC record available at https://lccn.loc.gov/2016018623

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

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This work is no substitute for individual patient assessment based upon health care professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data, and other factors unique to the patient. The publisher does not provide medical advice or guidance, and this work is merely a reference tool. Health care professionals, and not the publisher, are solely responsible for the use of this work, including all medical judgments and for any resulting diagnosis and treatments.

Given the continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and health care professionals should consult a variety of sources. When prescribing medication, health care professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used, or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law, or otherwise, or from any reference to or use by any person of this work.

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Reviewers

Josephine M. Britanico, MSN, RN, PNP, PhD(c) Assistant Professor of Nursing Borough of Manhattan Community College/CUNY New York, New York

Nicole Brodrick, DNP, RN, NP, CNS Assistant Professor University of Colorado Aurora, Colorado

Juliana DeHanes, MSN, RN, CCRN Nursing Faculty/Course Coordinator Middlesex County College Nursing Program Edison, New Jersey

Debbi Del Re, MSN, RN Mental Health Nursing Instructor University of St. Francis Joliet, Illinois

Kimberly Dever, MSN, RN Instructor University of Central Florida College of Nursing Orlando, Florida

Diane E. Friend, MSN, RN, CDONA/LTC Assistant Professor of Nursing Allegany College of Maryland Cumberland, Maryland

Melissa Garno, EdD, RN Professor, BSN Program Director Georgia Southern University Statesboro, Georgia

Barbara J. Goldberg, MS, RN, CNS Assistant Professor Onondaga Community College Syracuse, New York

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Judith E. Gunther, MSN, RN Associate Professor of Nursing Northern Virginia Community College Springfield, Virginia

Lois Harder, RN Senior Lecturer West Virginia University Morgantown, West Virginia

Tina L. Kinney, MSN, RNC, FNP-BC, WHNP-BC Nursing Instructor Lutheran School of Nursing St. Louis, Missouri

Lynne S. Mann, MN, RN, CNE Assistant Professor Charleston Southern University Charleston, South Carolina

J. Susan G. Van Wye, MSN, RN, ARNP, CPNP Adjunct Nursing Faculty Kirkwood Community College Cedar Rapids, Iowa

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Preface

The seventh edition of Psychiatric–Mental Health Nursing maintains a strong student focus, presenting sound nursing theory, therapeutic modalities, and clinical applications across the treatment continuum. The chapters are short, and the writing style is direct in order to facilitate reading comprehension and student learning.

This text uses the nursing process framework and emphasizes therapeutic communication with examples and pharmacology throughout. Interventions focus on all aspects of client care, including communication, client and family education, and community resources, as well as their practical application in various clinical settings.

In this edition, all DSM-5 content has been updated, as well as the Best Practice boxes, to highlight current evidence-based practice. New special features include Concept Mastery Alerts, which clarify important concepts that are essential to students’ learning, and Watch and Learn icons that alert students to important video content available on . Cultural and Elder Considerations have special headings to help call attention to this important content. The nursing process sections have a new design to help highlight this content as well.

ORGANIZATION OF THE TEXT Unit 1: Current Theories and Practice provides a strong foundation for students. It addresses current issues in psychiatric nursing as well as the many treatment settings in which nurses encounter clients. It thoroughly discusses neurobiologic theories, psychopharmacology, and psychosocial theories and therapy as a basis for understanding mental illness and its treatment.

Unit 2: Building the Nurse–Client Relationship presents the basic elements essential to the practice of mental health nursing. Chapters on therapeutic relationships and therapeutic communication prepare students to begin working with clients both in mental health settings and in all other areas of nursing practice. The chapter on the client’s response to illness provides a framework for understanding the individual client. An entire

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chapter is devoted to assessment, emphasizing its importance in nursing.

Unit 3: Current Social and Emotional Concerns covers topics that are not exclusive to mental health settings. These include legal and ethical issues; anger, aggression, and hostility; abuse and violence; and grief and loss. Nurses in all practice settings find themselves confronted with issues related to these topics. Additionally, many legal and ethical concerns are interwoven with issues of violence and loss.

Unit 4: Nursing Practice for Psychiatric Disorders covers all the major categories of mental disorders. This unit has been reorganized to reflect current concepts in mental disorders. New chapters include trauma and stressor-related disorders; obsessive–compulsive disorder and related disorders; somatic symptom disorders; disruptive disorders; and neurodevelopmental disorders. Each chapter provides current information on etiology, onset and clinical course, treatment, and nursing care. The chapters are compatible for use with any medical classification system for mental disorders.

PEDAGOGICAL FEATURES Psychiatric–Mental Health Nursing incorporates several pedagogical features designed to facilitate student learning:

• Learning Objectives focus on the students’ reading and study. • Key Terms identify new terms used in the chapter. Each term is

identified in bold and defined in the text. • Application of the Nursing Process sections, with a special design in

this edition, highlight the assessment framework presented in Chapter 8 to help students compare and contrast various disorders more easily.

• Critical Thinking Questions stimulate students’ thinking about current dilemmas and issues in mental health.

• Key Points summarize chapter content to reinforce important concepts. • Chapter Study Guides provide workbook-style questions for students

to test their knowledge and understanding of each chapter.

SPECIAL FEATURES • Clinical Vignettes, provided for each major disorder discussed in the

text, “paint a picture” of a client dealing with the disorder to enhance understanding.

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• Nursing Care Plans demonstrate a sample plan of care for a client with a specific disorder.

• Drug Alerts highlight essential points about psychotropic drugs. • Warning boxes are the FDA black box drug warnings for specific

medications. • Cultural Considerations sections highlight diversity in client care. • Elder Considerations sections highlight the key considerations for a

growing older adult population. • Therapeutic dialogues give specific examples of the nurse–client

interaction to promote therapeutic communication skills. • Client/Family Education boxes provide information that helps

strengthen students’ roles as educators. • Nursing Interventions provide a summary of key interventions for the

specific disorder. • DSM-5 Diagnostic Criteria boxes include specific diagnostic

information for the disorder. • Best Practices boxes highlight current evidence-based practice and

future directions for research on a wide variety of practice issues. • Self-Awareness features encourage students to reflect on themselves,

their emotions, and their attitudes as a way to foster both personal and professional development.

• Concept Mastery Alerts clarify important concepts that are essential to students’ learning and practice.

• Watch and Learn icons alert the reader to important resources available on to enhance student understanding of the topic.

ANCILLARY PACKAGE FOR THE SEVENTH EDITION

Instructor Resources The Instructor Resources are available online at http://thepoint.lww.com/Videbeck7e for instructors who adopt Psychiatric–Mental Health Nursing. Information and activities that will help you engage your students throughout the semester include:

• PowerPoint Slides • Image Bank • Test Generator

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http://thepoint.lww.com/Videbeck7e
• Pre-Lecture Quizzes • Discussion Topics • Written, Group, Clinical, and Web Assignments • Guided Lecture Notes • Case Studies

Student Resources Students who purchase a new copy of Psychiatric–Mental Health Nursing gain access to the following learning tools on using the access code in the front of their book:

• , highlighting films depicting individuals with mental health disorders, provide students the opportunity to approach nursing care related to mental health and illness in a novel way.

• NCLEX-Style Review Questions help students review important concepts and practice for the NCLEX examination.

• Journal Articles offer access to current research available in Wolters Kluwer journals.

• Online video series, Lippincott Theory to Practice Video Series includes videos of true-to-life clients displaying mental health disorders, allowing students to gain experience and a deeper understanding of these patients.

• Internet Resources provide relevant weblinks to further explore chapter content.

Practice Makes Perfect, and This Is the Perfect Practice. PrepU is an adaptive learning system designed to improve students’ competency and mastery and provide instructors with real-time analysis of their students’ knowledge at both a class and individual student level.

PrepU demonstrates formative assessment—it determines what students know as they are learning, and focuses them on what they are struggling with, so they don’t spend time on what they already know. Feedback is immediate and remediates students back to this specific text, so they know where to get help in understanding a concept.

Adaptive and Personalized

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No student has the same experience—PrepU recognizes when a student has reached “mastery” of a concept before moving him/her on to higher levels of learning. This will be a different experience for each student based on the number of questions he/she answers and whether he/she answers them correctly. Each question is also “normed” by all students in PrepU around the country—how every student answers a specific question generates the difficulty level of each question in the system. This adaptive experience allows students to practice at their own pace and study much more effectively.

Personalized Reports Students get individual feedback about their performance, and instructors can track class statistics to gauge the level of understanding. Both get a window into performance to help identify areas for remediation. Instructors can access the average mastery level of the class, students’ strengths and weaknesses, and how often students use PrepU. Students can see their own progress charts showing strengths and weaknesses—so they can continue quizzing in areas where they are weaker.

Mobile Optimized Students can study anytime, anywhere with PrepU, as it is mobile optimized. More convenience equals more quizzing and more practice for students!

There is a PrepU resource available with this book! For more information, visit http://thepoint.lww.com/PrepU.

This leading content is also incorporated into Lippincott CoursePoint, a dynamic learning solution that integrates this book’s curriculum, adaptive learning tools, real-time data reporting, and the latest evidence-based practice content into one powerful student learning solution. Lippincott CoursePoint improves the nursing students’ critical thinking and clinical reasoning skills to prepare them for practice. Learn more at www.NursingEducationSuccess.com/CoursePoint.

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http://thepoint.lww.com/PrepU
http://www.NursingEducationSuccess.com/CoursePoint
Acknowledgments

Many years of teaching and practice have shaped my teaching efforts and this textbook.

Students provide feedback and ask ever-changing questions that guide me to keep this text useful, easy to read and understand, and focused on student learning. Students also help keep me up to date, so the text can stay relevant to their needs. I continue to work with students in simulation lab experiences as nursing education evolves with advances in technology.

I want to thank the people at Wolters Kluwer for their valuable assistance in making this textbook a reality. Their contributions to its success are greatly appreciated. I thank Natasha McIntyre, Dan Reilly, Zach Shapiro, Helen Kogut, and Cynthia Rudy for a job well done once again.

My friends continue to listen, support, and encourage my efforts in all endeavors. My brother and his family provide love and support in this endeavor, as well as in the journey of life. I am truly fortunate and grateful.

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Brief Contents

UNIT 1 Current Theories and Practice

1. Foundations of Psychiatric–Mental Health Nursing 2. Neurobiologic Theories and Psychopharmacology 3. Psychosocial Theories and Therapy 4. Treatment Settings and Therapeutic Programs

UNIT 2 Building the Nurse–Client Relationship

5. Therapeutic Relationships 6. Therapeutic Communication 7. Client’s Response to Illness 8. Assessment

UNIT 3 Current Social and Emotional Concerns

9. Legal and Ethical Issues 10. Grief and Loss 11. Anger, Hostility, and Aggression 12. Abuse and Violence

UNIT 4 Nursing Practice for Psychiatric Disorders 13. Trauma and Stressor-Related Disorders 14. Anxiety and Anxiety Disorders 15. Obsessive–Compulsive and Related Disorders 16. Schizophrenia 17. Mood Disorders and Suicide 18. Personality Disorders 19. Addiction 20. Eating Disorders 21. Somatic Symptom Illnesses 22. Neurodevelopmental Disorders

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23. Disruptive Behavior Disorders 24. Cognitive Disorders

Answers to Chapter Study Guides

Appendix A Disorders of Sleep and Wakefulness

Appendix B Sexual Dysfunctions and Gender Dysphoria

Appendix C Drug Classification Under the Controlled Substances Act

Appendix D Canadian Drug Trade Names

Appendix E Mexican Drug Trade Names Glossary of Key Terms Index

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Contents

UNIT 1 Current Theories and Practice

1. Foundations of Psychiatric–Mental Health Nursing Mental Health and Mental Illness Diagnostic and Statistical Manual of Mental Disorders Historical Perspectives of the Treatment of Mental Illness Mental Illness in the 21st Century Cultural Considerations Psychiatric Nursing Practice

2. Neurobiologic Theories and Psychopharmacology The Nervous System and How it Works Brain Imaging Techniques Neurobiologic Causes of Mental Illness The Nurse’s Role in Research and Education Psychopharmacology Cultural Considerations

3. Psychosocial Theories and Therapy Psychosocial Theories Cultural Considerations Treatment Modalities The Nurse and Psychosocial Interventions

4. Treatment Settings and Therapeutic Programs Treatment Settings Psychiatric Rehabilitation and Recovery Special Populations of Clients with Mental Illness Interdisciplinary Team Psychosocial Nursing in Public Health and Home Care

UNIT 2 Building the Nurse–Client Relationship

5. Therapeutic Relationships Components of a Therapeutic Relationship Types of Relationships

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Establishing the Therapeutic Relationship Avoiding Behaviors that Diminish the Therapeutic Relationship Roles of the Nurse in a Therapeutic Relationship

6. Therapeutic Communication What is Therapeutic Communication? Verbal Communication Skills Nonverbal Communication Skills Understanding the Meaning of Communication Understanding Context Understanding Spirituality Cultural Considerations The Therapeutic Communication Session Assertive Communication Community-Based Care

7. Client’s Response to Illness Individual Factors Interpersonal Factors Cultural Factors

8. Assessment Factors Influencing Assessment How to Conduct the Interview Content of the Assessment Assessment of Suicide or Harm Toward Others Data Analysis

UNIT 3 Current Social and Emotional Concerns

9. Legal and Ethical Issues Legal Considerations Ethical Issues

10. Grief and Loss Types of Losses The Grieving Process Dimensions of Grieving Cultural Considerations Disenfranchised Grief Complicated Grieving Application of the Nursing Process

11. Anger, Hostility, and Aggression Onset and Clinical Course

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Related Disorders Etiology Cultural Considerations Treatment Application of the Nursing Process Workplace Hostility Community-Based Care

12. Abuse and Violence Clinical Picture of Abuse and Violence Characteristics of Violent Families Cultural Considerations Intimate Partner Violence Child Abuse Elder Abuse Rape and Sexual Assault Community Violence

UNIT 4 Nursing Practice for Psychiatric Disorders 13. Trauma and Stressor-Related Disorders

Posttraumatic Stress Disorder Etiology Cultural Considerations Treatment Elder Considerations Community-Based Care Mental Health Promotion Application of the Nursing Process

14. Anxiety and Anxiety Disorders Anxiety as a Response to Stress Overview of Anxiety Disorders Incidence Onset and Clinical Course Related Disorders Etiology Cultural Considerations Treatment Elder Considerations Community-Based Care Mental Health Promotion

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Panic Disorder Application of the Nursing Process: Panic Disorder Phobias Generalized Anxiety Disorder

15. Obsessive–Compulsive and Related Disorders Obsessive–Compulsive Disorder Cultural Considerations Application of the Nursing Process Elder Considerations

16. Schizophrenia Clinical Course Related Disorders Etiology Cultural Considerations Treatment Application of the Nursing Process Elder Considerations Community-Based Care Mental Health Promotion

17. Mood Disorders and Suicide Categories of Mood Disorders Related Disorders Etiology Cultural Considerations Major Depressive Disorder Application of the Nursing Process: Depression Bipolar Disorder Application of the Nursing Process: Bipolar Disorder Suicide Elder Considerations Community-Based Care Mental Health Promotion

18. Personality Disorders Personality Disorders Onset and Clinical Course Etiology Cultural Considerations Treatment Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder

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Antisocial Personality Disorder Application of the Nursing Process: Antisocial Personality Disorder Borderline Personality Disorder Application of the Nursing Process: Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Dependent Personality Disorder Obsessive–Compulsive Personality Disorder Elder Considerations Community-Based Care Mental Health Promotion

19. Addiction Types of Substance Abuse Onset and Clinical Course Related Disorders Etiology Cultural Considerations Types of Substances and Treatment Treatment and Prognosis Application of the Nursing Process Elder Considerations Community-Based Care Mental Health Promotion Substance Abuse in Health Professionals

20. Eating Disorders Overview of Eating Disorders Categories of Eating Disorders Etiology Cultural Considerations Anorexia Nervosa Bulimia Application of the Nursing Process Community-Based Care Mental Health Promotion

21. Somatic Symptom Illnesses Overview of Somatic Symptom Illnesses Onset and Clinical Course Related Disorders Etiology Cultural Considerations

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Application of the Nursing Process Community-Based Care Mental Health Promotion

22. Neurodevelopmental Disorders Autism Spectrum Disorder Related Disorders Attention Deficit Hyperactivity Disorder Cultural Considerations Application of the Nursing Process: Attention Deficit Hyperactivity

Disorder Mental Health Promotion

23. Disruptive Behavior Disorders Related Disorders Oppositional Defiant Disorder Intermittent Explosive Disorder Conduct Disorder Related Problems Cultural Considerations Application of the Nursing Process: Conduct Disorder Elder Considerations Community-Based Care Mental Health Promotion

24. Cognitive Disorders Delirium Cultural Considerations Application of the Nursing Process: Delirium Community-Based Care Dementia Related Disorders Cultural Considerations Application of the Nursing Process: Dementia Community-Based Care Mental Health Promotion Role of the Caregiver

Answers to Chapter Study Guides

Appendix A Disorders of Sleep and Wakefulness

Appendix B Sexual Dysfunctions and Gender Dysphoria

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Appendix C Drug Classification Under the Controlled Substances Act

Appendix D Canadian Drug Trade Names

Appendix E Mexican Drug Trade Names Glossary of Key Terms Index

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uni t 1 Current Theories and Practice

CHAPTER 1 Foundations of Psychiatric–Mental Health Nursing

Key Terms • asylum • boarding • case management • deinstitutionalization • Diagnostic and Statistical Manual of Mental Disorders (DSM-5) • managed care • managed care organizations • mental health • mental illness • phenomena of concern • psychotropic drugs • self-awareness • standards of care • utilization review firms

Learning Objectives

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After reading this chapter, you should be able to: 1. Describe characteristics of mental health and mental illness. 2. Discuss the purpose and use of the American Psychiatric Association’s

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 3. Identify important historical landmarks in psychiatric care. 4. Discuss current trends in the treatment of people with mental illness. 5. Discuss the American Nurses Association (ANA) standards of practice

for psychiatric–mental health nursing. 6. Describe common student concerns about psychiatric nursing.

AS YOU BEGIN THE STUDY OF psychiatric–mental health nursing, you may be excited, uncertain, and even somewhat anxious. The field of mental health often seems a little unfamiliar or mysterious, making it hard to imagine what the experience will be like or what nurses do in this area. This chapter addresses these concerns and others by providing an overview of the history of mental illness, advances in treatment, current issues in mental health, and the role of the psychiatric nurse.

MENTAL HEALTH AND MENTAL ILLNESS Mental health and mental illness are difficult to define precisely. People who can carry out their roles in society and whose behavior is appropriate and adaptive are viewed as healthy. Conversely, those who fail to fulfill roles and carry out responsibilities or whose behavior is inappropriate are viewed as ill. The culture of any society strongly influences its values and beliefs, and this, in turn, affects how that society defines health and illness. What one society may view as acceptable and appropriate, another society may see as maladaptive and inappropriate.

Mental Health The World Health Organization defines health as a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity. This definition emphasizes health as a positive state of well- being. People in a state of emotional, physical, and social well-being fulfill life responsibilities, function effectively in daily life, and are satisfied with their interpersonal relationships and themselves.

No single universal definition of mental health exists. Generally, a person’s behavior can provide clues to his or her mental health. Because each person can have a different view or interpretation of behavior (depending on his or her values and beliefs), the determination of mental health may be difficult. In most cases, mental health is a state of

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emotional, psychological, and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self- concept, and emotional stability.

Mental health has many components, and a wide variety of factors influence it. These factors interact; thus, a person’s mental health is a dynamic, or ever-changing, state. Factors influencing a person’s mental health can be categorized as individual, interpersonal, and social/cultural. Individual, or personal, factors include a person’s biologic makeup, autonomy and independence, self-esteem, capacity for growth, vitality, ability to find meaning in life, emotional resilience or hardiness, sense of belonging, reality orientation, and coping or stress management abilities. Interpersonal, or relationship, factors include effective communication, ability to help others, intimacy, and a balance of separateness and connectedness. Social/cultural, or environmental, factors include a sense of community, access to adequate resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive, yet realistic, view of one’s world. Individual, interpersonal, and social/cultural factors are discussed further in Chapter 7.

Mental Illness Mental illness includes disorders that affect mood, behavior, and thinking, such as depression, schizophrenia, anxiety disorders, and addictive disorders. Mental disorders often cause significant distress, impaired functioning, or both. Individuals experience dissatisfaction with self, relationships, and ineffective coping. Daily life can seem overwhelming or unbearable. Individuals may believe that their situation is hopeless.

Factors contributing to mental illness can also be viewed within individual, interpersonal, and social/cultural categories. Individual factors include biologic makeup, intolerable or unrealistic worries or fears, inability to distinguish reality from fantasy, intolerance of life’s uncertainties, a sense of disharmony in life, and a loss of meaning in one’s life. Interpersonal factors include ineffective communication, excessive dependency on or withdrawal from relationships, no sense of belonging, inadequate social support, and loss of emotional control. Social/cultural factors include lack of resources, violence, homelessness, poverty, an unwarranted negative view of the world, and discrimination such as stigma, racism, classism, ageism, and sexism.

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS

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The Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) is a taxonomy published by the American Psychiatric Association and is revised as needed. The current edition made some major revisions and was released in 2013. The DSM-5 describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research. All mental health clinicians who diagnose psychiatric disorders use this diagnostic taxonomy.

The DSM-5 has three purposes:

• To provide a standardized nomenclature and language for all mental health professionals

• To present defining characteristics or symptoms that differentiate specific diagnoses

• To assist in identifying the underlying causes of disorders

The classification system allows the practitioner to identify all the factors that relate to a person’s condition:

• All major psychiatric disorders such as depression, schizophrenia, anxiety, and substance-related disorders

• Medical conditions that are potentially relevant to understanding or managing the person’s mental disorder as well as medical conditions that might contribute to understanding the person

• Psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders. Included are problems with the primary support group, the social environment, education, occupation, housing, economics, access to health care, and the legal system.

Although student nurses do not use the DSM-5 to diagnose clients, they will find it a helpful resource to understand the reason for the admission and to begin building knowledge about the nature of psychiatric illnesses.

HISTORICAL PERSPECTIVES OF THE TREATMENT OF MENTAL ILLNESS

Ancient Times People of ancient times believed that any sickness indicated displeasure of the gods and, in fact, was a punishment for sins and wrongdoing. Those

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with mental disorders were viewed as being either divine or demonic, depending on their behavior. Individuals seen as divine were worshipped and adored; those seen as demonic were ostracized, punished, and sometimes burned at the stake. Later, Aristotle (382–322 BC) attempted to relate mental disorders to physical disorders and developed his theory that the amounts of blood, water, and yellow and black bile in the body controlled the emotions. These four substances, or humors, corresponded with happiness, calmness, anger, and sadness. Imbalances of the four humors were believed to cause mental disorders; so treatment was aimed at restoring balance through bloodletting, starving, and purging. Such “treatments” persisted well into the 19th century (Baly, 1982).

Possessed by demons

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In early Christian times (1–1000 AD), primitive beliefs and superstitions were strong. All diseases were again blamed on demons, and the mentally ill were viewed as possessed. Priests performed exorcisms to rid evil spirits. When that failed, they used more severe and brutal measures, such as incarceration in dungeons, flogging, and starving.

In England during the Renaissance (1300–1600), people with mental illness were distinguished from criminals. Those considered harmless were allowed to wander the countryside or live in rural communities, but the more “dangerous lunatics” were thrown in prison, chained, and starved (Rosenblatt, 1984). In 1547, the Hospital of St. Mary of Bethlehem was officially declared a hospital for the insane, the first of its kind. By 1775, visitors at the institution were charged a fee for the privilege of viewing and ridiculing the inmates, who were seen as animals, less than human (McMillan, 1997). During this same period in the colonies (later the United States), the mentally ill were considered evil or possessed and were punished.Witch hunts were conducted, and offenders were burned at the stake.

Period of Enlightenment and Creation of Mental Institutions In the 1790s, a period of enlightenment concerning persons with mental illness began. Philippe Pinel in France and William Tuke in England formulated the concept of asylum as a safe refuge or haven offering protection at institutions where people had been whipped, beaten, and starved just because they were mentally ill (Gollaher, 1995). With this movement began the moral treatment of the mentally ill. In the United States, Dorothea Dix (1802–1887) began a crusade to reform the treatment of mental illness after a visit to Tuke’s institution in England. She was instrumental in opening 32 state hospitals that offered asylum to the suffering. Dix believed that society was obligated to those who were mentally ill; she advocated adequate shelter, nutritious food, and warm clothing (Gollaher, 1995).

The period of enlightenment was short-lived. Within 100 years after establishment of the first asylum, state hospitals were in trouble. Attendants were accused of abusing the residents, the rural locations of hospitals were viewed as isolating patients from their families and homes, and the phrase insane asylum took on a negative connotation.

Sigmund Freud and Treatment of Mental Disorders The period of scientific study and treatment of mental disorders began with Sigmund Freud (1856–1939) and others, such as Emil Kraepelin

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(1856–1926) and Eugen Bleuler (1857–1939). With these men, the study of psychiatry and the diagnosis and treatment of mental illness started in earnest. Freud challenged society to view human beings objectively. He studied the mind, its disorders, and their treatment as no one had done before. Many other theorists built on Freud’s pioneering work (see Chapter 3). Kraepelin began classifying mental disorders according to their symptoms, and Bleuler coined the term schizophrenia.

Development of Psychopharmacology A great leap in the treatment of mental illness began in about 1950 with the development of psychotropic drugs, or drugs used to treat mental illness. Chlorpromazine (Thorazine), an antipsychotic drug, and lithium, an antimanic agent, were the first drugs to be developed. Over the following 10 years, monoamine oxidase inhibitor antidepressants; haloperidol (Haldol), an antipsychotic; tricyclic antidepressants; and antianxiety agents, called benzodiazepines, were introduced. For the first time, drugs actually reduced agitation, psychotic thinking, and depression. Hospital stays were shortened, and many people became well enough to go home. The level of noise, chaos, and violence greatly diminished in the hospital setting.

Move toward Community Mental Health The movement toward treating those with mental illness in less restrictive environments gained momentum in 1963 with the enactment of the Community Mental Health Centers Construction Act. Deinstitutionalization, a deliberate shift from institutional care in state hospitals to community facilities, began. Community mental health centers served smaller geographic catchment, or service, areas that provided less restrictive treatment located closer to individuals’ homes, families, and friends. These centers provided emergency care, inpatient care, outpatient services, partial hospitalization, screening services, and education. Thus, deinstitutionalization accomplished the release of individuals from long- term stays in state institutions, the decrease in admissions to hospitals, and the development of community-based services as an alternative to hospital care.

In addition to deinstitutionalization, federal legislation was passed to provide an income for disabled persons: Supplemental Security Income (SSI) and Social Security Disability Income (SSDI). This allowed people with severe and persistent mental illness to be more independent financially and to not rely on family for money. States were able to spend

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less money on care of the mentally ill than they had spent when these individuals were in state hospitals because this program was federally funded. Also, commitment laws changed in the early 1970s, making it more difficult to commit people for mental health treatment against their will. This further decreased the state hospital populations and, consequently, the money that states spent on them.

MENTAL ILLNESS IN THE 21ST CENTURY The Substance Abuse and Mental Health Services Administration (SAMSHA) estimates that more than 18.6% of Americans aged 18 years and older have some form of mental illness—approximately 43.7 million persons. In the past year, 20.7 million people or 18.6%, had a substance use disorder. Of these, 8.4 million had co-occurring mental illness and substance use disorder, or dual diagnosis (2015). Furthermore, mental illness or serious emotional disturbances impair daily activities for an estimated 15 million adults and 4 million children and adolescents. For example, attention deficit hyperactivity disorder affects 3% to 5% of school-aged children. More than 10 million children younger than 7 years grow up in homes where at least one parent suffers from significant mental illness or substance abuse, a situation that hinders the readiness of these children to start school. The economic burden of mental illness in the United States, including both health-care costs and lost productivity, exceeds the economic burden caused by all kinds of cancer. Mental disorders are the leading cause of disability in the United States and Canada for persons 15 to 44 years of age. Yet only one in four adults and one in five children and adolescents requiring mental health services get the care they need.

Some believe that deinstitutionalization has had negative as well as positive effects. Although deinstitutionalization reduced the number of public hospital beds by 80%, the number of admissions to those beds correspondingly increased by 90%. Such findings have led to the term revolving door effect. Although people with severe and persistent mental illness have shorter hospital stays, they are admitted to hospitals more frequently. The continuous flow of clients being admitted and discharged quickly overwhelms general hospital psychiatric units. In some cities, emergency department (ED) visits for acutely disturbed persons have increased by 400% to 500%. Patients are often boarded or kept in the ED while waiting to see if the crisis de-escalates or till an inpatient bed can be located or becomes available.

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Revolving door

Shorter, unplanned hospital stays further complicate frequent, repeated hospital admissions. People with severe and persistent mental illness may show signs of improvement in a few days but are not stabilized. Thus, they are discharged into the community without being able to cope with community living. However, planned/scheduled short hospital stays do not contribute to the revolving door phenomenon, and may show promise in dealing with this issue (see Chapter 4). The result frequently is decompensation and rehospitalization. In addition, many people have a dual problem of both severe mental illness and substance abuse. Use of alcohol and drugs exacerbates symptoms of mental illness, again making rehospitalization more likely. Substance abuse issues cannot be dealt with in the 3 to 5 days typical for admissions in the current managed care environment.

Homelessness is a major problem in the United States today with 610,000 people, including 140,000 children, being homeless on any given night. Approximately 257,300 of the homeless population (42%) have a severe mental illness of a chronic substance use disorder. The segment of

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the homeless population considered to be chronically homeless numbers 110,000 and 30% of this group has a psychiatric illness and two thirds have a primary substance abuse disorder or other chronic health condition (Substance Abuse and Mental Health Services Administration, 2015). Those who are homeless and mentally ill are found in parks, airport and bus terminals, alleys and stairwells, jails, and other public places. Some use shelters, halfway houses, or board-and-care rooms; others rent cheap hotel rooms when they can afford it. Homelessness worsens psychiatric problems for many people with mental illness who end up on the streets, contributing to a vicious cycle.

Many of the problems of the homeless mentally ill, as well as of those who pass through the revolving door of psychiatric care, stem from the lack of adequate community resources. Money saved by states when state hospitals were closed has not been transferred to community programs and support. Inpatient psychiatric treatment still accounts for most of the spending for mental health in the United States, so community mental health has never been given the financial base it needs to be effective. In addition, mental health services provided in the community must be individualized, available, and culturally relevant to be effective.

BOX 1.1 HEALTHY PEOPLE 2020 MENTAL HEALTH OBJECTIVES

• Reduce the suicide rate • Reduce suicide attempts by adolescents • Reduce the proportion of adolescents who engage in disordered eating

behaviors in an attempt to control their weight • Reduce the proportion of persons who experience major depressive episode • Increase the proportion of primary care facilities that provide mental health

treatment onsite or by paid referral • Increase the proportion of juvenile residential facilities that screen

admissions for mental health problems • Increase the proportion of persons with SMI who are employed • Increase the proportion of adults with mental health disorders who receive

treatment • Increase the proportions of persons with co-occurring substance abuse and

mental disorders who receive treatment for both disorders • Increase depression screening by primary care providers • Increase the number of homeless adults with mental health problems who

receive mental health services _________

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U.S. Department of Health and Human Services. (2010). Healthy People 2020. Washington, DC: DHHS.

Objectives for the Future More people are being treated for mental illness than in the past. Recent reports indicate that 68% of children and 57% of adults who need treatment are being treated; however, only 37% of homeless people with mental illness and 3% of people with both mental illness and substance abuse receive needed treatment (U.S. Department of Health and Human Services, 2010). Statistics like these underlie the Healthy People 2020 objectives for mental health proposed by the DHHS (Box 1.1). These objectives, originally developed as Healthy People 2000, were revised in January 2000 and again in January 2010 to increase the number of people who are identified, diagnosed, treated, and helped to live healthier lives. The objectives also strive to decrease rates of suicide and homelessness, to increase employment among those with serious mental illness (SMI), and to provide more services both for juveniles and for adults who are incarcerated and have mental health problems.

Community-Based Care After deinstitutionalization, the 2000 community mental health centers that were supposed to be built by 1980 had not materialized. By 1990, only 1300 programs provided various types of psychosocial rehabilitation services. Persons with severe and persistent mental illness were either ignored or underserved by community mental health centers. This meant that many people needing services were, and still are, in the general population with their needs unmet. The Treatment Advocacy Center (2015) reports that about one half of all persons with severe mental illness have received no treatment of any kind in the previous 12 months. Persons with minor or mild cases are more likely to receive treatment, whereas those with severe and persistent mental illness are least likely to be treated.

Community support service programs were developed to meet the needs of persons with mental illness outside the walls of an institution. These programs focus on rehabilitation, vocational needs, education, and socialization as well as on management of symptoms and medication. These services are funded by states (or counties) and some private agencies. Therefore, the availability and quality of services vary among different areas of the country. For example, rural areas may have limited funds to provide mental health services and smaller numbers of people needing them. Large metropolitan areas, although having larger budgets,

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also have thousands of people in need of service; rarely is there enough money to provide all the services needed by the population. Chapter 4 provides a detailed discussion of community-based programs.

The community-based system did not accurately anticipate the extent of the needs of people with severe and persistent mental illness. Many clients do not have the skills needed to live independently in the community, and teaching these skills is often time-consuming and labor intensive, requiring a 1:1 staff-to-client ratio. In addition, the nature of some mental illnesses makes learning these skills more difficult. For example, a client who is hallucinating or “hearing voices” can have difficulty listening to or comprehending instructions. Other clients experience drastic shifts in mood, being unable to get out of bed one day and then unable to concentrate or pay attention a few days later.

Despite the flaws in the system, community-based programs have positive aspects that make them preferable for treating many people with mental illnesses. Clients can remain in their communities, maintain contact with family and friends, and enjoy personal freedom that is not possible in an institution. People in institutions often lose motivation and hope as well as functional daily living skills, such as shopping and cooking. Therefore, treatment in the community is a trend that will continue.

Cost Containment and Managed Care Health-care costs spiraled upward throughout the 1970s and 1980s in the United States. Managed care is a concept designed to purposely control the balance between the quality of care provided and the cost of that care. In a managed care system, people receive care based on need rather than on request. Those who work for the organization providing the care assess the need for care. Managed care began in the early 1970s in the form of health maintenance organizations, which were successful in some areas with healthier populations of people.

In the 1990s, a new form of managed care was developed by utilization review firms or managed care organizations to control the expenditure of insurance funds by requiring providers to seek approval before the delivery of care. Case management, or management of care on a case-by-case basis, represented an effort to provide necessary services while containing cost. The client is assigned to a case manager, a person who coordinates all types of care needed by the client. In theory, this approach is designed to decrease fragmented care from a variety of sources, eliminate unneeded overlap of services, provide care in the least restrictive environment, and decrease costs for the insurers. In reality, expenditures are often reduced by withholding services deemed unnecessary or by substituting less

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expensive treatment alternatives for more expensive care, such as hospital admission.

Psychiatric care is costly because of the long-term nature of the disorders. A single hospital stay can cost $20,000 to $30,000. Also, there are fewer objective measures of health or illness. For example, when a person is suicidal, the clinician must rely on the person’s report of suicidality; no laboratory tests or other diagnostic studies can identify suicidal ideas. Mental health care is separated from physical health care in terms of insurance coverage: There are often specific dollar limits or permitted numbers of hospital days in a calendar year. When private insurance limits are met, public funds through the state are used to provide care. As states experience economic difficulties, the availability of state funds for mental health care decreases as well.

Mental health care is managed through privately owned behavioral health-care firms that often provide the services and manage their cost. Persons without private insurance must rely on their counties of residence to provide funding through tax dollars. These services and the money to fund them often lag far behind the need that exists. In addition, many persons with mental illness do not seek care and in fact avoid treatment. These persons are often homeless or in jail. Two of the greatest challenges for the future are to provide effective treatment to all who need it and to find the resources to pay for this care.

The Health Care Finance Administration administers two insurance programs: Medicare and Medicaid. Medicare covers people 65 years and older, people with permanent kidney failure, and people with certain disabilities. Medicaid is jointly funded by the federal and state governments and covers low-income individuals and families. Medicaid varies depending on the state; each state determines eligibility requirements, scope of services, and rate of payment for services. Medicaid covers people receiving either SSI or SSDI until they reach 65 years of age, although people receiving SSDI are not eligible for 24 months. SSI recipients, however, are eligible immediately. Unfortunately, not all people who are disabled apply for disability benefits, and not all people who apply are approved. Thus, many people with severe and persistent mental illness have no benefits at all.