Download Teaching and Learning Guide

Mental State Assessment Module
Teaching and Learning Guide
Table of contents
Page
Avatar basics
2
Featured areas in the learning together project
3
Students and facilitators Flinders Island guide
4
Reading preparation for Avatar scenarios on
5
Further reading and resources
8
Schizophrenia module
11
Learning outcomes
11
Psychosis scenario
12
Anxiety module
15
Learning outcomes
15
Anxiety scenario
17
Mood module
20
Learning outcomes
20
Depression scenario
22
Student assessment activities
26
Teaching and Learning Guide
Avatar basics
How to Speak
1. Plug in your headsets and ensure they are operating correctly
(if not you may have a firewall preventing you from speaking – call 12345 – then select 2
in the menu) – you can be shadowed to remove the firewall).
2. Press the “speak” button on your toolbar to activate voice/chat. (you don’t need to hold it
down). If you press the arrow beside the speak button you can also see who is voice active
around you.
3. When speaking in second Life you should be able to see green sound waves emanating
from above your avatar’s head. This means you are chat active.
How to Sit – versions 2.0
1. Click on the object that you want to sit on– right click for menu – then select “sit here”
How to Stand
1. Click on your avatar – right click and select stand
How to Fly
1. Press the “move” button – (in the centre bottom toolbar) - select the “fly” icon (little
superman flying image). To stop flying, press “stop” button that appears above your bottom
toolbar.
How to Teleport
1. There are teleport stations located throughout Flinders Island. Simply touch the teleport
station (use your mouse to click on the object) and your avatars arm will reach out and
touch the teleport.
2. From there, select from the menu that appears e.g. “Auditorium” and your avatar will be
transported to your allocated area.
Inventory
Details about your avatar and the project can be found in your inventory. Access inventory by
pressing the “suitcase” icon located on the right hand side toolbar. Depending on the scenario,
if you are playing “Paramedic Sam Piers” you can change the sex of your avatar using the
inventory menu.
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Featured areas in the learning together project
Meeting Point
The meeting point is a centralised area on Flinders Island that incorporates landmarks and tools
to assist your avatar to negotiate and navigate its surroundings. Surrounded by three
footbridges, within this area there are 3 distinct objects that can help you.
Although inactive, the Flinders sign is of note. It lets you know that you are on Flinders
University property and subject to its regulations and standards. If in doubt where to meet in
Second Life – this is a great spot with convenient access to all areas.
The Information Post (labelled with an “I”) is also located in the meeting point area within a
large rotunda. There you can touch the screen to view information about the Island.
Mental Health Teaching Space – (Home of Elaine Tachor and Jarod Mearcus)
The Mental Health Teaching Space is located 180 degrees opposite the Meeting Point area.
You can elect to walk or fly to this specially designed suburb. The area is land marked by a
Mental Health Teaching Space sign (clickable for resources) at the access point to the suburb.
The house is occupied by Elaine Tachor (mother) and Jarod Mearcus (patient). An ambulance
is also stationed in the driveway ready for any medical emergency.
Internally the house is wired to reflect Jared’s mental state complete with roaming paranoia
cameras, shabbily maintained room, mirrors that reflect his paranoia and sound scaping
befitting a man experiencing disturbed thoughts and feelings This area is where the psychosis
mental health scenarios take place.
Auditorium
The Auditorium can be accessed by clicking on the blue teleport station beside the rotunda.
Once teleported, your avatar will find itself on a grassy amphitheatre where students can sit
and listen to mental health information delivered from the podium beside a large display
screen. PowerPoint slide shows, lecture materials and other e-deliverables can be plugged in
and played.
Hospital
The hospital ward is accessed either by flying, walking or teleporting. The bay is equipped
with medical facilities where avatars can sit, stand and reveal a range of scripted symptoms for
medical practitioners to assess. This is where the anxiety scenario takes place.
Community Health Centre
The Community Health Centre is another building in the suite of learning centres located on
Flinders Island. It is a neutral space can be used for consultations and other learning practices.
This is where the depression scenario takes place.
Teleport Stations
There are two major teleport stations located on Flinders Island to access the hospital and
auditorium. One teleport station is located at the meeting point (next to the rotunda) to access
the auditorium and the other is situated at the Community Health Centre by which the hospital
can be accessed.
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Clickable Objects and Information Posts.
The following objects can be clicked to retrieve information:
1. Mental Health Teaching Space (located at the Mental Health teaching Space) – touch this
sign to access note cards.
2. Mental State Assessment (located with the other information boards in the research area) –
touch this sign to access mental health resources.
3. Information sign (located in the rotunda) – click this for “welcome and information”.
Students and facilitators Flinders Island guide
Read the materials supplied regarding orientation and practice in the virtual reality medium
Second Life. Second Life is the platform that we use for teaching in virtual reality. Only
students and staff are allowed access to Flinders Island teaching areas. The general public on
Second Life do not have access.
You will be given the time and activity/activities that you are expected to complete by your
tutor/facilitator, so pay attention to this. It is important that you do pre-readings to familiarise
yourself with the specific phenomena we are exploring each week.
We have a number of learning areas, like virtual teaching spaces that we can use on Flinders
Island. You will see in your learning materials that we have developed three modules on
symptoms associated with anxiety, psychosis/schizophrenia and depression. Each of these
takes place in a different virtual teaching space and you will be guided there by your facilitator,
flying, running or teleporting around the various areas on the island! Please refer to your
Flinders Island map so that you can orient yourself to the island.
Before and after each of the three role play sessions, that will occur on three consecutive
weeks, you will go to the auditorium on the island where the facilitator will brief and debrief
you in a small group. You will then have activities to complete and submit as part of the
assessments for that topic. Please remember that the role plays are being undertaken in real
time with real students in the specially designed avatars. The idea is to provide you with an
opportunity to be immersed in a clinical situation, where you can experience what it is like to
be in a clinical setting (or patient’s home), before you encounter a real situation. In these role
plays you can make mistakes (you are students and making mistakes is part of leaning) and try
out and develop new skills apply knowledge, decide on interventions, apply tests and undertake
mental state assessments in a safe environment.
The role plays will involve each of the students being assigned a role to play nurse, paramedic,
observer, parent or patient. Specific instructions are given for each role so please read these
carefully! The facilitator will be present in the area in which you undertake the role play and
will provide guidance and advice as the activity is completed. It is anticipated that each role
play will take about twenty minutes and be part of a two tutorial session. In each of the three
weeks covering mental state assessment, you will have an opportunity to play each of the roles
and experience what it is like to be anxious and experience disturbed thoughts and visions and
hear voices (through special effects that we can recreate in this virtual reality). This can all take
place in a supportive learning environment.
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Other learning activities
On Flinders Island it is possible to have highly structured learning activities with the presence
of a facilitator AND unstructured activities where the student is assigned a series of activities
that they work through in their own time. For example students and staff can:
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Undertake fully interactive tutorials using power points and video and audio podcasts in
real time, so is great for external students and students who cannot get to class during the
day or at all.
Be guided to many ‘found objects’ that you can touch such as the learning resources area
that can take you to other mental health interactive resources, government and nongovernment websites, You Tube clips and interactive online libraries.
Each of our learning areas is set up so that it is multipurpose and can be used in
multidisciplinary format, thus maximising the potential for its use!
Reading preparation for Avatar scenarios on
1. Anxiety
2. Depression
3. Psychosis
Read these text readings and make notes
Barling. J 2009, chapter 11 ‘Assessment & diagnosis’, in R Elder, K Evans & D Nizette (eds),
Psychiatric and mental health nursing, 2nd edn. Elsevier Australia, Chatswood, pp. 174-199.
Muir-Cochrane, E., Barkway, P., Nizette D (2010) Mobsy’s Pocket Book of Mental Health
Elsevier, NSW
Read this section
There are numerous forms of assessment that can be used in mental health, with the mental
health history and the mental state examination (MSE) being the most common starting points
of assessment. Though you may never need to undertake either of these in their entirety, it is a
good idea to have a basic understanding of what they are and what is covered within them as
this may assist you to provide accurate information if a referral to a mental health service is
required.
The reason these assessments are undertaken is primarily to provide a baseline of behaviours
and presentation to help with diagnosis. This can help the worker to understand the factors that
influence the symptoms or problems and help in developing individualised
treatment/management plans. Such assessments can also be used as tools for mapping change
and assisting with the transfer of information between staff. And they can help to rule out
physical illness. For instance, because of the nature of some mental health problems,
individuals may present with symptoms that at first appear to be psychiatric in origin but may
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end up being something entirely different, such as an organic or metabolic disturbance. You
must remember that physical illness and mental health disorders commonly coexist and that
some medications can cause side effects that imitate psychiatric symptoms!
When assessing someone for a mental health problem for the first time, we need to find out
several things, such as:
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Is there any immediate risk to the individual or another person?
Is it a mental health problem, a physical problem or both?
If the individual has a mental health problem, what are its specifics?
How are we best going to treat the person?
Can we provide treatment using the available health care workers or do we need to refer
this person to other services?
Are there any coexisting social or health problems that need urgent attention first before we
provide the mental health treatment (for example, lack of housing, suitable clothing,
finances or social support)?
What effect will the treatment have for this individual’s health status?
You are more than likely familiar with the general assessment interview, including checking
the person’s vital signs, taking the person’s history and a physical examination.
The mental health assessment covers the same areas but with much more focus on the mental
health problem and its history. Unlike the general history-taking, the mental health history
concentrates on the individual’s pre-morbid personality to help form a picture of what the
person was like before developing a mental health problem. This is sometimes referred to as a
mental health or case history.
Complete this activity
Below is a list of some of the most common assessment tools used. Before your tutorial
session, find out as much information as you can about two of these tools and in which context
they may be used.
Beck depression inventory (BDI) is a self- administered 21-item self-report scale measuring
supposed manifestations of depression.
HoNOS, the health of the nation outcome scales instrument, designed in Britain, is a brief,
easily administered tool to gather information on mental health and social functioning.
Kessler psychological distress scale (K-10) is widely recommended as a simple measure of
psychological distress and as a measure of outcomes following treatment for common mental
health disorders.
Depression anxiety stress scale (DASS) is a set of three self-report scales designed to
measure the negative emotional states of depression, anxiety and stress.
Life skills profile (LSP) is a measure of those aspects of functioning (‘life skills’) that affect
how successfully people with schizophrenia live in the community or hospital. Because many
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of the skills are relevant in other major psychiatric disorders and in some organic conditions
the LSP can also be applied to a broad range of other diagnoses. Mental health inventory
(MHI-5) is a five-item scale that is used for measuring wellbeing and psychological distress.
The mental health history is the subjective portion of the assessment, based on the client’s
experiences and their memory of them. This is often seen as a subjective element of assessment
because as one would expect the client is going to be biased in their understanding, experience,
intellect and personality. In contrast, the MSE is objective and is based on the current state of
the client rather than what has happened previously. It includes observing the client’s
behaviour and describing it in an objective non-judgmental manner and, like a medical
examination, it seeks to reveal signs of illness.
The mental state examination (MSE) is undertaken to obtain information about specific
aspects of the individual’s experience and behaviour concerning their mental health at the time
of the interview/assessment. In the general setting it would be similar to a general nurse doing
a blood pressure evaluation. An individual’s mental state, like blood pressure, can vary
significantly over time and in different settings.
Some components of the MSE may be completed purely through observation; for example,
from their dress or facial expressions, whereas other components require direct questioning or
specific testing.
An MSE usually involves several headings to guide you in making observations and asking
questions. The following lists of physical, emotional and cognitive characteristics demonstrate
areas that are likely to be covered in an MSE.
Mini mental state examination (MMSE) is a brief instrument/assessment tool consisting of
eleven questions intended to evaluate an adult patient’s level of cognitive functioning. It was
introduced in 1975 and designed for use to evaluate older adults for delirium or dementia
(Folstein, Folstein & McHugh 1975).
The MMSE concentrates on the cognitive aspects of mental functioning, excluding questions
about the client’s mood or abnormal experiences. It evaluates six areas of cognitive function:
orientation, attention, immediate recall, short-term recall, language, and the ability to follow
simple verbal and written commands.
The MMSE has gained popularity with clinicians and researchers as it can be completed fairly
quickly, has ease of administration and scoring, and when used repeatedly is able to measure
changes in cognitive status.
The examination is divided into two parts. The first part tests the patient’s orientation, memory
and attention and requires verbal responses to the examiner’s questions. These questions often
include the client being asked to repeat a short phrase after the examiner; to count backwards
from 100 by sevens; to name the current prime minister and similar brief items. The client is
scored for each answer.
In the second part of the examination, the client is asked to follow verbal and written
instructions, such as writing a sentence spontaneously, copying a complex geometric figure
and explaining the meaning of a simple proverb such as ‘people who live in glass houses
shouldn’t throw stones’.
The maximum total score on the MMSE is 30. As a rule, scores of 20 or lower can indicate
some problem with cognitive functioning that requires further assessment.
As with all assessment tools you must also recognise the limitations of the MMSE. The
MMSE is not able to diagnose changes in cognitive function and should not replace a complete
clinical assessment of mental status. In addition, the instrument relies heavily on verbal
responses and reading and writing. Therefore, hearing and visually impaired clients and
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individuals with low English literacy or communication disorders may perform poorly even
when cognitively intact.
Further reading and resources
Further reading on mental health
Burroughs, A 2002, Running with scissors: a memoir, Picador, New York.
Frame, J 1984, An angel at my table, Braziller Inc, New York.
Green, H 2009. I never promised you a rose garden, Halt paperback, New York.
Kaysen, S 1994, Girl, interrupted, Random House, New York.
Lamb, W 1998, She’s come undone, Pocket Books, New York.
Lamb, W 1998, I know this much is true, HarperCollins, New York.
Plath, S 1996, The bell jar, Harper and Row, New York.
Redfield, JK 1995, An unquiet mind: a memoir of moods and madness,
Random House, New York.
Winchester, S 2005, The professor and the madman, Harper Perennial, New York.
Wurtzel, E 1995, Prozac nation, Riverhead, New York.
Web resources on mental health
Anxieties.com: www.anxieties.com
This website provides free anxiety self-help.
Auseinet: Australian Network for the Promotion, Prevention and Early Intervention for Mental
Health: http://auseinet.flinders.edu.au. The key focus of Auseinet is to assist a range of sectors
to implement mental health promotion and illness prevention approaches in their respective
settings. These settings include, but are not limited to, mental health and health services,
community organisations, schools, non-government organisations (NGOs), educational
institutions (such as TAFE and universities) and general practice. Auseinet also works across
all population groups. Auseinet is a national organisation located at Flinders University in
Adelaide, South Australia.
Australian Bipolar: www.bipolar.com.au
This is a bipolar information website. Australian College of Mental Health Nurses:
www.acmhn.org. The college is the peak professional body for mental health nurses in
Australia. It is the only organisation that solely represents mental health nurses. The college
engages with its members and key stakeholders to advance mental health nursing across the
country.
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Australian Drug Information Network (ADIN)
www.adin.com.au/content.asp?Document_ID=1.
ADIN provides a central point of access to internet-based alcohol and drug information
provided by prominent organisations in Australia and internationally. It is funded by the
Australian Government Department of Health and Ageing as part of the National Illicit Drug
Strategy and is managed by the Australian Drug Foundation.
Beyond Blue: www.beyondblue.org.au/index.aspx?
Beyond Blue is a national, independent, not-for-profit organisation working to address issues
associated with depression, anxiety and related substance misuse disorders in Australia.
Beyond Blue works in partnership with health services, schools, workplaces, universities,
media and community organisations, as well as people living with depression, to bring together
their expertise around depression.
Black Dog Institute: www.blackdoginstitute.org.au
The institute is a not-for-profit, educational, research, clinical and community-oriented facility
offering specialist expertise in depression and bipolar disorder.
Carers Association of SA: www.carers-sa.asn.au
Carers provide unpaid care and support to family members and friends who have a disability,
mental illness, chronic condition, terminal illness or who are frail. More than one in eight
Australians provide care of this kind. The purpose of the Carers Association of SA is to
improve the lives of carers, as well as provide important services such as counselling, advice,
advocacy, education and training. The association also promotes the recognition of carers to
governments, businesses and the public.
Carers Australia: www.carersaustralia.com.au
The purpose of Carers Australia, and the network of carers’ associations in each state and
territory, is to improve the lives of carers, and provide important services such as counselling,
advice, advocacy, education and training. They also promote the recognition of carers to
governments, businesses and the public.
COMIC (Children of Mentally Ill Consumers): www.howstat.com/comic/Home.asp
COMIC was formed at a forum held in 2000, and is comprised of a group of adult children
who share a common interest for children of mentally ill consumers. The group shares a
common perception of the past failure by the mental health services to acknowledge them as
children with unique needs and offer support. COMIC has begun to lobby and advocate for the
rights of children of mentally ill consumers and their parents because of the lack of
acknowledgment, education and assistance by mental health services.
depressioNET: www.depressionservices.org.au
depressioNET is committed ‘around the clock’ to improving the mental health and wellbeing
of people impacted by depression through the provision of an internet-based service, offering
hope and understanding, information and support.
Headspace: www.headspace.org.nz/young-people/what-is-mental-health.htm
This website is for young people in New Zealand, as well as their families and schools.
Mental Health Foundation of New Zealand: www.mentalhealth.org.nz/page/5-Home
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The foundation’s work focuses on making mental health everybody’s business. Its work is
diverse and expansive, with campaigns and services that cover all aspects of mental health and
wellbeing. A holistic approach is taken to mental health. The foundation provides free
information and training, and is an advocate for policies and services that support people with
experience of mental illness, and also their families/whānau and friends.
Mental Illness Fellowship of Australia: http://esvc000144.wic027u.server-web.com
The fellowship commenced informally in 1986 as an association of the various state and territory
Schizophrenia Fellowships, which were then in existence. It was formed primarily to provide a
point of contact, a place to exchange information, lobby and to provide mutual support.
Multicultural Mental Health Australia (MMHA): www.mmha.org.au
This website provides national leadership in building greater awareness of mental health and
suicide prevention among Australians from culturally and linguistically diverse (CALD)
backgrounds.
Network for Carers of People with a Mental Illness (Victoria): www.carersnetwork.org.
The network is the Victorian peak body of organisations and individuals that support carers of
people with mental health issues. It comprises: carers or former carers linked with carer
groups; representatives of state-wide carer organisations with a significant carer focus; workers
from carer support programs; and carer-related academics.
Royal Australia and New Zealand College of Psychiatrists (RANZCP): www.ranzcp.org
RANZCP is the principal organisation representing the medical specialty of psychiatry in
Australia and New Zealand. It is responsible for training, examining and awarding the
Fellowship of the College qualification to medical practitioners.
SANE Australia: www.sane.org
SANE Australia is a national charity working for a better life for people affected by mental
illness.
Schizophrenia.com: www.schizophrenia.com
This is a non-profit community providing in-depth information, support and education related
to schizophrenia.
Supporting Families in Mental Illness New Zealand: www.sfnat.org.nz
This website provides education, advocacy and support for family/whānau of people
experiencing a major mental illness.
Victoria’s Mental Health Services:
www.health.vic.gov.au/mentalhealth/illnesses/index.htm
This website provides information on mental health and illness.
World Health Organization (Program and Projects; Mental Health; Disorders
Management—Depression):
www.who.int/mental_health/management/depression/definition/en;
World Health Organization (Programs and Projects; Mental Health; Disorders
Management—Schizophrenia): www.who.int/mental_health/management/schizophrenia/en.
These sites provide suggested readings about mental illness.
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Schizophrenia module
Learning outcomes for this week:
Upon the successful completion of this week’s study you will be able to:
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describe the stages involved in schizophrenia,
describe the range of signs and symptoms possible,
describe the different therapies that may be involved,
reflect on the community stigma and social isolation that may be reflected in nursing
practice,
understand some of the issues involved in communicating with a person with
schizophrenia.
What you need to do to meet your learning outcomes?
Text reading
Bardwell, M & Taylor, R 2009, chapter 15 ‘Schizophrenic disorders’, in R Elder, K Evans & D
Nizette (eds), Psychiatric and mental health nursing, 2nd edn, Elsevier Australia, Chatswood,
pp. 248-266.
Also read the appropriate sections in:
Usher, K, Foster, K & Luck, L 2009, chapter 25 ‘Psychopharmacology’, in R Elder, K Evans
& D Nizette (eds), Psychiatric and mental health nursing, 2nd edn, Elsevier Australia,
Chatswood, pp. 457-472.
Listen to the audio on the Sane website and note the definition of psychosis. Put yourself in
that position—imagine what it could be like to have such confused thinking.
Sane Australia, ‘Schizophrenia’,
http://www.sane.org/information/factsheets/schizophrenia.html, viewed 2 June 2009.
Access the following websites. Note points of interest and them bring to class for discussion.
National Institute of Mental Health, ‘Schizophrenia’,
http://www.nimh.nih.gov/health/publications/schizophrenia/complete-index.shtml, viewed 2
June 2009. This website provides more comprehensive information about schizophrenia.
Schizophrenia.com, http://www.schizophrenia.com/index.php, viewed 17 June 2009. This is a
non-profit US community site that provides information, support and education related to
schizophrenia.
Key terms
The following terms are defined in the glossary in Elder, Evans & Nizette (2009, pp. 473-481).
Read these definitions and bring any questions to the tutorial.
affect
delusion
dissociation
extra-pyramidal side effects
hallucinations
ideas of reference: an example of this would be a patient who could not watch Country
practice on television because he believed it referred to his life
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negative symptoms
positive symptoms
premorbid
psychosis
thought blocking
thought disorder.
Complete this activity
Summarise the text reading under these headings:
What are the different theories about the cause of schizophrenia?
What are the three phases of schizophrenia?
What are the common therapeutic interventions for this illness?
What are the common side effects of these medications?
Psychosis scenario
Patient role preparation notes
Jared: young man with psychotic symptoms
Jared is a 16 year old man who left high school in Year 11 and got a job working in a video
store. After working for about 6 months Jared began to hear voices that told him he was no
good. He also began to believe that his boss was planting small video cameras in the returned
tapes to catch him making mistakes. Jared became increasingly agitated at work, particularly
during busy times, and began "talking strangely" to customers. For example, one customer
asked for a tape to be reserved and Jared indicated that that tape may not be available because
it had "surveillance photos of him that were being reviewed by the CIA".
A few weeks later Jared quit his job one night, after yelling at his boss that he couldn't take the
constant abuse of being watched by all the TV screens in the store and even at home. Jared
lives with his mum. He has become increasingly confused and agitated. His behaviour became
more disorganised, he started spending long periods in his room and unwilling to wash or eat
or change his bedding. His mum wanted to take him to the hospital but he refused to go. One
evening after he began ranting that he had to fight back against the voices, his mum Elaine,
was fearful and rang an ambulance.
Jared becomes more agitated during the interview and verbally threatens to cut himself. He
looks around towards the kitchen for a knife but does not act on this and remains in the living
room. He is detained under the Mental Health Act so that he can be taken to a psychiatric
hospital for treatment.
Paramedic role preparation information
At 20.00 hours the call comes through the Operations Centre dispatching you to a 16 year old
male, Jared, who according to his mother (Elaine) has become increasingly agitated and ranting
that he had to fight back against the voices. His mother stated she wanted to take him to the
hospital but he refused to go. She is fearful of his increasing “odd and strange behaviour”.
On arrival, you find Jared sitting in the lounge room. His mother, Elaine, meets you at the
door. You find out that Jared is a 16 year old man who left high school in Year 11 and got a job
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working in a video store. After working for about 6 months Jared began to hear voices that told
him he was no good. Jared became increasingly agitated at work, particularly during busy
times, and began "talking strangely" to customers believing that the CIA were reviewing
surveillance photos of him.
Jared continues to live with his mum and has recently lost his job due to poor performance.
Since then his behaviour became more disorganised, he started spending long periods in his
room and unwilling to wash or eat or change his bedding.
As the paramedics attending this case consider:
1.
2.
3.
4.
5.
6.
Your approach to the patient (Jared) e.g. would you enter the house immediately? Would
you talk with the mother initially?
How would you communicate with Jared?
How would you begin your Mental State Assessment?
What role does the mother (Elaine) and her information play in your assessment of Jared?
How would you end the Mental State Assessment?
What might your partner be doing while you are interviewing Jared?
You notice during the interview that Jared becomes more agitated, verbally threatens to cut
himself and is continually looking at the kitchen, but doesn’t appear to be about to act on his
threats of self-harm.
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How would you respond to this?
Do you think Jared needs to be detained?
What other resources and support options do you have to assist in this case (e.g. the
Assessment Crisis Intervention Service, Medical Officer, Intensive Care Paramedics etc)?
Consider what options you would use in this situation and why.
What information would be important to hand over to the Mental Health Teams, Police or
Emergency Staff?
You have maximum of twenty minutes for this task.
Observer/Student nurse role preparation information
Patient presentation
At 20.00 hours the call comes through the Operations Centre dispatching you to a 21 year old
male, Jared, who according to his mother (Elaine) has become increasingly agitated and ranting
that he had to fight back against the voices. His mother stated she wanted to take him to the
hospital but he refused to go. She is fearful of his increasing “odd and strange behaviour”.
On arrival, you find Jared sitting in the lounge room. His mother, Elaine, meets you at the
door. You find out that Jared is a 16 year old man who left high school in Year 11 and got a job
working in a video store. After working for about 6 months Jared began to hear voices that told
him he was no good. Jared became increasingly agitated at work, particularly during busy
times, and began "talking strangely" to customers believing that the CIA were reviewing
surveillance photos of him.
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Jared continues to live with his mum and recently lost his job due to poor performance. Since
then his behaviour became more disorganised, he started spending long periods in his room and
unwilling to wash or eat or change his bedding. Two paramedics attend the house to assess
Jared.
Your role is to observe ONLY, do not take part in the scenario. Observe and take notes.
Make notes about the following:
The behaviour of the patient, the mother, the paramedics including their verbal and non verbal
communication.
What are your interpretations of this behaviour?
Did the person’s behaviour change during the interview? In what ways?
Make comment on how the nurse conducted the MSA. What worked, what did not appear to
work?
What other questions could have been asked?
Any other comments?
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Anxiety module
Exploring anxiety disorders
Written by Deb O’Kane
Anxiety is a part of everyday life. We have all been anxious, worried or apprehensive at some
point in our life—perhaps going for a job interview or being on the top of a high building.
Often this anxiety is accompanied by a vague sense of apprehension, headaches, palpitations,
increased perspiration, tightness in the chest, stomach upset or restlessness.
This degree of anxiety, however, is usually low or moderate and rarely threatens our coping
ability. In fact some people positively thrive on feeling anxious as it may motivate them or give
them the confidence to take on new challenges or risks. Other people may experience a severe
level of anxiety that overwhelms them to the point that it hinders their functioning and impacts
on their everyday life. These people would be classified as having an anxiety disorder. This
week’s session aims to help you explore anxiety within the context of mental health practice.
Anxiety disorders are the most common and disabling type of mental health problem in
Australia, affecting one in twenty people at any given time (Andrews, Hall, Teesson &
Henderson 1999). They can occur at any age, in people from all walks of life, and are known to
affect twice as many women as men (Andrews et al. 1999). Anxiety disorders account for onequarter of the burden of disease attributed to mental disorders (Mathers, Vos & Stevenson
1999).
Anxiety disorders comprise a group of conditions with the common feature of extreme anxiety
characterised by changes in behavioural, cognitive and physiological responses. For a
diagnosis of anxiety disorder to be made these changes and specific symptoms must be present
over a period of time and be interfering with the person’s ability to live a normal life.
Several theories have been proposed as to the causes of anxiety disorders, and they are likely to
be the result of a complex interaction between several factors, such as genetics, brain
chemistry, personality and life events.
People with anxiety disorders generally seek to hide their symptoms and problems from their
family, work or school peers and the community, due to strong embarrassment and shame.
Many people with an anxiety disorder also suffer from depression, sleep disorders, and
physical health problems that are related to stress; therefore it is sometimes difficult for
healthcare workers to gain an accurate picture of the problem, resulting in many anxiety
sufferers going undiagnosed or misdiagnosed.
The good news is that recovery from an anxiety disorder is possible because they are highly
receptive to treatment. This usually involves a combination of specialist treatment, education,
support and self-management skills. However, if left untreated, these disorders can become
chronic or progressively worsen, increasing the risk of other serious complications such as
suicide.
Learning outcomes for this week
Upon the successful completion of this week’s study, you will be able to:
 examine your feelings, beliefs and attitudes regarding individuals with anxiety disorders,
 identify positive and negative effects of anxiety,
 describe how anxiety disorders impair functioning,
 describe the current theories regarding the etiologies of major anxiety disorders,
 identify commonly used intervention approaches for people with anxiety disorders.
15
What you need to do to meet your learning outcomes
Text reading
Elder, R, Evans, K & Nizette, D 2009, chapter 18 ‘Anxiety disorders’, in R Elder, K Evans &
D Nizette (eds), Psychiatric and mental health nursing, 2nd edn, Elsevier Australia,
Chatswood, pp. 300-324.
Complete this activity
In small groups, summarise from your reading from this week, especially about the particular
features of and interventions for:
Panic attacks
Obsessive compulsive disorder
Phobias (including agoraphobia and social anxiety disorder)
Acute stress disorders
Generalised anxiety disorder.
Complete this activity
Think about how anxiety personally affects you.
In your small group, discuss your answers to the following questions with regard to your own
anxiety levels:
In what situations do you feel anxious?
What are the signs that let you know you feel anxious?
Has your anxiety ever prevented you from doing something?
How do you deal about the anxiety you experience?
Complete this activity
Summarise the key features of cognitive behaviour therapy (CBT), pages 317-318 of your text.
Complete this activity
Summarise the key issues identified with the use of anti-anxiety medication, pages 320-321 of
your text.
Complete this activity in class
Thinking about signs and symptoms, name and discuss some of the changes that can occur in a
person experiencing anxiety. Use the following headings:
Autonomic symptoms
Physical symptoms
Psychological symptoms.
Watch this week’s video and contribute to a class discussion
One of these videos will be selected.
SANE Australia, Anxiety disorders: personal perspectives on medical and social issues (32
minutes).
Video Arts Production for Videos for Patients, What you really need to know about ... anxiety,
phobias and panic attacks (39 minutes).
References
Andrews, G, Hall, W, Teesson, M, & Henderson, S 1999, The mental health of Australians,
Commonwealth Department of Health and Aged Care, Canberra.
Mathers, C, Vos, T & Stevenson, C 1999, The burden of disease and injury in Australia,
Australian Institute of Health and Wellbeing, Canberra.
16
Mental Health and Workforce Division n.d., What is an anxiety disorder? Australian
Department of Health and Ageing, Canberra, viewed 16 June 2009,
http://www.health.gov.au/internet/main/publishing.nsf/Content/B0FCEF50BADCFE24CA257
276002075BA/$File/whatanx.pdf.
Anxiety scenario
Nurse role preparation information
Patient Presentation
Ms Brenda Pollock is at an annual three day equestrian event in Adelaide parklands with her
husband and 10 year old daughter. She is a 35 year old school teacher and whilst interested in
horses is not an accomplished rider. She is attending at the instigation of her husband and
particularly her daughter who has become very interested in hoses. When they are standing
opposite one the more difficult jumps, a rider and horse misjudge the jump crashing heavily
into the logs causing the rider to fall. The horse is seriously injured with a fracture to a front
leg. In the excitement Ms Pollock is heard to groan then collapse to the ground unconscious.
Her husband is convinced she is having a heart attack and calls an ambulance and insists she is
taken to the local general hospital Emergency Department, where she is assessed and triaged.
Physical Assessment
Facial pallor, conscious, slightly confused place and time, anxious, sweaty, respirations 26,
pulse 125 but strong, ECG normal. She is placed in a bay and you as the RN are asked to
conduct a mental state examination.
Using the MSE documentation provided, conduct the assessment with the patient and make
written note of your assessment. Note verbal and nonverbal communication.
Before you commence, think about how you begin and end a MSA interview.
Also think about what you may say to Brenda to help remain calm while you conduct an
assessment.
You have maximum of twenty minutes for this task at which point you end the interview and
leave the bay.
Activities (note your answers)
What assessment can you make from the physical examination? What basic measurement is
missing? What ought a normal range be for that measurement?
Write up your MSA and consider the following:
 What other information would you wish to know from her husband about the collapse?
 What other information should you inquire about from Brenda about the circumstances
leading up to the collapse and the collapse itself?
 What other information would you ask about past history?
 What is your overall assessment?
 Write a few notes about your response to the patient’s request that you do not share any
information about her symptoms or cause with her husband.
17
Evaluate your performance undertaking this role play: What did you do well, areas you would
like to improve.
Observer role preparation
Make notes about the following:
 The behaviour of the patient, the mother, the paramedics’ including their verbal and non
verbal communication.
 What are your interpretations of this behaviour?
 Did the person’s behaviour change during the interview? In what ways/
 Make comment on how the nurse conducted the MSA. What worked, what did not appear
to work?
 What other questions could have been asked?
 Any other comments?
Patient role preparation
Ms Brenda Pollock is at an annual three day equestrian event in Adelaide parklands with her
husband and 10 year old daughter. She is a 35 year old school teacher and whilst interested in
horses is not an accomplished rider. She is attending at the instigation of her husband and
particularly her daughter who has become very interested in hoses. When they are standing
opposite one the more difficult jumps, a rider and horse misjudge the jump crashing heavily
into the logs causing the rider to fall. The horse is seriously injured with a fracture to a front
leg. In the excitement Ms Pollock is heard to groan then collapse to the ground unconscious.
Her husband is convinced she is having a heart attack and calls an ambulance and insists she is
taken to the local general hospital Emergency Department, where she is assessed and triaged.
You are anxious and short of breath, breathing fast, tearful at times, getting hot and edgy. See
below for an example of how you may play the role.
Example anxiety scenario preparation for students
Prompts for role play:
Learning Together Filming Script
Hospital Scenario – Elaine and Paramedic Sam
How are you?
Pt: I can’t catch my breath.
Just try… focusing on slowing your breathing down.
Pt: Ok – (Brenda nods – cntrl F6)
How are you feeling now?
Pt: Still very panicky
Yes, I understand but this will pass. When you’re feeling anxious it can be hard to catch your
breath.
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Brenda – nods cntrl F6
It can feel like you’re having a heart attack which is why we did an ECG, but your heart is fine.
Brenda nods cntrl F6
Have you ever felt like this before?
Yes, sometimes I get like this in crowds.
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Mood module
Exploring mood disorders
Written by Deb O’Kane
Across cultures the expression of basic emotions is remarkably similar. All of us have a
spectrum of emotions that can range from elation to despair. Our responses grow and develop
as we mature and, by adulthood, most societies would expect people to be able to control their
emotions and express them in appropriate ways.
However, how we respond to these emotions can be adaptive or maladaptive depending on the
physical, psychological and environmental factors surrounding us. Emotional control is slowly
developed from childhood. From an early age, the majority of people test and learn about the
appropriateness of their emotionally expressed behaviour and adapt accordingly within the
society or environment they live in. This week’s session will introduce you to some of the
common mood disorders you may come across as a health professional.
Learning outcomes for this week
Upon the successful completion of this week’s study, you will be able to:
 distinguish between the terminology of affect, emotion and mood,
 discuss some of the relevant theoretical explanations that contribute to understanding the
aetiology of mood disorders,
 distinguish between a person having a ‘bad day’, having a dysthymic disorder and being
diagnosed with a major depressive episode,
 describe the risk factors associated with mood disorders,
 describe the characteristics of mood disorders,
 recognise some of the personal challenges that may arise when working with people who
are experiencing a mood disorder,
 outline nursing interventions and your role when working with people experiencing a
mood disorder.
What you need to do to meet your learning outcomes
Text reading
Elder, R, Evans, K & Nizette, D 2009, chapter 16 ‘Mood disorders’, in R Elder, K Evans & D
Nizette (eds), Psychiatric and mental health nursing, 2nd edn, Elsevier Australia, Chatswood,
pp. 267-284.
Study this terminology section before class
Emotions are measurable physical responses to salient stimuli. They arise spontaneously as a
complex psychophysical process rather than through a conscious effort. They can evoke either
a positive or a negative psychological response related to feelings, perceptions or beliefs about
a number of things in reality or in the imagination.
Many psychologists adopt the ABC model, which defines emotions in terms of three
fundamental attributes: A, physiological arousal; B, behavioural expression (for example,
facial expressions); and C, conscious experience, the subjective feeling of an emotion.
20
Feelings, on the other hand, are the subjective experience that sometimes accompanies an
emotional process; that is, the sensations of happiness, envy, sadness and so on. Feelings can
come and go, but are logical, and are usually clearly visible on our face. Feelings can convey
information about situations on both a conscious and a subconscious level.
Affect is the subjective and immediate experience of emotion attached to ideas or mental
representations of objects.
Moods are pervasive and sustained feelings that are experienced internally. These relatively
long-lasting emotional or affective states differ from emotions in that they are less specific,
often less intense, and less likely to be triggered by a particular stimulus or event. Moods
generally have either a positive or a negative aspect to them. In other words, people often
speak of being in a good or a bad mood. Unlike acute emotional feelings such as fear and
surprise, moods generally last for hours or days. Even though moods are subjective states, they
can often be recognised by others from posture and observable behaviours.
Moods can be normal, elevated or depressed. Fluctuations in mood are common to the human
condition. A healthy person should experience a wide range of moods and have an equally
large repertoire of affective expressions. Most people feel in control of their moods and affects
but, in the extreme, moods can influence virtually all aspects of a person’s behaviour and
perception of the world.
eReading
Moussavi, S, Chatterji, S, Verdes, E, Tandon, A, Patel, V & Ustun, B 2007, ‘Depression,
chronic diseases, and decrements in health: results from the world health surveys’, Lancet, vol.
370, pp. 851-858.
Complete this activity
After doing the above eReading, reflect back on your clinical or personal experience and think
about someone you know or have cared for who has both depression and a medical condition.
What came first, the depression or the medical condition?
How did professionals and family respond to the person?
How did the person cope/manage?
What support mechanisms (if any) were in place for the person?
Be ready to discuss your answers in small groups in class.
Complete this activity
Summarise the text reading and terminology section for this week under the following
headings:
What is the difference between an emotion, a feeling and mood?
What criteria are used to judge whether or not a person is suffering from a major depressive
episode?
What is mania?
Describe bipolar disorder.
List the key interventions for people suffering from mood disorders.
Discuss your answers to the questions relating to the eReading above.
Raise any other questions you have from this week’s reading.
Complete this activity
In small groups discuss:
21
Would you, or your parents or siblings, be ashamed or embarrassed if someone in your family
became very depressed? What are the reasons for these feelings?
From your reading, discuss how you understand the relevance of gender to recovery from
depression.
How might healthcare look in the future, if there is a greater recognition that mental health and
medical conditions often coexist?
Watch this week’s video and contribute to a class discussion
One of these videos will be selected.
SANE Australia, Guide to bipolar disorder (40 minutes).
SANE Australia, Living with depression (43 minutes).
ABC Television, Four Corners: Beating the black dog (49 minutes).
NSW Consumer Advisory Group: Mental Health Inc, It’s only 1/100th of me.
Depression scenario
Student role play preparation information
Mr Geoff Somersley has been seeing his GP for a range of minor physical health complaints
over the past 6 months. Today he presented for an appointment, with the Practice’s Mental
Health Nurse following a referral from his doctor. Geoff generally reports that he lacks energy,
hasn’t been eating as well and hasn’t been going to his usual weekend outings to the football
with friends lately. More recently, he has had trouble sleeping and often wakes up during the
night and finds it hard to get back to sleep. Geoff is a 58 year old full time warehouse
administration assistant at a local hardware store. He and his wife Ruth have 3 children, 2 sons
who live interstate and 1 daughter who lives on the other side of the city. All have careers and
busy family lives with young children. Geoff and Ruth’s main contact with them is a phone
call every 2 weeks or so.
Geoff’s history is that he lost his mother when he was a child and the family moved a number
of times after that time so that his father could find work. This meant that he changed schools a
number of times and making friends was difficult. His father remarried when Geoff was in his
teens. He and his stepmother Janet were never really close. Brian described his teens as
troublesome with lots of alcohol use. He left school at 17 and got a job, finding he couldn’t
settle at study and because he wanted to get out on his own. He says meeting his wife was a
positive part of his life.
Geoff’s wife reports that he has been snappy lately and spends most of his time alone watching
TV till very late at night and that they have had trouble communicating. Their marriage has had
the usual ups and down, but has been generally a good one.
Physical assessment
Geoff is quietly spoken with minimal content in his conversation, seeming to respond to the
nurse’s question with little interest in the interview. He looks tired and drawn and is mainly
hunched over and looking down at his feet with his hands clasped tightly. He has little
expression on his face. He doesn’t make good eye contact, at times, looking away to avoid her
contact and seeming slightly agitated and bothered with the questions and at other times,
looking directly into the nurse’s face with a silent far away look.
His breathing is shallow and he looks pale.
22
Investigations by the GP over the past months have shown no irregularities eg. BP 125/85,
pulse, 72, respirations 12, B12, thyroid function and glucose tolerance test results were within
the normal range. ..
You are a student on clinical placement with the mental health nurse who has asked you to
conduct a mental state examination on Geoff.
Using the MSE documentation provided, conduct the assessment with the patient and
make written notes of your assessment. Note verbal and nonverbal communication.
Before you commence, think about how you begin and end a MSA interview.
Also think about what you may say to Geoff to establish a rapport with him.
You have maximum of twenty minutes for this task at which point you end the interview
and leave the consulting room.
Activities (Note your answers)
What assessment can you make from the physical examination? Write up your MSA and
consider the following:
 What other information would you wish to know from his wife?
 What other information should you inquire about from Geoff about his previous
experiences with depression?
 What other information would you ask about past history?
 What is your overall assessment?
 Write a few notes about your response to the patient’s statement that he sometimes wished
he did not wake up. What questions would you ask to seek clarification about this
statement?
Evaluate your performance undertaking this role play: what did you do well, areas you would
like to improve.
Patient role preparation notes
History
Mr Geoff Somersley has been seeing his GP for a range of minor physical health complaints
over the past 6 months. He generally reports that he lacks energy, hasn’t been eating as well
and hasn’t been going to his usual weekend outings to the football with friends lately. More
recently, he has had trouble sleeping and often wakes up during the night and finds it hard to
get back to sleep. Geoff’s history is that he lost his mother when he was a child and the family
moved a number of times after that time so that his father could find work. This meant that he
changed schools a number of times and making friends was difficult. His father remarried
when Geoff was in his teens. He and his stepmother Janet were never really close. Geoff
described his teens as troublesome with lots of alcohol use. He left school at 17 and got a job,
finding he couldn’t settle at study and because he wanted to get out on his own. He says
meeting his wife was a positive part of his life.
Geoff’s wife reports that he has been snappy more lately and spends most of his time alone
watching TV till very late at night and that they have had trouble communicating. Their
marriage has had the usual ups and down, but has been generally a good one.
23
Personal details
Geoff is a 58 year old full time warehouse administration assistant at a local hardware store. He
and his wife Ruth have 3 children, 2 sons who live interstate and 1 daughter who lives on the
other side of the city. All have careers and busy family lives with young children. Geoff and
Ruth’s main contact with them is a phone call every 2 weeks or so.
Further history
Geoff reported that he has felt like this previously, after the death of a close friend in a
motorcycle accident when Geoff was a young man and again when his father died
approximately 5 years ago. On each occasion he was hospitalised and discharged home on
tricyclic anti depressant medication.
The nurse will come in to undertake a MSA. You appear sad, tired and fed up. You do not
immediately look up or respond to the nurse. You talk quietly and appear to struggle to find the
words to say at times. When you do, you show little animation in your tone. You appear as
helpless and negative about suggestions made by nurse, reluctant to make any suggestions or to
try anything. You will be interviewed for a maximum of twenty minutes about how you are
feeling. A few minutes into the interview you tell the nurse that you feel there is little hope of
change and that you wish it would all go away, that you wished that you wouldn’t wake up one
morning because it is too hard living like this.
Written activities
Make notes about how you felt in the role of the patient.
 What was your mood prior to, during and after the interview? Reflect on your level of
concentration, ability to answer the questions.
 Did the nurse demonstrate empathy towards you?
 Did you feel cared for?
 How did you feel about the nurse’s response to your statement that you wished you
wouldn’t wake up?
 State any things you didn’t like while in this role (e.g. feeling uncomfortable).
Observer role (student nurse) preparation notes
Patient presentation
Mr Geoff Somersley has been seeing his GP for a range of minor physical health complaints
over the past 6 months. Today he presented for an appointment, with the Practice’s Mental
Health Nurse following a referral from his doctor. Geoff generally reports that he lacks energy,
hasn’t been eating as well and hasn’t been going to his usual weekend outings to the football
with friends lately. More recently, he has had trouble sleeping and often wakes up during the
night and finds it hard to get back to sleep. Geoff is a 58 year old full time warehouse
administration assistant at a local hardware store. He and his wife Ruth have 3 children, 2 sons
who live interstate and 1 daughter who lives on the other side of the city. All have careers and
busy family lives with young children. Geoff and Ruth’s main contact with them is a phone
call every 2 weeks or so.
Geoff’s history is that he lost his mother when he was a child and the family moved a number
of times after that time so that his father could find work. This meant that he changed schools a
number of times and making friends was difficult. His father remarried when Geoff was in his
teens. He and his stepmother Janet were never really close. Geoff described his teens as
troublesome with lots of alcohol use. He left school at 17 and got a job, finding he couldn’t
24
settle at study and because he wanted to get out on his own. He says meeting his wife was a
positive part of his life.
Geoff’s wife reports that he has been snappy more lately and spends most of his time alone
watching TV till very late at night and that they have had trouble communicating. Their
marriage has had the usual ups and down, but has been generally a good one.
Physical assessment
Geoff is quietly spoken with minimal content in his conversation, seeming to respond to the
nurse’s question with little interest in the interview. He looks tired and drawn and is mainly
hunched over and looking down at his feet with his hands clasped tightly. He has little
expression on his face. He doesn’t make good eye contact, at times, looking away to avoid her
contact and seeming slightly agitated and bothered with the questions.
His breathing is shallow and he looks pale.
Investigations by the GP over the past months have shown no irregularities eg. BP 125/85,
pulse, 72, respirations 12, B12, thyroid function and glucose tolerance test results were within
the normal range.
Make notes about the following:
 The behaviour of the patient, verbal and non-verbal communication.
 What are your interpretations of this behaviour?
 Did the patient become appear to engage with the nurse as the interview went on?
 Make comment on how the nurse conducted the MSA. What worked, what did not appear
to work?
 What other questions could have been asked?
 Any other comments?
25
Student assessment activities
From the roles you played in the three scenarios (maximum 1500 words):
Health professional role
Complete the following tasks:
 Write up your Mental Health Assessment and suggest symptoms (with evidence).
 What nonverbal communication did you observe and what might it mean?
 Describe our observations of his verbal communication and your interpretations.
 What physical assessments will this young man require?
 Under what three main criteria can someone be detained under the Mental Health Act in
South Australia?
 How has the South Australian Mental Health Act (2009) changed the role of first
responders, particularly paramedics, in regards to detaining an individual?
 7.1(b) of the South Australian Mental Health Act (2009) says “services should be provided
on a voluntary basis as far as possible, and otherwise in the least restrictive way and in the
least restrictive environment that is consistent with their efficacy and public safety, and at
places as near as practicable to where the patients, or their families or other carers of
Supporters”. What implications does this have for Jacks care?
 What information at this point in time would you give to the mother?
Observer role
Make notes about the following:
 The behaviour of the patient, the mother, the paramedics’ including their verbal and non
verbal communication.
 What are your interpretations of this behaviour?
 Did the person’s behaviour change during the interview? In what way/s?
 Make comment on how the nurse conducted the MSA. What worked, what did not appear
to work?
 What other questions could have been asked?
 Any other comments?
Patient role
Make notes about the following:
 Make notes about how you felt in the role of the patient.
 What was your mood prior to, during and after the interview? Reflect on your level of
concentration, ability to answer the questions.
 Did the nurse demonstrate empathy towards you?
 Did you feel cared for?
 How did you feel about the nurse’s response to your statement that you wished you
wouldn’t wake up?
 State any things you didn’t like while in this role (e.g. it made you feel uncomfortable).
26