NRSG210 revision
Fetal alcohol syndrome (FAS) DX
S&S of child & maternal alcohol history
What is Form 17
Notification to Near Relative (Discharge of Involuntary Patient)
anxiety disorders theories
neurotransmitters; conflict between ID and Super Ego
social phobia
fear of behaving in a way that will cause embarrassment
agoraphobia
fear of public places
what do people with all eating disorders have in common
feel of a lack of control
CNS depressants withdrawal S&S
peaks within 3-4 days, can last 10 days
What is an Enduring Power of Attorney
- allows you attorney to make the necessary financial and legal decisions for you in care you become mental incapable because of age, accident or illness
cognitive disorders affect
thinking, reasoning, learning, language, intellect, & social skills
define psychopathologic sequalae
A pathological condition resulting from a disease.
Cannabis use disorder
A: A problematic pattern of cannabis use leading to clinically significant impairment if distressed as manifested by at least two of the following over a 12 month period: • 11 points to select from including tolerance and withdrawal
ATOD stands for
Alcohol, Tobacco, or Other Drugs
Buspirone (BuSpar)
Anxiolytic. Used to treat Social Phobia & OCD as an adjunct tx for refractory OCD
Define Designated Mental Heath Service
Approved MH service
CAGE
C....Cut back A....Annoyed G....Guilty E....Eye opener
What is Form 15
Nomination of Near Relative
Fluoxetine (Prozac)
SSRI used to treat Anxiety Disorders -
Medications used for Mood Disorders
SSRIs
disorganized schizophrenia
flat or inappropriate affect, incoherence
bipolar (manic depressive)
periods of mania (extreme elation, agitation) & periods of severe depression; can cycle slowly over weeks, months, or years or fast over hours
residual phase
phase 4- 2 parts
What do families need to know about police and the mental health act
- A polive officer does not need to witness the person doing anything dangerous
Early warning signs of relapse for psychosis
- Changes to sleeping patterns (hyper or hypo somnia) - Straying from treatment plans - Tension, agitation, irritability - Alterations in eating habits (hyperphagia/anorexia) - Concentration issues - Anxiety, restlessness - Increased feelings of fear or apprehension - Decline in personal hygiene and/or living environment - Social withdrawal - Unusual/disturbing/recurring thoughts
What is Ulysses Agreement
- Not legally binding
When releasing information to 3rd parties what is important to document
- Reason for disclosing information
What is the Representation Agreement act and when did it start
- in 2000
What are the steps a family must go through in order to receive an Order By A juDge for Involuntary admission when a client is not willing to go voluntarily
1. Keep Notes: symptoms and behaviour, the need for psychiatric treatment, decompensation, dates, times, locations, reason
What are the 3 ways to arrange for involuntary admission
1. Medical Certification - Form 4
What is a model of healthcare?
1. People 'spout' the term quite often in the field of health 2. A model of healthcare is a system or structure that has been formally developed to organise, guide and explain the way in which health professionals deliver healthcare within a particular setting 3. Should not be mistaken with a 'service model', 'nursing models of care', 'nursing models of practice'...
Principles of Effective Treatment for substance abusers
1. Possible drug use during treatment must be monitored continuously 2. Treatment programs should assess for HIV/AIDS, Hepatitis B & C, Tuberculosis and other infectious diseases and help clients modify at‐ risk behaviors 3. Recovery can be a long‐term process and frequently requires multiple episodes of treatment
Progression of Dependence Measured in Two Ways...
1. The effect that dependant behaviors have on effective and healthy personal functioning. 2. The intensity of cravings for the substance, activity, relationship, or thing. • These 2 measures can help one gauge a persons progression towards dependence.
According the the Freedom of Information and Protection of Privacy what are the situation where we can provide information to 3rd parties
1. continuity of care
Demographics of Ageing
17% of males, 19% females aged 60+ ATSI population have poorer health and lower life expectancy than non ‐Aboriginal populations Higher rates of MI in aged populations living in 'institutionalised' residential care However, 92% of people aged 65+ live in own home Older people living alone 3x more likely to be depressed than those living with others.
12 cranial nerves
1st Olfactory Relays smell 2nd Optic Transmits visual information 3rd Oculomotor External muscles of the eye 4th Trochlear Also supplies muscles of the eye 5th Trigeminal Chewing and sensation in the face 6th Abducent Controls lateral eye movement 7th Facial Muscles of facial expression, taste buds, sensation in fingers and toes, blinking 8th Auditory Hearing and balance 9th Glossopharyngeal Sensation, taste and swallowing 10th Vagus Organs in chest and abdomen 11th Accessory Supplies two neck muscles, the sternomastoid and trapezius 12th Hypoglossal Muscles of the tongue and neck
CLUB DRUGS
Acute Effects: MDMA - mild hallucinogenic effects; increased tactile sensitivity, empathic feelings; lowered inhibition; anxiety; chills; sweating; teeth clenching; muscle cramping Flunitrazepam - sedation; muscle relaxation; confusion; memory loss; dizziness; impaired coordination GHB - drowsiness; nausea; headache; disorientation; loss of coordination; memory loss Health Risks: MDMA - sleep disturbances; depression; impaired memory; hyperthermia; addiction Flunitrazepam - addiction GHB - unconsciousness; seizures; coma
OPIOIDS
Acute Effects: Euphoria; drowsiness; impaired coordination; dizziness; confusion; nausea; sedation; feeling of heaviness in the body; slowed or arrested breathing Health Risks: Constipation; endocarditis; hepatitis; HIV; addiction; fatal overdose
DISSOCIATIVE DRUGS
Acute Effects: Feelings of being separate from one's body and environment; impaired motor function Also, for ketamine - analgesia; impaired memory; delirium; respiratory depression and arrest; death Also, for PCP and analogs - analgesia; psychosis; aggression; violence; slurred speech; loss of coordination; hallucinations Also, for DXM - euphoria; slurred speech; confusion; dizziness; distorted visual perceptions Health Risks: Anxiety; tremors; numbness; memory loss; nausea
Define Acute mental health services:
Acute mental health services provide specialist psychiatric care for people who present with acute episodes of mental illness. These episodes are characterised by severe clinical symptoms of mental illness that have potential for prolonged dysfunction or risk to self and/ or others. The treatment effort is focused upon symptom reduction with a reasonable expectation of substantial improvement. In general, acute services provide relatively short term treatment.
Define Authorised Person
Ambulance paramedic, police officer, medical practitioner employed by a designated
Define Admitted patient
An admitted patient is a patient who undergoes a hospital's formal admission process, completes an episode of care and 'separates' from the hospital.
what is CAGE used for?
An alchohol screening test
How much does mental illness cost the government
Annual cost of mental illness in Australia is around $20 billion
Haloperidol (Haldol)
Antipsychotic. Targets dopamine levels. Can reduce irritability and labile affect. Used for Autism Disorder (drug of choice) and tics of Tourette's syndrome.
How do Anxiety disorders affect the Australian population?
Anxiety disorders are most common affecting 14% of adults annually, depression 6% • ~3% Australians affected by psychotic illness • ~2% affected by eating disorders • ~5% affected by substance use disorders
How has Australia's suicide rate in 2010‐11 changed?
Australia's suicide rate in 2010‐11 was almost double the country's annual road toll in 2013 - 1193 (road toll) vs 2, 282 (suicide) - >6 people per day commit suicide in Australia (a further 30 attempt)
what does alcohol do to the body
CNS depressant; blocks judgment; metabolizes in the liver; cirrhosis, diuretic, toxic to bowels; ataxia, memory loss
α- Adrenergic agonists
Clonidine. Used for Disruptive Disorder Behaviors - ADHD
Define Consumer:
Consumer: A person who uses or has used a mental health service or who has experienced/is recovering from a mental illness.
Opiate Withdrawal Timeline
Heroin • 8‐12hrs after last dose • Methadone
Self stigmatisation - define
How people view themselves relating to their mental illness The prejudice people turn against themselves
Assessment & management in Alcohol withdrawal
If none of the following: • Differential Dx • Lack of previous Hx • Two or more seizures in succession • Partial onset (focal) type seizures • Seizure occurring > 48 hours after last drink • No recent heavy R‐OH use or other features of R‐OH withdrawal
some mixed support for
Implication of the orbital, cingulate cortex, caudate nuclei (frontal-subcortical dysfunction) Serotonin Significant cognitive (thought) factors generate and maintain intrusive thoughts and schemas
Clomipramine (Anafranil)
May help treat anger and compulsive behavior. Used for Pervasive Developmental Disorders - Autistic Disorder.
Define Patient
Person being treated under VMHA (2014)
Primary mental illness with subsequent substance abuse
Primary mental illness leads to addictive behaviour through self‐medication to manage symptoms • Impaired judgement • Poor impulse control • Impaired social skill • Inappropriate coping strategies
Principles of recovery model of practice
Promote recovery: • Grounded in appreciation of recovery (hope, power, purpose, skills & connection) Strengths based: • Discover and focus on consumer strengths Community focused: • Occurs in community context, focuses on connections Person driven: • Fosters choice and self‐determination Culturally responsive: • Sensitive to social and cultural needs Reciprocity in relationships: • Allows for enhanced sense of value Grounded in life context: • Appreciate the consumer's unique life story and sense of self Addresses socioeconomic context: • Identifies and minimises barriers as a result of poverty, housing etc. Relationally mediated: • Relationships are central Optimises natural supports: • Fosters connections and supports
Psychosis is most commonly seen....?
Psychosis is most commonly seen in schizophrenia
Pemoline (Cylert)
Psychostimulant to improve symptoms in ADHD.
Fluoxetine (Prozac) and Paroxetine (Paxil)
SSRIs used to treat Panic/School phobias
Medications fro Panic Disorders and School phobias
SSRIs: citalopram, fluoxetine, paroxetine, TCAs: impramine
Propanolol
Sympatholytic β- Blocker.Reduces rage outbursts, aggression and severe anxiety. Used for Pervasive Developmental Disorders - Autistic Disorder. Used for ADHD. Used for Conduct Disorder.
Do you need a living will if you have a Last will and Testament
YES
alcohol abuse S&S
binge lasting 2 or more days, N&V, dehydration, disorientation, blackouts, increased susceptibility of infections & injury
Transference - define
blurred and inconsistent consumer/nurse boundaries where the consumer may place feelings and emotions that are meant for a significant other upon the nurse caring for them.
Korsakoff's psychosis
brain disorder that occurs with alcoholism
most frequently used psychoactive stimulant
caffeine
CNS stimulants
caffeine, nicotine, cocaine, amphetamines (usu. mixed with heroine or weed)
post traumatic stress disorder (PTSD) S&S
can appear immediately or years later; flashbacks (as if it were happening now) usu. triggered by certain sites or smells;
most used elicit drug in the US
cannabis
inhalants
chemicals that alter thinking when inhaled
Medications for Tourette's Syndrome
clonidine, neuroleptics, haloperidol, pimozide, fluphenazine, botulinum toxin
Medications for Autistic Disorders (subtype of Pervasive Developmental Disorder)
clonipramine, propanolol, haloperidol, SSRIs, respiradone, olanzapine
drug that affects the limbic system
cocaine
Fetal alcohol syndrome (FAS)
congenital defect d/t daily maternal alcohol consumption (as little as 2 drinks / day)
antisocial personality
extreme patterns of disregard & violation of the rights of others;
Medications for Anxiety Disorders
fluoxetine, TCAs (imipramine)
DX down syndrome
genetic & chromosome testing; Denver II- assess developmental levels of children
schizo- Positive (excessive) behaviors
have a better prognosis
bulimia nervosa
ingesting of a large amount of food then purging
simple phobias
irrational fear of a specific object or situation
Oculogyric Crisis
is the name of a dystonic reaction to certain drugs or medical conditions characterized by a prolonged involuntary upward deviation of the eyes. • Contracted positioning of the eyes upward • Initially restlessness • Agitation • Fixed stare
prodromal phase
phase 1-usu. begins in adolescence. lack of motivation & energy, withdrawal, blunt affect, odd ideas, excessive interest in religion or philosophy, decrease in self care and hygiene, emotional liability, speech is difficult to follow, c/o multiple physical problems, magical thinking or belief that thoughts control events
prepsychotic phase
phase 2- quiet, passive behaviors, prefers to be alone, starts to withdrawal, hallucinations, delusions, odd suspicious behavior, eccentrics, strange
acute phase
phase 3- S&S vary widely; disturbances in thought, perception, emotion, and behavior, often loses contact with reality and is unable to function
physical withdrawal syndrome
physical response to abruptly stopping or reducing a substance used for a long period of time
delerium
possible at any age; altered mental state; rapid onset, short duration; Features- disorientation, decreased LOC, illusions, hallucinations
phases of schizophrenia
prodromal; prepsychotic; acute; residual
Medications for Conduct Disorders
propranolol
DX addiction
r/o physical reasons first, drug & alcohol levels, increased liver enzymes, S&S of withdrawal
Public stigma - define
reaction the general population have on those with a mental illness
causes of delerium
surgery, trauma, drugs/ meds, infection, acid/ base & lyte imbalances
dependent personality
uncontrollable desire to please others; fear of abandonment
abusive personality
uses verbal &/or physical aggression as a coping mechanism
Aetiology & Epidemiology of BPAD
• Australian lifetime prevalence for BPADI is up to 1% (no gender variance) • Australian lifetime prevalence for BPADII is up to 5% (higher rates in women) • Emergence is usually mid‐to‐late adolescence • Strong genetic links - 1 parent ~25% risk - 2 parents ~ 50% risk • More common in high‐income countries • Separated, divorced or widowed individuals have higher rates • Positive family history is strongest & most consistent factor
Interventions for alchohol • Brief interventions ‐ FRAMES
• Brief interventions ‐ FRAMES
Principles underlying the assessment
• Clinician needs to be aware of behaviour ranges/abilities expected at each age & what is known about child/youth psychiatric disorders • Intrinsic & extrinsic factors interweave • Behaviours may reflect different psychological processes at different ages • Behaviours may change form, however still be manifestations of initial process • Take note of major life events and transitions occurring in social contexts and individuals response • Evaluate risk and protective factors
Headspace Psychosocial Assessment
• Conduct difficulties & risk-taking • Anxiety • Eating • Depression & suicide • Psychosis & mania Home & environment • Education & employment • Activities • Alcohol & other drugs • r/ships & sexuality Plus final subsection • Summary (Strengths & Difficulties) and Goals
Addiction/Dependence
• Dependency has real life consequences that seriously impair, negatively affect, and destroy relationships, health (physical and mental), and the capacity to function effectively. • Dependence involves regular drug use, increased tolerance and experience of withdrawal when reduced or discontinued • Someone who is 'addicted' is 'dependent" on that thing which dominates their thoughts and desires, directs their behaviors, and the pursuit of that thing becomes the most important activity in their lives.
Causes of Anorexia
• Genetic predisposition • Cultural and social pressures • Family pressure to conform to body image • Low self esteem • Childhood abuse or trauma • Control issues Course of the Anorexia Nervosa • Typically begins in mid-late adolescents (14-18) • May be associated with stressful life event • Mortality rate higher than any other mental illness • Mortality rate between 6-20% • This increases each year the illness continues
Ethical Issues: Suicide
• Is the intervention in a person's choice justified? • On what grounds? • What about duty of care?
Negative Symptoms of Schizophrenia
• Poverty of speech • Poor maintenance of ADL's • Alogia • Anergia • Affective blunting • Avolition • Apathy • Loss of warmth or vibrancy • Poverty of thought • Passive or social withdrawal
Working Within a Recovery Framework
• Providing a culture of hope • Promoting autonomy & self‐motivation • Collaborative partnerships and meaningful engagement • Focus on strengths • Holistic and personalised care • Involvement of family, carers, support people and significant others • Community participation & citizenship • Responsiveness to diversity • Reflection & learning
Some attributes of partnerships
• Purpose • Trust • Respect • Structure • Identity • Roles, rules, responsibilities • Commitment • Collaboration • Knowledge base & skills • Professional boundaries • Membership dynamics • Power • Leadership
Contemporary Concepts of Mental Illness Recovery?
• Recovery is a non‐linear process • Treatment in the community is best‐practice • Practitioners acknowledge the need for balance between reduction of symptoms with acceptable medication regimes • An inability to return to premorbid levels of functioning does not equate to failure
Alcohol withdrawal seizures
• Typically occur 6‐48 hours after last drink is consumed • Usually generalised seizures • Occur as BAL decreases • Prevention: Benzodiazepines (rapid onset and long acting preferred) • Carbamazepine: prevention of R‐OH withdrawal seizures but not in preventing further seizures
Recovery Works When...
• We align people with the right help at the right time for however long they need it • Refrain from judgement - give equal help regardless of who the individual is • Adopt a holistic approach • MHC treat individuals with respect, dignity & equity • Advocate consumers to take on competent roles • Protect rights • MHC provide support only when necessary • Encourage consumer to use services and supports and how to access these • Are staffed by workers who support these core values
most common form of substance abuse disorder?
▪ Substances used by people with dual diagnosis may include prescription drugs or other substances, whether legal or illegal, including alcohol, opiates, stimulants and cannabis. The most common form of substance abuse disorder is alcohol dependence. Other legally available substances are solvents and petrol, ingested by 'sniffing'. ▪ Tobacco use, is not treated as part of the dual diagnosis spectrum.
Define Therapeutic Relationship:
"A therapeutic relationship is defined as "one in which the patient feels comfortable being open and hones with the nurse' and is linked to the development of a productive and positive patient outcome" "the relationship between the health professional and person that enables change in or for the person" Components include: - Rapport - empowerment - collaboration
Sexual Dysfunction & AD's Symptoms:
- Decreased libido - Impotence/erectile difficulties - Painful erections - Decreased vaginal lubrication - Anorgasmia - Delayed orgasm • Treatment: - Reducing medication - Changing medication - Adding antidote
Essential elements to therapeutic relationship:
- Empathy - the ability to recognise the immediate emotional perspective of another person while maintaining ones own experiences - Unconditional positive regard - relating to and accepting the client with genuine caring and without attaching conditions - Genuineness - direct and honest attitudes towards people - Therapeutic use of self
Psychosis Symptoms include:
- Hallucinations - Delusions - Thought organisational difficulties
Suicide Methods:
- Hanging, strangulation,suffocation (54.4%) - Poisoning by drugs (14.5%) - Poisoning by other methods (8.5%) - Firearms (6.8%) - Drowning, jumping, other (15.8%)
What is the loop whole in the Form 4 certification
- If this is a first medication certificate, it becomes invalid on the 15th day after the date upon which the physician examined the person who is the subject of there certificate unless the person has been admitted on the basis of it.
What does Police intervention result in involuntary admission
- Section 28
How does Oder by a Judge result in involuntary admission
- Section 28(3)
What is a living will
- Written instructions about what level of medical treatment you want in the event you are unable to express you wishes verbally
how does someone become certifies with a medical certification
- a doctor fills out Form 4 which is good for 48 hours
What is a power of Attorney
- a document that appoints another person, to make FINANCIAL and LEGAL decisions for you
Is a living will a power of Attorney
- it is a type of power of attorney
What is it important for the family to keep notes
- symptoms or behaivour indicating that substantial deterioration is likely to occur or that protection is needed may not be clearly evident during the physicians examination
Capacity to consent - guidelines
- understand the information given - able to weight the information - able to convey an answer - w/out capacity act in the best interests of the patient including acknowledging an advance statement if applicable.
Define recovery:
...a personal process of changing one's attitudes, values, feelings, goals, skills and/or roles...the development of new meaning and purpose...beyond the effects of psychiatric disability... "...a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills, and/or roles. It is a way of living satisfying hopeful and contributing in life when with limitations caused by illness..."
Major Depressive Disorder Must have DEPRESSED MOOD and/or LOSS OF PLEASURE Must be 2+ weeks Must meet at least 5 criteria (1 of which must be depressed mood or loss of pleasure) Age of onset is early 20s If one episode, highly likely to have more Manic Episode Elevated and expansive mood (or irritable in children) Must meet 3 additional criteria Must be 1 week in length, or hospitalized Severely impact functioning If a Manic episode is diagnosed, automatic Bipolar I diagnosis Hypomanic Episode Same criteria as Manic, just less severe Needs to last at least 4 days Bipolar II Bipolar I Manic Episode REQUIRED for Diagnosis Onset is 18+ More likely to commit suicide 80% concordance rate with twins Bipolar II Hypomanic Episode + Major Depressive Episode Onset is mid 20s Higher lethality rate Persistent Depressive Disorder (PDD) Depressed mood most of the day for 2+ years (children, 1 year) 2+ symptoms Cannot be without symptoms for 2 + months Never had a Major Depressive Episidoe Their experience is FLAT (rather than guilt or worthless) Cyclothymic At least 2 year period with hypomanic and depressive symptoms that never meet full criteria Never been without symptoms for 2+ months Premenstrual Dysphoric Disorder (NEW) ... Disruptive Mood Dysregulation Disorder (NEW) Main feature is IRRITABILITY Created to lower Bipolar diagnoses in children Anxiety Disorders For almost all, treatment of choice is exposure therapy or desensitization therapy. Medication - SSRIs, not anti-anxiety medication Distinguishing factors is CONTENT of fear (i.e. what you're afraid of) Early onset Female to Male ration is 2
1 Must be more than NORMAL fears Must be at least 6 months Panic Attack This is not a code-able disorder. This is a specifier. Needs to be differentiated from anxiety attack (unexpected vs expected) 4+ symptoms Dissociative quality to panic attacks Panic Disorder Recurrent, unexpected panic attacks Needs to be followed by 1 month of persistent worry re another attack Avoidant behavior to minimize another attack Age of onset is 20 to 24 years Agoraphobia Used to be linked to Panic Disorder If you meet criteria for both, you can have BOTH Fear and anxiety of more than TWO situations (if just ONE, you have a phobia) Separation Anxiety Disorder Excessive fear of anxiety concerning separation from home or attachment figures. Selective Mutism Not initiating speech or responding when spoken to Specific Phobia Marked fear or anxiety about a specific object or situation Give a separate diagnosis for each phobia 75% of individuals with one phobia have another Social Anxiety Disorder Marked fear or anxiety about one or more socials situations in which the individual is exposed to possible scrutiny by others. Age of onset is typically 8 to 15. Generalized Anxiety Disorder Excessive anxiety and worry occurring more days than not for at least 6 months GAD Worry is difficult to control 3 or more physiological symptoms -9% lifetime prevalence -Diagnosed less frequent than other anxiety disorders -Onset- generally teens to 20's -More females than males -Strong correlations with mood disorder GAD Genetic factors- twin studies suggest 30% of variance due to genetics -Psychological factors -Interpretation of potential threat -Exposure to aversive circumstances -Biological factors -Benzodiazepine receptor complex- GABA -Autonomic inflexibility - Hippocampal abnormalities SPECIFIC PHOBIAS TREATMENT Short term situational: Benzodiazepines (e.g. fear of flying) Long term and preferred: In-vivo behavioral Adjunctive therapies tend not to increase efficacy SOCIAL PHOBIA TREATMENT Treatment Cognitive Behavioral Therapy In-vivo exposure, role-playing, skill training Beta-blockers, SSRIs PANIC DISORDER TREATMENT *Strong evidence that cognitive behavioral packages are the preferred treatment & more effective long-term than medication *Those treated with both medication and CB therapy may have less effective outcome than CB alone *Predominant medical clinical practice Short term: Benzodiazepines, beta blockers Longer term: SSRI GAD TREATMENTS Medications: *Benzodiazepines and SSRIs used most often in clinical practice *Disadvantages- risk of dependency on benzodiazepines and relapse of symptoms upon termination of drug treatment *Cognitive behavioral treatments recognized as most effective over the long term *More resistant to drug therapy than other anxiety disorders Reactive Attachment Disorder *Inhibited, withdrawn behavior toward adult caregiver *Persistent emotional and social disturbance *Experience of insufficient care is cause of behavior toward adult Disinhibited Social Engagement Disorder *Child actively approaches and interacts with unfamiliar adults *Due to socially disinhibited behavior *Experience of insufficient care is cause of social behavior PTSD1 *Exposure to traumatic event *One or more intrusive symptoms *Persistent avoidance of stimuli associated with the trauma *Negative alterations in cognitions or emotions (2 or more) *Alterations in arousal and reactivity (2 or more) *Lasts longer than 1 month *Disturbance causes clinically significant distress and not attributable to medical conditions or substances Specify: Dissociative symptoms OR Delayed expression PTSD IN CHILDREN (6 AND UNDER) *Exposure to traumatic event (reduced) *One or more intrusive symptoms *Persistent avoidance or negative alterations in cognitions (1 or more) *Alterations in arousal and reactivity (2 or more) *Lasts longer than 1 month *Disturbance causes clinically significant distress and not attributable to medical conditions or substances Specify: Dissociative symptoms OR Delayed expression PTSD 2 *60% of men and 50% of women report exposure to potentially traumatic event *40% of 10-16 year-olds report exposure to violent victimization *Most individuals do not develop PTSD *Estimated lifetime prevalence 7%: 10% in women
How Many Australians have a mental illness and when does this start?
1 in 5 (20%) Australians will have a mental illness in any 12 month period - 11.5% have one disorder - 8.5% two or more "75% of all severe mental illness begins before the age of 24 years, with the peak onset between 18‐24 years of age"
Principles of Effective Treatment for substance abuse
1. Counseling and other behavioral therapies are critical components of effective treatment 2. Medications are an important element of treatment for many patients 3. Co‐existing disorders should be treated in an integrated way 4. Medical detox is only the first stage of treatment 5. Treatment does not need to be voluntary to be effective 6. Non‐judgmental approach 7. Client's own goals 8. Focus on alternative activities 9. A 'suite of approaches' 10. Harm Minimisation 11. Longitudinal perspective. Flexibility & optimism
Ten Personal Areas of Life
1. Managing mental health 2. Physical health and self‐care 3. Living skills 4. Social networks 5. Work 6. Relationships 7. Addictive behaviour 8. Responsibilities 9. Identity and self esteem 10. Trust and hope
Principles of Effective Treatment for substance abusers:
1. Right to treatment 2. No single treatment is appropriate for all 3. Assertive engagement 4. Practical assistance & basic needs first /Stable accommodation 5. The clinician‐client relationship 6. Long term ongoing contact 7. Takes place in the client 's own environment and focuses on working on the clients recovery 8. Treatment needs to be readily available (Mainstreaming of treatment‐ 'core business') 9. Effective treatment attends to the multiple needs of the individual 10. Treatment plans must be assessed and modified continually to meet changing needs 11. Remaining in treatment for an adequate period of time is critical for treatment effectiveness
Autism Spectrum Disorders
4 different disorders involving decreased brain functioning & social skills
Social inclusion and recovery - aim
4th national mental plan - 2009-2014 - reduce stigma - expand education, employment, vocational programs - improve service coordination - adopt recovery culture - develop approaches to link housing, justice, community and aged care for people at trick of homelessness
DSM 5 Classification ‐ MDD
5 or more of following symptoms present for same 2 week period (must include at least 1 & 2): 1. Depressed mood (dysphoria) 2. Markedly diminished interest or pleasure in all or most activities most of the day, nearly every day (anhedonia) 3. Significant weight loss when not dieting or weight gain (change <5% in one month) or decrease or increase in appetite nearly every day 4. Insomnia or hypersomnia nearly every day 5. Observable (by others) psychomotor agitation or retardation nearly every day 6. Fatigue or loss of energy nearly every day (anergia) 7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day 8. Diminished ability to think or concentrate, or indecisiveness nearly every day 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide
caffeine withdrawal
5-7 cups a day can cause symptoms
Define: Mental illness
A mental illness is a health problem that significantly affects how a person feels, thinks, behaves, and interacts with other people. It is diagnosed according to standardised criteria. The term mental disorder is also used to refer to these health problems"
Self‐efficacy
A person's belief about their ability or capacity to accomplish a goal/change behaviour/make less mistakes next time/become more resilient/utilise support services • According to the Transtheoretical Model of Change: ‐ Pre‐contemplation stage - person is not currently thinking about changing their behaviour - why? a) Doesn't think behaviour needs to change; b) Change would be too difficult c) Have tried before & failed d) Don't make the connection between behaviour & consequences
Harm Minimisation
A variety of drugs, both legal and illegal, are used in society. There are different patterns of use for drugs and not all drug use is problematical. E.g. Large proportions of young people try alcohol or other drugs, including illicit drugs, without becoming regular or problem drug users. Drug use is a complex behaviour. Interventions that try to deal with single‐risk factors or single‐risk behaviours are ineffective. Drug use represents (in part at least), the persons attempt a functional behaviour This means that drug use can best be understood in the broader context of the lives of the young people using them. Any interventions need to take the broader context into account The idea of a mosaic of middle range polices: preference for pragmatic measures that match the spectrum of drugs and patterns of use
Schizoaffective Disorder DSM 5 (2013) Classification
A. An uninterrupted period of illness during which there is a major mood episode (mania or depression) concurrent with criteria A of schizophrenia B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness D. The disturbance is not attributable to the effects of a substance or other illness • Specify if bipolar type (if manic episode is part of the presentation. MD may also occur) • Specify if depressive type (only applicable if major MD are part of presentation
DSM 5TM Classification anarezia
A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. B. Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight. C. Disturbance in the way in which ones body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. For adults: • Mild: BMI >17 kg/m2 • Moderate: BMI 16-16.99 kg/m2 • Severe: BMI 15-15.99 kg/m2 • Extreme: BMI <15 kg/m2 DSM 5TM Classification • Restricting Type: during the last 3 months, the person has not regularly engaged in binge-eating or purging behaviour (i.e., self- induced vomiting or the misuse of laxatives, diuretics, or enemas). Weight loss is primarily through dieting, fasting, and/or excessive exercise. • Binge-Eating/Purging Type: during the last 3 months, the person has regularly engaged in binge-eating or purging behaviour (i.e., self- induced vomiting or the misuse of laxatives, diuretics, or enemas)
Schizophrenia - DSM 5 (2013) Classification
A. Two or more of the following (must include 1, 2, or 3, and be present for one month or less with treatment) 1. Delusions 2. Hallucinations 3. Disorganised speech 4. Grossly disorganised or catatonic behaviour 5. Negative symptoms B. Significant impact on work, interpersonal relations or self‐care C. Continuous disturbance lasting at least 6 months (at least 1 month active symptoms ‐ or less if treated successfully)
OTHER COMPOUNDS
Acute Effects Steroids - no intoxication effects high blood pressure; blood clotting and cholesterol changes; liver cysts; hostility and aggression; acne; in adolescents—premature stoppage of growth; in males—prostate cancer, reduced sperm production, shrunken testicles, breast enlargement; in females—menstrual irregularities, development of beard and other masculine characteristics Inhalants - (varies by chemical) stimulation; loss of inhibition; headache; nausea or vomiting; slurred speech; loss of motor coordination; wheezing Health Risks: Steroids - high blood pressure; blood clotting and cholesterol changes; liver cysts; hostility and aggression; acne;—in adolescentspremature stoppage of growth; in males—prostate cancer, reduced sperm production, shrunken testicles, breast enlargement; in females—menstrual irregularities, development of beard and other masculine characteristics Inhalants - cramps; muscle weakness; depression; memory impairment; damage to cardiovascular and nervous systems; unconsciousness; sudden death * Schedule I and II drugs have a high potential for misuse. They require greater storage security and have a quota on manufacturing, among other restrictions. Schedule I drugs are available for research only and have no approved medical use; Schedule II drugs are available only by prescription (unrefillable) and require a form for ordering. Schedule III and IV drugs are available by prescription, may have five refills in 6 months, and may be ordered orally. Some Schedule V drugs are available over the counter. ** Some of the health risks are directly related to the route of drug administration. For example, injection drug use can increase the risk of infection through needle contamination with staphylococci, HIV, hepatitis and other organisms.
HALLUCINOGENS
Acute Effects: Altered states of perception and feeling; hallucinations; nausea Also, for LSD and mescaline - increased body temperature, heart rate, blood pressure; loss of appetite; sweating; sleeplessness; numbness; dizziness; weakness; tremors; impulsive behavior; rapid shifts in emotion Also, for psilocybin - nervousness; paranoia; panic Health Risks: Also, for LSD - Flashbacks, Hallucinogen Persisting Perception Disorder
CANNABINOIDS
Acute Effects: Euphoria; relaxation; slowed reaction time; distorted sensory perception; impaired balance and coordination; increased heart rate and appetite; impaired learning, memory; anxiety; panic attacks; psychosis Health Risks: Cough; frequent respiratory infections; possible mental health decline; addiction
STIMULANTS
Acute Effects: Increased heart rate, blood pressure, body temperature, metabolism; feelings of exhilaration; increased energy, mental alertness; tremors; reduced appetite; irritability; anxiety; panic; paranoia; violent behavior; psychosis Health Risks: Weight loss; insomnia; cardiac or cardiovascular complications; stroke; seizures; addiction Also, for cocaine - nasal damage from snorting Also, for methamphetamine - severe dental problems
Define Addiction:
Addiction: synonymous with the term dependence. Is unlike simple habits or consuming interests... Instead, synonymous with the term dependence. Is unlike simple habits or consuming interests... Instead,
Avoiding ageism
Although (healthcare) needs are greater than when they were younger Their wisdom, experience, generosity, care, compassion, contribution to society should be valued and acknowledged.
What is a Mental State Exam (MSE)
An interview between a mental health professional and a client recording findings that include information on the clients appearance, speech, motor activity, behaviour, alertness, mood, intelligence, and cognition • Permits MHW to make unified clinical judgements or interpretations, and plan appropriate interventions • Observing mental functioning of client, their areas of strength and any problems or deficits • Gathering of baseline data • Anticipate that they are probably in a state of distress, or disbelief or denial
Bupropion (Wellbutrin)
Antidepressant. May improve hyperactivity, attention & global functioning.
Fluoxetine (Prozac)
Antidepressant. May improve hyperactivity, attention & global functioning.
Nortriptylline (Aventyl)
Antidepressant. May improve hyperactivity, attention & global functioning.
Risperidone (Risperdal)
Antipsychotic (atypical). Reduces hyperactivity, fidgetiness and labile effects. - Pervasive Developmental Disorders. May be used to control falshbacks and aggression - PTSD. Decreases aggression - ADHD
Olanzapine (Zyprexa)
Antipsychotic. Reduces hyperactivity, social withdrawal, use of language and depresssion. - Pervasive Developmental Disorders
How to start an MSE
Confidentiality & Introduction: • Introduce yourself • Your designation (e.g., student RN) and purpose of meeting • Will you be taking notes...? • Inform about confidentiality - it is never absolute - Where is this information shared?
explain Denial
Denial of a substance abuse problem is an individual's attempt to avoid accepting a diagnosis of substance abuse or dependence. It can be exhibited by attempts to rationalise the substance use, minimise the harmful effects, deflect attention from one's own problem to society's or some else's, or blame childhood experiences.
Principles of Intervention
Detection & Assessment Immediate management & treatment Early & late recovery Continuing care
Challenge to service delivery
Difficulties in definition • Lack of consensus around diagnosis, assessment & treatment • Separation of psychiatric and AOTD services • Lack of data • Clinicians lack confidence, training & optimism. • Under recognition of the effects of substance use upon mental states.
Background to substance use & misuse
Drug (substance) use occurs on a continuum Substance (drug) use: non-problematic use of a substance (illegal) Substance (drug) misuse: use of a drug that is likely to cause harm (alcohol)
Neuroleptic‐Induced Torticollis
Dystonic reactions are reversible extrapyramidal effects that can occur after administration of a neuroleptic drug. • Contracted positioning of neck • Gradual development • Neck and head pain • Uncommon • Twisting and sustained muscle spasm
Developmental Stage ‐ Erikson
Erikson - "integrity versus despair" Period of looking back and looking forward Feelings of positive contribution to society, maintaining a sense of purpose, a sense of control and autonomy. A fear of death, feelings of dissatisfaction of time left to live
Percentage of homeless who have mental illness?
Estimated 85% of the homeless are mentally ill
Define Evidence based practice:
Evidence based practice: Developing responses based on identified client needs and the best available evidence on effectiveness through research and evaluation.
Children's behaviour to assess
General areas • Internalising problems - inhibited or over controlled behaviours, anxiety or depression • Externalising behaviours - antisocial behaviours, aggression Specific areas • Somatic complaints - physical problems (no known cause, cannot be medically verified) • Delinquent behaviour - breaking rules • Attention problems - inability to sit still, concentrate (includes problems at • Aggressive behaviour - bullying, teasing, fighting • Social problems - impairment with social interactions • Withdrawal - shyness, social isolation • Anxious/depressed behaviours - loneliness, sadness, feeling unloved, anxiety, generalised fear • Thought disorders - bizarre behaviour/thinking
Hardiness
Hardiness ‐ ability to resist illness when under stress 3 components 1. Commitment: active involvement in life activities 2. Control: ability to make appropriate decisions in relation to life activities 3. Challenge: ability to achieve change as beneficial rather than just stressful
cognitive disorders DX
IQ of 50-70 = mild cognitive impairment, MR
Asperger's Disorder DSM-IV-TRTM Classification
Impairment in social interaction as manifested by at least two of the following: 1. Marked impairment in the use of multiple nonverbal behaviours (e.g., eye contact, facial expressions, body postures, and gestures to regulated social interaction) 2. Failure to develop peer relationships appropriate to developmental level 3. Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., lack of showing, bringing, or pointing out objects of interest to others) 4. Lack of social or emotional reciprocity Restricted repetitive and stereotyped patterns of behaviour, interests, and activities, as manifested by at least one of the following: 1. Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus 2. Apparently inflexible adherence to specific, non-functional routines or rituals 3. Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole body movements) 4. Persistent preoccupation with parts of objects Disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning There is not clinically significant general delay in language (e.g., single words used by 2 years, communicative phrases by 3 years)
Cannabis
In 2010, cannabis was still the most common illicit drug used in Australia. Recent use of cannabis has increased since 2007, from 9.1% to 10.3% but is still lower than the peak of 17.9% observed in 1998 • 34.8% of Australians aged 14 years and over have used cannabis one or more times in their life1. 10.2% of Australians aged 14 years and over have used cannabis in the previous 12 months
Demographics of Ageing
In 2014, 14.7% of Australian population was aged 65+ 25% increase over the past 20 years In 2014, 1.9% of Australian population was aged 85+ 100% increase over the past 20 years
Long Term Heavy Use Cannabis Can cause:
Increased risk of respiratory disease • Change in motivation • Decreased concentration, memory & learning ability • Interference in sexual & hormone production • Psychiatric disturbances
Substance misuse Remote/regional & Aboriginal and Torres Strait Islander peoples
Indigenous Australians who drink are more likely to drink at harmful levels. Between 2004‐2008 indigenous Australians died from mental and behavioural disorders due to alcohol use 7 times the rate of non‐indigenous Australians. • Drink alcohol at that increase lifetime risk of harm (24% and 21% compared with 19%) or at risk of an alcohol‐related injury from a single occasion (52% and 47% compared with 43%) • High proportions of indigenous Australians use cannabis (measured over 12/12 period) that non‐indigenous Australians ( 18% & 10% respectively)
Initial Information for MSE:
Initial Information • Identify person (preferred name etc.,) • Age & DOB • Present address, phone number • Language spoken - Do they need an interpreter? • Name of GP/Psychiatrist (if relevant) • NOK • Serology - (TFT, LFT, U&E, CBC, Urinalysis etc.) • T, P, R, BP • CT scan?
R‐OH intoxication
Intoxication occurs from the direct pharmacological effect of the drug on the CNS. • DSM‐5 Diagnostic criteria: • A: recent ingestion of alcohol • B: clinically significant problematic behaviour or psychological changes • C: One or more of the following developing during or shortly after alcohol use: Slurred speech, in‐coordination, unsteady gait, Nystagmus, impaired memory or attention, stupor or coma • D: S&S not attributable to another medical condition, are not better explained by another mental disorder , including intoxication with another substance (e.g. benzo's)
Mental Health Risk Factors
Issues of retirement, loss of financial capacity, changes in family and friendship support networks. Increased rates of depression and anxiety in the elderly Illness (including self‐perceived porr health) Death of significant other ↓ willingness to talk about mood
Define MHS & a mental health practitioner
Mental Health Practitioner: Registered nurse, registered psychologist, registered occupational therapist or social worker employed by a designated
Define: Mental Health
Mental Health: a state of complete physical, mental and social well ‐ being, and not merely the absence of disease
Why do an MSE?
Mental State Examinations (MSE) can help the mental health professional assess what the person is currently experiencing, focusing on their behaviour, cognition and emotional state. The MSE is an important tool mental health nurses use to identify behaviours that deviate from the norm, in addition to outlining patient and service goals within a recovery-oriented framework. It also helps us identify and guide how these experiences are affecting individuals and the people around them
CONSUMER & CARER COLLABORATION
Mental health team must work closely with & support carers, families and consumers: ‐ as they go through the process of adaptation to the family member's mental health problem ‐ includes listening to families/carers, following through requests, giving information, linking them to support services, referring them to specialist services for more focussed interventions • Families/carers will have different levels of understanding and communication - developed within the family; impacted on by stress • Discuss how the family member's mental health is affecting them • Explore ways they can cope better and manage physical, psychological & social demands Common concerns: ‐ how the health issue came about ‐ did anyone cause it ‐ could something have been done to prevent it ‐ is it contagious ‐ how long can it last; will it ever end? ‐ how long will the person be in hospital ‐ medical expenses ‐ when will the person get back to normal ‐ what supports are available • High rates of depression & sense of burden • Higher rates of use of medication (eg. Psychotropics) • Long‐term stress • Social restrictions ('prisoners') • Limitations on choices • Financial constraints • Physical & psychological demands • Impacts on younger carers - work, schooling
Define Addiction
Misuse of substances related to an illness state or biological malfunction
What is Form 13
Notification to Involuntary patient of Rights Under the Mental Health Act
obsessive compulsive disorder (OCD)
Obsessive-thoughts that are recurrent, senseless, intrusive, & produce anxiety
Why does it occur?
Old age seen as A process of degeneration Lack of productivity Arise from generalisations 'all old people are sick and depressed' 'they don't have anything to offer to society' 'they are just waiting to die' Results in social exclusion Isolation marginalisation
Acronyms for MSE
PAMSGOTJIMIR • Perception • Affect • Mood & Memory • Speech • General Appearance • Orientation • Thought • Judgement • Insight • Memory • Intelligence • Risk BATOMI‐PJR • Behaviour & appearance • Affect • Thought form & content • Orientation • Mood • Insight • Perception • Judgement • Risk
Pseudoparkinsonism
Parkinsonism is a clinical syndrome characterized by tremor, bradykinesia, rigidity, and postural instability. Quantity: talkative, verbose, garrulous, chatty, taciturn, restrained, pressured
Prevention and Promotion
Personal growth and learning are significant needs of the elderly Are the elderly resistant to change? Will they benefit from health care interventions? Aged people are interested in health promotion activities Listening, acknowledging and accepting that reflection and redefinition are normal Challenging of stereotypes
Hardiness explained
Personal hardiness - a pattern of attitudes & actions that helps the person turn stressful circumstances into opportunities for growth Study showed that persons with high hardiness perceived stressors more accurately & were able to problem‐solve in the situation more effectively Study - stressful life events found to cause more harm to epeople with low hardiness than with high hardiness • Study ‐ Identified as an important resilience factor for families coping with the mental illness of one of their members • Problems with the concept of Hardiness: ‐ concept is vague & ill defined ‐ effects may not be the same for men & women ‐ useful only to those who value individualism
Clinical recovery - define
Pertains to mental health professionals involves a reduction or cessation of the symptoms pertaining to mental illness removal of clinical symptoms
Areas of assessment include
Presenting Problem (what is your need? / what is happening for you right now?) Past history (Hx) Past Hx of presenting problem( find out whether they have had this compliant/ issue before and any treatments or interventions used) Family Hx - genetic disposition etc.( some illness have a genetic link - e.g. Schizophrenia/ Bipolar) Substance & alcohol Hx Forensic Hx Medication Hx ( what previous medications/ amount/ how often/ were they successful) Of any previous medical conditions/ illness ( including surgical procedures) Trauma (including sexual / emotional/physical abuse ....) Personal or developmental Hx (milestones reached ......) Strengths Ax Understanding what the individual brings to the assessment. Coping strategies. How does the individual cope usually? What has worked in the past what hasn't? Duration of problem and how they have managed. What supports do they require? Positive supports/ social supports - friends. Family who do they think would be a resource? Resilience? Social Ax Housing , accommodation, NFA( no fixed address) Live alone or with others Any housing risks Rural areas? Community supports/ sporting clubs Relationships - self & others ( friends, family) Connections - schooling/ peers Employment/ work environment Type of work Work times ( shift work) Paid or unpaid Centrelink assistance Social media (face book)/ gaming Cultural Ax Values Beliefs/ traditions/ rituals. Language. Interpreters. Ideas of mental illness. Western cultural medicine. Use of own herbs/ remedies o Spiritual Ax Meaning and purpose in their life. Religion. Beliefs. How they view themselves in the world. Community supports. Physical Ax Vital signs (BP, RR ,P, T .) - can indicate a number of things, require baseline, need to understand the individual norm; may be medication related Laboratory tests / blood tests Urine screening ( UTI/ AOD screening) Head - toe physical looking at all systems Looking for signs of any organic symptomotology ( biological causation) Taking into consideration - DSMV - general medical condition) Medication Ax e.g. Delirium/ hyperthyroidism What are they currently taking? What is the medication for? Do they know the effects/ are there any side effects? What have they used in the past - has it been effective? Nutritional Ax Dietary intake Intake = output BMI Overweight/ obese Underweight? anorexia / bulimia What sorts of food do they eat? Sleep Ax Day/ night cycle ( is it related to illness) Quantity and quality of sleep Do they use Mx to help them sleep Decreased sleep may be first sign of mania Neurological Ax Cognition Level of consciousness Orientation - TPP Memory ( recent/ recall/ remote) Organic disorders ( delirium/ dementia/ ABI) Psychological Ax Trauma - particular event ( e.g. assault/ rape) Sexual, physical, emotional abuse Personality Intellect/ academic ability ( age appropriate) Developmental milestones Sexual Current use of contraception STD's Any factors of risk associated with illness ( e.g. sexual disinhibition with mania) Preferences- gender specific. MSE ( mental Status examination) Risk Ax Self harm Suicide Violence/ aggression Homicidal Absconding Vulnerability - exploitation by others Neglect ( of self) To dependents ( children/ pets) Non- Adherence to treatments Drugs & alcohol Ax Current use - screening tool What type of drug / alcohol health Hx How much? Do they seek out for it intoxication withdrawal (may be similar symptoms to MI symptoms) dependence The impacts usage has on all other aspects of the individual's life. Family Ax Genogram Dynamics Genetic disposition to illnesses ( also captured in Hx) Role and responsibility in family Positioning Support network Current family trauma's Pain Assessment Understanding pain both physical and emotional pain Level of pain (acute/ chronic etc...) Is the pain localised? Is it referred pain? Use of medication to relieve the pain What helps what doesn't? Is it related to somatic delusions? Demographics Age Gender Address Contact Number ( where possible mobile) Socio- economic status Race
Application to ATOD use
Pre‐contemplation • People are happy/unconcerned about drug use. Ignore advice. Benefits > risks/adverse consequences • "WHAT THE PROBLEM?" Contemplation • Ambivalent about use. Enjoyable but emotional/physical consequences evident and worried because of increasing impact • "MAYBE THIS ISN'T DOING ME ANY GOOD." Preparation • Time for change. Costs outweigh benefits. OR the decision is made to do nothing. • "ENOUGH ALREADY! I'M QUITTING." Action • Resolved to change. Take active steps • "I'M ACTUALLY DOING SOMETHING ABOUT IT" Maintenance • Cessation has been sustained for long enough to state that drug use is not a problem, • "I'M STILL NOT USING." Relapse • Can affect action and maintenance. A number of factors can contribute to relapse • "I USED AGAIN,"
Primary substance abuse with psychopathologic outcomes
Primary substance abuse with psychopathologic outcomes • Psychiatric symptoms as a consequence of: drug/alcohol intoxication • withdrawal symptoms • cognitive impairments
Dexmethylphenidate (Focalin)
Psychostimulant to improve symptoms in ADHD.
Mixture of salts & L-amphetamine (Adderall)
Psychostimulant to improve symptoms in ADHD.
Methylphenidate (Ritalin, Daytrana, Concerta)
Psychostimulant to improve symptoms in Disruptive Behavior Disorders -ADHD. Short-acting and given in several doses throughout day. Increases blood flow.
Medications used for ADHD
Psychostimulants: methyphenidate, salts & L-amphetimine, dexmethylphenidate, pemoline (rarely used d/t hepatotoxicity); lithium, carbazemapine (tegretol), α- Adrenergic agonists: clonidine, antidepressants: nortriptylline, buproprion, fluoxetine, dexedrine
explain resilience
Resilience Helps people cope with stress & minimises effects of illness; 'successful' coping Having healthy responses to stressful circumstances/risky situations Adapts well to adversity, trauma, tragedy, threats, significant sources of stress Promotes & protects one's mental health Helps to explain why one person reacts to a stressful event with severe anxiety whilst another person does not experience distress Factors associated with resilience include: ‐ positive outlook ‐ spirituality (must be healthy though; may be related to increases in resilience - finding meaning following stress events; associated with positive emotions ‐ good relationships ‐ flexibility (emotional & mental) ‐ good communication & supportive networks ‐ spends quality time with others; volunteering
Other things to concider with MSE
Risk Management & Assessment • Based on past history, current presentation, observation etc. • What are the potential or actual risks to staff, the patient and/or co‐ patients , the environment? - DSH - Suicide - Interpersonal violence - Property damage - Absconding - Substance misuse - Vulnerability - Medication non‐adherence - Others...? • Constant (arms length) - At arms length from an RN at all times - 1:1 'special' • Constant (visual) - 1:1 nursing where the patient is within vision of RN • Intermittent - RN engages with person at regular intervals - May be several set times per hour or random lengths of time between observations • Negotiated - Low risk patients - Negotiated frequency of engagement • Mental Health Triage Scale • Risk Watch • Risk Watch
What contributes to mental health in children & youth?
Risk factors • Genetics • Biochemical • Pre & post-natal influences • Individual temperament • Psychosocial development Protective factors • Attachment to family • Supportive parenting • Social competence • Economic security • Positive school/work environment • Good networks
Medications used for OCD
SSRIs: fluoxetine, paroxetine; atypical anxiolytics & buspirone
Tensions
Service delivery ▪ Mental health services mandated treatment and necessary orientation towards addressing immediate psychopathology Vs involuntary nature of treatment through Psychiatric disability and/or A&OD services ▪ Medical Vs. Social models Maintaining engagement when behaviour threatens safety of client and/or others ▪ Care must be balanced with consequences and contingent learning for each client and in each service setting
Explain Stigma?
Stigma surrounding mental illness has often been described by those experiencing it as 'worse' than the mental illness itself. Stigma allows people to be easily dismissed as others adopt a prejudiced notion of what they think is expected or anticipated behaviour. A good example of this is the common myth that 'a person with schizophrenia is inherently dangerous to others'. These stigmatising behaviours emerge early in life and are a multifactorial interplay of attitudes obtained from society, culture, upbringing, and media representation, and have significant impact on those individuals experiencing mental illness from seeking and remaining adherent to treatment (Arboleda-Flórez & Stuart, 2012).
Define stigma
Stigma: Stigma is a mark or label that sets a person apart. Stigma can create negative attitudes and prejudice which can lead to negative actions and discrimination.
Substance Abuse Continuum of Care
Substance abuse treatment can be characterised as a continuum arrayed along a particular measure, such as the gravity of the substance abuse problem, level of care ‐inpatient, residential, intermediate, or outpatient or intensity of service The continuum is arranged chronologically, moving from case finding and pre‐treatment through primary treatment, either residential or outpatient, and finally to aftercare
Imipramine (Tofranil)
TCA used to treat Anxiety Disorders. - Panic/ School phobias. CAUTION: risk of cardiac dysrrhthmias and seizures in children.
Mapping the Reform Directions
The critical importance of the three key Reform Directions can be understood by using an ecomap to depict the range of supports and services which are potentially available to Western Australians with mental health problems and/or mental illness and to explore the interrelationships between them.
Stages of Treatment for substance abuse
The four stages of treatment are: • engagement • persuasion • active treatment • relapse prevention.
Action Areas of mental Health?
There are many actions that can be taken to implement the three Reform Directions of Mental Health 2020. Nine Action Areas have been identified as priorities to implement the Vision and the Reform Directions. Each Action Area relates to a greater or lesser extent to each of the three reform directions.
describe depression
There are many analogies of depression given by those experiencing it; "like the Terminator, but with a little more subtlety...and a lot less leather", "(like) being underwater and attempting to run", "the vampire of diseases...it sinks its teeth into your psyche, draining your confidence, your energy levels and your self-worth". It is also indicated that people who have depression experience feel that their feelings are readily dismissed by others, including their loved ones. Common myths and misconceptions about depression include: "it's not a real illness", "depressed people should snap out of it" and "they have nothing to be sad about".
Tornstam ‐ Gerotranscendence
Tornstam (1989) Gerotranscendence is regarded as the final stage in a possible natural progression towards maturation and wisdom. Perceived disengagement in the older adult is due to an increased need to reflect on matters of life, rather than a loss of interest in life or the world.
psychomotor activity: agitation, hyperactive, retardation, tics
Trans Magnetic Stimulation (TMS) http://www.australianprescriber.com/magazine/35/2/59/61 • Less invasive then ECT • Option for patients who cannot tolerate other methods (AD's, psychotherapeutic interventions or to augment these • "...application of rapidly time variable magnetic field, administered via a coil placed over the scalp, to stimulate brain activity" • ~40/session 5 days/week (typical course 4‐6 weeks • S/E - uncommon - headaches, painful scalp sensations, facial twitching (with TMS pulses), transient hearing problems • Rare - seizures
Self medication and dual diagnosis of substance abuse
Treatment of substance abuse and mental health disorders is complicated by the fact that alcohol or drugs are often used by mental health consumers to alleviate the stresses of their mental illness, including psychotic systems, depression or to deal with the side effects of medication or the stigma of being mentally ill. • Drug use (and/or withdrawal) can cause (and worsen) psychiatric symptoms and mimic psychiatric syndromes. • Drug use can mask psychiatric symptoms and syndromes. • Drug and alcohol abuse can make side effects from medication worse, and more likely to occur • Psychiatric behaviours can mimic drug use problems
Diphenhydramine (Benedryl)
Used as an anxiloytic
Anticonvulsants
Used for ADHD
Antidepressants
Used for ADHD
Botulinum Toxin
Used for Tourette's Syndrome. Research has shown that for small number of patients with motor medication resistance, injections may be useful.
Clonidine (CataPres)
Used for aggressiveness, impulsivity & hyperactivity (disordered behaviors) in ADHD & Tourette's Syndrome
Lithium carbonate & carbamazepine (Tegretol)
Used to decrease aggression. - ADHD
SSRIs
Used to treat Anxiety Disorders - Panic/School phobias, OCD, Mood Disorders - Suicidal Risk in Children
Atypical anxiolytics
Used to treat OCD
Citalopram (Celexa)
Used to treat Panic/School phobias
Anxiolytics
Used to treat Social Phobia
Fluphenazine (Prolixin)
Used to treat tics of Tourette's Syndrome
Pimozide (Orap)
Used to treat tics of Tourette's Syndrome
Fenfluramine
When desired serotonin levels are achieved, improves autism and IQ
4% in men. *Gender difference remains when sexual assault is accounted for PTSD3 Premorbid risk factors Event-type risk factors Post-exposure risk factors Comorbidity with other disorders extremely high (approximately 80%), but PTSD varies as to its temporal relation to other disorders ACUTE STRESS DISORDER Exposure to traumatic event Nine or more -intrusive symptoms -negative mood -dissociation -avoidance -arousal *Lasts 3 days to 1 month *Disturbance causes clinically significant distress and not attributable to medical conditions, psychotic disorder or substances ADJUSTMENT DISORDER Development of emotional or behavioral symptoms in response to identifiable stressors occurring 3 months of the onset of the stressors *Clinically significant Not better accounted for by another mental disorder *Do not represent normal bereavement *Once stressors have terminated, the symptoms do not persist for more than and additional 6 months Specify
With depressed mood, With anxiety, With mixed anxiety and depressed mood, With disturbance of conduct, With missed disturbance of emotions and conduct, THE O-C RELATED DISORDERS *Obsessive Compulsive Disorder *Body Dysmorphic Disorder *Hoarding Disorder *Trichotillomania *Excoriation Disorder *Substance / Medication *Induced Obsessive-Compulsive Disorder *Obsessive Compulsive and Related Disorder due to Another Medical Condition *Other Specified Obsessive-Compulsive and Related Disorder *Unspecified Obsessive-Compulsive and Related Disorder OBSESSIVE-COMPULSIVE DISORDER *Recurrent or persistent thoughts *Attempts to ignore, suppress, or neutralize thoughts or Compulsions *Repetitive behaviors in response to obsession or ridged rules *Behaviors aimed at anxiety reduction *But are not connected to thought or are clearly excessive *Cause marked distress and are time consuming (min. 1 hour daily) Rule out other diagnoses Rule out substance or medical cause COMMON OBSESSIONS AND COMPULSIONS Common fears -Fear of contamination -Repeating -Fear of harming self or others -Thoughts of symmetry -Checking -Washing -Somatic concerns -Religious intrusions OBSESSIVE-COMPULSIVE DISORDER- prevalence/comorbidity Most severe and chronic of the anxiety disorders. Lifetime prevalence estimated-1.5-2.5% Comorbid disorders are diagnosed in 42-80% of patients Diagnostic reliability high No gender differences (although varies over lifespan) OCD Neurobiological Factors Neurobiological Factors- greater evidence than other anxiety disorders
avoidant behaviors maintain the cycle RELIGION AND OCD Relationship between religiosity and OCD *Relationship between specific religions and OCD mixed, Muslim most supported *Scrupulosity / Hypermorality *CBT /ERP *Other thoughts -God doesn't expect us to be morally perfect or strive for perfection -System of forgiveness is in place, as sin is expected -But, extensive discussions on religious doctrine are rarely helpful BODY DYSMORPHIC DISORDER *Preoccupation with 1 or more perceived deficits in physical appearance *Repetitive behaviors or mental acts have occurred at some point during illness *Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. *Not better accounted for by focus on body fat or weight in an eating disorder Specify
With muscle dysmorphia Level of insight EXCORIATION (SKIN PICKING DISORDER) *Repeated attempts to decrease or stop skin picking. *The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. *The skin picking is not attributable to the direct physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies). *The skin picking is not better accounted for by symptoms of another DSM-5 disorder (e.g., skin picking due to delusions or tactile hallucinations in a Psychotic Disorder, preoccupation with appearance in Body Dysmorphic Disorder). HOARDING DISORDER A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. B. This difficulty is due to a perceived need to save the items and distress associated with discarding them. C. The symptoms result in the accumulation of possessions that congest and clutter active living areas and substantially compromise their intended use. If living areas are uncluttered, it is only because of the interventions of third parties . D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (maintaining a safe environment). E. The hoarding is not attributable to another medical condition (e.g., brain injury). F. The hoarding is not better accounted for by the symptoms of another DSM-5 disorder (e.g., hoarding due to obsessions in Obsessive-Compulsive Disorder, decreased energy in Major Depressive Disorder, delusions in Schizophrenia or another Psychotic Disorder, cognitive deficits in Dementia, restricted interests in Autism Spectrum Disorder). Specify if: With Excessive Acquisition, Good or fair insight, Poor insight, Absent insight TRICHOTILLOMANIA A. Recurrently pulling out one's hair, resulting in hair loss B. Repeated attempts to stop hair pulling C. Hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning D. The hair pulling is not attributable to another medical condition (e.g., dermatological). E. The hair pulling is not better accounted for by the symptoms of another DSM-5 disorder
Tardive Dyskinesia
a disorder resulting in involuntary, repetitive body movements. • Late occurring movement disorder • Can be irreversible • Embarrassing & troublesome symptoms • Tongue writhing & protrusion • Teeth grinding • Lip smacking • Course tremor • Spasm‐like movements
personality disorders
a pattern of thinking, relating, & interacting to the environment in disturbing ways
Stages of Change Models
a stage theory has four properties: • A classification system to define stages: • Stage classifications are theoretical constructs and although a prototype is defined for each stage, few people will perfectly match this ideal. • Ordering of stages: • People must pass through all the stages to reach the end point of action or maintenance, but progression to the endpoint is neither inevitable nor irreversible. • Common barriers to change facing people within same stage: • This idea would be helpful in encouraging progression through the stages. Different barriers to change facing people in different stages: • If the factors producing movement to the next stage were the same, regardless of stage (e.g. self‐efficacy), the same intervention could be used for all, and the stages would be redundant.
Anxiety - define
a state of feeling apprehension, uneasiness, agitation, uncertainty and fear resulting from the anticipation of threat or danger
panic disorder
acute, unpredictable & recurrent, intense, overwhelming fear
CNS depressants
alcohol; sedatives (xanax, Ativan, valium), opioids ( heroine, morphine)
hallucinogens
alter perception & thinking
dementia
altered mental state, secondary to cerebral disease; slow progressive loss of intellectual function; usu. diagnosed in older adults. Features- short term memory loss (primary symptom), personality changes, disorientation and impaired judgment
commonly mixed with other stimulants; cause hallucinations and paranoia
amphetamines
define prodrome
an early symptom indicating the onset of a disease or illness.
Medications used for Social Phobias
anxiolytics: buspirone
amotivational cannabis syndrome
apathy, decreased motivation,& mood swings, decreased goal- directed activity
schizo- Negative (absent) behaviors
apathy; social withdraw; alogia (reduced speech); flat affect; anhedonia (inability to express happiness); catatonic
Wernicke's encephalopathy S&S
aphasia, memory loss, disturbed vision, disturbed muscle coordination
anxiety disorders
apprehension and fear resulting from an anticipated danger
savants
autistic ppl that excel in a particular area (math, memory, music, art)
cause of mood (affective) disorders
can occur with schizo, be a side effect of meds, unbalanced fluids or electrolytes, & with infections
Personal recovery - define
create and live a meaningful life with or without the presence of mental illness
Wernicke's encephalopathy
d/t a thiamen (B1) deficiency, usu. caused by alcohol abuse
S&S of CNS depressants
decreased respirations, passiveness, listlessness, heaviness in extremities, memory loos, decreased sex drive, slurred speech, N&V, ataxia, pinpoint pupils (opioid effect)
what determines between social drinker and alcoholic
degree of need to drink & amount of alcohol consumed
organic brain disorders
delirium and dementia
paranoid schizophrenia
delusions, auditory hallucinations
undifferentiated schizophrenia
delusions, hallucinations, incoherence, gross disorganization (doesn't fir criteria of other types)
residual schizophrenia
demonstrates typical signs and symptoms associated with schizophrenia without displaying evidence of gross disorganization, incoherence, delusions, & hallucinations
types of personality disorders
dependent; paranoid; borderline; antisocial; abusive
major (unipolar) depression S&S
depressed mood, anhedonia (can't express joy), flat affect & at least 5 of the following- wt. gain or wt. loss; sleep pattern disturbances; increased fatigue; increased agitation; social withdraw; indecisive; anergia (lack of energy); suicidal; decreased libido;
warning signs of an impaired nurse- Mental Health Disorder
depressed, lethargic, unable to focus or concentrate, apathetic, many mistakes at work, erratic behavior & mood swings, inappropriate or bizarre behavior or speech, sometimes exhibit same or similar behavior as being chemically dependent
major (unipolar) depression
depression is disproportionate with reality; interferes with functioning
bipolar (manic depressive) S&S
depressive phase is the same as with major depression.
S&S of LSD use
dilated pupils, loss of appetite, dry mouth, sensory perception cross over ("hearing colors, seeing sounds"), altered perceptions ("melting walls")
subtypes of schizophrenia
disorganized; paranoid; catatonic; undifferentiated; residual
Mental health act 2014 - define
document that outlines the criteria for admission of a compulsory patient, whilst also defining a compulsory patient. It provides guidelines to restrictive interventions, allows for a second psychiatric opinion, reflects the human rights principles, protects a consumers autonomy and presumes capacity unless otherwise tested
theories of causes for schizophrenia
enlarged ventricles; excessive dopamine; genetics; mom child relationships
causes of addiction theories
genetic metabolic disorder; cognitive behavior (learned behavior); addictive personality
Autism causes
genetics, environmental factors
schizophrenia
gross disorientation of reality, withdrawn from society, disorganized thought, disturbed communication. usu. starts in young adulthood
attention deficit hyperactive disorder (ADHD)
group of behaviors including hyperactivity, inattentiveness, impulsiveness
ADHD S&S
hyperactive, decreased attention span, aggressive, non compliant
autism S&S
impaired social interactions, avoid eye contact, don't like to be touched, impaired communication, delayed speech or lack of language, inflexible, repetitive mannerisms
1997 & 2007 Australian National Survey of Mental Health and Wellbeing (NSMHW)
in any 12 month period: • 9.7 per cent of the population met criteria for an anxiety disorder; • 5.8 per cent met criteria for an affective (mood) disorder; and • 7.7 per cent met criteria for a substance use disorder • 14.4% met criteria for anxiety disorder • 6.2% met the criteria for an affective disorder and • 5.1% met the criteria for a substance use disorder. people aged 16‐85 years: • 5.1% (819,800) had a 12‐month Substance Use disorder. • Alcohol Harmful Use was the most prevalent Substance Use disorder (2.9%). • Men experienced higher rates of 12‐month Substance Use disorders than women (7.0% and 3.3% respectively). • They also had nearly twice the rate of Alcohol Harmful Use (3.8% of men and 2.1% of women). • 12‐month Anxiety disorders highest prevalence, • highest rate in the 35‐44 years age group (18%). • People in younger age groups had higher prevalence of 12‐ month Substance Use disorders • Of the 2.5 million people aged 16‐24 years, 13% (323,500) had a 12‐month Substance Use disorder.
Akathisia
indicating negation or absence, lit. "inability to sit") is a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting. • Restless legs • 'Jittery' feelings • Nervous energy • Pacing, agitation • Alternating between sitting & standing • Very common and has poor responses to medication
ketamine
intended for use by vets. as an animal sedative
warning signs of a chemically impaired nurse- Alcohol
irritability, mood swings, elaborate excuses for behavior, unkempt appearance, blackouts, impaired coordination, slurred speech, flushed, blood shot eyes, numerous injuries with vague explanations, smell of alcohol on breath, excessive use of mouthwash or mints, increased isolation from others
nicotine withdrawal
irritable, restless, cravings, increased appetite, disturbed sleep
Describe Schizophrenia
is often described as the most misunderstood of all mental illnesses, in addition to being one of the most highly stigmatised and devastating of all mental disorders. Individuals suffering from schizophrenia often experience acutely disabling and distressing symptoms which have significant consequences to all aspects of their life (personal, work, study, social, sexual etc.) and impacts their ability to distinguish reality from fantasy.
personality disorders S&S
lack of insight, fails to realize there are consequences for their actions, lack of impulse control, unable to handle change, grossly distorted self view ( either absolutely loves themselves or hates themselves)
Aspergers
less debilitating of the spectrum; no significant delays of cognitive or language development;
mood (affective) disorders
major (unipolar) depression
Define Dependence
maladaptive pattern of substance use leading to clinically significant impairment or distress. Manifested by a need for increasing amounts of the substance to achieve desired effect, to avoid withdrawal symptoms, unsuccessful attempts to cease or reduce drug use and continued use in despite harmful consequences (Ritter, King & Hamilton, 2013) Common patterns of use: • experimental use • recreational use • situational use • bingeing • dependent use
ADHD DX
many different grading scales, should involve more then just family physician
postpartum depression
may be hormonal; if lasts longer than 2 weeks pt. needs help
CNS stimulants S&S
mental alertness, insomnia, bruxism (grinding teeth), tachycardia, hypertension, increased concentration, euphoria, elation, anxiety, paranoia, anorexia, dilated pupils, twitching, tremors
Phobias
most common anxiety disorder
downs syndrome
most common chromosomal abnormality, extra chromosome on #21 (trisomy 21); affects 1 in 1000
binge eating
most common eating disorder; no purging or inappropriate behaviors; frequent recurring eating of large amounts of food
LSD
most potent hallucinogen, can last over 12 hrs; flashback trips over a year later; non addictive, doesn't cause drug seeking behavior
ecstasy use S&S
muscle tension, bruxism (grinding teeth), nausea, blurred vision, chills, sweating, faintness; euphoria
the most difficult addiction to overcome
nicotine
countertransference - define
nurse forms an emotional attachment toward the consumer based on a perceived connection with the consumer
anorexia nervosa S&S
obsessed with food labels, fear of weight gain, may excessively exercise, may purge, amenorrhea, may develop arrhythmias, hypotention, constipation, lyte imbalances. if inducing vomiting- large calloused knuckles; socially withdrawn
Retts disorder
only effects females; starts between 4months and 5 yrs. of age; develop multiple deficits after a period of normal functioning
paranoid personality
overly sensitive, suspicious, distorted reality, secretive
delirium tremors (DTs)
part of alcohol withdrawal symptoms, visual hallucinations, tremors,& seizures, elevated vitals, N&V
Objects of the MHA 2014
provide a legislative scheme for assessment, temporary treatment order, treatment order, restrictive interventions. Facilitates the care and treatment of the mentally ill.
GAD (generalized anxiety disorder)
pt. worries about everything
warning signs of a chemically impaired nurse- Drug Addiction
rapid changes in mood or performance, frequent absence from unit, possibly works a lot of OT, comes early, stays late; increased somatic complaints to get scripts for pain meds, signs out more or larger amount of controlled drugs then anyone else, excessive wasting of drugs, often volunteers to medicate pts. for other nurses, wears long sleeves a lot, isolation from others, pts. report that pain meds not effective or didn't receive them, excessive discrepancies in signing and documenting of controlled substances
childhood disenegrative disorder
regression in multiple areas of functioning after normal development ; usu. starts between 2 -4 yrs old; must affect at least 2 of the following areas- language, social skills, motor skills, bowel or bladder control
addiction
repeated compulsive use of a substance that continues despite negative consequences; may have more then one addiction at a time
tolerance
requiring increased amounts of a substance to achieve the same effect
chemical dependency
requiring increased amounts of a substance to prevent withdrawal symptoms
post traumatic stress disorder (PTSD)
response to an unexpected emotional or physical trauma when there is a real threat of harm
Medications for PTSD
risperidone (atypical antipsychotic)
obsessive compulsive disorder (OCD) S&S
ritual of behaviors to relieve anxiety; pt. recognizes the absurdness but can't stop it, if behavior is stopped anxiety increases
thought process disorder
schizophrenia
inhalant use S&S
short lived- euphoria, hallucinations, slurred speech coughing
Korsakoff's psychosis S&S
short term memory loss, disorientation, delirium, insomnia, hallucinations, painful extremities
cannabis effects
sleepiness, increased appetite, euphoria, difficulty concentrating
Fetal alcohol syndrome (FAS) S&S
some degree of cognitive impairment, wide set eyes, malformed body parts, very thin upper lip, flat nose, low set ears
catatonic schizophrenia
stupor, negativism, rigidity, excitement, posturing
ADHD causes
theories- environmental factors, mom baby bond
cognitive disorders causes
theories- genetics, environmental factors, drug & alcohol abuse, decreased social stimulation (mom baby bond), infections
downs syndrome causes
theories- genetics, environmental, lead exposure, infection (syphilis, rubella) exposure
Neuroleptic malignant syndrome (NMS) define and information:
threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs. • Potentially lethal • More common in typical high potent antipsychotics (e.g., haloperidol) • Usually occurs within one week of treatment • Symptoms • Hyperthermia (>42°) • Rigidity • Impaired ventilation • Tremor • Altered consciousness • Tachycardia • Diaphoresis • Hypersalivation • Death
addictive personality
traits identified in addictive individuals
Stigma - define
unjust labelling of an individual affected by a mental illness often misconstruing their character and personality
borderline personallity
unstable self image,mood, & relationships; decreased impulse control; no self- identity
drug abuse
use of meds for something other then medical reasons or in amounts greater than recommended
pcp use S&S
usu. mixed with other drugs
bulimia nervosa S&S
usu. normal weight or over weight; if vomiting- develop hoarseness,esopagitis, tooth erosion, calloused knuckles, broken blood vessels in eyes and face; cardiac arrhythmias, lyte imbalances
down syndrome S&S
very small skull, flat face, protruding tongue, protruding abdomen, short thick neck, simian crease on palms, shorter 5th digit (pinky finger); cryptorchidism (undistended testicles), frequent respiratory infections, congenital heart defects (major cause of death )
types of purging
vomiting, laxatives, enemas, diuretics
anorexia nervosa
willful starvation d/t altered perceptions of an obese body image
seasonal affect disorder (sad)
winter depression
Advance statement
written document created by the consumer outlining their treatment wishes in the event they become unwell
Disorganised Speech Example - Incomprehensible Language
• 'That's wish‐bell double vision. Like walking across a person's eye and reflecting personality. It works on you like dying and going into the spiritual world but landing in the vella world' ^^^ Neologism • Snortie - to talk through walls • Trominoes - tiny people who live in one's body • Split‐kippered - to be simultaneously alive in Lancaster and dead in Yorkshire
Relapse for psychosis
• 50‐70% of sufferers will experience early warning signs 1‐4 weeks prior to relapse • Vulnerability factors • Protective factors • 'Trivial' side effects can result in non‐adherence • Strong emphasis on care in community context • Pre 21st century ~95% of sufferers would have been institutionalised • Symptom amelioration? - Living independently/successfully with symptoms = recovery?
What is a Mental Illness
• A mental illness is a medical condition that is characterised by a "significant disturbance of thought, mood, perception or memory" (VMHA, 2014) • Mental health as defined by WHO (2015) is a "state of complete physical, mental and social well‐being, and not merely the absence of disease"
Dual Diagnosis of substance disorders
• A person diagnosed as having an alcohol or drug‐ use problem in addition to some other diagnosis,usually psychiatric such as a mood disorder or schizophrenia • Simplistically, dual diagnosis is defined as the existence of both a substance misuse or dependency problem, in conjunction with at least one mental illness • These conditions occur concurrently, independent of each other Often, it is difficult to determine which problem existed first - the substance misuse or the mental illness? • e.g., did the individual begin using drugs to deal with symptoms of mental illness (i.e., distressing auditory hallucinations 'eased' by alcohol consumption) which has exacerbated the illness? OR • e.g., did the individual start misusing cannabis in his teens and developed a drug‐induced psychosis which has resulted in permanent dysfunction? • 30-60 per cent of substance users have a mental health problem (NSW Health, 2009) • 40-55 per cent of people with a mental health problem have a substance‐ use disorder (NIDA, 2010) • About 25% of individuals with anxiety disorders, affective disorders and substance use disorders also have another mental disorder
The Continuum of Dependence
• A person does not become dependent on a substance overnight...there is a progression. • Tolerance - is created through repeated use, in which more and more of the substance or activity is required to feel the emotional satisfaction that the addiction brings.
Assessment Order (s.28) (Inpatient & Community)
• A registered medial practitioner or mental health practitioner may make an assessment order • Enables the person to be taken to AMHS for assessment by psychiatrist • Valid for max. 72hrs (to allow for transport) • Must state whether the Order is a Community Assessment Order, or an Inpatient Assessment Order • Must notify the authorised psychiatrist of the relevant designated mental health service, and provide a copy of the order • AP must take reasonable steps to ensure that the following are notified of the order: - The nominated person - A guardian - A carer - A parent (if under 16yrs) - Secretary to DHS if subject to a Secretary Order • MHA 101
Interventions/Treatments for substance dependence
• A substance dependence is like other chronic health conditions in that they are characterized by periods of wellness and periods of relapse. Like other chronic health conditions the longer a person is engaged in treatment the better the outcomes generally are for that person. • The greater the choice of treatment options the higher the chance of people accessing services and completing treatments
R‐OH withdrawal Diagnostic criteria (DSM‐5 )
• A: Cessation/reduction in R‐OH use that has been prolonged & heavy • B: 2 or more of the following within several hours to a few days after uses in point A • C: S&S in B cause clinically significant distress /impairment in social, occupational or other important areas of Fxing • D: S&S not attributable to another medical condition & are not better explained by another mental disorder (inc. alcohol intoxication or withdrawal form
DSM 5TM Classification - Autism Spectrum Disorder
• A: Persistent deficits in social communication and social interaction across multiple context as manifested by the following, currently or by history 1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions 2. Deficits in nonverbal communication behaviours used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication 3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behaviour to suit various social context; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behaviour DSM 5TM Classification - Autism Spectrum Disorder • B: Restricted repetitive patterns of behaviour, interests or activities as manifested by at least two of the following, currently or by history 1. Stereotyped or repetitive motor movements, use of objects, or speech (eg., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases 2. Insistence on sameness, inflexible adherence to routines, or ritualised patterns of verbal or nonverbal behaviour (eg. Extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day) 3. Highly restricted, fixated interests that are abnormal in intensity or focus (eg., strong attachment to or preoccupation with unusual objects, excessively circumscribed or preservative interests) 4. Hyper - or hypoactivity to sensory input or unusual interests in sensory aspects of the environment (eg., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement) Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behaviour • C: Symptoms must be present in the early development period(but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies later in life) • D: Symptoms cause t clinically significant impairment in social, occupational or other important areas of functioning • E: These disturbances are not better explained by another illness
Cannabis withdrawal
• A: cessation of cannabis use that has been heavy and prolonged (usually daily or almost daily over at least a few months) • B: 3 or more of a range of S&S develop within 1 weeks after criterion A • C: S&S in B cause clinically significant distress or impairment in social, occupational or other important areas of functioning • D: S&S not attributable to another medical condition and not better explained by another mental disorder, including intoxication with another substance
Cannabis intoxication
• A: recent use of cannabis • B: clinically significant or problematic behavioural or psychological changes • C: two or more of a range of S&S • D: S&S not attributable to another medical condition and not better explained by another mental disorder, including intoxication with another substance
Communication in the ATOD context
• ATOD use is a health issue, not a moral issue. • Clinicians need to be clear &transparent about who they are, their name, their role, what they need to know from the person, and why they are asking about ATOD use. • Emphasise description rather than interpretation or evaluation • Empathy • Being clear, concrete and specific
BPADI - Manic Episode
• Abnormally & persistently elevated, expansive, irritable mood & abnormally & persistently increased goal‐directed activity or energy (lasting 1 week & present most of the day) • Three or more of the following (4 if mood is only irritable) 1. Inflated self esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed 6. Increase in goal‐directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposelessness non‐goal‐directed activity) 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
Dual Diagnosis Incidence
• About 13.8% of the general population misuse D&A • About 64% of in-patients in psychiatric facilities have a previous or current drug use problem • About 75% of individuals with problematic alcohol or substance misuse issues probably have a mental illness • About 90% of males with schizophrenia may have substance misuse problems • About 61% of people with Bipolar disorder also experience substance abuse or dependence • Comorbidity of depression with nicotine, alcohol & drug abuse ranges from 32-54% • Individuals with PTSD have combined substance abuse disorders in 22‐43% of cases • Adolescents with ADHD, ODD & CD who also misuse substances is estimated at about 30‐50% • Rate of nicotine dependence for individuals with schizophrenia is estimated at 70‐90% • In the US, smokers with mental illnesses consume almost half of all cigarettes consumed in US
Delirium Tremens (DT's) - Severe Alcohol Withdrawal
• About 5% of cases of acute ethanol withdrawal progress to Delirium Tremens (DT's), mortality of up 15% (often as a result of complications) • Symptoms are evident about 72hrs after the last drink, but may occur up to 7‐10 days after cessation of drinking Moderate symptoms in addition to: • Fever, sweating, tachycardia • Visual hallucinations • Fluctuating level of consciousness • Cardiovascular collapse • Seizures • Death (with 10% of cases though significantly higher if untreated) Treatment • Medical emergency • Higher doses of Thiamine, Benzodiazepines, Haloperidol
Attitudes towards substance abuse
• Acceptable versus negative • Cultural versus outlawed views • Community values versus Health Professional
The impact of mental illness on youth
• Adolescence is a time of structural and functional changes in the brain • Adolescents are becoming autonomous, defining individuality, establishing and negotiating work/social networks, beginning sexual relationships, and completing education or moving into employment • Ongoing disability can include impaired social functioning, poor educational achievement, unemployment, substance abuse, & violence
Recovery Models of Care
• Adopts a holistic approach where positives are the focus • What can the person do...? • What can they achieve...? • How can they control and take ownership of their own • recovery...? • How can the nurse empower them to do this...? • Attempts to prevent the label of mental illness from taking over their life "I like to spend time with people and find out what practical self help things they already have in place and getting them to recognise what their strengths are. Going from a strength space "
schizophrenia: who does it affect
• Affects 1% of population globally - >21 million people worldwide • Onset varies in males & females • Males tend to onset earlier • Both genders peak 15‐24 years • Males have higher lifetime risk of schizophrenia • More likely to be single (never married) especially in males • More likely to be unemployed - prodromal issues? • Country of birth • Urban living • UTI's??
Schizoaffective Disorder?
• Affects about 1 in 200 people • 1/3rd as common as schizophrenia (lifetime prevalence 0.3%) • Typical onset age is early adulthood; more common in females (probably because of likelihood of depressive type in women) • Prognosis slightly better then for schizophrenia, but worse than prognosis for mood disorder • A disorder characterised by symptoms of schizophrenia and major mood disorder (mania or depression) • Can be more complicated to diagnose & therefore an individual who had a diagnosis of schizophrenia or BPAD, may be re‐diagnosed to schizoaffective disorder later
Psychosis & CBT
• Aims to develop an individual account of the development and maintenance of currently distressing experiences that is less threatening than the beliefs that are currently held • Helps an individual make sense of their perceptual experiences by making links between emotional states, thoughts and earlier life events
Statement of Rights (s.12)
• All Victorian patients treated under the MHA (2014) must be given a statement of rights by - A psychiatrist - Who must answer and allow for questions - If the individual is unable to understand, then further attempts and oral explanations must be made to provide information • Individuals also have the right to uncensored communication (Section 14) via; - Letter - Electronic means - Telephone • And receive visitors at reasonable times • Except (Section 16[1]) where AP can restrict communication if they are satisfied that the restriction is reasonably necessary to protect the health, safety and wellbeing of the inpatient or of another person • Statement of Rights
Context of Practice
• All health practitioners require a regulated practice - AHPRA • Standards of practice - Accountability - Profession groups have ethical codes • Codes of ethics - Can guide practice • Ethical issues are ever present
Presumption of Capacity (s.68‐70)
• All persons receiving treatment are presumed to be able to make decisions about their own treatment • Just because someone is mentally unwell or under compulsory treatment, does not mean they are mentally incapable • Capacity fluctuates and needs to be reassessed • A person has the capacity to give informed consent if s(he): - Understandsthe information he or she is given that is relevant to the decision, and - Is able to remember the information that is relevant to the decision, and - Is able to weigh information that is relevant to the decision, and - Is able to communicate the decision he or she makes by speech, gestures or any other means
In what setting are withdrawal symptoms managed?
• Ambulatory withdrawal (mild - moderate) • Community residential (moderate to severe) • Inpatient Hospital (moderate - severe) • detox. inpatient Monitoring • Physical signs • Severity of alcohol withdrawal • General progress (e.g. • Clear screenings, response to medications
Side Effects Common to Most Anti Depression medications
• Anticholinergic effects - Dry mouth, dry eyes, blurred vision, constipation, urinary retention • Insomnia • Sedation • Orthostatic hypotension • Sexual dysfunction (common to paroxetine, sertraline & citalopram)
Treatment of Schizophrenia Spectrum Disorders
• Antipsychotic medication - Dopamine antagonists - Work by decreasing dopamine activity in brain - Typical/conventional/1st generation agents - Atypical unconventional/2nd generation (novel) agents - Atypical/unconventional/3rd generation agents - Orals trialled before depot (LAI) is considered • CBT • ACT • ECT • Strengths recovery perspective
Treatment of BPAD's
• Antipsychotic medication • Mood stabilising medication • ECT • Counselling • Anxiolytics • Antidepressants (with care)
19 Pharmacological Treatments of autisom
• Antipsychotics - used to control symptoms • Used to treat the aggressive behaviours • RisperidoneTM most common • Reduces violent behaviours • Causes weight gain, sedation, muscle stiffness and dizziness • OlanzapineTM also used • Manages violent outbursts • Causes weight gain, sedation, dizziness • Medications are a last resort treatment Pharmacological Treatments • Anticonvulsants - reduce aggressive and violent behaviour • Antihypertensive's - may regulate violent outbursts • SSRI's - can reduce stereotypical and self-injurious behaviours
General principles of intoxication management
• Any intoxicated person is at risk of aspiration and asphyxiation due to vomiting at a time of diminishing consciousness, whether or not there are overt signs of injury. • All intoxicated people are at risk of and should be monitored for poisoning and overdose. • All intoxicated people must be kept under observation until their intoxication diminishes and they can safely manage their environment. • All intoxicated people with a low blood alcohol/breath alcohol reading but whom appear grossly intoxicated must be assumed to have either consumed other drugs, sustained a head injury or have another severe illness. • Thorough physical and mental status examinations need to be conducted to reveal the level of intoxication. • If the intoxication does not diminish with falling serum alcohol/drug levels, the person must be assessed for other possible causes of their condition. People who appear intoxicated may be suffering other conditions. • Maintenance of the airway is of paramount importance to the semi‐conscious or fully comatose person. • People who have stabilised after being intoxicated should be further assessed for any possibility of withdrawal • Alcohol withdrawal can occur before a zero blood alcohol reading. • Any person presenting with seizures should be assessed for alcohol withdrawal, benzodiazepine withdrawal or stimulant intoxication, as well as other possible causes. Withdrawal seizures must be treated according to best practice, with the person observed for at least four hours post seizure, using the Glasgow coma scale Score.
Psychiatric Second Opinions (s.78‐87)
• Any person (or person on their behalf) subject to a TTO or TO is entitled to seek a second opinion at any time • Purpose of a second opinion is to assess whether treatment criteria apply and/or review treatment and recommend changes • Written report must be provided to AP, patient & nominated person • AP must consider the second opinion & determine whether to adopt all, some or none of the recommendations • Patient may apply to the chief psychiatrist for treatment review, if none or only some of the recommendations are adopted
MSE for children
• Appearance • Sensorimotor development • Manner of relating to clinician & family • Mood/affect • Capacity/level of play • Thought processes/content • Perceptual abilities • Cognitive abilities/intelligence • Attention level/concentration • Language/speech • Concept of self • Positive attributes/adaptive capacity • Temperament (overall)
Harm reduction
• Approaches to drug policy that seek to minimise the harmful consequences of drug use to individuals, families & communities. Value‐ neutral • Pragmatic approach (not confined to cure) Supply reduction • Regulation and law enforcement Demand reduction • Prevention through information, education and treatment
Autism spectrum Disorder
• As the child gets older these concerns include • Preoccupation with particular objects or topics • Difficulty making friends - or no friends • Inflexibility with rules, regulations or routines • Language difficulties • Repetitive behaviours clip • http://www.youtube.com/watch?v=GRR9BXFLjoU • Note the repetitive motions in tune to the music
Conduct Disorder Client/family education
• Assist parents with clear communication skills • Teach parents social and problem solving skills, limit setting techniques • Help parents to avoid 'rescuing' their child • If needed, encourage parents to seek treatment for own problems
Youth mental health disorders
• Attention-deficit disorder (ADD) & attention deficit hyperactivity disorder (ADHD) - see early childhood slides • Oppositional defiant disorder (ODD) • Conduct disorder (CD) • Psychosis • Biploar affective disorder • Emerging borderline personality disorder • Eating disorders • Depression
Depression Facts & Stats
• Australian lifetime prevalence of depression is 1 in 7 • Third highest burden of disease in Australia & globally affecting over 350 million people worldwide • About 5% of adolescents experience depression worthy of treatment • About 20% of adolescents will have suffered significant depressive symptoms by the time they reach adulthood • MDD associated with high mortality rate (suicide) • Elderly persons who are depressed and admitted to RAC have markedly increased likelihood of death in the first year ('natural' causes) • Affective/mood disorders (depression, BPAD, dysthymia) affect 6% of Australian's aged 16‐85
Ethical Principles
• Autonomy - Right to make own decisions, provided it doesn't violate another's autonomy • Beneficence - Care provided is for the benefit of the individual; positive action or intervention • Non‐maleficence - To do no harm; avoid actual harm, risk of potential • Justice - Society's expectation of what is fair & right
BPAD Facts & Stats
• BPADI affects 1% of Australian's (no gender variation) • BPADII affects 5% of Australian's (higher in women) • Diagnosis can take 10‐20 years - Consider the resultant biopsychosocial damage in this interval • Manic episodes are more common as first presentation in men • Depressive episodes are more common as first presentation in women • High incidence of non‐adherence to tx • High incidence of suicide - Lifetime suicide risk at least 15 times higher than of general populations & account for ~25% of all suicides • More than 90% of BPAD sufferers will experience recurrence
Asperger's Disorder
• Believed to be genetically linked - relationships exist between family incidences • Brain abnormalities is another theory • Scientists are still looking for the gene (or group of genes as is theorized) • Brain activity changes have been studied • Spectrum disorders are not linked to MMR vaccination as has been • Often referred to as High Functioning Autism • The sarcasm sign..... • http://www.youtube.com/watch?v=DF7MroTLDfU • http://www.youtube.com/watch?v=goU9_bhnHSE&list=PLAD471DDC 77CD92ED
Prognosis of schizophrenia
• Better outcomes are associated with: - Female - Older age onset - Married - Living in a developed country - Functional premorbid personality - No previous psychiatric history - Good education and employment history - Acute onset (affective symptoms) - Medication concordance
Managing Side Effects of antipsychotic medications
• Busiprone (BuSpar®) - Similar to benzodiazepine in its pharmacology - Anxiolytic (without risk of dependence) • Antihistamines (e.g., benadryl®) • Benzodiazepines & hypnotics • Propranolol • Anticholinergics - Benztropine
Resources & Services
• CAMHS (The Child & Adolescent Mental Health Service) • TheAlfred,0-18yrs • Child & Youth Mental Health Service (CYMHS) • EasternHealth,children&youngpeopleupto25yrs • Orygen Youth Health • Worldleadingmentalhealthorganisation • Aimsataddressingneedsof15-25yroldsinNorth-WestMelbourne • EPPIC • EarlyPsychosisPreventionandInterventionCentre • Aimsataddressingneedsof15-24yroldswithfirstepisodepsychosisinNorthWestMelbourne Area • PACE (Personal Assessment and Crisis Evaluation clinic) • Providestreatmenttoyoungpeopleat'ultrahighrisk'ofdevelopingapsychoticdisorder(including biploar I) • Youth Mood Clinic • Providestreatmentforyoungpeopleexperiencingnon-psychoticillnesses(predominatelymajor depression, biploar II) • HYPE (Helping Young People Early) • Providestreatmenttoyoungpeoplewithemergingborderlinepersonalitydisorder • headspace (National Youth Mental Health Foundation) • ReachOut - http://au.reachout.com/ • Youth Beyond Blue - http://www.youthbeyondblue.com/ • Young & Well Cooperative Research Centre (YAW CRC) • Australia-based, international research centre, exploring the role of technology in young people's lives, aged 12-25 yrs and how it can be used to improve their mental health and wellbeing
Cannabis related disorders
• Cannabis use disorder • Cannabis intoxication • Cannabis withdrawal • Other Cannabis‐induced disorders • Unspecified cannabis‐related disorders
PARTNERSHIPS IN CARE
• Carers have exceptional first ‐hand knowledge of the needs of the person they care for • Health care professionals can help to ensure better outcomes for patients by working together with their carers • Need to acknowledge the carer as part of the care team • Respect the relationship between the carer and the person they care for • Include the carer in the design and delivery of treatment plans • Listen to the carer and maintain clear and honest communication with them • Consider the needs and preferences of the carer • Find strategies that support the rights of caring families Collaborating for positive results • Will be able to better plan and respond to the needs of individuals Keeping a look out for the carer's health • Need to support carers to continue to carry out this important role. Recognise when carers are experiencing poor physical and emotional health (Jaloweic Coping Scale; Zarit Burden Scale; Barriers to Caregiving Index) • Help them to locate and obtain support (eg. Alzheimer's Association; Carers' Association, NSW, ARAFMI, Alcoholics Anonymous, Black Dog Support Groups, Aftercare, SANE Australia, Schizophrenia Support Groups, Mental Health Association, Substance Abuse and Addiction Recovery Support Groups) • Understand and recognise the impacts of caring on relationships. Understand the factors that impact on carer health and well‐ being & potential health risks such as depression and mental illness • Keep informed of services, supports and resources that may be helpful • Support carers to maintain their own health and well‐being Partnership: an association between people • The concept of shared responsibility for health &wellness outcomes: capacity building/addressing multifactor's/inter-connectedness of health • Demystifies the concept of the client, families and communities being a passive recipient of policy, programs/ care • A reminder that requires the health professional to have a ethical & legal responsibility to the patient to deliver a high level of care to the clients, families and communities. • The partnership involves a range of people.
Metabolic Syndrome • Caused by : • Characterised by: • Exacerbated by
• Caused by second‐generation antipsychotic agents (namely olanzapine & clozapine) • Characterised by: - Abdominal obesity / BMI / waist measurements - Elevated triglycerides - High density cholesterol levels - Elevated fasting glucose - Hypertension • Exacerbated by - Increased sedation - Appetite stimulation - Thirst & hypersalivation - Negative symptoms - Poverty - Access to healthcare
Attention Deficit Hyperactivity Disorder (ADHD)
• Characterised by patterns of behaviour that can result in performance issues in social, educational or work settings. • More common in boys • Onset: usually identified & diagnosed in preschool/school. May be earlier. • Can be over-diagnosed • Paediatrician/child psychiatrist • Rule out psychological stressors at home or other MH disorders • Previously believed that children grew out of ADHD, however we now known can persist into adulthood.
Conduct disorder
• Characterised by persistent antisocial behaviour in children & adolescents that significantly impairs social, academic or occupational functioning • Symptoms: aggression, physical fights, lying, bullies/threatens/intimidates others, use of weapons, arson, vandalism, truancy, property damage, violation of rules • Frequently associated with risky behaviours: early onset of sexual behaviours, drinking, smoking, drug use & reckless/risky behaviour • Onset: symptoms in children before age 10. These children more likely to have persistent conduct disorder in youth & develop antisocial disorder as adults • Aetiology: genetic vulnerability, environmental adversity • Risk factors include: poor parenting, abuse, poor peer relationships, low academic achievement, low self-esteem • Protective factors: family support, positive peer relationships, good health
Pervasive developmental disorders
• Characterised by pervasive & severe impairment of social interaction skills, communication deviance & restricted stereotypical behaviour patterns • Includes: • Autistism spectrum disorder, • Rett's syndrome, • Childhood disintegrative disorder, • Asperger's disorder
Children's mental health
• Childhood focuses largely on individual strengths of the child and the family (considering the influence of school and other social environments) • Clinicians need to be aware of behaviour ranges/abilities expected at each age & what is known about child/youth psychiatric disorders • Determine what a child requires at any age to minimise risk and foster protective factors
What Happens Overtime?
• Children do not grow out of Asperger's, they grow with it • Core social, communicative and behavioural difficulties persist • Parents may need a 'booster' session in Asperger's during particular years to help manage a particular stage of life (e.g. teenage years, finishing school etc)
Asperger's Clinical Presentation
• Children with AS become isolated from peers due to their peculiar preoccupation with said obsession, and poor social skills - not due to withdrawal (like in Autism) • Usually have some development delays in motor skill acquisition (playing spot, riding bike etc) • No attempts to make friends • http://www.youtube.com/watch?v=5Cuoxa59jxI • Lack of understanding of social cues • Lack of empathy • http://www.youtube.com/watch?v=ZDb5jQqXXVU • http://www.youtube.com/watch?v=no48zCCLHHg • Difficulty sharing • Aggressive or self-injurious behaviour • Can have high IQ • Fail to initiate play; follows the other children around and becomes upset when 'rules' are broken • http://www.youtube.com/watch?v=l2hIIvF5gJI • Has lots of toys but doesn't know how to play with them - lacks imagination • Prognosis is better then Autism • Won't do things 'just to please others' • Behaviour is rigid, inflexible and demanding • Good verbal memory skills, absorbs facts easily • Appears odd or eccentric • Impairments in two-way social interactions - inability to understand the rules governing social behaviour • Victim of teasing or bullying • Difficulties remembering who people are, but remembers specific events or statements • Boys and Girls will have different special interests • b Trains, dinosaurs, science, electronics, computers, sports facts, football, numbers •g Soft toys, food, dancing, running, homework, classic literature, music
Postpartum 'Blues'
• Common in men & women ~30 days after birth • 50‐80% women affected to some degree - Transient - Mood lability, irritability, tearfulness - Feeling of sadness - Dysphoria - There are periods of normalcy - Assess for postpartum depression in these symptoms persist longer than ~ 2/52
Treatment of Autism
• Counselling • Parents training and support • Social skills training • Cognitive behavioural therapy • Speech therapy • OT & physical therapy • Medication • Antipsychotics • Anticonvulsants • Antihypertensives • Anxiolytics
Opiate Withdrawal
• Craving the drug • Restlessness • Hypotension • Tachycardia • Stomach & leg cramps; muscle spasms • Anorexia, vomiting & diarrhoea • Runny nose & watery eyes • Increased irritability • Insomnia • Depression • Withdrawal usually subsides after 6‐7 days, but psychological symptoms may persist for months or years
Interventions for alchohol
• Cycle of change model • Stage of treatment model • Motivational Interviewing • Brief interventions ‐ FRAMES
The Prodrome to Psychosis via the Duration of Untreated Psychosis (DUP) Pathway
• Decline in social, work & school functioning • 'Something is not right....' • Initially symptoms are not as prominent or disabling as seen in an acute psychotic episode • At some point they intensify • Reality is lost, blurred... • Meet standard DSM 5 (2013) diagnostic criteria • There is often significant delay in recognition, diagnosis, treatment & management (from weeks to years) • Identifying the DUP interval is a particular focus of early intervention strategies • Significant research indicates delayed first treatment = poor outcomes
Harm reduction for alcohol abusers
• Definition: '... policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community."
Traditional Concepts of Mental Illness Recovery?
• Degenerative, life long and permanently disabling • Medication is the focus of recovery • A diagnosis of mental illness does not correlate with successful, independent living • Consumers are passive recipients of care
Positive (Florid/Productive) Symptoms:
• Delusions • Hallucinations • Grandiosity • Suspiciousness • Insomnia • Obsessed & abnormal thoughts • Hostility • Paranoia • Agitation • Bizarre behaviour
Harm Minimisation??
• Demand reduction • Supply reduction • Harm reduction
Aetiology & Epidemiology Depression
• Depression affects 1 in 7 (17%) women vs 1 in 10 (10%) men • Genetic factors • Multifactorial • Neurochemical • Environment
Increase Risks
• Depression social isolation/loneliness • Anxiety others not conforming to their inflexible rules, being bossy; results in inability to cope with outcomes • Issues coping with change • Suicidal thoughts Suicide attempts
Tenth part of MSE: Form of Thought
• Describes the way thoughts are connected & expressed • Is there an excess or absence of thoughts?
Risk Management Management involves?
• De‐stimulisation of area • Therapeutic interventions • Observations (15/60's etc.) • Documentation • Frequent communication between staff • Thorough hand‐over • Obtaining guarantees • Restrictive interventions • Medication adherence techniques (observations 45 minutes after; depot, wafers, serum levels etc.)
Schizophrenia: The Warning signs
• Differs from frank psychotic features in intensity, frequency & duration • Pre‐hallucinatory perceptual abnormalities - Brief subtle changes in perception (e.g., hearing or seeing something others cannot) - Usually once or twice/month, lasting only a few minutes & usually less than a day - Impaired body sensations • Subtle changes in behaviour - Deterioration of school work or work performance • Social withdrawal • Pre‐delusional unusual thoughts - Emergence of unusual or strange beliefs • Non‐specific symptomssuch as depression, anxiety • Pre‐thought disordered speech disturbances • Motor disturbance • Impaired tolerance to stress • Disorders of emotion, energy, concentration & memory • Adolescents who go on to develop schizophrenia often display significant issues with executive functioning in the prodrome
Secondary Negative Symptoms of Schizophrenia
• Difficulty in differentiating from primary (i.e. illness‐related) & secondary sources of negative symptoms remains a challenge • Often caused by unrelieved/untreated positive symptoms, adverse effects of antipsychotics or social isolation imposed by schizophrenia • Often subside with resolution of causative factor
Schizophrenia Cognitive Symptoms
• Disorganised thoughts • Disturbances in executive functioning • Goal‐completion difficulties • Poor concentration/attention • Difficulty following instructions • Memory impairment
BPAD I&II - Hypomanic Episode
• Distinct period of abnormally & persistently elevated, expansive or irritable mood & abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day • Three or more of the following (4 if mood is only irritable) 1. Inflated self esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed 6. Increase in goal‐directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. Excessive involvement in activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) • The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalisation. • If there are psychotic features, the episode is by definition, manic
Seventh part of MSE: Hallucinations (Perceptual Sensory Disturbance)
• Do not engage in an argument about voices • Adopt a trial & error approach utilizing different strategies: - Relaxation and other anxiety management techniques - Taking a walk, exercise - Distraction techniques - Increased social activity - talking to a friend - Change sensory input, e.g., music though headphones - Low stimulus environment - Simply staying with client, providing emotional support & reality feedback - Use of PRN anxiolytics/antipsychotics as last resort
Families/carers of those effected by alcoholism
• Double stigma • Dilemmas of responsibility • Grief (past & future) • Guilt • Loss of trust • Loss of security
Anorexia Nervosa
• Eating disorders (Anorexia, Bulimia & EDNOS) affect between 2-3% of people • 90% are women • Anorexia Nervosa is relatively uncommon • Affects no more then 0.5% of women over 15 years of age • Bulimia Nervosa is higher at 0.5-1% Risk Factors • Female gender • Restrictive dieting • Substance misuse • Personal and family history of obesity and/or mood disorders • Low self esteem and perfectionism Physical Symptoms • Weight loss that's 15% below ideal weight range • Amenorrhea • Tachycardia • Decreased body temperature & cold sensitivity • Lanugo on face and body • Constipation • Muscle wasting, bones protruding, sunken-in eyes
Components of a treatment approach (include):
• Educational lectures • Counseling • Group • Individual • Family • Self - help groups • Vocational rehabilitation • Pharmacotherapy • Drug withdrawal
Ethical Issues: Psychiatric Diagnosis
• Effect of a diagnosis & impact of diagnostic labelling can result in - Loss of personal freedom - Imposed treatment - Labelling - Stigma • Coercive practices: overuse of psychotropic mx & use of restrictive interventions - Rights when being prescribed psychotropic mx? - Information about drug, effects, side effects, contraindications, complications, the right to refuse? - These rights are limited if involuntary/compulsory • Context - Decreased length of stay - Increase in acuity - Acute interventions & containment = care provided - Less attention to rehabilitation & discharge planning • Consumers view interventions as punishment, or restriction to their autonomy
ECT & Psychosurgery
• Electro Convulsive Therapy (ECT) & psychosurgery can only be performed: - Without consent on a person over 18 after approval from the tribunal - On a person under 18 even with consent only after approval of the tribunal • In 2010‐11 there were 19,912 ECT treatments in Victoria's public & private healthcare sector - Usually for major affective disorders (71%) & psychotic illness (19%) • Application for ECT • ECT With Informed Consent
Oppositional Defiant Disorder (ODD)
• Enduring pattern of uncooperative, defiant and hostile behaviour, without any major antisocial violations • Equal amongst females and males • Often co-morbid with ADHD, anxiety disorders • Treatment approaches are similar to conduct disorder
Cannabis Can cause:
• Euphoria, laughter • Decreased inhibitions & concentration • Increased appetite & HR • Impaired memory and recall • Detachment from reality, paranoia & hallucinations • Excitement & restlessness • Anxiety & panic • Impaired motor skill and ability to perform complex tasks (driving a car)
Substance abuse evaluation should include:
• Evaluation of all abusable substances for pattern of use • Factors of tolerance • Withdrawal symptoms • Consequences of use • Loss of control of amount, frequency, or duration of use • Social, vocational, and recreational activities affected by use • History of previous alcohol or drug abuse treatment
Early Intervention
• Evidence indicates that preventing mental health disorders are greatest when focused on children and youth (McGorry and Yung, 2003) • Aim is to prevent or minimise serious mental illness • Important for young people; early stages critical as essential treatment is important to reduce risk of ongoing disability & focus on recovery • Initial contact/engagement is crucial • Young people can experience a wide range of symptoms - these symptoms can continue to evolve later in youth
Manic Switching, 'BPADIII' or Antidepressant‐Induced Mania
• Evidence to support use of AD's in BPAD is limited & increasingly controversial • Antidepressants have been associated with inducing rapid cycling • One study identified adjunctive tx with AD's for BP depression was associated with 'substantial risk of threshold switches to full‐duration hypomania or mania even during short‐term treatment' (Baldessarini et al, 2013 p.2) • More commonly associated with TCA & Venlafaxine
Positional Asphyxia
• Exacerbated by - Obesity - Psychosis - Pre‐existing medical conditions - Pressure on abdomen • Signs - Person telling you they cannot breathe - 'Gurgling/gasping'sounds, indicating airway occlusion - Cyanosis in lips, face, hands - Increased panic - prolonged resistance - Sudden tranquillity - an active, loud, threatening, violent, abusive person who suddenly becomes quiet and still • "Getting a violent individual into seclusion against his/her will, almost invariably involves some form of physical intervention & mechanical restraint as observed is clearly not without its own risks"
Behaviours Exhibited
• Excessive exercising • Self-induced vomiting or purging • Use of appetite suppressants or diuretics • Preoccupation with food • Sudden and severe weight loss • Obsessing about food, weight and/or appearance • Pretending to eat, or lying about food intake • Not eating in public • Avoiding social situations that include food Eating an odd or restricted diet (eg., only one food) • Vomiting after eating • Wearing bulky clothes to hide weight loss • Abusing diet pills and/or laxatives • Heightened awareness of calories in foods • Thin hair & dry skin • Amenorrhea
Risk Factors Depression
• Family history • Personality • Serious medical condition • Situational • Gender • A&OD use • Absence of protective factors
Treatment ana
• Few options, there is no specific medication • SSRI's (namely Fluoxetine) • Atypical antipsychotics • Counselling/Therapy • Behavioural Therapy • Cognitive Therapy • Family Therapy • Group Therapy
BPAD I&II - Depressive Episode
• Five or more of the following symptoms have been present during the same 2‐ week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure 1. Depressed mood (dysphoria) 2. Markedly diminished interest or pleasure in all or most activities most of the day, nearly every day 3. Significant weight loss when not dieting or weight gain (change <5% in one month) or decrease or increase in appetite nearly every day 4. Insomnia or hypersomnia nearly every day 5. (Observable) psychomotor agitation or retardation nearly every 6. Fatigue or loss of energy nearly every day 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self‐reproach or guilt about being sick) 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or observable) 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with out a specific plan, or a suicide attempt or a specific plan for committing suicide
Ninth part of MSE: Delusions
• Fixed false beliefs not shared by the general population • Delusions are accepted without question, regardless of reality & include: - Grandeur - Persecutory - Paranoid - Somatic - Nihilistic - Erotomanic - Religious • Delusion Example • Delusions of control: - Thought withdrawal - Thought insertion - Thought broadcasting - Thought control
Clinicians should...
• Focus on positives • Avoid labels • Respect individuality • Encourage control • Acknowledge we all have good and bad days • Mistakes are OK • Holism is vital - this is a person, not "the schizophrenic" • Need to move away from the perception that a person who has a mental illness has needs, to one where people who live with mental illness are consumers who have options • Need to work in partnership with consumers
Strengths recovery model (6 principles)
• Focuses on strengths, interests, abilities (not on deficits or pathology) • The case manager‐client relationship is pivotal • People inherently posses the ability to learn, grow and change • This process is client‐driven/directed • Therapeutic alliance is fundamental to achieving this • The community is a sanctuary for achieving these goals and a wealth of resources • Application to practice: ISP
Criteria for Compulsory Treatment (s.29)
• Following criteria enable a person to be made subject to a Temporary Treatment Order or Treatment Order a) The person has a mental illness; and b) Because the person has a mental illness, the person needs immediate treatment to prevent: I. Serious deterioration in the person's mental or physical health; or II. Serious harm to the person or to another person; and c) The immediate treatment will be provided to the person if the person is subject to a Temporary Treatment Order or Treatment Order; and d) There is no less restrictive means reasonably available to enable the person to receive the immediate treatment
ECT for Adults & Young Persons (s. 92‐94)
• For adults: - A compulsory patient with capacity can consent or refuse ECT without tribunal approval - Tribunal will determine applications for ECT for compulsory patients without capacity • For young persons (<18yrs) - AP may make an application to the MHT to preform ECT on inpatient who: • Has given consent in writing; or • Who does not have capacity to give informed consent but the AP is satisfied there is no less restrictive way to treat them • If they do not have capacity their legal authority person must consent in writing • MHT can authorise ECT on a person if they are satisfied that a patient: - Does not have capacity to consent; and - There is no less restrictive way to be treated
What Constitutes Treatment (s.6)?
• For the purposes of this Act: a) A person receives treatment for mental illness if things are done to the person in the course of exercise of professional skills: (i) To remedy the mental illness; or (ii) To alleviate the symptoms and reduce the ill effects of the mental illness; and b) Treatment includes electroconvulsive treatment and neurosurgery for mental illness
Goals of Treatment for substance abuse
• Four basic goals • Enhance function • Optimize motivation toward abstinence • Restructure life without substances • Relapse prevention
Challenges in Recovery
• Gaps/fragmentation in programs and services • Inequitable access to services, limitations on services available • Stigma • Cultural and linguistically diverse (CALD) consumers Understanding, communication, trust, acknowledgement of beliefs. Culturally competent.
Conduct disorder: Treatment
• Geared towards age • Child, family & school environment the focus for school aged children: parent education, family therapy, social skills training to improve relationships, improve academic performance • Adolescents: individual therapy, must address drug/alcohol problems if present, conflict resolution, anger management, social training • Pharmacology • Alone have little effect • May be used in conjunction with psychosocial/behavioural interventions for specific symptoms
Autism Aetiology
• Genetics • X-linked factors • Links with other disorders • In utero environment • Brain structure/function • Perinatal factors • Food intolerance
Psychosis information
• Grossly impaired understanding of reality • Devastating mental state where internal stimuli is hard to distinguish from reality • Psychosis can be present in: - Acute mania - Depression - Drug intoxication - Delirium - ABI - Dementia
Resourcefulness of nurses
• Help people to cope with stress & minimise effects of illness • Involves using problem solving skills • Believing one can cope with adverse or novel situations • Developed through: ‐ interactions with others ‐ successful coping with life's experiences ‐ monitoring one's thoughts & feelings ‐ taking action to deal with stressful situations ‐ performing health‐seeking behaviours
Opiates
• Heroin (horse, hammer, H, dope, smack, junk, gear & boy) • Opium • Morphine • Pethidine • Oxycodone • Buprenorphine • Methadone
Why youth mental health?
• High prevalence & burden of mental ill health • Young people 12-25yrs face unique challenges that affect their wellbeing and • Youth peak period for emergence of mental ill-health; many disorders fall within early teens to mid 20s • 1 in 4 young people experience mental disorder in 12 month period • 13-17yrs - 19% increase their vulnerability • 18-24yrs - 27% • Mental and substance abuse disorders account for over 60% of health burden in 15-24 yr olds • Related impact on families, communities and society • This is an emerging field, and youth mental health is now being recognised as a speciality
Mental Health Recovery Star
• Holistic and personalised properties • • 10 areas of person's life into focus • • Recovery properties • • Recovery‐focused journey • • Motivates individuals to make progress • • Small achievable steps are significant and achievable • For every point on the star, there are 10 steps on the ladder • • People fluctuate on where they are located depending on current • situation and coping mechanisms etc. • • Recovery is fluid and changes over time • • Not all change is for the 'better'
Headspace Psychosocial Assessment
• Holistic assessment • Age range of clients (12-25yrs), the young persons developmental stage needs to be taken into account • Commence each domain with a screening question - elaborate further for more comprehensive understanding • Be sure not to make assumptions - asking about mum and dad (assumes lives at home), or young women about 'boyfriends' (assumes heterosexuality)
The Recovery Star Model
• Holistic model • Personalised outcome measurement • Recovery focused • Collaborative approach • Based on 10 outcome measures
Clinical Presentation of Autism
• Hyperactivity • Short attention span • Impulsiveness • Aggressive or self-injurious behaviour • Tantrums • Sensory issues with food (only eating a few things, texture dependent, must be yellow etc) • Sleeping issues (frequent waking, long time to settle etc) Clinical Presentation of Autism • Repetitive patterns of behaviour or interest • Extreme preoccupation (intense and focused) • Rigid, inflexible following of rules • Non-functional rituals or routines • Difficulty coping with even minor change • Catastrophic reactions to slight changes • Stereotypic motor activity • Fascination with movement of objects • Attachment to strange objects • Lack of emotion, fail to engage in social play • Mood or affect abnormalities • Lack of fear • 80% have a degree of mental retardation • 50% have profound or severe retardation • 30% have mild retardation • "Islands of Genius"
Immediate management/treatment
• Identify any immediate risks to self or others/from others • Drug/alcohol use • Psychological interventions (individual & families/carer) • Pharmacological interventions • Group programmes • Peer programmes • Multidisciplinary team input
Ethical Issues: Restrictive Interventions
• Impacts of trauma to consumer • Impact to therapeutic relationship • What about other's safety?
Detection & Assessment
• Important to understand the context of the referral • Why now? Who is most worried? What are they worried about? Who else has assessed the child/youth? What has been tried before? • The individual (very few referrals) • Families/carers • GPs • Teachers/sporting coaches • Law enforcement (police, courts) • Many mental health disorders occur across the lifespan, however presentations differ • Mental state examination • Child Behaviour Checklist (CBCL) - teachers
Fourth National Mental Health Plan 2009‐14 Priority Area 1: Social Inclusion and Recovery
• Improve community and service understanding and attitudes (reduce stigma) • •Expand education, employment and vocational programs linked to mental health programs • •Improve service coordination (between primary care/mental health services) to enhance consumer choice • •Adopt recovery oriented culture with mental health services • •Develop programs between mental health services and housing agencies to provide better housing assistance • •Develop approaches to link between housing, justice, community and aged care for people at risk of homelessness • •Recovery ‐oriented practice is guided by six principles (see Standard 10: Delivery of Care ) • uniqueness of the individual ‐ real choices ‐ attitudes & rights ‐ dignity & respect ‐ partnership & communication ‐ evaluating recovery
Impact & Burden of Disease of substance abuse
• In 2011 mental disorders were responsible for 754 deaths • This excludes suicide & dementia • Most of these deaths are due to substance abuse - particularly alcohol • Mental disorders account for ¼ of years lived with disability • Drug use disorders are ranked in the top 10
Commonly Identified Implications of Dual Diagnosis
• Increased rates of relapse • Worsening psychiatric symptomatology • Higher frequency of inpatient admissions • Poor medication adherence • Higher rates of violence, suicide & self‐harm • Higher likelihood of involvement with the criminal justice system • Higher rates of HIV and other substance use related physical problems • Homelessness • Lower educational and employment attainment • Family problems & issues • Social exclusion & stigmatisation
Autistism Spectrum Disorder
• Increasing prevalence • 1 in every 160 children diagnosed • More common in boys 4:1 • Cost associated with Autism is estimated $7 billion/annum • No cure • Early intervention can dramatically improve quality of life for affected children and families
Aetiology of Violence & Aggression in Inpatient Mental Health Facilities
• Internationally ~ 1/3 of people in mental health settings behave violently - Based on analysis of literature (n = 128) which identified variations in defining violence and aggression • Limitation of consumer freedoms • Medication administration • Restraint • Care provision • Consumer‐consumer provocation • Previous positive history for violence • Involuntary (compulsory) admission • Illicit drug use
Collaboration
• Involves engagement with people (individuals/ group, communities) • Supports participation of all members • Recognises knowledge/experience /skills of all members • Is focused on strengths (i.e. capacity, not deficits)
Third part of MSE: Mood
• Is an internal state of mind that is exhibited through feelings and emotions • Subjective data : What does the client tell you? • Is what they tell you congruent to what you observe? • Mood states can often be described as elevated, depressed, anxious, labile, suspicious, euphoric, irritable, euthymic • Ask the client to rate their mood (1‐10) • Moods can fluctuate in extremes - Happy one minute sad the next (labile mood) • Is the mood congruent to expressed topics? • Consider the duration of the mood Think about aspects of your life that are expressed in your mood, or affected by your mood • Appetite - Increase - Decreased • Sleep - Hypersomnia - Insomnia - What is the quality of sleep like? - How often do they wake? Why? - Do they feel rested when they wake? - Do they have a usual bedtime routine? - Sleep/nap during the day? - Use of sedatives? • Libido - Increased in some instances (e.g., mania) - Decreased in others (e.g., depression) • Clarify & establish clients meaning to words they use
Fourth part of MSE: Affect
• Is an observable, objective, visual response to a mood • Affect is an emotional range which is attached to ideas - outwardly demonstrable • Affect can be described in terms such as: - Appropriate affect - Restricted affect - Blunted affect - Flat affect - Inappropriate affect - Labile affect
Temporary Treatment Order (s.44‐51)
• Is made after an assessment order (by a different person) • Must meet section 29 criteria (Compulsory Treatment) • Treated in the community or inpatient (less restrictive environment) • Must take into account persons wishes (inc. nominated person/carer/family/parent/advance statement) • After TTO has been made, psychiatrist must notify the tribunal • Unless revoked, a TTO remains in force for 28 days • MHA 110
Engagement
• Is one of the most crucial aspects of service delivery • Allow for enough time, patience & effort to develop trust/rapport • Involve family/carer • Reluctance to seek help for a variety of reasons - denial of problem, no insight, negative beliefs about mental health/services, stigma related to treatment/outcomes • Developmental stage of young people - age appropriate, lack of trust/suspiciousness, health a low priority, strongly influenced by peers & having related stigma concerns • Other factors - unaware of available health services, substance use, illness related factors such as paranoia
Seclusion (s.110‐112)
• Is the confinement of a person where the windows and doors are locked from the outside • Seclusion may be initiated by AP, or in their absence, medical practitioner or senior nurse on duty - AP must be notified as soon as practical if they are not involved • Seclusion used to prevent imminent and serious harm to the person or to another person - Clinically observed by RN or MO as often as appropriate at intervals no greater than 15/60 - Review by AP (or MO) as frequently as appropriate but at intervals no greater than 4/24 • Restrictive Interventions • Urgent Restraint • Restrictive Interventions Observations (MHA 142)
Drug Prevalence issue of substance abuse
• Its estimated that about 200 million people use illicit drugs each year globally • In Australia the social costs of drug & alcohol abuse to the community from factors such as ill health, premature death, reduced productivity, crime and accidents cost: • Tobacco‐ $31.5 billion • Alcohol‐ $15.3 billion • Illicit Drugs‐ $8.2 billion
What is a loading regime? How does it differ from a symptom triggered or fixed schedule regime?
• Loading dose regimens (also called 'front‐loading') quickly administer high doses of benzodiazepines in the early stages of alcohol withdrawal : Indications: • Patients who have a history of severe withdrawal complications (seizures, delirium) • patients who present with severe alcohol withdrawal and/or severe withdrawal complications (delirium, hallucinations, following an alcohol withdrawal seizure).
Eleventh part of MSE: Formal Thought Disorder
• Loosening of associations - Poor progression of thoughts, ideas change rapidly and are unconnected - Unrelated & unconnected ideas shift from one topic to another • Flight of ideas - Continued flow of accelerated speech which changes abruptly - Can be based on environmental factors or understandable associations - Rapid thinking in its extreme • Tangentiality - Indirect replies to questions in an irrelevant way - Digression may never get back to the topic, client goes "off on a tangent" • Circumstantiality - A delay in reaching the goal due to the inclusion of excessive or irrelevant details • Word salad - An incoherent mixture of words or phrases. Essentially incomprehensible mixture of words & phrases • Neologisms - A new creation of a word • Clanging / Clang Association - Words chosen for their sound, not meaning • Punning - Plays on words that are clever or humorous - Like a homophone. - Bare‐bear or scents‐cents • Thought blocking - Abrupt gaps in the flow of thought • Echolalia - Imitating words of others, often mocking, repetitive & persistent
Why risk assess in MSE
• MHN work in a high‐risk area known for assault • Statistics are under‐represented (est. that ~75% of assaults are not reported due to lack of privacy, fear, lack of time for paperwork, or being judged as incompetent or unable to cope in their chosen profession) • 13,709 'Code grey' calls in Melbourne hospitals in 2011‐12 - Research suggests how violence is managed....is determined by how individuals working in this environment understand its aetiology (van der Zwan, Davies, Andrews & Brooks , 2011) • 95% of hospital workers have experienced verbal abuse • 35‐40% physical abuse • Duty of care to patient(s), visitors, staff • Violence in the healthcare industry may contribute to ¼ of all workplace violence worldwide
Treatment Order (s.52‐57)
• Made after a TTO • Made by the MHT • MHT conducts a hearing to determine whether to make a Treatment Order • The Treatment Order will state - Whether inpatient or community - Length of the order (>18yrs community max.12mths; inpatient max.6mths; <18 max. 3mths) • AP can vary the setting of the TO • MHA 113
Police Powers (s.351‐356)
• May apprehend a person if: - The person appears to have a mental illness (the police do not need to exercise any clinical judgement however) - Because of this apparent illness the person needs to be apprehended to prevent serious and imminent harm to the person or to another person - Police may be accompanied with a MHP - May apprehend person and take them to designated MH service • Police now have new search powers which include: - Provision to search person for dangerous items - Search for items which will assist in escape - Powers to seize such items as listed above
Common Characteristics of Dual Diagnosis
• May be alienated Lack of supports (friends, family) • Poor compliance with health care providers • Emotional • Often has severe psychiatric symptoms • Often homeless or itinerant • Propensity to relapse • Hospitalisations due to accidents
Anti Depression Abrupt/Withdrawal Discontinuation Syndrome
• May cause withdrawal symptoms - GI (nausea, V&D) - Dizziness, vertigo - Flu‐like symptoms (sweating, lethargy, headache, anorexia) - Sleep disturbance (insomnia, nightmares) - Anxiety - Agitation or irritability • Usually short duration & mild • Need for tapering and titration
Depot Antipsychotic Medications (LAI)
• Medication adherence/concordance • Incidence - About 30% of Australian service users with schizophrenia are on LAI • Indications...? • Uses...? • Issues...? - Legal - Ethical • Benefits...? • Disadvantages...?
Legal & Ethical considerations
• Mental Health Act Queensland 2000 • Mandatory reporting - suspected abuse/neglect • Confidentiality • Major concern of young people • Always discuss at first meeting • A legal right for competent young person (can differ btw states/territories) • Information cannot be disclosed, unless • Young person gives permission • At risk of harming self/others & suicide • They are being threatened/harmed by someone else Lawstuff
Interventions for alchohol • Motivational Interviewing
• Motivational Interviewing Motivational interviewing approaches are most effective using empathy and nonjudgemental approach and helping the patient realise the discrepancy between life goals and engaging in substance abuse, thus motivating one to change one's own self-destructive behaviours and make personal choices regarding treatment goals. "Motivational interviewing is a directive, client-centered counseling style of eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with non-directive counseling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the counselor is intentionally directive in pursuing this goal."
Aetiology & Epidemiology of schizophrenia
• Multifactorial • Genetics - Family history for schizophrenia may be positive • Neurodevelopment - Foetal brain injury - Season of birth (increases in winter)‐ 10% increase - Obstetric complications - Low birth weight - CT/MRI abnormalities • Cannabis - Gene interaction • Environmental - High expressed emotion - Adverse life events (trigger) - Socioeconomic deprivation
Asperger's Disorder
• NO LONGER DSM 5TM Classification • Autistic Spectrum Disorder (ASD) • ASD's affect about 1% of the population in Australia • Most parents recognize "something is wrong" by about age 3 • Boys are significantly more likely to have Asperger's Disorder (10- 13:1) • This male prevalence may point to the possibility of an X-linked element to AS but needs further study • Extreme male brain theory
Health Promotion
• National Drug Strategy - demand reduction, supply reduction & harm reduction • Harm Minimisation - pragmatism • Continuum of abstinence based interventions to harm reduction • Acceptance acknowledges every person's right to choose • Ethical principle
Serious Side Effects of Antipsychotics
• Neuroleptic malignant syndrome (NMS) • Tardive dyskinesia (TD) • Agranulocytosis • Extra pyramidal side effects (EPSE) - Akathisia - Pseudoparkinsonism - Acute dystonia's (oculogyric crisis, neuroleptic induced torticollis, retrocolosis, glossospasm)
ADHD Treatment
• No one effective treatment. Most effective combination pharmacology with behavioural, psychosocial and educational interventions • Behavioural interventions & CBT • Lifestyle changes • Exercise, diet, sleep • Pharmacology • methylphenidate (Ritalin) Reduces hyperactivity, impulsivity and mood lability Side effects: insomnia, loss of appetite, weight loss • Nursing considerations for medication: monitor for appetite supression/growth delays, after meals, full drug effect can take 2 days • Antidepressant second line of treatment
Risk Management Identification involves?
• Observations • Threats • Themes in conversations • Actions • Past history • Conversations with carers • Information provided by services • Thorough & frequent mental state exam
Second part of MSE: Observations, Psychomotor Activity & Attitude
• Observe clients behaviour and their degree of arousal - Type & amount of movement - mannerisms and gestures (tics, grimacing, tremors) - Hostility, anger, agitation - verbal or physical abuse - Psychomotor retardation - Social skills - positive or unpleasant habits (shy, withdrawn, overfamiliar etc.) - Evidence of bizarre behaviours - Degree of cooperation with interview
Asperger's Clinical Presentation
• Obsessive interest in objects such as trains, dinosaurs, Dora The Explorer etc • Obsessive interest in the mechanics of a certain object (vacuum cleaner, DVD player etc) they become experts on the item • Obsessive interest in knowledge of a particular interest (all the AFL footy stats, makes and models of cars etc) • They will continually converse about their obsession • Often speak in monotone voice, little infliction, they may be loud all the time - not able to discern when to moderate their voice
Twelfth part of MSE: Sensorium & Cognition
• Organic brain functioning and IQ • Insight - Ability to understand the reasons for & meanings of behaviour, feelings - Capacity to gain an understanding of something • Judgement - Ability to understand consequences of actions = to use previous learning in new situations • Concentration • Serial 7's or 3's • Cognition • Issues with consciousness usually involve organic brain impatient • Orientation (T,P,P) • Memory (remote, recent‐past, recent & immediate) • Abstract & concrete thinking • Four Patients with Schizophrenia
Recovery Star
• Outcome Properties • • Planning, quantifying and describing their progress • • Identification of organisations and service providers to capture, • measure and summarise change • • Key working properties • • Written information, visual maps of where they are in their • recovery process • • Plotting progress • • Plan actions required to meet recovery goals • • Collaboration with key workers
ADHD Client/family education
• Parent programmes • Focus on child's strengths - as well as problems • Balance praise and correcting behaviour • Emphasise the need for structure in routines and behavioural expectations
Treatment of Asperger's
• Parent training and support • Social skills training • Cognitive behaviour therapy • Speech therapy • Occupational and/or physical therapy • Medication
When a Patient Does not Give Consent to Treatment (s.71)
• Patient may not have capacity to give consent or has capacity but has refused informed consent • AP may make treatment decision (exc. ECT & psychosurgery) for pt. if there is no less restrictive avenue for treatment • AP must take into account: - Patients views & preferences - Advanced statement - Views of nominated person - Views of guardian - Views of carer (if they will be directly affected) - Views of parent if patient is under 16 - Likely consequences if treatment is not performed - Any second opinion
Historical context of substance mood
• People with co‐morbidity have had poor treatment from both psychiatric and Drug & alcohol treatment systems. • Right to treatment • Large amount of Negative Outcomes related to DD that, may be avoidable: Dependence on alcohol/drugs has medical risks for the Individual. The state of intoxication or withdrawal poses medical risks that if not treated properly can result in significant distress, injury and even death to the individual. It needs to be treated like other medical conditions. However due to stigma associated with dependence it is often treated as only moral/legal issue.
Ethical Issues: Advanced Statement
• Permits a person to communicate their preferences for treatment in event they become unwell • Should be written when they are well • MHA dictates these wishes should be taken into consideration but ultimately they do not need to be followed.... • Is this ok?
Bodily Restraint (s.113)
• Physical restraint • The application of devices such as harness, belts, sheets, straps to restrict movement • Prevent imminent and serious harm to self or others • For the purpose of medical treatment • Must be approved by AP (senior nurse in emergency) • Continuously observed (1:1 special) and reviewed every 15 minutes by nurse • Examined by AP or MO every 4/24 • Food, toilet, clothing, water • Restrictive interventions observations register
Recovery includes accepting, overcoming:
• Physiological effects of mental illness • Trauma associated with acuity of illness, hospitalisation • Attitudes of others - family, friends, colleagues, self • Loss of positive identity in society • Lack of enriching opportunities • Stigma/discrimination • How does/can stigma influence recovery?
What impacts negatively on recovery?
• Physiological effects of mental illness • Trauma associated with acuity of illness, hospitalisation • Attitudes of others - family, friends, colleagues, self • Loss of positive identity in society • Lack of enriching opportunities • Stigma/discrimination • How does/can stigma influence recovery?
A Person is not Deemed Mentally Ill Because of
• Political or religious beliefs and/or activities • Sexual preference, gender identity or sexual orientation • Sexual promiscuity • Immoral conduct • Antisocial behaviour • ID • Use of A&OD • Economic or social status or racial group • Involvement in family conflict • Previous treatment for mental illness
Indications for Considering Changing Antipsychotics
• Poor treatment response - Acute illness relapse in spite of adherence - Persisting & impairing positive or negative symptoms - Persisting & impairing mood or cognitive symptoms - Little or no improvement in psychosocial functioning - Relapse or clinical instability due to poor adherence in otherwise treatment‐responsive patient (suggests LAI) - Ongoing high suicide risk despite otherwise adequate antipsychotic therapy (?Clozapine) • Intolerable adverse effects - Severe effects leading to threatened or actual non‐adherence - Aggravation of general medical condition by antipsychotic agent - adverse‐ effect burden clearly increased as a result of specific drug/drug interactions • Request of patient/carers
Negative & Positive (Productive) Symptoms
• Positive Symptoms - Best described as 'excess' of, or additional symptoms/afflictions/experiences - Positive does not mean 'good' - not a literal interpretation - Respond well to unconventional/atypical antipsychotics • Negative Symptoms - Best described as a 'removal' or withdrawal of normal everyday functioning - Negative symptoms are the relative absence of normal patterns of behaviour involving emotional responsiveness, spontaneous speech & volition - Respond poorly to typical/conventional antipsychotics
Serotonin Syndrome
• Potentially fatal (mortality 2‐12%) • Care with titration of AD's when changing • Serotonergic agents such as all other AD's, pethidine, tramadol, LSD, busiprone, amphetamines, cocaine, ecstasy, lithium & St John's wort can all cause this syndrome
Gathering Information for the MSE:
• Presenting data - Negative/positive recent life events? • Socioeconomic • Sexual history CDC's Guide to Taking a Sexual Health History • A&OD history National Guidelines for Alcohol Consumption • Medical history • Psychiatric history • Family history • Forensic history • Work history • Values, spirituality, religious • History from family (if applicable) & previous admissions
Stages of change & readiness
• Pre‐contemplation • Contemplation • Preparation • Action • Maintenance stage
Models of health carein mentalhealth
• Primary healthcare model • Recovery model - Hope, optimism,self‐determination, empowerment, support people to live life to the full • Biomedical model - Stabilise and discharge.... (maintain)
substance abuse: Manifestations of Dual Diagnosis
• Primary mental illness with subsequent substance misuse • Primary substance misuse with psychopathologic sequalae (A pathological condition resulting from a disease.) • Dual primary diagnosis • A common aetilogy
Why do we need to know about and work in partnerships?
• Professional competency standards: • (6) Plans nursing care in consultation with individuals/groups, significant others and the interdisciplinary health care team • (10) Collaborates with the interdisciplinary health care team to provide comprehensive nursing care • Partnerships are key to capacity building: processes that infrastructure, program development and problem solving (the invisible hand of health promotion)
Example of Typical Presentation Pattern - Schizoaffective Disorder
• Pronounced auditory hallucinations and persecutory delusions for 2 months before onset of prominent major depressive episode • Psychotic symptoms and major depressive episode are present for 3 months • Individual recovers completely from MD episode, but psychotic symptoms persist for another month before they too disappear • During this period of illness individual's symptoms concurrently met criteria for a MD episode & criterion A for schizophrenia and delusions and hallucinations were present both before and after depressive phase. • Total period of illness lasts about 6 months - Psychotic symptoms alone first 2 months - Depressive & psychotic symptoms present during next 3 months - Psychotic symptoms alone 1 month
Recovery models in practice
• Provides an approach to both case management and rehabilitation • Departure from traditional deficit model of assessment • Founded on the environmental conception of human behaviour • Results in more focused and goal oriented behaviour • Promotes better community linkages and less dependence on hospital
Dual primary diagnosis
• Psychiatric and substance abuse diagnoses exacerbate each other • A common aetilogy • One common factor that causes both disorders • Genetic • A defect in dopaminergic function that predisposes people to: psychiatric conditions - schizophrenia • Dopamine antagonists ‐ amphetamines • Defect in cholinergic activity Affective disorders • Substance abuse affecting cholinergic pathways
Recovery
• Recovery enables people to address the experience of loss and grief that are major components of mental illness • Loss of employment • Loss of friends/family/support networks • Loss of identity • Loss of independence • Loss of control over destiny • Loss of confidence • Others?
Key Features of the VMHA (2014)
• Recovery framework - Establish a recovery ‐oriented framework & embed supported ‐decision making • Compulsory treatment orders - Minimise the use and duration of compulsory treatment • Safeguards - Increase safeguards to protect the rights & dignity of people with mental illness • Oversight & service improvement - Enhance oversight & encourage service improvement • Presumes capacity unless tested to suggest otherwise
Recovery : Contemporary Concepts of Mental Illness...
• Recovery is a non‐linear process • Treatment in the community is best‐practice • Practitioners acknowledge the need for balance between • reduction of symptoms with acceptable medication regimes • An inability to return to premorbid levels of functioning does not equate to failure
Early/Late Recovery
• Recovery is possible - holistic and inclusive • Involvement of family/carer • Cultural/personal identity • Partnerships - links to other service providers (housing, employment, education) • Some youth will be vulnerable to future exacerbations of mental illness, or may need more assistance with their recovery
Family trauma/loss/grief
• Relationship strain • Violence • Increased financial burden • Housing • Compliance & outcomes • Service access • Losses: intangible & uncertain • Loss is cyclic • No rituals or norms exist for these losses • Grief is disenfranchised • Grief often placed in abeyance.
Depression - Peripartum Onset
• Relatively common (affects ~10‐15% new mothers) • Consider impact of unplanned pregnancies, dysfunctional relationships etc., contributing • Prolonged, more serious version of baby blues • May present with over‐concern with infant • Can present with psychotic features (very rare, <1%) • Diagnostic criteria same as MDD • 50% of episodes actually begin prior to delivery • Symptoms usually occur within 12 weeks of birth & include: - Depressed more - Severe anxiety - Panic attacks - Weight gain/loss
Why do people use substances?
• Research provides a number of reasons that are given for why people use drugs. These include for pleasure, to manage aspects of living, increase a sense of belonging, to 'fit in', to maintain a physiological dependence: WHAT ARE SOME ADDITIONAL REASONS? • HOW DO DFFERENT THEORIES INFLUENCE THE WAY WE THINK ABOUT AND RESPOND TO DEPENDENCE? • NAME AS MANY TERMS AS YOU CAN THAT ARE USED TO DESCIBE PEOPLE WHO CONSUME PSYCHOACTOVE DRUGS
ATOD context
• Responding with immediacy and timeliness • Respecting taboo • Sensitivity to embarrassment
Restrictive Interventions (s.105‐116)
• Restrictive interventions may only be used after all reasonable and less restrictive options have been tried or considered and have found to be unsuitable • AP must ensure that after the use of restrictive intervention, the following persons in relation to the patient are notified of the restrictive intervention and the reason for using it: - The nominated person; - A guardian; - A carer (if AP is satisfied that the use of the restrictive intervention will affect the carer & care relationship) - A parent , if the person is under 16 years - Secretary to DHS is subject to a custodial order - Chief psychiatrist must receive a report
Mental Health Tribunal (MHT) and what do they do?:
• Review Treatment Orders • Revoke TTO & TO • Determine transfer of compulsory patients to other facilities • Applications for ECT without consent • ECT for all <18's • Applications for neurosurgery • Review applications for court secure treatment • Make TO
Risk & Preventative Factors of resilience
• Risk factors contribute to a person's vulnerability to develop, exacerbate or relapse mental illness • Risk factors increase the likelihood that the disorder will develop • Protective factors provide resilience in the face of adversity • Protective factors can moderate the impact of stress & symptoms on holistic parts of a consumers life reducing the likelihood of developing, exacerbating or relapsing mental illness
Risk & Preventative Factors
• Risk factors contribute to a person's vulnerability to develop, exacerbate or relapse mental illness • Risk factors increase the likelihood that the disorder will develop • Protective factors provide resilience in the face of adversity • Protective factors can moderate the impact of stress & symptoms on holistic parts of a consumers life ----->reducing the likelihood of developing, exacerbating or relapsing mental illness
Depression Assessment
• Risk: - Self - Others - Vulnerability - Spending • MSE • Physical Assessment - Nutrition - Sleep - Elimination • Psychoeducation - Understanding of illness, mx
Assessment for psychosis
• Risk: - Self - Others - Vulnerability etc. • MSE • Physical Assessment - Nutrition - Sleep • Psychoeducation - Understanding of illness, mx
Nominated Persons (s.23‐27)
• Role of the nominated person is: - Provide support to patient & represent their interests - Receive information about the patient - Be consulted about treatment - Assist patient to exercise their rights • NP 1
Schizophrenia: Myths & Facts
• Schizophrenia is 10 times more common than AIDS, SIDS & melanoma COMBINED and costs $2.5 billion/year • About 10% of individuals will commit suicide - 12 times the national average • About 25% will have 1‐2 episodes & recover completely • About 50% will have more episodes, will need ongoing medication, but experience reasonable quality of life • About 25% will suffer chronically, experience frequent hospitalisation and treatment resistance • History of cannabis misuse is more common in patients who have schizophrenia than in general population • "Based on incidence of First Episode Psychosis per year in Australia, and assuming treatment was universally applied & maintained over the 'critical period' of five years after the first episode, it has been estimated that the next present value of savings for each year's cohort...would be $212.5 million" Suffers have a 20% decrease in life span due to cardiovascular disease • Schizophrenia is associated with increased mortality from all infectious diseases, including pneumonia & influenza • Increased risks of: - Metabolic syndrome - Smoking (and associated risks) - Poverty - Poor nutrition - Reduced access to medical care • Whilst suffers don't have higher rates of cancers, they are more likely to present with metastases at diagnosis & experience higher fatality rates • Perception that those with schizophrenia are less competent in decision making despite research to indicate that they have adequate competency in decision‐making unless psychotic • Individuals with schizophrenia will die on average 15 years younger than the general population
Dually Diagnosed Individuals Reasons to Misuse Substances
• Self medication of psychiatric symptomatology • Side effect reduction of psychotropic medications • Facilitation of social interactions • Participation in certain subcultures • To develop an identity more acceptable than that of a person with a mental illness • To help cope with the disabilities of mental illness including isolation, poverty, lack of affordable housing, and social drift • To improve unpleasant moods (anxiety & depression)
Alcohol withdrawal syndrome
• Set of symptoms observed in a person who ceases drinking alcohol following continuous & heavy consumption • Typically occurs with 6‐24 hours after an individual's last drink • Withdrawal is also recognised for the following groups of substances, opioids, amphetamines, cocaine, sedatives, anxiolytics, nicotine, hypnotics (APA, 2000) • The dose and duration of intake impacts on withdrawal • Severe alcohol withdrawal potentially life threatening • Most people do not experience al symptoms and course is usually several days. However a percentage of people do experience more severe symptoms
Advanced Statement (s.18‐22)
• Sets out individual preferences in relation to treatment in the event they become a MH patient • Effective from the time it is made • Can be made any time & must: - Be in writing - Signed & dated by the person - Witnessed by an authorised witness • Treating team must take note if person has an AS & make reasonable efforts to enforce patients recommendations • In the even they do not, they must notify the patient in writing
Disorders diagnosed in infancy/ early childhood
• Sleep, feeding and eating disorders • Pervasive developmental disorders • Relationship problems/attachment disorders • Anxiety disorders • Motor skill disorders • Attention deficit hyperactivity disorder/ attention deficit disorder • Pica - persistent ingestion of non-nutritive substances (paint, rocks, hair, soil) • Seen in children with intellectual disabilities • Rumination disorder - repeated regurgitation and re-chewing of food • Feeding disorder - failure to eat adequately • Tic disorders (Tourettes, chronic motor or tic disorders) - a sudden, rapid, recurrent, non rhythmic sound or movement • Separation anxiety disorder
Psychoactive effects of cannabis:
• Some CNS depressant qualities and Hallucinogenic qualities at higher doses. • People experience distortion od time, distance and some sensory input • Recent research indicates/suggests that cannabis causes psychosis & schizophrenia in vulnerable people (Lynch, Rabin & George 2012, cited in Hungerford et al, 2015) • Associated with depression • Can lead to mild cognitive impairment, reduced sperm count in males, respiratory diseases and some cancers
Theories about dependence?
• Some people see dependence as a disease • Social learning model • Public Health Model • Psychological theories
Limitations of the recivery star
• Some suggestions it needs to be more spiritually centred • Practitioner reluctance to change! • "Doing with" as opposed to "doing to or for" consumers • Only works well in recovery‐focused organisations • Time/cost in retraining staff • Not scientifically tested/measured
Fith part of MSE: Speech
• Speech patterns are described with regards to the rate of production, quantity of information, quality and volume - Rapid, slow, pressured, hesitant, emotional, talkative, garrulous/loquacious, dramatic, monotonous, loud, whispered, slurred, staccato, spontaneous or mumbled • Common terms are: - Pressured speech, poverty of speech, disorganised speech, latency of speech Quantity of Speech • Poverty of speech - Client uses few words • Poverty of content - Lack of substance in conversation • Voluminous - Uses too many words Quality of Speech • Articulate - Well spoken, uses appropriate language • Congruent - Content makes sense, is easily understood and relevant • Monotonous - Monotone, no infliction • Talkative • Repetitious • Spontaneous - Conversation flows, without prompting • Confabulation • Unconscious replacement of fact with imagined or false experiences. Client believes this to be true but it has no basis in reality. • Disorganised • Speech is unstructured • Example of disorganised speech
Strategies to Reduce Restrictive Interventions
• Staff skills - Characteristics of effective de ‐escalators (eg., confidence, articulation/coherence & showing genuine concern) - Maintaining personal control (including paralinguistics) • Process of intervention - Engaging with client - Deciding when to intervene - Ensuring safe conditions for attempting de‐escalation - Implementation of de‐escalation strategies • Observations and prompt limit setting • ? PRN Medication - No real evidence base to suggest PRN mx are effective although they are routinely used - "The use of PRN medications is based upon clinical experience and habit rather than empirical evidence and clear guidelines." - "Although PRN medications are frequently used, this practice is not evidence‐based and has the potential to do harm"
Goal of harm minimisation:
• Strategies that aim to minimise harm form AOD. Includes abstinence & harm reduction strategies. • Reduce the harmful effects of drugs on individuals and on society. • Harm minimisation has three components (pillars): harm reduction, supply reduction and demand reduction. • 'fourth pillar' - law enforcement
Managing the Prodrome
• Studies have indicated that: - Combined antipsychotic (risperidone) & individual psychotherapy - Antipsychotic therapy alone (olanzapine) - Psychotherapy (CBT) alone - All showed delayed onset psychotic symptoms in prodromal stages • This was not without risk - Weight gain - Other side effects - Would the individual have developed a psychotic illness...?
Substance Related & Addictive Disorders (DSM‐5)
• Substance Use Disorders/Substance Induced Disorders • Alcohol Related Disorders • Caffeine Related Disorders • Cannabis Related Disorders • Hallucinogen Related Disorders • Inhalant Related Disorders • Opioid Related Disorders • Sedative, Hypnotic or Anxiolytic Related Disorders • Stimulant Related Disorders • Tobacco Related Disorders • Other (or unknown) Substance Related Disorders • Non‐Substance Related Disorders
Co‐Morbidity in BPAD
• Substance misuse - Triggering, exacerbating & 'treating symptoms' of BPAD • Anxiety disorders - PTSD - Social phobia • ADHD - Share symptoms such as restlessness, concentration issues & distractibility • Eating disorders - Approx. 14% of BPADII have at least one eating disorder (often binge eating disorder)
Suicide facts and stats
• Suicide is responsible for over 800,000 deaths globally per annum - 75% of these deaths from low‐and middle‐income countries - Accounts for 1.4% all deaths (15th leading cause of death) - In Australia at least 6 Australians die and 30 others attempt suicide daily • Approx. 90% of individuals who commit suicide meet criteria for one DSM disorder • 35‐44 year olds (ā = 43.8) have highest suicide rates (males & female) • About 1.7% of all registered deaths in Australia are attributed to suicide (2012) • 2,535 Australian's died to suicide in 2012 • 75% of all deaths to suicide are male
Family
• Support & education • Information & assistance • Referral • Support groups • Children • Homelessness
Autistim spectrum Disorder
• Symptoms vary considerably, from • Non-verbal, intellectually impaired, challenging behaviours, egocentric self absorption to, • Bright, engaging, verbally responsive • Individuals are affected by various degrees of impairment
Recovery Oriented Services
• The Fourth National Mental Health Plan 2009 - 2014 includes a priority area focused on 'Social Inclusion and Recovery' • •Focuses on service delivery that adopts a recovery‐oriented culture to achieve health, social inclusion and well‐being outcomes for consumers
Interview Success for MSE:
• The MSE will be more successful if you: - Respect the client - Choose the environment - Set goals - Avoid negative personal judgements - Tune into non verbal cues - Be mindful of your responses - Adopt a conversational approach - Cognizant of your non‐verbal commination skills(eye contact, active listening)
Research into recovery "The slow demise of incurability"
• The Scottish Recovery Network (2004) • Narrative research with service users: factors that helped and hindered recovery: • Building a good base for recovery • Believing recovery is possible • Being in control of your own recovery • Looking for the positives in life • Finding the right support & Rx • Keeping busy/finding meaning & purpose • It's a personal thing • Kidd, Kenny & McKinstry (2015) • Meaning of recovery‐ oriented care for people with psychosocial disability associated with mental illness Regional mental health service (Australia) - six consumers, one carer and four clinicians. Overarching theme: "I want people to hear me" (Kidd et al. 2015) Interconnecting themes that led to overarching theme: 1.Recovery values and the service model 2.Clinical services have a significant impact 3.A particular kind of communication 4.Involuntary treatment 5.Worker self awareness 6.Addressing systemic issues
Why Don't They Just Stop When They Start to Suffer Negative Consequences.....?
• The reward pathway is intimately connected, via neural pathways, to our judgement and emotional areas (via projections to the prefrontal cortex and limbic system) • The brain begins to treat the chemical as necessary for homeostasis and thus survival • The client may be logically aware they do not 'need' the drug, but survival drives tend to take precedence over logic and judgement • Continued substance use slowly take 'survival precedence' over life goals, self esteem, relationships, stability, safety and health
First part of MSE: General Appearance
• This is our first impression of the client: - Grooming (state of clothing) - Weight - Clothing (appropriateness non judgemental) - Posture - Malodorous? - Age: do they appear older/younger then their stated years? - Tattoos, nose rings etc. - Glasses, hearing aids etc. • Why is this information important?
Ethical Issues in MH
• Those experiencing mental illnesses are vulnerable and politically powerless • May find autonomy difficult • Safeguards exist to counter this in MHA • Nurses with be faced with issues around ethical decision making - Will be faced with challenge of making decisions vs. ensuring consumer autonomy & choice • Nurses role in advocating
Contraindications to Changing Antipsychotics
• Those who have recently recovered from an acute psychotic episode and are taking antipsychotic drug that was clearly beneficial during acute‐ phase treatment • Those who are currently stable on LAI antipsychotic but have a history of clinical instability before using LAI agents resulting from poor adherence to PO antipsychotics • Those who are presently stable with a clear positive response to antipsychotic treatment but have a history of violence, self‐harm, severe symptoms, or profound self‐neglect during acute psychotic episodes
Reasons to Misuse Drugs
• To feel euphoric or to feel nothing • To feel more confident • To work longer hours or enhance performance • To belong to a social group (peer pressure) • To kill time (alleviate boredom) • To alleviate physical pain and other health problems • Because it is a habit • To satisfy cravings and avoid withdrawal symptoms • For weight loss • To experience an altered state of consciousness • To unwind after a stressful day • To socialise with friends or meet people....
Continuing Care
• To promote wellness & prevent relapse • Treatments & ongoing care will obviously differ between individuals • Involvement family/carer
How did we get to a recovery model of health care?
• Traditionally, mental illness is degenerative, life long and permanently disabling • A perception that a diagnosis of mental illness does not correlate with successful, independent living. Consumers are passive in care • Medication is the focus of recovery • The concept of recovery originated from addiction concepts • Alcoholics Anonymous (1935) marks the beginning of modern addiction recovery • The recovery movement - late 1980s . More recently, MH services have seen a move to recovery‐oriented approaches to treatment • The consumer movement within the recovery model provides us with an understanding that the consumer is the 'expert' of themselves, and define their recovery • Family/carer involvement and participation are vital to enhance consumer outcomes
Recovery oriented services
• Uphold hope for the consumer • Understand and allow for individualised recovery • Engage consumers in an active sense of self • Protects the rights of service users • Understands and supports family perspectives • A nurse must have self‐awareness and respectful communication skills • n the context of mental illness, recovery is dependant on clinical care, but means more than the absence of symptoms
How Do We Ask About Substance Abuse?
• Use appropriate, meaningful language that's understandable to the individuals educational level • Ask in a non‐judgemental way • Don't 'react' or appear shocked • Be direct • How long have you been using .............? • How often do you use it? • How much do you use per day? • Why do you use the substance? • How do you feel when you take it? • How do you feel when you can't get it? • How do you pay for it? • Empathise It must be very stressful for you when your desperate for another 'hit' • Have you ever tried to stop? How long? What happened? • Have you ever felt that you should cut down?
Use of Restraint & Seclusion
• Use of 'chemical restraint' in ED & MHU - Is it for the provision of care (improving the underlying condition) OR - Behavioural modification? • Consider why you are sedating/medicating a patient...is it for them, for staff or other patients? - Is this a good enough reason? • Symptom amelioration is not the principal focus of strengths recovery models of MH care - Fine balance between symptom amelioration & unwanted side effects resulting in non adherence to all forms of treatment
Electroconvulsive Therapy
• Used to treat MDD, BPAD, Schizophrenia • 2‐3 sessions/week for a total of 6‐12 sessions • Very effective in treatment resistive MDD & ~90% of patients using it experience improvement • Use GA • Induced seizure 70‐150 volts via electrodes (bilaterally, one on each side; unilaterally, both on one side) • Seizure lasts ~30‐60 seconds • Side effects: - Transient short term memory loss - Headache - Confusion - Nausea - Muscle aches • Legalities as per MHA (2014)
Sixth part of MSE: Perception
• Virtual Hallucinations • When assessing perception, you are looking for the presence of hallucinations and illusions • Hallucination - A false sensory perception not involving real external stimuli - Hallucinations involve the senses (auditory, gustatory, visual, olfactory, tactile, somatic & kinaesthetic) - It is important to empathise with the patient how distressing this must be, and validate their feelings without concurring their basis in reality • Illusions - A misinterpretation or misperception of a real, external stimuli. - Occurs in alcohol withdrawal • Depersonalisation - A feeling that you are not 'yourself' - Being an observer to one's own body • Derealisation - Unreality or detachment to surroundings/environment - Others or surroundings may be seen as 'foggy' or 'dreamlike'
Recovery Works When...
• We align people with the right help at the right time for however long they need it • Refrain from judgement - give equal help regardless of who the individual is • Adopt a holistic approach • MHW treat individuals with respect, dignity & equity • Advocate consumers to take on competent roles • Protect rights • MHW provide support only when necessary • Encourage consumer to use services and supports and how to access these • Are staffed by workers who support these core values
Eighth part of MSE: Thought Content
• What is the focus of their conversation? • Expressed ideas: - Themes (religious, paranoid, persecutory) - Risk of harm (to self, others), antisocial thoughts, fantasies or urges - Phobias (excessive or irrational fears) - Preoccupations (with illness, symptoms) - Obsessions (repetitive, intrusive thoughts, images or impulses) - Delusions (discussed further)
General principles related to managing R‐OH withdrawal symptoms?
• assessment and early recognition • monitoring, documenting and reporting • preventing withdrawal complications where possible • minimising progression to severe withdrawal • decreasing risks of any injury to self/others • eliminating any risk of dehydration, electrolyte or nutritional imbalance • reducing any risk of seizures • identifying concurrent illness that masks/mimic or complicate withdrawal • providing supportive care • preparing for discharge after‐care and referral as desired.
