Psych/Mental Nursing Final

Goals During Behavioral Crises (therapeutic goals)

Therapeutic Goals: -everyone remains safe -arousal is reduced to manageable levels -pt is able to use internal & external resources to de-escalate him/herself further -likelihood of recurrence is reduced

-Relational dysfunction—counseling, teaching significant others about PTSD -Safety risks: suicide, aggressive acting out—monitoring as needed. Prevent access to weapons -Inderal (propranolol) may reduce risk of developing PTSD in trauma survivors -Doxycycline may reduce formation of fear & neg thoughts -The antihypertensive Clonidine reduces nightmares, hypervigilance, startle reactions, and outbursts of rage -Ketamine showing promise -Antidepressants, antianxiety agents are helpful for those issues -Trauma-focused cognitive behavioral therapy

Therapy dogs esp. for military PTSD applications -act like seeing-eye dogs, trained to watch for danger. -For pts who are beginning to show a fight or flight response when no danger is actually present, the dog can place a gentle paw on the foot or curl around the legs, reminds pt that "everything is safe here". -The soldier can also direct the dog by commanding "block me," "watch me," or "pop a corner," (check around the corner for threats) and the dog will do an appropriate check to reassure the soldier. The dogs cost about $25,000 each to train.

Treatment & Nursing Care: Bulimia

There is a high frequency of depressive symptoms and anxiety; treatment of these can improve the bulimia Individuals who purge are more likely to have medical complications (dental caries, esophagitis, etc) Combination of cognitive behavioral therapy and antidepressant medication has demonstrated efficacy Helpful: Counseling r/t stress, teaching and promoting more effective coping Lisdexamfetamine (LDX, Vyvanse), a stimulant, approved for binge eating disorder, may be helpful for bulimia

Vortioxetine (Brintellix)

a multimodal antidepressant that inhibits serotonin reuptake, modulates serotonin (5-HT) receptor activity and inhibits 5-HT reuptake, Side effects are similar to those of SSRIs generally but with an increased incidence of GI distress (nausea, vomiting, constipation). Abusable drug

Deep Brain Stimulation

akin to vagal stimulation except electrodes are typically implanted in anterior cingulate, used when other treatments fail

Involuntary/Forced Medication

1.Being "probated" or involuntarily admitted via "pink slip" only provides for the person's detention and evaluation; the person can still refuse treatment once hospitalized, e.g. refuse medication (exception: one-time doses in behavioral emergencies, e.g. for sedation).

A Downside to Deinstitutionalization

Economic & political issues led to planned outpt services never being fully developed or funded. Staff turnover and insufficient staffing disrupt care. The result has been that patients often have long waits to access needed services. Due to access issues, rural persons are also typically underserved, though technology (e.g. video appoint-ments over the internet) can help address this. The readmission rate for state hospital admissions has risen (from 25%/yr in 1960 to 65%/yr today) d/t premature discharge, inadequate community services, inadequate service coordination and handoffs, non-adherence, etc.

During the ECT

•Bilateral or unilateral (most common, less memory impairment) electrode placement produces seizure lasts 25-60 seconds •Continue mechanical ventilation

Cannabis (Marijuana)

•Binds with an opioid receptor in the brain to block dopamine reuptake (may contribute to increased risk of psychosis in vulnerable persons) •Produces a euphoric sense of calm, increased social comfort •Impairs the ability to form memories, recall events, and shift attention from one thing to another •Blunts responsiveness to one's environment, impairs judgment and responsiveness •Long-term marijuana use produces amotivational syndrome, memory impairment •Can be stored for weeks in fat tissue and in the brain •Can contribute to respiratory disease

Amphetamines

•Block reuptake of norepinephrine and dopamine, not as strong effect on serotonin as cocaine has •Affect the peripheral nervous system

Developmental

•Borderline PD is strongly associated with profoundly ineffective/inconsistent parenting (esp. r/t individuation-separation issues) and emotional and other abuse during early childhood, (80%+) •Antisocial also often have significant abuse histories (some profoundly so) •Family dysfunction (impaired reasoning, irrational expectations and requirements, substance abuse, impaired boundaries, etc) are linked to PD's in general

Alcohol

•CNS depressant and euphoriant •Legal Intoxication is determined by the level of alcohol in the blood (blood alcohol level) but neurobehavioral manifestations vary with the degree of physiological tolerance •Excessive or long-term alcohol abuse can harm any and all body systems •Patterns of alcohol abuse vary •Prenatal use can cause Fetal Alcohol Syndrome (FAS)

Intoxication:

•CNS stimulation followed by depression (crash) •Increasing doses: restlessness ® tremors and agitation ® convulsions ® CNS depression

A Word About False Memories

•Children do not usually lie spontaneously about abuse unless the clinician somehow enables this. •Only skilled/certified interrogators should be questioning the child after abuse becomes suspected, and interrogation should be videorecorded. •False memories are more likely if interrogation includes leading questions or the patient senses that certain responses are expected (reinforcement by interrogator). •Memory tends to distort over time; early, detailed, objective recording of patient reports is key. •Some adults do develop false memories, and such reports have sometimes harmed innocent persons •"Eye witness" testimony is less reliable than believed; very prone to distortion, contamination.

Why Do They Leave?

•Concern for the children •Come to believe they can leave—that it's an option, that they can be safe; they develop confidence and/or decrease dependence •Support from others becomes available •Other resources become available: shelters or other safe housing, finances, transportation, a job •"Awakening" phenomena results in readiness

When Mental Illness Causes Crime

•Consider a situation wherein a person commits a crime due to a mental illness, and would not have committed that crime were it not for the mental illness. -Should that person be treated in the same manner as those who committed a crime for other reasons? -Should the mentally ill person be incarcerated as criminals are, or treated for the illness that cause the crime? •An accused may plead Not Guilty by Reason of Insanity (NGRI). This is commonly referred to as the "Insanity Defense". Less than 2% of defendants plead NGRI; most are instead found guilty. •Persons found NGRI are usually involuntarily hospitalized (or court-mandated to participate in outpt tx) and may be held much longer than if they had been convicted of the crime.

Cluster B—behavior that is erratic, dramatic, and emotional

•Histrionic—attention-seeking and overly emotional •Narcissistic—self-centered, heightened self perception, needy re admiration of others •Antisocial—disregards/violates rights of others •Borderline—unstable relationships, affect, and identity; impulsive & erratic

Cocaine medications

•METHYLPHENIDATE (ritalin) may aid self-control and reduce craving (but is abusable) •GABAPENTIN (Neurontin) may reduce tension, cravings •VIGABATRIN (Sabril) increases GABA and reduces craving •BACLOFEN (Gablofen; Lioresal) reduces cravings •N-ACETYLCYSTEINE (NAC) seems to improve glutamate levels and reduce craving •TOPIRAMATE—decreases cocaine use •NOCAINE (experimental) mimics effects of cocaine but at a weaker level while blocking the effects of cocaine itself; substitutes for cocaine while enabling users to gradually & safely decrease use

Hallucinogens

•More than 100 different hallucinogens, e.g.: Psilocybin (mushroom) D-lysergic acid diethylamide (LSD) Mescaline Numerous amphetamine derivatives •Produce euphoria (or dysphoria), altered body image, distorted or sharpened visual and auditory perception, confusion, incoordination, perception of enhanced spirituality, dissociative effects in some cases, and impaired judgment and memory

Interventions for Child Abuse

•Mostly are same as for survivors of domestic violence except done in child-friendly manner and environment (e.g. special room child friendly furnishings) •Increased emphasis on counseling •Stuffed animals can comfort children •Even a SUSPICION requires reporting—proof or evidence is not needed (providers are protected)

Cocaine Withdrawal:

•Norepinephrine depletion causes person to sleep 12-18 hours •Then, sleep disturbances with rebound REM, lethargy, decreased libido, depression, suicidality, anhedonia, poor concentration and cocaine craving

Children

•Not often diagnosed in childhood, typically begins in adolescence •Menstrual-related problems usually one of first presentations

Treatment for the Person with a Dual Diagnosis (SAMI)

•Now: integrated treatment model (treat both at once in the same setting); is EBP. Main steps: -Engage -Persuade -Actively treat -Provide relapse prevention interventions -Often: provide intensive case management—monitor pt, link to services, support

SNRIs

•These include desvenlafaxine, duloxetine, and venlafaxine •Side effects include those for SSRI's plus: •nausea •dizziness •sweating •sexual dysfunction •Tiredness •Constipation •Insomnia •Anxiety •Headache •loss of appetite •

Buprenorphine/Naloxone (Suboxone, Zubsolv [sublingual])—

•naloxone blocks effect if med is crushed or ingested at higher doses in attempt to produce euphoria. STRIPS SOLD IN JAILS

Avoidant

•socially inhibited and uncomfortable •low self-esteem—feels socially unappealing & inadequate, avoids risk or new situations due to potential for embarrassment •fears shame, humiliation and rejection •requires clear and unwavering acceptance and approval from others to be comfortable •avoidant of social and vocational situations where they might be subject to criticism or evaluation

Mental Illness in Jails and Prisons

*Crimes committed by mentally ill persons are usually minor, rarely violent, and very, very rarely involve murder *Many persons who are mentally ill do not plead NGRI and are instead incarcerated *16% of all inmates self-reported current mental illness or a recent overnight stay in a mental hospital; another 14% had received mental health services in past *Los Angeles County Jail is the largest de facto mental institution in the US, with approximately 3,300 seriously mentally ill inmates on any given night *Suicide rates among mentally ill inmates are more than 100 times higher than the rate in the general population

Health Care system variables

-Chaotic or overly stimulating environment -Staff are disconfirming, judgmental or disapproving -Staff who are unduly fearful -Institutional rigidity -Ineffective limit setting -Insufficient staffing

•Sleep deprivation/sleep shifting

-Circadian rhythm "reset"; quick antidepressant effect in 60%

Pt Bill of Rights

-Necessary because of vulnerability to abuse and mistreatment due to power held by others -Universal Bill of Rights for Mental Health Patients -Ohio law requires that all patients who are admitted to psychiatric inpatient settings are given notification of their rights

Americans with Disabilities Act (ADA)

-Outlaws discrimination against individuals with disabilities -Protects people with mental disorders

Motivational Interviewing

-Underlying theory: Acceptance facilitates change -Accept that ambivalence is normal -Five principles motivate change: •Express empathy •Develop discrepancy—help pt see contradictions in behavior, how actions interfere with goals •Avoid arguments—be neutral, matter-of-fact •"Roll" with resistance •Support self-efficacy

Assessment (indications for hospitalization)

-need for extensive diagnostic evaluation -Weight loss > 25% of body weight over 3 months -Dysrhythmia or pulse <40/minute or >100/minute -Temperature <97 F -BP <70 mm HG or marked orthostatic hypotension Potassium <2.5 mEq/L despite supplements Severe dehydration or vomiting of blood concurrent severe depression, psychosis or risk of suicide inadequate response to outpatient treatment

Non-Therapeutic or Unrealistic Expectations:

-patient will admit he/she's wrong, apologize -pts are restrained, secluded, or punished-can make situation worse there will not be any anger or conflict

Incompetence

1.A person who has a mental disorder or defect that results in impairment sufficient to make him unable to handle his own affairs can be found to be incompetent by a Probate Court. 2.Incompetence is only determined by a court (not by health care providers, though their eval is part of the process) & can be based on mental illness or on non-psychiatric causes such as dementia or TBI. 3.Involuntary commitment does not automatically prove incompetence; it requires a separate act by the Court. 4.A guardian (a relative, HC professional, attorney) is then appointed. It can be a guardian of the person or it can be a financial guardian

Ways to reduce/prevent incarceration of the mentally ill:

1.Adequately fund services, improve access 2.Provide adequate services and timely, coordinated care 3.Increase use of outpt commitment when needed 4.Educate police, prosecutors and judges so they can recognize and understand mental illness 5.Provide special courts to handle cases involving SPMI 6.Educate the public—reduce stigma, increase empathy 7.Improve adherence; relapse reduction programs

Nsg Interventions for Boundary Violations

1.Establish and maintain clear, consistent boundaries then role model them yourself (always maintain professional demeanor and behavior). 2.Give examples of possible boundary violations you anticipate could occur (e.g. sexual contact with other patients) to head these off. 3.Label boundary violations when they occur, and set/reinforce limits (supportively) as needed (ALWAYS offering acceptable alternatives the patient could use to meet his/her needs instead). 4.Teach and role-model effective ways of meeting one's needs without violating boundaries. 5.Point out social and other consequences for boundary violations (e.g. legal charges) and apply them consistently if the behavior repeats.

Clinicians in Ohio have four options and must choose one or more those which best provides for safety while minimizing impact on pt/pt's rights, such as right to privacy:

1.Hospitalize the pt so he cannot access intended victim(s) 2.Treat pt in a manner that removes the risk 3.Warn the intended victim(s) when identifiable 4.Notify police in victim and pt's area of residence &/or work of: (a) the nature of the threat; (b) the identity of person making the threat; and (c) the identity of each potential victim of the threat. Generally speaking, one chooses ONLY the action that provides for safety while still protecting the pt's privacy as much as possible. Taking one or more of these actions protects the clinician against liability and other legal actions.

Advocates for the mentally ill seek 4 primary changes:

1.Improve services and reduce obstacles to treatment to reduce untreated SMI in the community 2.Teach caregivers how to intervene effectively to promote and maintain pt stability and recovery 3.Train all first responders (police, EMS and ED staff) to recognize and respond helpfully to disabled persons 4.Improve MH services so that the first responders are MH professionals, or so that MH professionals accompany all first-responders to crisis situations

Biologic Responses to Alcohol

1.Increased GABA activity—causes relaxation, sedation 2.Acute: CNS depression and euphoria 3.Long-term: physiological tolerance and dependence 4.WERNICKE'S ENCEPHALOPATHY—alcohol causes gastric irritation, reduces absorption of B vitamins, interferes w/ conversion of thiamine into thiamine pyrophosphate (bioactive form of thiamine); Characterized by: acute onset; oculomotor dysfunction (bilateral abducens nerve palsy), ataxia, ptosis and confusion (may have any or all of these symptoms) Requires emergency treatment to prevent permanent damage (IV thiamine)

Nursing Interventions for Manipulation

1.Keep in mind that people may not even know when they are being manipulative. 2.Label manipulative behavior when you see it and point out that it doesn't work and will be ignored; then offer an alternative. 3.NOTE: Label repetitiveness, loudness, and intensity as being forms of manipulation. 4.Do not let people wear you down or provoke a punitive response; take a break or trade off working with them if necessary to prevent this. 5.Teach and role model other, more adaptive ways for pts to meet their (realistic) needs.

Special Considerations in Caring for the Person with Borderline PD

1.Objectivity is key— a.Self awareness b.Do not take it personally 2.Limit the number of staff working with pt to promote communication and consistency 3.Provide for stability in staffing (minimize turnover, assignment changes, etc) 4.Structure—predictable and stable routine 5.Consistency in all aspects of care (but not rigidity) 6.Anticipate and avert/reduce perceived rejection

NOTE:

1.Persons with unusual medical disorders that are not easily diagnosed may present with some of the same patterns/behaviors as noted above, yet have true illness. 2.Disorders vary in their presentation; sometimes all the usually expected symptoms aren't present, or they present atypically, and the true dx can be overlooked. 3.Providers must be careful not to assume that cases where the presentation is dramatic/intense or the diagnosis is unclear are due to psychiatric disorders; misdiagnosing a pt with a Somatic Symptom Disorder could delay needed treatment and lead to tragic outcomes.

Nursing Interventions for Splitting

1.Realize that splitting is an unconscious defense mechanism, not a chosen behavior. 2.Follow the guidelines for manipulative behavior. 3.Label splitting when it occurs; point it out, teach pt about it, process (explore it) and suggest alternatives. 4.If a patient idealizes or devalues another person, guide pt to understand that all people have positive and negative elements 5.Teach and role model more effective coping techniques, and particularly ways to deal with strong negative emotions (see "acting out"). Help the patient to understand that despite the intensity of the feeling, it will not in fact engulf or harm them, that they can cope with it, and that it will pass in time.

Nursing Interventions and Treatment Modalities

1.Tx priorities = safety, harm reduction, and relapse prevention 2.Assure self awareness and continually monitor self for countertransference—assure objectivity (though do not need to compromise your own values) 3.Administer prescribed meds & monitor response 4.Address cognitive deficits—cognition (esp. memory, judgment) can be impaired for up to 2 months—repetition of teaching, visual cues & reminders, handouts, etc. 5.Observe for and respond to risk of withdrawal and signs of withdrawal 6.Assure adequate nutrition and rest 7.Communicate the treatment plan to the patient and to others on the treatment team 8.Encourage recognition and honest expression of feelings 9.Listen to what the individual is really saying 10.Express caring for the individual, 11.Promote hopefulness, relapse happens, is normal, never give up 12.Hold the individual responsible for behavior: Provide consequences for negative behavior that are fair and consistent (and/or allow natural consequences)

Criteria for involuntary admission: Due to a mental illness* the pt is an imminent:

1.a substantial risk of physical harm to self, and/or 2.a substantial risk of physical harm to others, and/or 3.unable to meet basic physical & safety needs 4.a grave risk to the rights of self or others; e.g. kidnaps child or gives away all belongings *Note: involuntary admissions and the "pink slip" process apply only to mental illness and only authorize an emergency psychiatric evaluation; one cannot "pink slip" a person to force non-psychiatric (i.e. medical, substance abuse) care, and can forcibly medicate only in emergencies

EBP for Borderline PD; two main parts:

1.weekly 1:1 sessions focusing on a specific problem from the previous week, from what caused it to alternate solutions that could have been used to what kept the pt from a better solution (telephone calls between sessions are OK) 2.Weekly group sessions (2+hrs) focusing on interpersonal effectiveness, emotion regulation, mindfulness, self-acceptance and distress tolerance Targets: high risk behaviors (e.g. suicide), reducing behavior that interferes with therapy, and decreasing behavior that interferes with coping and quality of life

13.Talk about how specific actions contribute to negative responses in others, the costs of substance use vs the benefits 14.Guide pt to discover, use more adaptive ways of meeting needs, replacing what pt sees as benefits of using 15.Monitor for inappropriate behavior, e.g. encouraging substance use by others, bringing contraband into treatment setting, boundary violations, testing or violating limits 16.Cognitive and cognitive behavioral interventions to alter irrational/automatic thinking

17.Psychoeducation re: Harm-reduction strategies, relapse prevention; expect & plan for impaired memory 18.Group therapy = primary modality, EBP 19.12-step programs: AA, NA, AlAnon 20.For opiate addiction: Medication Assisted Treatment (MAT): supervised meds to replace opiates or to dull their effects, plus counseling and other services 21.Treat for related issues, e.g. loss, depression 22.Family therapy to increase understanding, counter co-dependence and enabling, reduce unhelpful responses 23.Cuyahoga Co drug court mandates intensive tx instead of jail, only 8% of those tx'd were rearrested (vs 27% in those not handled via drug court)

The 1980's to the Present

1980's—biological tx's dominate over psychological tx Medications steadily improve—more effective, fewer side effects 1990s: NIH, NAMI promoted "Decade of the Brain" nFocus is on treatment in the least restrictive setting Average LOS in non-state hospitals is down to 5-15 days Tx setting is largely determined by the payer source Criteria for hospitalization for mental illness shifts: Must be "medically necessary" in view of payer sources (not just felt to be needed by the pt or his MD) High/imminent risk of harm to self or others Substantial inability to care for self

Partial Hospitalization Programs (PHP's)—

2.the therapeutic programming typical of an inpt setting, pulled out and made available to outpts who do not need the 24/7 aspect and higher level of care provided by inpt mental health units. These are usually hospital-based & affiliated.

Sociological Causation of Eating Disorders

20-50% with bulimia and anorexia report history of sexual abuse Emphasis on slimness and athleticism Sociocultural value on Slimness Almost exclusive in developed countries

1.Approximately 5.5-6% of the US population has a severe and persistent mental illness (SPMI). 2.As treatment improved and community resources became available, pts who had been previously been hospitalized for months and years in large state hospitals began to be discharged in mass— deinstitutionalization. 3.The intent of deinstitutionalization was to improve care and provide more freedom for those with severe/persistent mental illnesses. 4.State hospital censuses dropped dramatically—beds in state hospital have been reduced by 90% since 1965. That trend continues. In some cases bed reductions have led to bed shortages (we eliminated too many)

5.To provide care in the community, the Community MH Act of 1963 mandated the creation of community mental health centers and other services 6.Most MH tertiary care for severe mental illness is now delivered via outpatient mental health centers, AKA Community Mental Health Centers (CMHC's). 7.Since 1963, about 700 community mental health centers have been created, along with many other services for SMI persons in the community. 8.However, the process went awry. The expected range and number of outpt programs that were to serve the newly discharged were never fully developed, and services have steadily eroded as funding has diminished (there is a consequence to cutting taxes). 9.Finding adequate services is now a challenge for many.

2.Psychiatric emergency centers (e.g. Coleman) or Psych ER's (e.g. St Vincent's) 3.Day programs—similar to PHP programs but typically part of community mental health centers. 4.Clubhouse or "drop-in" programs, featuring: a.Consumer-run programming b.Social support c.Vocational supports

6.Crisis programs, incl'g Mobile Crisis Teams that do emer-gency eval's and crisis intervention outside of institutions, and Crisis Residential Centers, which are short term, 24/7 care similar to a MH unit but crisis focused; can treat people earlier in relapse to prevent inpt care, or can serve as a outpt step-down unit so pts can leave inpt care sooner. 7.Police CIT (Crisis Intervention Teams), trained to recognize mental illness, de-escalate persons in distress, & intervene effectively in psychosis and psychiatric crises 8.Crisis (suicide) hotlines (professional or para-professional staff for emergencies) and 'warm-lines'(support, usually via peers/volunteers) 9.Residential services, including short-term and indefinite term group homes with varying degrees of staffing, board and care homes (akin to foster care for mentally ill

6.Set limits; to be therapeutic and to minimize potential "side effects", limits must: -involve reasonable and realistic expectations -be clearly, unambiguously stated -describe both what is undesirable behavior and what is acceptable -be interpreted and enforced consistently (but not rigidly) -Should be renegotiaed by the team (not individuals) if appropriate indications exist -be backed up with reasonable consequences (not punishment) made known in advance.

7.WORK AND MAKE DECISIONS AS A TEAM; keep all communications crystal clear and worded with precision. 8.Have clear guidelines for dealing with situations that aren't covered by the rules or limits, or for when it seems best to bend the rules (or revise the limits).

Cross tolerance:

: substances that are pharmacologically interchangeable in terms of how the body responds, e.g. alcohol and most benzodiazepines; i.e. if one develops tolerance to alcohol, he also has tolerance for benzodiazepines and would require a higher dose of the benzodiazepines to achieve their usual effect. We take advantage of this property to treat dependence, e.g. we replace alcohol with benzodiazepines and gradually reduce their dosage during medically supervised detoxification. Note: there may be limited cross tolerance between alcohol and narcotic analgesics

Alcohol abuse

> 1 of the following in a year: •Recurrent use in hazardous situations •Recurrent alcohol-related legal problems •Recurrent use and failure to meet role obligations •Continued use despite social or interpersonal problems

Alcohol dependence

> 3 of the following in a year: •Tolerance •Withdrawal •Increased time spent in alcohol related activities •Important activities given up or reduced •Drinking more or longer than desired •Persistent desire or unsuccessful efforts to cut down on alcohol use •Continued use despite knowledge of self harm

Case Management

A case manager helps locate services, links the patient with these services, and assists the pt in accessing services Can be provided by an individual or a team (ACT, PACT) Includes both face-to-face and telephone contact Contact with other service providers and caregivers

Continuum of Care

A continuum of care consists of an integrated system of settings, services, clinicians, and care levels, spanning illness-to-wellness states, in inpatient and outpt settings Provided over an extended or ongoing time Across multiple organizations and levels of care In theory: Maximizes range and coordination of care Examples: acute and long-term inpt mental health units; community mental health centers and the services they provide (e.g. case management, day programs, and medication management)

ECT Mechanism of Action

Affects multiple neurotransmitters releases hypothalamic and/or pituitary hormones Exerts a paradoxical anticonvulsant effect that results in an antidepressant effect

Powerlessness—I cannot change the illness, have little control over what my adult loved one does, sometimes cannot even get info from his care providers. NOTE re HIPAA: although you cannot share private health info about a pt without his permission, if a family says "my loved one has ________ (illness), what is it, what can we do to help, etc?" you CAN provide that info, so long as it is not specific to that individual pt. Isolation—stigma prevents sharing about the illness, using others for support Guilt—did I do something to cause the illness? etc

Anger—Why my child? Why am I burdened this way? Tension, CONFLICT during family contacts, gatherings; The conflict often arises as caregiver try to get the pt to do things that his illness is interfering with, e.g. hygiene, sobriety, helping with chores, finding and maintaining employment, and staying adherent with treatment Poor skills for addressing these issues causes conflict that can result in aggression towards caregivers Frustration with nonadherence, relapses &/or chronicity Loss of the child they once had, with resulting grief and chronic sorrow

patient's own responses

Another phenomena that can lead to further aggression is secondary gains: responses which are unplanned or unintentional, but which reinforce or encourage more of a particular behavior nonetheless. For example: 1.an angry pt throws a chair; other pts nod approvingly and the behavior is reinforced 2.a pt hits a peer who has been bullying him; staff smirk and comment that the peer got what he deserved. Both of these would tend to encourage more use of violence

Etiology

Biologic components •Genetic predisposition •Neurotransmitter variations & effects Psychological components •Temperament •Feelings about self •Environmental factors Social components •Family & other relationships •Peer pressure

Theories of Causation

Biological •Schizotypal, borderline and antisocial are more common among 1st degree relatives •Children who've been adopted tend to resemble their biological parents in terms of PD's (though less so than those who aren't adopted) •Some neurological "soft signs" (very subtle neuro changes) and neuro-structural deficits have been found in some PDs, e.g. Schizotypal

Tricyclic Antidepressants (TCA's)

Block reuptake of serotonin and NE as do SSRi's, but also block Ach receptors, causing more anticholinergic side effects and anticholinergic toxicity Blocks muscarinic, histamine, Alpha 1 receptors, Block Na channels in the heart and brain CARDIOTOXIC

ECT High risk with

CHF Severe pulmonary disease Severe osteoporosis Spinal disorders, weakness, trauma, surgery Glaucoma, retinal detachment Thrombophlebitis Anesthesia intolerance

Medical Complications Related to Severe Weight Loss (Include in Assessment)

Cachexia, decreased growth hormone causes small stature Decreased cold tolerance Cardiac—dysrhythmias, hypokalemia, & bradycardia, damage to heart muscle (potentially fatal); hypotension Gastrointestinal—constipation Reproductive—amenorrhea, reduced fertility, diminished secondary sexual characteristics Dermatological—fine hair, dry skin Hematological—anemia, decreased hemoglobin & hematocrit, pancytopenia, cyanosis Neuropsychiatric—seizures, peripheral neuropathy, reduced concentration Skeletal—osteoporosis, fractures

Nursing Roles in the Community

Case management—may act as case mgr or ACT team member Medication (AKA med-somatic, or med-som) evaluation, monitoring and administration Therapist in individual, group, and family modalities in outpt, private, or partial programs (APN's) Home care provider (e.g. visiting nurse), if pt is homebound and meets other social security or insurance requirements Patient advocate, political activist (e.g. working to maintain adequate funding, safety nets)

Common Tricyclics

Clomipramine (Anafranil) Imipramine (Tofranil) Amitriptyline (Elavil) Nortriptyline (Pamelor) Protriptyline (Vivactil) Maprotiline (Ludiomil) Amoxapine (Ascendin) Doxepin (Sinequan) Desipramine (Norpramin) Trimipramine (Surmontil)

Reporting Requirements r/t Background Checks for Weapons

Courts and other entities with the authority to take the actions listed below are required to report any persons in any of the following categories to federal authorities; such persons would presumably be flagged during pre-purchase background checks and would be prevented from purchasing firearms. Note: individual clinicians are not required to make such reports, just courts. 1.involuntarily committed to a mental institution, 2.judged to be mentally defective or incompetent to handle their own affairs, or 3.found incompetent to stand trial or found not guilty in a criminal case by reason of insanity.

Although many fewer SPMI persons live in state hospitals and have been presumed to be living higher quality lives, in reality many former state hospital patients are simply in different institutions (jails, nursing home or homelessness), not living successfully in the community. This is called TRANSINSTITUTIONALIZATION, and it can mean less care, and inferior care. For example: while there are <40,000 pts now in state hospitals, 668,000 SPMI persons now live in nursing homes There are more SPMI pts in jails than in hospitals (350,00 vs 90,000 as of 2012) Formerly there were 312 public psych beds per 100,000 people; now there are only 12 (not nearly enough, causing waiting lists for beds & delaying proper tx).

Critics contend that the quality of care SMI persons receive in nursing homes, which often do not have psychiatric specialists on-site, is less than that once received at state hospitals. Research suggests that of SMI persons in prison, only 35% are receiving appropriate treatment; the number drops to <20% for county and city jails. Some estimate that about 1/3 of homeless persons have severe & persistent mental illnesses (SPMI), and most of these persons receive no treatment and regularly cycle through jails and prisons. Funding cutbacks worsen the problem (and can shift pts and expenses to other settings, e.g. ER's, police and prisons/jails).

Maladaptive coping mechanisms

Denial Avoidance Isolation of affect intellectualization

Case managers:

Determine pts' Case Mgmt needs Participate as a team member in the collaborative development of care plans Help monitor the pts' response to care Assist pts to overcome obstacles to accessing treatment and achieving recovery Occasionally transport pts to essential services when there are no other options

Suggestions for the Nurse Working in the Community

Forming and maintaining a trusting alliance with the patient is the foundation for all other care Treat the person as an adult and as a partner, no matter how severe the symptoms nMeet the patient where he/she is (and start from there) Concentrate on the person rather than the diagnosis, and on strengths rather than weaknesses Accept that the patient's life is a matter of personal choice, and that he may not always make the best decision

Nursing Role R/T Evidence

Great care must be taken in the intentional and unintentional collection and preservation of evidence: •If you neglect or damage evidence you help the perpetrator. •Seek only that information needed to treat the survivor. •DO NOT INTERROGATE THE PT R/T THE TRAUMA d/t the risk of "contaminating" reports (via leading questions, implanting "memories", etc •Instead, seek only info that you need to treat the pt (e.g. where injured, not who injured you). •For spontaneous comments by pt, include detailed documentation of pt's comments in quote •Assure that physical evidence is immediately bagged and labelled before it can become contaminated.

Alcohol Use Disorder Assessment questions

Have you: •Had times when you ended up drinking more, or longer than you intended? •More than once wanted to cut down or stop drinking, or tried to, but couldn't? •Spent a lot of time drinking? Or being sick or getting over the aftereffects? •Experienced craving — a strong need, or urge, to drink? •Found that drinking — or being sick from drinking — often interfered with taking care of your home or family? Or caused job troubles? Or school problems? •Continued to drink even though it was causing trouble with your family or friends? •Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink? •More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)? •Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout?

For persons in the community:

If a person meets the criteria for involuntary admission but refuses to be evaluated, concerned others (e.g. family) can petition the probate court to order a psychiatric evaluation. The court then issues an Order of Detention that requires local law enforcement to locate and transport the pt to an evaluation center.

The 1960-70's

Increasingly effective medications became available: antidepressants, mood stabilizers, antipsychotics Lengths of stay decreased from months and years to weeks and months Began the shift toward primary prevention and community-based care with the Community Mental Health Centers (CMHC) Act (1963) Community Mental Health Centers are developed Dismantling of state hospital system begins as treatment improves, states seek to save money Mass exodus from state hospitals—deinstitutionalization—intensifies. Nearly 500,000 pts are discharged between 1965-1975. The number of state hospital beds has been reduced by 90% from their peak in the 1950's.

SPMI patients in the community often experience:

Loneliness, social isolation, alienation Substance abuse Substandard housing or homelessness Unemployment/underemployment Boredom Inadequate physical health care (50% higher mortality rates, premature death by 20+ years per ODMH) Poverty Stigmatization and rejection Powerlessness and a lack of control Non-adherence (and resulting increased relapse)

Domestic Violence: Myths

Most victims are impoverished or less educated FALSE—Happens in all classes & categories Divorce will help FALSE—In the long-term, yes, but in the short-term, risk can increase: 75% of attacks occur soon after separation or divorce Victims do not seek help FALSE—many have tried but have been disbelieved or ill-helped, others want to but are intimidated and prevented from doing so. Providers are obligated to report domestic violence FALSE—only child and elder abuse reporting is mandatory; Reporting adult DV, especially if ill-timed, can worsen the problem; PROVIDERS MUST HAVE THE VICTIM'S PERMISSION TO REPORT DOMESTIC VIOLENCE (see EXCEPTIONS)

Recovery focuses on:

Motivation and goal achievement Constructive use of leisure time Finding and maintaining housing (shelters, nursing homes, foster care, group homes, board and care homes, independent living apartments) (HOUSING FIRST model focuses on housing as the priority, does not require that the pt recover first in order to be eligible for housing assistance) Managing one's treatment and meds (e.g. access to care, reducing & coping with side effects, remembering meds & appts) Finding and maintaining employment, volunteer work, school, or some form of daily activity and structure

To reduce craving and/or rewards from drinking:

Naltrexone—(Revia) binds with opioid receptors to block euphoric effects of alcohol & reduce craving; available in LAI form. Nalmefine [Revex] is a related compound. Acamprosate (Campral)—agonist activity at GABA receptor, used after detox, neuronal excitation/inhibition imbalance. Citalopram (Celexa)—SSRI Ondansetron (Zofran)—Serotonin antagonist Baclofen—muscle relaxant, reduces craving, withdrawal Gabapentin (Neutrontin)—anticonvulsant; reduces dysphoria, insomnia when stopping EtOH use, is an EBP for reducing relapse and amount of EtOH consumed.

SSRI Serotonin Syndrome

Potentially fatal SX: Mental cognition changed, diarrhea, fever, tachycardia, delirium, hallucinations, dilated pupils, muscle cramps/tonicity, seizure, comas

Sample Questions to Ask

Preface your question with empathy ("I know this may not be an easy question to answer, but ____"), then ask: •"Do you feel safe in your home? In your relationships?". Then go beyond this to also ask: •"What happens when you and your partner disagree?" •"Do you worry about your children's safety?" •"What happens when you or your partner become angry?" •"What do you worry about (fear) most?" •"Have you ever thought about calling the police?" •"Are there weapons in the home?" (removing lethal weapons can save lives)

1930's-1950's:

Previously care was mostly provided in large state hospitals where pts were institutionalized for years and decades. Private psych hospitals and mental health units in general hospitals begin to grow in the 1940's. Outpt services were largely limited to private psychiatrists and psychologists; outpt services for those without insurance or ability to pay were very limited. Care was primarily custodial in nature until the 1930's, when first somatic tx arrives: hydrotherapy, insulin shock, psychosurgery (aka lobotomies). Late 1950's: First true psych meds arrive (just sedatives before that)

Public system

Primarily composed of state hospitals and Community Mental Health Centers (CMHC's) Outpt is mostly via separate not-for-profit agencies Tax supported, mostly via local levies; money flows through county Mental Health/Recovery Boards (aka 648 Boards) Range of services that vary by size of population and available funding Accept insurance, Medicare, Medicaid or charge pts on a sliding scale (low income pts pay no out-of-pocket costs) State hospitals have been overseen by the Ohio Dept of Mental Health and Addiction Services since 7/2013

Private System

Primarily inpt mental health units (MHU's) in general hospitals, with admission via private providers May also include partial hospital programs nIs a mixture of not-for-profit and for-profit providers; for-profit providers often run by national chains Usually not a complete, coordinated range of services Mostly paid for via insurance, Medicare, Medicaid Usually does not serve indigent pts (some self-pay but is too expensive for most, e.g. psychologist: $120+/hr) Licensed by state May contract with local MH Board to serve some low-income persons.

For persons already in the hospital:

Probate court can hold a hearing to determine if the pt's initial involuntary admission should be extended; if so the pt is committed to the hospital for a set period, e.g. 90 days. Subsequent hearings can extend the hospitalization period.

The Recovery Model of Treatment

Recovery is a process whereby persons live, learn, work, grow and fully participate in their communities, living a full and productive life despite a disability, until they (hopefully) achieve a full remission (Stuart & Laraia). Recovery's key characteristics include: Hope—recovery is presumed to be possible for all Continued growth (rather than maintenance) A focus on strengths and abilities An expectation of self-care and independence (vs. dependency) Providers partner with the patient An emphasis on interconnectedness with others

Binge Eating Disorder

Recurrent episodes of binge eating with 3 or more of the following: 1. Eating much more rapidly than normal 2.Eating until feeling uncomfortably full 3.Eating large amounts when not feeling hungry 4.Eating alone because of embarrassment 5.Feeling disgusted, depressed, or guilty afterward 6.Person experiences marked distress re: binge eating 7.Binge eating occurs on average at 2+ days/wk for 6 months

DELRIUM TREMENS—Treatment:

Replace thiamine, niacin, folate, magnesium—all IV Replace electrolytes as needed—all IV Glycogen—D5W IV Benzodiazepines—usually diazepam (Valium) or chlordiaze-poxide (Librium), IV, replace alcohol, doses based on object-tive physiologic signs (e.g. HR), administered aggressively and in high dosages as needed then gradually tapered off. High alcohol tolerance may require very high dosage; caution: those not expert in SUDs may undertreat. Baclofen (Lioresal)—GABA analog, muscle relaxant, rapid action; non-addictive; mechanism unclear. 10mg q8h x 30 days, reduces relapse; mixed research support Antipsychotic for psychotic features, agitation; prn

Social Forces

Social isolation, unstable family structure (divorces, children living in multiple relationship situations), parents unprepared for the role (intellectually, financially, etc), lack of assimilation into dominant culture, extreme social events (war, civil unrest and lawlessness)—all are believed to contribute to increased development of personality disorders in a population.

Caring for Persons with PD's

Some particular maladaptive coping and behavioral patterns are common to many of the personality disorders (though far from exclusive to them). Depending on their severity and prevalence, these can range from mildly/intermittently problematic to chronically disruptive. Major examples of these include: •Manipulation •Splitting •Boundary violations •Aggression •Acting Out •Self-injurious behavior (SIB)

Ohio Commitment Process

Taken into custody, on affidavit of court or medical certificate (pink slip) Transported Patient info must go to Probate Court within 3 days Initial hearing within 5 days of time of detention or the patient's letter of intent to leave If ruling is "Not subject to hospitalization," patient is discharged If the court rules the person is "Subject to hospitalization," interim order of detention is filed & full hearing is scheduled within 30 days If patient is still considered subject to hospitalization at full hearing, detention order can be enforced up to 90 days (then 2 years)

Coordination of Care

The goal is integration of appropriate services to provide "one-stop shopping" for the patient (not there yet), e.g. Medical health homes (office with MH and physical health services together), joint services for dually diagnosed (substance abuse + mental illness, or SAMI) pts Agencies are to avoid duplication of services Goal= collaboration and coordination among services Services are tailored to patient's strengths and needs Case management usually coordinates and facilitates, sometimes by a nurse (usually social workers, paraprofessionals—RN's are too expensive) NOTE: All of above are "in theory" and "as available"; recent funding cuts have reduced service availability

Promoting Treatment Adherence

Tx non-adherence is common and occurs in many disorders (HTN, infection, diabetes, etc) Non-adherence in SMI increases relapse risk >4-7x Teaching pts about meds, by itself, has little effect on adherence, esp. for pts who have anosognosia Instead, to be effective a multi-pronged approach is needed; factors/interventions that help include: Trust in providers—a solid therapeutic alliance Stability in providers (low turnover) Tying adherence to the pt's own goals Reducing and/or helping pts cope with side effects

Summary of OH Reporting Requirements

Under Ohio Law (ORC 2921.22 et al): •Providers must report all suspected abuse or neglect of children, persons 60+ years old, or those unable to protect themselves d/t physical or mental handicap •Providers must have the survivor's permission to report domestic violence against adults (but must document knowledge or belief of DV). •EXCEPTION: ALL STAB AND GUNSHOT WOUNDS, SEVERE PHYSICAL HARM, AND 2ND AND 3RD DEGREE BURNS, MUST BE REPORTED •Providers who report in good faith are protected from criminal charges or civil action

Encounters with Law Enforcement

Unfortunately, d/t inadequate or overloaded MH systems in many communities, police are often required to be the primary responders to mental health crises and incidents involving those with SMI. Some police have training, e.g. Crisis Intervention Training (CIT), on how to recognize and respond helpfully to mentally ill persons in crisis, and how to de-escalate anyone in crisis However, some officers lack training or the inclination to use it. In other cases, officers with that training are not available to respond to incidents.

Opiate Withdrawal

Withdrawal syndrome includes rebound hyperexcitability Autonomic symptoms: diarrhea, rhinorrhea, diaphoresis, lacrimation, shivering, nausea, vomiting, fever, hyper- or hypotension, bradycardia or tachycardia, piloerection (hence expression "cold turkey" for withdrawal) Central nervous system: sleeplessness, restlessness, agitation, fasciculations and tremor, yawning, impaired concentration, dysphoria, irritability Pain: abdominal cramping, bone pain, backache, and diffuse muscle aching

Psychosomatic

a physical illness, actual or perceived, arising from one's psychological state or needs

Critical Incident Stress Debriefing (CISD)—

a team response to groups that have experienced trauma, e.g. police and other first responders, survivors of natural or manmade disasters. •Is designed to help prevent serious psychological conse-quences (e.g. PTSD, suicide) •CISD team (usually specially trained first responders and mental health professionals) responds within 24 hours •Team encourages survivors to share their experiences while in a supportive setting where assistance is available •Teaches survivors about normal vs. pathological responses to trauma, what to expect as one recovers from trauma, and how to recognize when needs professional help

1. Assertive Community Treatment

a.Each patient has his own multidisciplinary team b.The team directly provides a wide range of services (not brokered to others), with flexible access c.The team design provides a high staff:patient ratio d.The team is accessible 24/7 and goes to client e.Research suggests that ACT clients: Are less symptomatic and spend less time in hospital Spend less time unemployed and earn more income Experience more positive social relationships Have greater satisfaction with life

Alexander experiment

addicted rats were divided into two groups, one placed in a "rat park" with toys and tunnels and food and company, while the other was in a traditional rat cage lacking amenities. This time, when offered the drugged water and plain water, the rats in the rat park chose the plain water, while the rats in the standard cage continued to abuse the drug. Conclusion: if we have what we need we will not self medicate with drugs

Bulimia nervosa, cont'd

affects 1-4% of population Age of onset between 15-18 years old Behavioral: cyclic eating behavioral pattern (dieting/binging), purging, sporadic exercise Affective: repressed feelings; hopelessness; fear of loss of control of eating, weight gain, feelings, rejection; anxiety, guilt Cognitive: obsessional concern with weight, cognitive distortions, perfectionistic

Craving

an urgent desire for a substance or behavior to which one is addicted, often in response to triggers, that is very difficult to resist

Substance-Related and Addictive Disorders

are disorders wherein one has great difficulty refraining from using a substance (e.g. alcohol, amphetamines, cannabis [marijuana], cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedative-hypnotics, anxiolytics, nicotine, caffeine, etc) or engaging in a behavior (e.g. gambling) despite significant resulting harm.

Lesser withdrawal states

as for DT's except benzodiazepines, applicable other meds may be lower dosages (or not needed) and IM instead of IV Benzodiazepine dosages are usually somewhat lower than in DT's but high dosage may still be needed d/t cross tolerance with alcohol may feed pt instead of IV glucose B-complex IM; multivitamins

Phychological causation of eating disorder

associated with conflicts during stage of separation/individuation Personality characteristics of regidity, ritualism, and meticulousness Pervasive sense of ineffectiveness and helplessness Negative self-esteem, shame and guilt

Frustration

can be to a response to loss, threat, fear -emotional and physical distress -learned response -psychosis or other impaired thinking -Punitive or non-therapeutic staff behavior -conflict about rules or limites

Best treatment is PREVENTION:

consistent and effective screening for risk vigilance for early signs—tremor, tachycardia, HTN risk can be delayed by cross tolerant meds, can increase as opioids or other cross-tolerant meds are decreased must prevent with adequate amounts of benzodiapines (some undertreat)

dislocation of expectations

do what the client does not expect

Alcohol Withdrawal

early symptoms (above) worsen hallucinosis—primarily visual, pt usually recognizes as not real; usually starts 24+ hrs after last drink grand mal seizures—generally self-limiting, starts 24-48 hrs after last drink changes in cognition (memory, disorientation) at any point; memory impairment may last 30-50 days

Purging Anorexia

especially after binge eating, about 40% -self-induced vomiting -misuse of laxatives, diuretics, enemas Excessive execerise -occurs in both

Orthorexia nervosa

fixation on righteous eating, an unhealthy obsession with otherwise healthy eating habits, taking good nutrition to extreme Features: -fixated on food quality and purity -feel superior to others -guilty if you have one slip-up leading to self-punishment

"Duty to Protect

is the Ohio standard. It means that a practitioner is required to take some form of action to protect persons to whom the pt presents a danger

Cocaine Toxicity

mydriasis, encephalopathy, seizures, decreased responsive-ness, HTN, rapid & possibly irregular pulse, hyperpyrexia, coma, respiratory & cardiovascular failure

Factitious Disorder

oDifferent than malingering in that it serves psychological needs rather than from a desire for personal/tangible gain or benefit oMay injure or sicken themselves covertly, e.g. contaminate an IV site with feces oMay produce physical symptoms, e.g. drink coffee covertly to produce elevated oral temp oFactitious Disorder Imposed on Another (aka "By Proxy" form)—a person causes, feigns or perpetuates an illness in another in order to gain attention or other psychological benefit (usually a mother hurting a child); person injuring the child faces criminal charges, may lose custody

Somatic Symptom disorders

oPatient experiences physical symptoms as a result of psychological distress or need oSymptoms are not consciously/purposely created oPts experience genuine distress and may repetitively seek medical care without relief, going from provider to provider, often for many years

Factitious disorders

oPatient intentionally presents as if ill (e.g. he may self-inflict or feign injury or illness, or worsen actual illness) to meet a psychological need (e.g. obtain support from others). NOTE: This is NOT the same as malingering, which is done to obtain tangible benefit, e.g. disability income, be excused from work.

Somatization

oPsychological distress is expressed or manifests as physical symptoms instead oAlso used to describe any expression of psychological distress via somatic symptoms (e.g. depressed children or elderly persons often complain of multiple, vague bodily concerns rather than sadness)

Anorexia Nervosa

refusal to maintain body weight at or above a minimally safe weight for age and height Intense fear of gaining weight or becoming fat, even though underweight Grossly distorted body image-perceives self as overweight even when dangerously thin Persistent efforts to prevent weight gain (severe caloric restriction and/or compensatory activities_ Depression, co-occuring typically CAN CAUSE CARDIAC PROBLEMS

Anticipatory fantasy

talk about what is likely if things continue on the same trajectory

Chemical hook theory

the nature of the substance itself reinforces its use—once the brain has been exposed, it "has to have it". E.g. rats exposed to the drug and then offered a choice of water that contains the drug and plain water will choose the water with the drug, and will continue to consume it even to their own detriment.

Relapse:

the recurrence of alcohol- or drug-dependent behavior in an individual who has previously abstinence for a significant time beyond the period of detoxification

Impaired Response Inhibition and Salience Attribution (iRISA)—

with accumulating exposure to rewarding activities/substances, the brain narrows its focus to just those behaviors/substances, resulting in an every-increasing focus on thoughts and actions that cue evokes (i.e. the brain attributes greater salience to these behaviors and substances); a common manifestation is the selective attention to cues r/t that substance or behavior (e.g. seeing white powder). At the same time the brain becomes less and less able to control one's responses to those cues (e.g. seeking cocaine after seeing white powder) irrespective of resulting consequences.

Reasons the mentally ill may be incarcerated instead of tx'd:

• 1.The illness not recognized, or is ignored, by police or prosecutors; pt receives poor legal representation 2."Mercy arrests"—the person is jailed because police believe it is the only way to protect the person (e.g. so he does not die from exposure during severe weather) 3.Law enforcement sees no alternative to arrest d/t a lack of psych services, or are not familiar with how to obtain them 4.NGRI would result in longer institutionalization, pt prefers prison as less time would be served there than in hospital 5.Deinstitutionalization without adequate or coordinated outpt services results in non-adherence, relapse 6.Insufficient funding for care—pts cannot access help 7.No way to force tx unless person is a danger to self or others, but one can be very sick and not be dangerous

Detoxification:

• safely withdrawing a person from an addictive substance, usually under medical supervision, by providing a substance for which there is cross tolerance in gradually decreasing amounts

Buprenorphine (Temgesic, Subutex [sublingual])

•- taken every 3 days. Mimics effects of narcotics in some ways but not others, e.g. produces limited euphoria; ceiling action: blocks further effects of opioids when present in higher amounts (i.e. is a partial agonist/antagonist).

Chemical Dependency and Nurses

•10 to 15 percent of nurses are chemically dependent •Usually no hx of drug use until prescribed following surgery or a chronic illness •Often a family history of alcoholism or addiction •Nursing licenses can be suspended/revoked as a result of addictions; some states have mandatory reporting laws •Any nurse who knows of any health care provider's incompetent, unethical, or illegal practice must report that information through proper channels •Contract with Oh Bd of Nsg to take action to achieve sobriety, participate in peer assistance programs + professional treatment

CHILD ABUSE

•2.8 million cases of child abuse are reported each year (2/3 of abuse is not reported) •Four children die from abuse each day •Abuse leads to societal problems as well as personal problems: 1/3 of survivors will abuse their own children, survivors are 2.5x more likely to abuse alcohol and 3.8x more likely to become drug-addicted; survivors are also more likely to be incarcerated for non-abuse crimes) •Abused children spend less time in school (kept out to prevent discovery of abuse by perp's, or too ashamed to go)

Codependency

•A dysfunctional coping pattern resulting from living in a committed relationship with a person with an alcohol, substance or behavioral addiction •Sacrificing self for the relationship; one person is trying to make the relationship work while the other isn't (lacks motivation to change). •Signs: staying in an abusive/unrewarding relationship; focusing on changing the other person while neglecting oneself; chronic pain, hurt, and strife. •Ask self: •Is the relationship more important than I am? •What price am I paying for this relationship? •Am I the only one who's working and trying to make it better?

Community Commitment •AKA ASSISTED OUTPATIENT CARE

•A probate court can commit a person to outpatient care, requiring him to receive care in the community even if he does not wish to accept it. •Similar to inpatient commitment, it is often used when a pt has a history of repeated nonadherence that has led to disruptive relapses and/or endangered the pt or others. •It usually occurs when the pt has been hospitalized and is now being discharged into the community. •A key difference from involuntary inpatient treatment in Ohio and some other states is that there is an additional criteria that is sufficient to provide for outpt commitment: The pt has a history of nonadherence that is detrimental to his health and recovery.

Synthetic "Marijuana"

•Alleged to be cannibus analogues that mimic MJ effects, but composition and effects vary •Purity varies and changes over time •Usually made illegal soon after discovery •HTN, agitation, nausea/vomiting, hallucinations, psychoses, seizures, and panic attacks blurred vision •Many names; K2, Spice, bliss, blaze, skunk, etc •Spice can cause anticholinergic effects, nausea, seizures, tachycardia and hypertension. Can contribute to onset of, or worsen, mental illnesses.

Other Synthetics

•Alleged to be synthetic analogues of other drugs, e.g. ecstasy, cocaine; actual contents are highly variable, likely stimulants akin to but much more powerful than cocaine •E.g. bath salts, plant food, purple wave, numerous others •Usually marked as "not for human consumption" (wink wink) to evade legal and other responsibility •Snort, IV, put in food or drinks •Composition, purity, and effects vary: HTN, tachycardia, various cardiac symptoms, headache, hyperthermia, diaphoresis, tremor, abnormal movement, seizures, mydriasis, paranoia, anxiety, panic, irritability, suicidality, psychosis. Sometimes fatal.

Why Do They Stay?

•Ambivalence—they also love the person •Financial and/or emotional dependence (places to go, money to live on, poor self esteem, fear of being alone, etc) •Fear will lose custody of kids, put kids at more risk •Denial—believe the perpetrator is not at fault, will somehow change (rarely happens w/o treatment) •Fear of even greater violence—leaving will increase the risk (often true, especially in the short term) •Believe there is no help, will be rejected, authorities wont listen, others will "blame the victim" (we feel safer if we believe survivors are "not like us")

Personality Disorders:

•Are characterized by a maladaptive pattern of inflexible, limited ways of coping and of relating to others •Involve dysfunction that is sufficient to significantly impair social or vocational functioning. •Impaired role function and reduce quality of life (often r/t pts' limited or maladaptive ways of coping and relating to others). Result in disruption and distress that ranges from mild to profound, intermittent to chronic

INVOLUNTARY ADMISSION

•Authorized personnel certify that pt meets criteria •In Ohio, this can be initiated by law enforcement, licensed clinical psychologists, any physician, or public health officers using a form called an Application for Emergency Admission (AKA "pink slip") •An involuntary admission allows the pt to be held for emergency psychiatric eval for up to 3 court days; by the end of that period one of three things must happen: *Pt agrees to stay as voluntary pt (this is the most common outcome) *Pt is "probated" (i.e. probate court orders continue stay in hospital) *Pt is released

Cluster C—behavior that is fearful or anxious

•Avoidant—socially inhibited, feels inadequate, oversensitive to criticism •Dependent—clingy and submissive to others; needy; wishes to be cared for •Obsessive-Compulsive—overly focused on order, perfectionistic, controlling (things must be a certain way)

Key pt rights under Ohio law include the right to:

•Be informed of one's rights •Tx info in a manner suitable to the pt's age, culture, religious preferences, other needs (e.g. translators) •Tx in the least restrictive setting, and to be free of undue/arbitrary restriction •Informed consent, and to choose desired tx's and refuse undesired tx's (exception: emergencies) •An individualized tx plan, and to participate in developing that plan •Privacy; confidentiality of personal health info •Respectful, humane care that maintains pt's dignity and is free from abuse, harassment •Access and communicate with advocates, support persons (visitation, written, phone-based) •Independent evaluation, counsel (at own expense) •Freedom from reprisal when asserting one's rights

GHB (Xyrem)—

•CNS depressant, treatment for narcolepsy, metabolite of GABA; liquid or powder; odorless, colorless, and tasteless; "date rape drug"; Coma and seizures can occur following use of GHB. can result in nausea and breathing difficulties when combined with EtOH; coma and death in OD.

Cocaine

•CNS stimulant that produces a euphoric rush of mental alertness and energy, feelings of self-confidence, perception of being in control, and sociability; lasts 10-20 minutes; can produce paranoia, psychosis •the high is followed by an intense let-down effect in which the person feels irritable, depressed, and tired, and craves more of the drug •significant risk for psychological dependence •snort, smoke, inject (choice of route affects rapidity of absorption and duration of euphoria); "crack" form= cheaper

Benzodiazepines

•Cause CNS depression •Increase total sleep time but decrease the duration of REM sleep •Withdrawal symptoms may begin as long as 8 days after last taken (depending on half-life) •Withdrawal is potentially dangerous; symptoms include: oAnxiety rebound oAutonomic rebound oSensory excitement oMotor excitation oCognitive excitation •Withdrawal tx'd via benzodiazepine tapering

MDMA (Ecstasy)

•Causes hallucinations, confusion, depression, sleep problems, drug craving, severe anxiety, and paranoia

Possible Survivor Responses to Abuse

•Depression, anxiety •Increased risk of developing PTSD, Borderline Personality Disorder, or Dissociative Disorders •Increased risk of abuse, suicide, and homicide •Isolation (shame, fear of discovery and subsequent legal and social consequences) •Discomfort with relationships, sexuality •Substance abuse •Acting out sexually or aggressively (e.g. identify with aggressor and become a perpetrator yourself) •Repression of memory of abuse

Kratom

•Derived from a tree that grows in SE Asia •Contains opioid compounds but is not yet illegal in US •Under investigational use for chronic pain, anxiety •Self-administered as an alternate to conventional opioids, to help reduce opioid withdrawal symptoms, to treat anxiety, pain and depression •Some assume it is benign because it is plant-derived and legal, but it is addictive and has unknown health risks •FDA WARNING: Associated with 44 known deaths in US •Sometimes contains added synthetic opioids, resulting in increased OD risk

Interventions for Elder Abuse

•ELDER ABUSE/NEGLECT INVOLVES MANDATORY REPORTING TO ADULT PROTECTIVE SERVICES: •As in other abuse, even a SUSPICION requires reporting—proof or evidence is not needed, and reporters are protected •Applies to all persons who are 60+ years or physically or mentally handicapped (any vulnerable adult)

Criminal Law and Psychiatry

•Each accused must be competent to stand trial (i.e. understand the court process and aid in his own defense) or the trial cannot proceed. Defense attorneys can request that their client be evaluated for competency. •If, based on a psychiatric evaluation, a judge finds a person to be incompetent to stand trial d/t mental defect, and if it is believed that the pt can be restored to competency, he is remanded to a state forensic setting to be treated until he is competent to stand trial. When he becomes competent the trial goes forward. •If treatment is unable to restore the person to competency, the court may order that the pt remain hospitalized for ongoing treatment for the duration of what would have been their maximum sentence, or the pt may be released, or be converted to civil commitment status.

Assessment re: Domestic Violence

•Each time she is asked about abuse she has another opportunity to break the silence •If you do not ask, she probably will not tell •Enable clients to acknowledge abuse by how you word your assessment questions, e.g. "Because violence is so common, and because we know about half of all women will be victims at some point in their lives, we ask all women about abuse..." •Look for: unlikely explanations for injuries, increased incidence of accidents, somatic complaints, dehydration or malnourishment, reluctance to speak with provider or stay in care setting, partner tries to cut the contact short •Assess the children as well as the spouse to be sure they are safe, too

Conversion Disorder

•Emotional distress or unconscious conflict are expressed or resolved through physical symptoms, usually of a neurological type (e.g. paralysis, blindness) •Symptoms are created unconsciously. •Symptoms often have a very sudden onset, & in therapy are found to have a psychological cause or purpose •Pts often are not very distressed by the symptoms (not as much as one would expect) •When the emotional cause/need is address the symptoms abate •E.g. Pt is pressured to become engaged but does not want to marry, suddenly loses vision or becomes paralyzed as wedding nears, symptoms abate when marriage is placed on hold.

New Opioid Guidelines

•Establish realistic treatment goals with all patients •Discuss (addiction) risks as well as benefits with all patients •Limit most prescriptions for acute pain to 3 days or less •Prescribe the lowest effective dosage •Try non-drug and nonopioid tx first for chronic pain •Use immediate-release opioids instead of extended-release •Limit prescriptions >7 days to cancer, palliative care, and end-of-life care •Use in conjunction with nonpharmacological therapy •Test urine periodically to rule out drug abuse

Health Implications of Alcoholism

•Excessive alcohol consumption accounts for 1 in 10 deaths among working-age adults. •Annually from 2006 to 2010, excessive alcohol use led to an average of 87,798 deaths and 2.5 million years of potential life lost. It shortened the lives of those who died by about 30 years. •69% of these deaths involved adults 20-64 years old. About 5% involved people under 21 years •Alcohol abuse is associated with increased risk of cancers (e.g. breast cancer, esophageal), liver and heart disease, dementia (esp early onset dementia), and depression •Also: many negative consequences affecting physical and mental health from acute excessive use, e.g. violence, alcohol poisoning, and motor vehicle crashes.

Treatment of Factitious Disorders

•Goal: Replace dysfunctional, attention-seeking behaviors with positive, adaptive behaviors •Support, counseling to improve stress management, strengthen boundaries, increase coping, resolve conflict, recognize and meet needs in adaptive manner •Long-term psychotherapy to address emotional issues, e.g. childhood abuse •Promote acceptance and valuing of patient by others •Confrontation can be helpful if patient feels supported; in proxy form it is often necessary to protect the victim.

Elderly

•Increased physical health needs confound diagnosis •Important to differentiate somatization disorder (or somatic expression of psychological needs) from actual medical problems—the same person may have both somatization and genuine medical disorders

Biologic Effects of Cocaine

•Increases the release of, and blocks the reuptake of, norepinephrine, serotonin, and dopamine • dopamine: euphoria and potential for psychotic symptoms (paranoia, hallucinations) • norepinephrine: tachycardia & hypertension (potentially fatal), dilated pupils and rising body temperature • serotonin: sleep disturbances (paranoia), anorexia (wt loss) •Long-term use: depletion of dopamine

Treatment for Tobacco Addiction

•Is especially important in severe mental illness d/t higher rates of smoking, greater inhalation •Nicotine replacement •patches, gum, electronic delivery devices, inhalers, etc. •replaces nicotine in decreasing doses •Note—replacements may be abused, e.g. chewing patches •Nicotine replacement via electronic cigarettes (vapor-based nicotine delivery systems) ???? Valid use ???? (BTW: also being used to deliver THC, etc) •Bupropion (Wellbutrin) reduces cravings and weight gain associated with smoking cessation. •Varenicline (Chantix) blocks nicotine receptors

Interventions for Domestic Violence

•Keep in mind that the survivor knows more about her situation than anyone and is the expert about what SHE needs to do (and not do) •Remember that her response makes sense for her, in her situation (in any given situation people are usually doing the best they can under the circumstances, even if it "does not make sense" to others) •Know that she will try to leave 7-10 times before succeeding •Each time she hears "no one deserves to be treated like this" she becomes stronger •"No Contact" and "Temporary Protective Orders"—complicated, limited, can help (but may be ignored)

Relapse Prevention

•Keep it simple—many abusers have cognitive problems while using and during early recovery, esp. poor concentration and memory impairment •Review instructions and repeat as needed (put them in writing, be very concise, make them concrete) •Encourage notebook use, journaling—to ID and process feelings, ID connection to drug use •Identify situations that are stressful and/or difficult to handle and create a crisis plan for these •Identify triggers and guide pt to avoid these (others who use, bars, bottles, etc) •Teach strategies for coping with craving

Meds Used For Opiate Addiction

•LAAM- (L-alpha acetyl methadol) every other day •Methadone taken daily •Both are opioid agonists and are Schedule II narcotic drugs administered only in special programs •Both replace other opiates and although addicting, they do not significantly impair functioning or produce significant euphoria •Intent is to replace other, more disruptive and addictive opioids with meds that reduce craving and dysphoria without producing euphoria. Makes it easier to abstain. People may be on for years or life.

Professional Treatment

•Led by specially trained personnel, usually licensed; some are in recovery themselves •Follow varying treatment models (often incorporating principles of 12-step programs) •May or may not include detox, pharmacological treatment (special licensure needed for some med'l tx's; more costly) •Usually group based—often closed, commitment needed •For-profits—accepts self-pay or insurance, often expensive •Not-for-profit—usually tax or grant supported, free or sliding scale fee, may have waiting lists d/t limited spaces •Access may be challenging d/t demand outweighing availability; addicts often want services now, don't wait

Support groups/lay treatment

•Led by volunteers, may or may not have training •Most are 12-step programs or incorporate their principles •Do not include detox, pharmacological treatments •Group based—usually are open groups, open ended (no start or stop dates, addicts who want services now can drop in any time, in any meeting location •Free—subsist on donated space & funds •Access varies with the size of community; populous areas have more #' of groups, types of groups, and mtg times •Acceptance, peer support, informal education are stressed •Usually tolerant of ambivalent members who vary in their commitment and degree of sobriety; most accept court-ordered members

Loperamide (Imodium)

•Once a Schedule V abusable drug, it is a piperidine opioid med that reduces gastric motility •In therapeutic doses (8-16mg), its actions are restricted to the GI tract •When larger doses are taken, CNS effects similar to those of other opioids begin to develop. •The practice of ingestion of large doses (>70 mg QD) has been gaining popularity among opioid users, e.g. to manage withdrawal symptoms and, less frequently, to achieve a high akin to those of more powerful opioid meds.

Opiates and Morphine Derivatives

•Opioid meds: Codeine, fentanyl, heroin, morphine, oxycodone, hydrocodone, etc. •Produce pain relief; euphoria at higher doses •Physical dependence can develop rapidly •Increasing concern: heroin is replacing more expensive pharmaceuticals, causes high risk of unintentional OD because heroin can be cut with more potent drugs (e.g. fentanyl), or addicts who've been detoxed resume previous levels of use without first re-building tolerance (treated with IM Narcan)

Cluster A—behavior that is odd or eccentric:

•Paranoid—mistrustful and suspicious, sees others as intending harm •Schizoid—socially detached and emotionally constricted •Schizotypal—eccentric in behavior &/or thought, uncomfortable in relationships

Malingering

•Person intentionally feigns, creates, or worsens an illness for personal gain; e.g. to collect insurance, win a lawsuit, obtain food or shelter (e.g. to become eligible for subsided housing), to avoid criminal prosecution or work/family responsibilities •Tx = supportive/empathetic confrontation, helping pt to cope and/or meet needs more appropriately

Signs of Chemical Dependency in Nurses

•Poor judgment and concentration •Lying •Volunteering to be the med nurse •High achievement, both as a student and a nurse •Volunteering for overtime, extra duties •Alcohol on breath •Increased time in bathroom •Forgetfulness •Mood swings •Inappropriate behavior •Frequent days off •Noncompliance with policies and procedures •Deteriorating appearance •Deteriorating job performance, increased errors •Sloppy, poor quality charting

Indicators Suggestive of Increased Risk of Perpetrating Abuse

•Previous abusive relationships •Lack of empathy; jealousy •Pressure for quick involvement/commitment •Controlling/demanding personality; easily threatened •"Anger management issues" •"Playful" use of force in romantic/sexual encounters •Rigid expectations re: roles in the relationship •Attempts to isolate partner; blames partner for his problems •Stalking; cruelty to animals or people

Illness Anxiety Disorder

•Previously known as hypochondriasis •Pt misinterprets normal physiological functioning and sensations as being pathological •Pt is unduly anxious about actual but minor health problems, anticipates highly negative outcomes even where these are unlikely •Prone to excessive preoccupation and worry about bodily functions and sensations •Tends to be chronic, worsens stress & anxiety increase •Pts use significantly more healthcare •Treatment is similar to Somatic Symptom Disorder

VOLUNTARY

•Pt decides, or at least agrees, to be admitted •Pt considered competent unless adjudicated otherwise •Retains right to refuse treatment unless involuntary medication treatment criteria are later met •Cannot simply sign self out or leave against medical advice (AMA); instead, pt must request discharge (preferably in writing), & psychiatrist has three days to decide its response •If psychiatrist disagrees, he/she may: -Require client to sign out AMA -Hold pt for up to 3 "court days" while seeking court commitment for involuntary hospitalization

Somatic Symptom Disorder

•Pt experiences multiple symptoms that are often subjective and difficult to assess objectively (e.g. pain) •Is unconscious (pt believes he/she is truly ill) •Often seen in persons with high emotional distress •Usually involves recurring, multiple, and clinically significant somatic problems involving several body systems (typically GI, neuro, sexual/reproductive, and musculoskeletal) •May present symptoms intensely, "Sicker than the sick" •Some have estimated that about 5% of pts seen in medical offices have this disorder (undiagnosed) •

Common Findings in Somatic Symptom Disorders

•Pt is preoccupied with illness, somatic complaints •May present in dramatic, even exaggerated manner •Often focused on tx history, chronicling tx experiences (may keep multiple, voluminous records) •Hx of a series of personal crises •Hx of emotional reactions to life stressors •Hx of taking a large number of meds that have varied over time •Hx of self-medicating, revising med regimens without provider approval •Hx of seeking care from multiple providers (serial health care) •Spends much time seeking medical care, getting tx •Family members—tired of pt's complaints, resentful, sometimes enabling; substance abuse is not uncommon

Assessment for Abuse and Neglect

•Recurrent and/or unexplained injuries (esp. if of varying ages) •History of multiple or suspicious accidents •Old or new fractures, esp. if multiple; bone overgrowth (Caffey's Syndrome) •Bruises, abrasions etc where they would not be expected from normal activities (e.g. back) •Bruises, abrasions on upper arms/wrists (from restraining or shaking the person); •Bruises on ankles suggesting restraint •Cigarette or other burns •Unkempt, body odor, fleas or lice; contaminated with urine or feces, soiled clothing or bedding •Elderly or physically incapacitated: Decubiti

Dissociative Anesthetics

•Reduce (or block) signals to the conscious mind from other parts of the brain •Ketamine, PCP (angel dust) •Intoxication can last 4 to 6 hours •Horizontal & vertical nystagmus, increased muscular rigidity, dissociation (blank stare), slow/disorganized speech, increased pain threshold, agitation, combativeness, hallucinations, elevated VS, delirium •Interventions: reduce stimuli, maintain a safe environment for the patient and others, manage behavioral manifestations, and observe for medical and psychiatric complications

Assessment r/t Addiction

•Reflect to increase own self awareness re: attitudes toward substance abuse •Physical and mental status exams, laboratory tests incl'g tox screen—R/o concurrent illness, withdrawal, •Thorough, nonjudgmental substance use history and related risk factors (e.g. needle-sharing, sexual practices, malnourishment) •Motivation •Co-dependency & enabling in family •Corroborate with family and/or friends •Observe for denial, projection, rationalization •Screening and rating questionnaires and scales

Methamphetamine (crystal meth)

•Releases excess dopamine; highly addictive •Relatively easy to make at home, even in car; chemical used are dangerous, potentially toxic •Longer duration "high", used in a "binge and crash" pattern

Indicators suggestive of sexual abuse:

•STD's, genital or rectal bleeding, recurrent UTI's, insomnia •In children, precocious sexual activities/knowledge; sexual acting out; seductiveness

Sexual Abuse

•Sexual contact w/o consent (or unable to give consent) •Rape—sexual contact w/o consent under the threat of force (does not require physical resistance be demonstrated) •70% of sexual assaults involve someone known to the survivor •25% of women and 10% of men are sexually assaulted during their lifetimes •Only 5% of college students who are raped report it to police, and 40% TELL NO ONE •The primary dynamic is CONTROL; it is not a crime of sex, but of control •Most sexual assaults are planned (perp sets out to commit the offense, and though the victim may be random, he/she is usually chosen based on perceived vulnerability)

S-Adenosylmethionine (SAMe)

•Somewhat variable in potency and oral absorption (better in enteric coated form & when taken on empty stomach) -may induce mania in persons with bipolar disorder •Side effects: dry mouth, mild GI distress (gas, N/V, diarrhea, constipation), HA, anxiety, insomnia, anorexia, diaphoresis, dizziness Similar effectiveness to TCA's with somewhat faster onset of actions

Treatment

•Special effort is needed r/t self awareness to assure that the nurse remains objective and compassionate •Treat co-existing psychiatric and physical problems (in a manner that addresses the pt's underlying emotional needs and distress) •Emergency and routine care for true physical problems (pt may also have genuine medical needs as well) •Attempt to obtain past tx records, consult previous and future providers to validate provider shopping, minimize duplicate testing •Use confrontation cautiously as it may cause pt to flee if he is not also supported emotionally

Other Crime/Trauma Info

•Staff assaults against mentally impaired persons (e.g. patients in psychiatric units) are felonies •Many jurisdictions offer specialized courts for domestic violence or crimes committed d/t mental illness or substance abuse; these usually use the power of the court to compel treatment and in some cases can offer tx in lieu of incarceration (and/or can later expunge convictions) •Protective orders can be helpful but cannot be counted on to protect intended victims. •Persons who are victims or witnesses of highly traumatizing events are at risk for PTSD &/or other psychological disorders.

Caffeine

•Stimulates cerebral cortex, increases mental acuity •300 mg can cause tremors, poor motor performance, and insomnia •Doses >500 mg cause tachycardia; stimulate respiratory, vasomotor, and vagal centers and cardiac muscles; dilate pulmonary and coronary blood vessels; and constrict blood flow in the brain •Concentrated powders used to lose weight, promote increased exercise tolerance; POTENTIALLY FATAL! •Withdrawal syndrome includes headache, drowsiness, and fatigue, sometimes with impaired psychomotor performance, difficulty concentrating, craving, and psychophysiologic complaints such as yawning or nausea

Nicotine

•Stimulates the central, peripheral, and autonomic nervous systems, causing increased alertness, concentration, attention, and appetite suppression •Toxic in high doses (mostly to young children) •Nicotine withdrawal: mood changes (anxiety, irritability, depression) and physiologic changes (craving, difficulty in concentrating, sleep disturbances, headaches, gastric distress, and increased appetite) •Is a special concern in mental health because of higher rates of smoking among persons with severe mental illness (45-65% vs 19% in general population); amount smoked is also significantly higher; smoking reduction/cessation interventions are essential

tox screens

•Substances screened for in a standard tox screen can vary with the lab doing the test, and screens do not test for all abusable substances •Even when a screen tests for a substance (e.g. opioids) some related substances may not show up, e.g. synthetic opioids such as fentanyl •Some common meds can cause false positives for other drugs, e.g. using dextromethorphan may cause a false positive for PCP •Bottom line: don't assume that a neg tox screen means the person is not abusing substances, nor that a positive tox screen means the person is abusing substances

Brief Intervention Therapy (e.g. during ER visits)

•Teach re: how to reduce drug use (e.g. avoid all peers who use), cope with craving •Provide harm reduction info and/or self-help manuals •Giving info about the consequences of a drug conviction on travel, housing and employment; •Provide info on and discuss harm reduction strategies, e.g. oOverdose (e.g. use with peers, naloxone) oViolence reduction (victim and perpetrator) oDon't drive under the influence oSafe practices (e.g. safe injecting, safe sex) •Offering and arranging a follow-up visit

BODY DYSMORPHIC DISORDER

•The pt is preoccupied with imagined or real (but slight) defects in appearance or function, such as a large nose, thinning hair, body odor, or small genitals •The preoccupation with the defect causes significant distress and interferes with ability to function socially •Now categorized as an anxiety disorder, it is a variant of obsessive-compulsive disorder that involves the pt's obsessive focus on a perceived defect and related compulsive behavior (such as frequently checking mirrors, checking for body odor)

The Role of Control & Power

•The survivor's efforts to protect herself and her family are seen by the perpetrator as an intolerable, unacceptable threat to his control and masculinity •Even something as simple as returning to school, getting a cell phone, having friends, or getting a job can be threatening to those demanding control over others •Faced with a survivor's efforts to take back some power in the relationship, the perpetrator redoubles his efforts to assert control, and will often kill his victim and himself before surrendering control

Disulfiram (Antabuse)

•Used adjunctively for aversion therapy, causes unpleasant response when alcohol is consumed: facial flushing, headache, nausea, vomiting, chest pain, weakness, blurred vision, mental confusion, sweating, choking, breathing difficulty, and anxiety •Even small amounts of inadvertent alcohol (e.g. from mouthwashes) produces adverse effects •Infrequently used d/t often being discontinued by pt, inadvertent alcohol exposure (mouthwash, etc).

Violence Within Families

•Usually involve issues of power and control •Often involves multigenerational transmission (victims become perpetrators d/t norm of violence) •Often accompanied by social isolation (sometimes d/t legal/social sanctions) •Often involve or accelerated by drug or alcohol abuse (this can be claimed as an excuse to reduce culpability) •Affects all categories and classes of people •Can occur in outwardly "loving families" •Can affect later health, e.g. female survivors have higher risk of later cardiovascular events

Liver cancer

•While the incidence and mortality for every other type of cancer have been decreasing in the past 10 years, liver cancer incidence and mortality are increasing by over 2% per year. •Liver cancer is 2-3 times more common in men than women. •>50% is due to hepatitis C (often r/t drug abuse); cirrhosis is second most common cause (remember that cirrhosis is not just from EtOH, but is also increased by diabetes & obesity). •Fatty liver disease is increasing rapidly and is expected to replace hep C as the primary cause of liver cancer in the next 10 years. It is primarily due to effect of metabolic syndrome on the liver.

Naloxone (Narcan)—

•a narcotic antagonist, used in emergency treatment of opiate intoxication or overdose to reverse the effects of narcotic; causes immediate withdrawal by displacing opiates from receptors.

Addiction

•an irresistible psychological and/or physiological need to continue the substance use or behavior despite the harm it causes; may or may not include physical dependence.

Trigger:

•anything which cues or prompts a response, e.g. seeing a bar may trigger a craving for alcohol (the bar is the trigger)

Nalmefene (Revex) and Naltrexone (Revia; long acting IM form= Vivitrol)

•are related opioid antagonists that reduce opioid receptor response to abused opioids, essentially blocking the effects of opioids. Also available in a long-acting injectable (LAI) form called Naltrexone XR. They reduce craving and relapse, and treat opioid OD's (in active users, they cause acute withdrawal by displacing opioids from receptors). It can cause nausea, and in high dosages can cause hepatocellular injury.

Secondary gains

•circumstances that unintentionally reinforce a behavior •E.g. a pt with somatic concerns makes a medical appointment and during the appt receives caring and support from her nurse that she does not receive at home; •The secondary gain is that the pt's need for caring has been met, which although it is not the original reason for the appt, was coincidentally met during treatment; •Later, the pt may unconsciously develop more somatic concerns and seek more frequent contact with the nurse in order to sustain the caring response she desires

"Molly

•crystalline form of MDMA but often cut with other drugs, e.g. methamphetamine; confusion, anxiety, depression, paranoia, sleep problems, muscle tension & cramps, tremors, involuntary teeth clenching, nausea, faintness, chills, sweating, and blurred vision. Larger doses interfere with temperature regulation leading to acute hyperthermia that can lead to liver, kidney and cardiovascular failure. Can cause severe dehydration and hyperthermia

Designer MDMA

•designer drugs that are commonly being offered as MDMA. Other drugs are also misrepresented as MDMA. •Often taken at parties or raves, they are marketed under the names such as Nexus, Erox, Performax, Toonies, Bromo, Spectrum, and Venus •They are usually is taken orally in powder or tablet form and reach maximum effect in 15-30 minutes, then plateaus for 2-7 hours, and comes down within 1-2 hours. •Effects mimic psychosis and mania, with FOI, LOA, paranoia, agitation, and catatonia. Treatment is usually with IV saline, IV benzodiazepines, and antipsychotic meds.

Paranoid

•distrustful of others •excessively wary or hyperalert •sees hidden meanings where others do not •prone to bear multiple or extended grudges •senses insult or slights where others do not (and is unforgiving of these) •preoccupied with unjustified doubts or suspicions about others' loyalty or love or trustworthiness; pathologically jealous

Histrionic

•excessively emotional and dramatic; speech and affect are "over the top"; melodramatic •attention seeking; uncomfortable if not receiving attention; uses physical appearance, skills to draw attention to self; craves excitement •easily threatened emotionally; easily angered •often inappropriate socially (e.g. provocative, seductive); overly intimate in social situations and possessive in relationships •overly abstract, but often lacking in detail or depth •suggestible or gullible

Narcissistic

•grandiose, inflated view of self; self-important; •exploitive of others—limited empathy; •preoccupied with fantasies of success, power, ideal love, etc; •envious of others or believes they are envious of her; idealizes or devalues others; •expects favors but does not return them; •often perceived as arrogant, aloof, haughty; •if criticized is indifferent or flies into rages

SEVERE ALCOHOL WITHDRAWAL, aka DELIRIUM TREMENS:

•is a medical emergency (>10% mortality rate even when treated) •ANS instability—tachycardia, HTN, pyrexia •mental status changes: disorientation, reduced awareness of environment, somnolence, delusions (paranoid), hallucinations (visual/tactile, pt believes are real), marked tremor, agitation, diaphoresis •onset: 3-5 days after last drink & other cross-tolerance meds (varies with liver function) •lasts: 2-3 days (usually; can last longer...)

Why do people manipulate?

•it's simply the way they have learned to get their needs met •they don't know many other ways to get what they need; •It has worked in the past for themselves or others (don't argue with success!); •they are desperate—other approaches don't seem to be available or aren't working; •Rarely: they like the challenge of getting something for nothing, or d/t habit or laziness.

Schizoid

•little affect •lacks warm/tender feelings for others •seems emotionally distant, cold or aloof •derives little pleasure from interpersonal activities •indifferent to the reactions or opinions of others (including praise or criticism) •disinterested in friendships, romantic relation-ships, sexual activity, and even contact with others

Schizotypal

•odd or inappropriate affect •peculiar behavior; social anxiety •often shares the features of schizoid PD •vague or odd speech (e.g. eccentric use of words) •oddities in thinking: magical thinking, ideas of reference, odd fantasies or preoccupations

Dependent

•pervasive desire to be taken care of—has exaggerated fears of being unable to take care for self and wants others to assume responsibility for key areas of her life •submissive and clingy in relationships; reluctant to "make waves" or assert self •fears abandonment; feels helpless and intolerably uncomfortable if alone •lacks self confidence and self esteem, and is reluctant to take risks or initiate activities •urgently seeks relationship wherein she will be cared for, and feels threatened when this is (or might be) withdrawn

Tolerance:

•physiological adaptation to a substance such that increasing amounts are needed to achieve the same effect

Obsessive-Compulsive

•preoccupation with orderliness and mental and social control; perfectionistic •insists others conform to his expectations; intolerant of imperfection or casualness •focuses on details, rules, lists, organization •excessively devoted to work or productivity to the exclusion of other aspects of life •overly conscientious, scrupulous; reluctant to delegate •miserly in money matters; rigid and stubborn •seen as cold, stiff; has difficulty expressing tenderness

Borderline Personality Disorder (BPD)

•sense of self is distorted; uncertain re: vocational, gender, other aspects of identity •pattern of instability in relationships, mood, and how one sees oneself •difficulty with bonding and trusting others; prone to feel abandoned by others & often is preoccupied with abandonment fears •relationships tend to be intense, and marked by alternating clinginess and aloofness; •tends to ill-advised social behavior (excessive spending, impulsive relationships, promiscuity, reckless driving, binge eating/gambling) •marked impulsiveness; many regrettable and/or self-destructive behaviors •unstable, inappropriate, and/or dramatic in mood and affect ("brittle affect"); •chronic dissatisfaction, emptiness, dysphoria •difficulty tolerating or managing own emotions; restricted range of coping ability •tend to "split", i.e. to see things as black or white, good or bad, rather than in shades of gray (e.g. is either overly positive [idealizes] or overly negative [denigrating] about each staff person)

Withdrawal:

•state characterized by adverse physical and psychological symptoms occurring when on ceases using a substance to which the brain has acclimated

MDMA (ecstasy)—

•users report euphoria, sense of emotional oneness with others, emotional openness, increased empathy or sympathy with others, increased energy, heightened sexual arousal and pleasure, increased sensory sensitivity. Can cause potentially fatal hyponatremia and hyperpyrexia (esp. when pt is also dehydrated, as during overexertion in hot environments as is often the case during raves)

Antisocial Personality Disorder

•violates social norms and laws; deceitful •often has criminal hx and/or substance abuse •does not seem to learn from his experiences •reckless regarding safety of self or others •often easily irritated and responds with undue or excessive anger •places own desires above the needs of others; disregards others' needs in meeting his own •lacks empathy, guilt, remorse or distress r/t his own behavior (unless he comes to be held accountable by others, e.g. is incarcerated or dishonorably discharged); does not seem to have a conscience •Is at significantly higher risk of suicide

Use:

•when one drinks, swallows, smokes, sniffs, inhales or injects a mind-altering substance

FINANCIAL ABUSE/NEGLECT:

•with financial access or information •Money is being spent without benefits to show for it (e.g. no improvements to home, insufficient food/toiletries, clothes) •others accompany the person when spending or accessing money and seem to be directing the purchases or withdraws

Use the STATE, SEEK, DO method:

-STATE what you see & what you'd like to see -SEEK info on how pt sees things, and his ideas on what he/she thinks would help -DO those reasonable things the pt suggests, or guide pt's responses to be more "doable"

•Vagus Nerve Stimulation

-Vagus nerve has extensive connections to many areas of the brain and body -Hypothesized to change levels of several neurotransmitters -Approved by FDA & effective for adjunctive treatment of severe depression for adults who fail treatment with four or more antidepressants (not used routinely) -Involves a permanent implant

Restricting Anorexia

-Weight loss achieved through dieting, fasting, stimulants Calorie restriction can be severe and can be accompanied by inadequate protein intake and other nutritional deficiencies Higher risk of suicide for those who exercise Stopping the amount of calorie people take in, they can use small plates small portions, hide food, order low calorie food can

Staff actions

-can become part of the desperation cycle -for example, putting the pt in restraints, if not truly essential for safety, ca be seen as punitive and increases the pt's desperation, anger or fear -if staff shame the pt he may be overwhelmed by guilt or embarrassment and be unable to communicate THAT feeling BOTH can result in further acting out

5.CI also involves promoting resilience in everyone (increase sturdiness, ability to weather stress and crises) 6.Persons in crisis are usually between moderate anxiety and panic; with activation of the sympathetic nervous system (fight or flight), disordered or dangerous behavior may occur. 7.Crisis symptoms include: numbness, shock, insecurity, fearful-ness, disorganization, impaired judgment or decision-making, maladaptive coping (EtOH, violence), impaired sleep &/or intake, nightmares, flashbacks; PTSD can develop later on 8.Interventions used in Crisis Intervention include: -reduce (or remove pt from) precipitants or triggers -provide supportive care -Connect to and promote use of support systems/persons

-education re: normal vs pathological response to crisis, what to expect, how to recognize when prof'l help is needed -promotion of use of relaxation techniques -guide patients away from maladaptive coping, eg. alcohol -sometimes: limited antianxiety meds (e.g. benzodiazepines e.g. Ativan (lorazepam), Inderal (propranolol); -linkage to community services (e.g. hotlines) -peer support groups (e.g. for Katrina and domestic violence survivors) -monitoring for PTSD (by both staff & the pt himself), educating on its prevention and recognizing its onset for early intervention

•Transcranial Magnetic Stimulation

-repetitive transcranial magnetic stimulation (rTMS) -helps 50-70% (better response in younger pts and female pts) -Research ongoing re: best placement, dosage still being evaluated

Interventions to promote Communication

1. teach and role-model communication skills 2. observe for signs of increasing desperation and preemptively engage pt 3. convey empathy and openness not respond punitively 4.Teach ways to ID and convey feelings 5. Make staff available and actively convey desire to communicate with patients and hear their concerns 6.Avoid overloading pt with information, feedback, or expectations that will evoke strong feelings and overwhelm the pt

Escalating

1.Always make sure that help is on the way (call code, etc); do not respond alone 2.Stand with your side towards the patient 3.Stay out of the range of assault 4.Manage your own demeanor—present in the same way you want the patient to act (calm and in control), and neither over nor under-react 5.Reduce stimulation (without isolating)—remove other pts, unnecessary personnel from the area 6.Determine level of arousal (fight-or-flight response, anxiety) and match your response to the pt's level; e.g. if at severe level of anxiety, be concrete, concise & directive rather than using verbal reasoning.

Factors Affecting One's Tendency To Violence

1.Anxiety and impaired coping 2.Impaired ability to cope with negative emotions -Fear, anger -Shame, embarrassment, humiliation (narcissistic injury) 3.Ability to communicate 4.Ability to defer gratification—impulsiveness; 5.Ability to process information 6.Psychosis -Impaired reasoning ability and/or reality testing -Paranoia -Command hallucinations

When Are Health Care Staff Assaulted?

1.Conflicts over rules, requirements, restrictions 2.Ineffective limit setting 3.Shift change—confusion and reduced staff availability 4.Interventions that cause pain 5.When nursing care requires that they become physically close to the patient 6.Intervening with pts who are delirious or confused 7.Intervening with patients who are psychotic 8.Intervening with pts who are menacing or violent

Crisis Intervention (CI)

1.Crisis: an event that overwhelms one's coping abilities 2.Goal = bolster pt's coping ability, return to pre-crisis functioning (goal is not to change personality, cure addiction, etc) 3.CI focuses on stabilization and PTSD prevention 4.There are various delivery models: -individual counseling, family therapy, -crisis hotlines—anonymous crisis & suicide intervention -mobile crisis teams—CI staff respond to pt's location -Crisis Stabilization Centers—community-based, brief-residential programs for persons in crisis who need more than outpatient help but who do not need inpt care

Selective Serotonin Reuptake Inhibitors (SSRI's)

1.Like most antidepressants, delayed onset of action (2+ weeks, up to 4-6 weeks) and individualized response patterns 2.Have fewest side effects of the antidepressant meds, 3.May increase risk of CVA (but overall risk is very small) 4.Safer in OD situations than most other antidepressants 5.Some are also used to treat PTSD, obsessive-compulsive disorder, generalized anxiety disorder, premenstrual dysphoric disorder, and social phobia.

Weight and Mental Illness

1.Poor nutritional habits, lack of nutritional knowledge, limited access/affordability r/t healthier foods, and metabolic side effects of meds all increase risk of obesity 2.Obesity in turn is part of metabolic syndrome 3.All contribute to significantly increased mortality 1.Waist measurement likely a better indicator than BMI

Interventions r/t Staff's and Patient's Own Responses to the Acting Out

1.Process events & pt's feelings about them; discuss what happened and why 2.Convey empathy; do not absolve the pt re: negative behavior but do forgive& convey acceptance of the pt 3.Manage own emotions to stay objective; if anger is shown, apologize & process w/ pt (genuine-ness, immediacy) 4.As above; correct/undo punishment 5.Monitor, correct secondary gains; process w/ pt

A note on "Giving Bad News"

1.Understand likely impact news will have on pt/others and convey it empathetically 2.Give news privately but in public area of unit, never in small closed room 3.Alert staff of need to share the info, seek input on best way to do so 4.Give news with another staffer present and with additional staff standing by 5.Provide support and share ways to cope with the news 6.Assure that staff subsequently follow-up with pt to continue support and encourage effective coping

First: Address External (System-based)

1.active self awareness—monitor our own situation and feelings in an ongoing manner 2.be empathic—put ourselves in the other's place, walk in their shoes; imagine you are the patient 3.take care of our own mental health—be well-rested, manage your stress, etc. so you can cope effectively with your own stress and frustrations 4.assure that staff's expectations are realistic 5.reduce screw-ups and other provocations—are we part of the problem? Would we be upset if we were treated the same way that we treated him?

Nursing Care During Restraint And Seclusion

1.constant monitoring to prevent injury (esp. airway restriction/asphyxiation) 2.Prevention of excess isolation 3.attending to elimination needs 4.attending to nutritional needs 5.providing for ROM and preventing damage to tissue 6.All nsg care must be done in manner that keeps everyone safe, e.g. that keeps nurse out of range of pt's extremities, that reduces risk of being bitten. Care During Restraint And Seclusion, cont'd 7.as appropriate and when tolerated, help the pt to understand the purpose of the seclusion or restraint 8.After restraint or seclusion ends, help the person to: a.understand the purpose of the seclusion or restraint b.Master ways to prevent or cope with whatever circumstances or feelings contributed to the loss of control c.Cope with any unintended distress or trauma from the seclusions/restraint itself

To prevent acting out, the nurse

1.helps the pt to communicate his feelings and meet his needs effectively, and/or 2. reduces the pt's degree of desperation, and/or 3. prevents secondary gains via self awareness, and/or (secondary gains are factors that unintentionally reinforce a behavior) 4. helps the pt cope with his own response

Electroconvulsive Therapy (ECT), cont'd

80% response rate -begins to work much faster than medication Adverse effects: -headache immediately after treatment -short term memory impairment and confusion -cardiovascular complications -Fractures if bones are fragile and/or insufficient muscle paralytic is used

Anorexia Characteristics

Behavioral: obsessive rituals r/t food and intake, excessive exercise, refusal to eat or to consume adequate intake, secondary food phobia; caloric intake is usually <1000/day. Affective: fear of maturing/sexuality, assuming adult responsibilities, loss of control Cognitive: denial, cognitive distortion & rigidity (lacks flexibility in thinking), severely distorted body image, self-depreciation, perfectionistic, obsessive thoughts (e.g. fear of weight gain)

ECT contraindications

Brain tumor Recent myocardial infarction Angina pectoris

Examples of SSRI

Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Fluoxamine (Luvox) Citalopram (Celexa) Escitalopram Oxalate (Lexapro)

Side Effects of SSRI's

GI- N/V Endocrine- wt gain, sexual dysfunction CNS- HA, anxiety, restlessness, insomnia other- dizziness, dry mouth May increase risk of CVA and increase bleeding if on ASA Increased suicidality in adolescents and young adults

HARM: a Screening Tool for PTSD

Hyperarousal--does the person exhibit irritability, difficulty concentrating, insomnia, or heightened startle reflex? Avoidance—does the person avoid people or activities, lack feelings, or feel detached from others? Re-experiencing—does the person frequently experience nightmares, recollections, or flashbacks about the traumatic event? Month—has the person experienced related symptom clusters for at least 1 month? Did the onset of symptoms occur at least 6 months after the traumatic event?

Medical Complications Related to Purging

Metabolic—erratic blood glucose levels Gastrointestinal—decreased absorption, irritation, altered elimination Dental—caries, cracking, discoloration Assessment for the above complications is an important part of nursing care, as is teaching pts how to mitigate such damage by reducing purging, rinsing mouth afterwards, etc.

Hypericum (St. John's Wort)

More effective that placebo for short-term treatment of mild to moderate depression •Very effective inducer of hepatic CYPs (reduces levels of other drugs, e.g. cyclosporine, oral contraceptives), but intensifies others (e.g. some antidepressants) side effects: insomnia, vivid dreams, anxiety, irritability, mild GI distress, fatigue, dry mouth, dizziness, HA Usual dose is 300mg TID

PTSD—Interventions

Nursing care to address: -Increased anxiety and fearfulness—teach and promote effective coping -Sleep disruption—teach and promote sleep hygiene -Alpha-adgrenergic blocker Minipress (prazosin) may help with nightmares and sleep disturbance -Irritability, anger, emotionality—guide pt to understand and modulate his emotional responses -Hypervigilance, insecurity—measures to increase security such as lights on at night, always announcing self when approaching pt -Depressed mood—antidepressants, instilling hope, countering withdrawal (while still allowing pt alone time)

"Crisis Post-mortem"

Once the situation has been de-escalated, it should be processed ASAP, with the pt and among team members. The goal of processing is to learn from the experience in order to reduce reoccurrences; consider: 1.what caused it (both pt and staff factors)? 2.what would have prevented it, or reduced its intensity? 3.what signs or symptoms (if any) did we miss, or what would let us catch it and respond faster next time? 4.what strategies are likely to work best to de-escalate this particular pt the next time?

Posttraumatic Stress Disorder (PTSD)

PTSD= a psychological condition that occurs in response to an overwhelming traumatic event; symptoms include: -Persistently re-experiencing the trauma (e.g. via flashbacks, intrusive memories, nightmares); this does not gradually subside -One's recall of trauma is accompanied by same emotional response that had occurred at the time of original trauma -Avoidance of stimuli associated with the trauma -Persistent increased arousal (e.g. hypervigilance, inability to calm or relax)

Immediately prior to the ECT

Pulse oximeter, BP, usually ECG monitoring O2 per mask Bite block to protect teeth Anesthesia personnel administer IV anticholinergic to decrease oral secretions Short-acting anesthetic, methohexital Short-acting muscle paralytic, Succinylcholine Mechanically ventilate patient until paralytic wears off

Binge Eating Disorder, cont'd

Purging and other compensatory behaviors are usually absent or very infrequent (they do not follow the majority of binging episodes as occurs in bulimia) Weight: usually overweight or obese Prevalence of 2-4% of population Includes 19-40% of people who seek treatment for weight control Females are 1.5 times more likely to have this eating pattern than males Onset usually in late adolescence or early 20s Course is generally chronic

Bulimia Nervosa

Recurrent episodes of binge eating, defined as within any 2-hour period consuming an amount of food that is significantly larger than most people would eat in 2 hours A sense of lack of control over eating during the episode Shame, embarrassment, guilt re binging Recurrent inappropriate compensatory behavior in order to prevent weight gain, e.g. purging, alternating between binging and calorie restriction, exercise Typically normal weight or fluctuating weights Purging is typical: laxatives, emetics, diuretics, compulsive exercise

Dissociative identity disorder (formerly multiple personality disorder)

Some question its existence but is accepted by mainstream psychiatry To cope with severe trauma the mind splits so that there is still the main personality but also one or more alternate personalities (called "alters") that in various ways help the pt to cope with trauma; e.g. the alter may become dominant during abuse so that it is the personality that is hurt, not the main personality The main personality is usually unaware of the alters, though some hear the alters talking to each other (which can be mistaken for, but are not, hallucinations) Alters can be of different ages, genders, races than the main personality Alters have their own names (sometimes reflecting their role, e.g. Guardian) Characteristics of alters can be very different, e.g. different voices, values, behaviors (e.g. one sober, one substance abusing). Some even have different EEG's. Main personality does not recall events experienced by alters; experiences them as missing periods of time (e.g. main personality may lack awareness of past 12-24 hours, may "wake up" in a foreign situation unable to recall how he got there, may have possessions or injuries he cannot explain, may be recognized by other persons he does not know because they met him while an alter was dominant) Treatment involves gradually reintegrating the alters into a single personality

Dissociative Disorders

They involve a failure to integrate identity, memory, and consciousness due to stress or trauma; a separation from the self Dissociative amnesia: inability to recall important personal information due to psychological reasons Dissociative fugue variant: amnesia + unexpected travel away from home Depersonalization/derealization disorder: depersonalization is a sense of being detached from one's thoughts, action, or body; derealization is a sense of detachment from one's surroundings

Biological Causation of Eating Disorders

Three times more common in identical than non-identical twins There is a higher risk for eating disorders, depression and substance abuse in first degree relatives Dysregulation of neurotransmitters, neuromodulaters, and hormones that control hunger and satiety

Treatment and nursing care: anorexia

Treatment contracts are often useful Control is a significant issue, intervene to maximize pt's sense of control when safe/feasible (allow pt to make as many decisions as possible) -daily weight taken in the same clothes -avoid power struggles

Altercasting

convey positive expectations so that pt will tend to assume the desired qualities

"Acting out"

expressing one's feelings behaviorally rather than verbally usually unconscious, not intentional Acting out has two main causes: 1. an inability to communicate, coupled with... 2. a sense of desperation When both of these are present at high enough levels, acting out occurs

Causes of Aggression in PT care

frustration-unmet needs response to loss response to threat or fear -physical or emoitional distress -a learned response -psychosis or other impaired thinking (in particular paranoia internal stimuli such as hallucinations) -punitive or non-therapeutic staff behaviors -conflict about the rules and limits

Transcranial near-infrared light

increases energy production by mitochondria, believed to have anti-inflammatory and neuroprotective effect

Coping resources

motivation to changed how eating behavior serve as a form of coping -what are precipitants -what follows (how do they benefit the pt)

Desperation

occurs when feelings are not communicated, or when they accumulate too quickly for the patient to be able to communicate or resolve them. 1.Monitor for developing desperation (signs of escalation) & address the pt's feelings/needs ASAP; 2.Promote communication by being receptive, actively encouraging interaction, and actively eliciting the expression of feelings in 1:1, via journaling, etc; 3.Provide alternative outlets for the energy that accompanies desperation (e.g. allow/encourage pacing, exercise, safe discharge of violent impulses by punching pillows, etc); 4.Anticipate pt frustration and process/manage it; 5.Decrease demands on the pt in general.

Anorexia Nervosa continue

onset usually between 13-20 years Occurs in females 10x more often than males Highest death rates among psychiatric disorders due to both complication and suicide full recovery is not the norm, but improvement and recovery are possible Increased risk of suicide, when people are hospitalized, Some people are forced fed and distressing time for anorexia

ECT Process

usual course is 6-12 treatments, 2-3 x per week' occasional outpatient preventive or maintenance treatment Informed consent required NPO after midnight that night before the procedure

Cultural Issues

•Alcohol use is highest among Native Americans and Mexican-American adolescent males •African American youth use both licit and illicit substances at lower rates than do Caucasians, but experience more related health and legal problems; alcohol is the most widely used drug by African Americans •Mexican American men report the most frequent, heavy drinking and alcohol-related problems •Substance abuse is lowest among Asian and Pacific Islanders and Cuban Americans •Men abuse chemicals more than women

Electroconvulsive Therapy (ECT)

•Artificial induction of a grand mal seizure by passing an electrical current through electrodes applied to the patient's head •Primary indications: -Extreme depression with grave danger of self-harm, needing fastest possible therapeutic effect -Acute mania (usually with risk issues/high acuity) -Unresponsive to meds -Patient unable to take/tolerate antidepressants d/t physical illness, pregnancy -(Rarely) used with some forms of schizophrenia

Healthcare-Related Trauma

•Being in the midst of a health crisis is stressful and distressing, and experiencing serious illness can be very traumatic. -Fear of dying— -Fear of loss of function, loss of independence, of pain, of suffering, of embarrassment •Treatments themselves can be inherently traumatic - Open chest surgery - Chemo, radiation, amputation, etc • Surviving and healing are the immediate priorities, leading to delayed experience of the traumatic aspects

Seclusion and Restraints

•Each is an intervention that requires an MD's order (RN may initiate in emergency) •As with all other interventions, there are specific indications for their use, typically to provide for the immediate safety of pt and staff when no other intervention will do so adequately •They often are traumatizing experiences, and for those who had been restrained during a criminal act (physical or sexual abuse) they can reawaken such trauma, or cause flashbacks

Emotional Trauma

•Emotional trauma results from factors such as abuse, violence, accidents, natural disasters, terrorist actions, war, manmade disasters, bullying, etc. •Causes also can include betrayal by a trusted person or institution (e.g. police, ministers, teachers) •It can be dehumanizing and terrifying •It can induce fear, powerlessness, hopelessness •Trauma impacts one's relationships and spirituality; how one sees others, his communities, and his world •Dissociation and feelings of rage, shame, despair, guilt, isolation, and are common after trauma Advocates prefer the term "survivor" not "victim", as it conveys and connotes empowerment instead of passivity

Phototherapy or Light Therapy

•Exposure to artificial therapeutic lighting matching the intensity and color composition of outdoor daylight •EBP for Seasonal Affective Disorder but may help others •50-60% response rate •Time-intensive: e.g. 2 hours with 2500 lux per day (or 30 minutes/day at 10,000 lux), from October to April •Relief of symptoms in 3-5 days, but relapse if treatment terminated •Effect occurs via optic nerve to hypothalamus, reduces melatonin production, alters circadian rhythm, affects neurotransmitters

Monoamine Oxidase Inhibitors (MAOI's)

•Infrequently used d/t required dietary restrictions, possible med interactions •Faster onset of action than most other antidepres-sants, 7-14 days •Symptoms of hyperadrenergic crisis: acute HTN, dizziness, HA (occipital), agitation, blurry vision, SOB, chest pain, hyperpyrexia, seizures, coma

Post-treatment care:

•Observe in PACU until awakens •Check vital signs, O2 sat should be > 90% •Reorient, assess for possible side effects, e.g. headache, confusion •Provide for fall prevention •Return to room & breakfast, if desired •Observe for possible complications, e.g. vertebral damage

Trauma-Informed Care

•Trauma-informed care is a treatment philosophy that can be incorporated into all human service fields: mental health, substance use, etc. •It recognizes that trauma is a common life experience and that trauma-related symptoms may exist in any patient. •It involves engaging people in a way that recognizes and acknowledges the role that trauma played in their lives. •Trauma-informed care changes "What's wrong with you?" to "What has happened to you?" •Short story: it is a way of caring that recognizes the role trauma has played in the person's life, that appreciates how trauma affects coping and health, and that makes trauma something we address as an integral part of all health care.

Side Effects of Tricyclics

•anticholinergic: impairs smooth muscle function dries mucous membranes. E.g. constipation, blurred vision, dry eyes/mouth, urinary retention. -drowsiness, dizziness -impaired sexual functioning -headache, tachycardia -weight gain, increased appetite -sensitivity to sunlight

Risk of hyperadrenergic crisis

•can increase NE and epinephrine, causing acute hypertension and tachycardia. Treatment= diazepam, propranolol, possibly vasodilators. Prevention requires low-tyramine or tyramine-free diet (bananas, aged meats & cheeses, red wine, overripe foods, fava beans, beer, avocado, and yeast extracts) and avoidance of certain sympathomimetic meds (e.g. OTC decongestants, stimulants, antidepressants)

Physical Dependence

•physiological requirement for the substance by the brain, as evidenced by development of tolerance and withdrawal when use decreases or stops

Abuse:

•use of alcohol or drugs for the purpose of intoxication, or, in the case of prescription drugs, for purposes beyond their intended use

Scopolamine

•used in motion sickness, produces a rapid antidepressant effect without precipitating mania; oral form not effective.