Todays Menu. Behavior 101 the big 3 Perception = Reality = Behavior 20/10/2014

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1 Todays Menu Stigma.assumptions, and beliefs Murray Hillier Nurse Educator Providence Care Hospital Kingston, ON Professor Algonquin College Ottawa, ON PRB model it s all about us Overview of Mental Disorders and associated Strategies Crisis Intervention Mental Health in Canada One in five Canadians will experience a mental health problem this year. Chances of having a mental illness in your lifetime in Canada: One in four. Mental illness touches all of us. If not you, it could be a family member, friend, colleague, or neighbour. (MHCC, 2009) Behavior 101 the big 3 Perception = Reality = Behavior 1

2 Mental Health Disorders, Strategies and Interventions Psychotic disorders e.g. Schizophrenia Mood Disorders e.g. Major Depression, Bipolar Affective disorder Anxiety disorders Personality disorders.. Focus on Cluster B Substance abuse Crisis intervention What is Psychosis? A distortion of reality There are several types The most prevalent is schizophrenia This comes from the Greek roots; schizen, to split, and phren, the mind or a fragmentation of emotions and thoughts of the mind Schizophrenia effects the way the person thinks, feels, and interacts with other people age of onset typically between 15 and 35 effects about 1% of the population found in every society that has been studied Causes Neuropathology structural brain imaging: CT and MRI enlarged lateral ventricles decreased size of temporal & frontal lobe structures cerebellar atrophy functional brain imaging: hypo frontality (dysfunction in frontal cortex) 2

3 Symptoms Delusions (usually bizarre), Schizophrenia hallucinations (auditory is most common) Disorganized speech, disorganized/catatonic behavior, looseness of association Thought insertion/withdraw/broadcast and making volition (ie. believe they can make it rain) Strategies Delusions and unusual beliefs are best dealt with by listening ( they are seeking validation) Hear the client s own descriptions of their distress Be reassuring, objective and disempower the voices by rational responding Strategies Perception Supports Coping skills 3

4 Treatment of Schizophrenia Pharmacologic antipsychotic (neuroleptic) medication motor side effects (tardive dyskinesia) atypical antipsychotics (e.g., clozapine and resperidone) have many fewer side effects Major Depression Mood is depressed for most of the day Increase/decrease appetite/sleep Decrease energy Loss of interest in activities (anhedonia) Poor concentration Psychomotor agitation/retardation Inappropriate feelings of guilt or worthlessness Seasonal Affective Disorder Changes in season can bring on episodes of mood disorder Usually depression Most often treated with light therapy regulate circadian rhythm increase production of certain hormones Bipolar Disorder A person with Bipolar Disorder experiences cycles of moods: extreme happiness, then sadness. Unreasonable optimism delusions of grandeur Hyperactivity often described as racing thoughts Rapid speech at times incoherent Decreased need for sleep Extreme short attention span Rapid shifts in emotions from rage to joy Irritability 4

5 Neurotransmitters and Depression based on observing the effects of drugs catecholamine hypothesis (not enough norepinephrine, dopamine and serotonin) Deficiency leads to difficulty transmitting neural impulses Excess NE occurs in mania Acetlycholine excess in depression and deficient in mania Exact mechanism/role unknown Major Anxiety Disorders in DSM-IV Panic disorder Agoraphobia Specific phobia Social phobia (social anxiety disorder) Generalized anxiety disorder Obsessive compulsive disorder Posttraumatic stress disorder Acute stress disorder Anxiety Unpleasant feeling of tension, uneasiness apprehension, or diffuse feeling of dread accompanied by physical symptoms e.g. sweating, nausea, dry mouth, need to urinate, shaking, dizziness early warning to person of a threat real or perceived & motivation to take action Fundamental Features of Anxiety Disorders Unwanted emotions panic attacks chronic anxiety excessive fear Unwanted thoughts obsessions excessive worries intrusive recollections Unwanted actions avoidance, escape, distraction compulsions 5

6 Panic Attack: Defining Features Discrete period of intense fear or discomfort: abrupt onset peaks within 10 min peak intensity lasts an average of 20 min can occur during waking hours or during sleep Panic Attack Symptoms Palpitations Sweating Trembling or shaking Dyspnea Choking sensations Chest pain or discomfort Nausea or GI distress Chills or hot flushes Paresthesias (numbness or tingling) Dizziness or faintness Derealization or depersonalization Fear of losing control or going crazy Fear of dying Anxiety Specific Interventions 1. Cue controlled relaxation 2. Become aware of breathing patterns that may trigger hyperventilation 3. Coping self statements 4. Distraction Empirically Supported Treatments for Anxiety Disorders Drug therapies SSRIs: e.g., Prozac High potency benzodiazepines: e.g., Xanax Cognitive behavioural therapies exposure therapy cognitive restructuring Important considerations Patient preference High addiction potential for some drugs (e.g., Xanax) Relapse rates: higher for drugs than for CBT 6

7 Impact PTSD 20 25% display symptoms of PTSD after experiencing a traumatic event PTSD ranked 5 th among all psychiatric disorders Impact D detaches emotionally from events or relationships R re experiences events E events involves substantial distress A avoids places, activities or people M lasts longer than one month S sympathetic hyperactivity, poor concentration, insomnia, irritability Personality Personality is a combination of : emotional attitudinal behavioral response patterns of an individual. Different personality theorists present their own definitions of the word based on their theoretical positions Types of Personality Traits There are many different personality types, and it is sometimes difficult to classify a person into a single type as there are many different personality traits you can possess. Personality traits are simply: Actions Attitudes Behaviors..that are unique to you 7

8 Traits vs Disorders Traits Vigilant/skeptical Introvert/shy Eccentric/imaginative Forceful/calculating Spontaneous/risky Sociable/gregarious Confident/successful Inhibited/self sufficient Co operative/joiner Controlled/conscientious Traits vs Disorders Disorders Paranoid Schizoid Schizotypal Anti social Borderline Histrionic Narcissistic Avoidant Dependent Obsessive compulsive Clues to P. D. 1. Repetitive patterns 2. Maladaptive 3. Over a long period of time Clues to Identification Extreme sense of self entitlement I m OK Project Blame Hyper vigilant Black and White attitude I m not the same as others Longstanding issues 8

9 Personality Disorders MAD: Paranoid, Schizoid, Schizotypal BAD: Antisocial, Borderline, Histrionic, Narcissistic SAD: Avoidant, Dependant, Obsessivecompulsive BAD: Antisocial Presentation: initially charming & flirtatious ranging to angry intimidation Core Beliefs: See self as unconventional outside society s rules and regulations, see others as trying to limit their freedom Defense Mechanisms: Rationalization, projection and denial Management: Non authoritarian approach, point out how out lined consequences can limit their freedom, look for secondary gains BAD: Borderline Presentation: May be carrying teddy bear, child like behavior, often in control in public, may have extreme emotional instability (self harm) Core Beliefs: I m bad, unworthy, people will abandon me because of this Defense mechanisms: regression, splitting, projection, idealize and devalue Management: reassure that you will not abandon them, provide unwavering attention, help to find alternative ways to get needs met or cope with anxiety, safety first BAD: Histrionic Presentation: Sexually provocative dress, flirtatious, dramatic physical focus, attentionseeking behavior Core beliefs: Others are here to serve and admire them, You don t have the right to deny or reject them, fear they won t be admired Defense Mechanisms: regression, dissociation Management: pay attention to true problem and not behavior, leave room if over dramatic and return once they settle, address fear or they will become more needy, provide sincere self esteem building feedback 9

10 The Fine Art of Limit Setting Do not tolerate abuse but be cautious with threats and ultimatums Set as few limits as possible Be flexible within the environment Limits must be realistic, achievable and clearly defined Take control and be direct Outline consequences and enforce promptly Be alert for escalation DSM-IV Definition of Substance Abuse a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following: 1. Recurrent substance use, 2. Resulting in failure to fulfill role obligations 3. Use in situations in which it is hazardous 4. Substance-related legal problems 5. Continued use despite recurrent social or occupational problems caused by the drug What is a drug of abuse? also called a psychoactive substance a chemical that alters a person s mood, level of perception, or brain functioning what is an addictive drug? a chemical that is self-administered and leads to (1) compulsive use, (2) tolerance, and / or (3) withdrawal Substance Use Disorder 1. Substance Abuse: Hazardous circumstance does not deter use Evasion of obligation due to use Legal problems due to substance use Personal problems due to use 10

11 Substance Abuse Disorder con t 2. Substance Dependence Include signs and symptoms of substance abuse Aware of problem due to use Unsuccessful efforts to cut down or control use Invest vast amounts of time in substance related activity Longer duration of use than initially intended Symptoms of withdrawal Relief of withdrawal symptoms with substance use Increase amounts needed for same effect Decrease effect with use of same amount Coping Mechanisms Denial of problems Projection of responsibility Rationalization of behavior Minimization of the amount consumed Substance Abuse Disorder con t 3. Delirium Tremens 5% of alcoholics in withdrawal experience agitation, disorientation, confusion, hallucination, fever, hyperactivity of autonomic nervous system (tachycardia and hypertension) Occurs after 3 to 10 days of abstinence with mortality rate of 5 to 15% C.A.G.E. Ewing, J.A.M.A. (1984) Have you ever felt you had to CUT down your drinking? Have people ever ANNOYED you by criticizing your drinking? Have you ever felt bad or GUILTY about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? EYEOPENER 11

12 Withdrawal phase # 1 Early ( 6 24 hrs ) Smells of alcohol Shakes,tremors Anxiety,agitation Sleepless Flushing Mild hypertension, tachycardia Seizures may occur in first 24 72hrs Phase #2 (1 st 36 hours) Hallucinations (visual, auditory, tactile bugs) Oriented to time, place and person Intense agitation/anxiety Senses heightened/easily frightened Phase #3 DT s (day 2 to 5) Life threatening emergency carries a 5 15% morbidity rate Extreme agitation Delirium, hallucinations and delusions Fever (infection or dehydration) No longer oriented to person, place or time Speech incoherent, paranoia Tachycardia, hypertension, diaphoresis Pneumonia, cardiac failure, dehydration leads to death if no intervention 12

13 Definition (Caplan 1964) State of disequilibrium Unable to function in one or more areas Customary coping mechanisms have failed Assumptions about Crisis (Kantor 2002) Existence of a crisis is based on the individual Usual coping mechanisms are proving to be ineffective Crises can result from positive and negative events No one is immune to crisis in right circumstances Crisis is time limited by definition Early intervention can maximize return to function Signs and Symptoms of a Crisis: Feel overwhelmed Helpless/hopeless Loss of control Difficulty with routine activity Increased independence on others High anxiety (severe to panic) Many somatic (px) complaints How to Respond: Necessary to begin at the end The emotions/delusions/hallucinations are blocking the persons ability to think and cope deal with the emotions be aware of your approach Most importantly, strive to understand and empathize 13

14 How to Respond con t For someone with mental illness: their delusions and hallucinations are their reality. YOU CANNOT TALK SOMEONE OUT OF A DELUSION How to Respond con t Understand their perception of the situation Have person identify the problem (their perception) While listening to them, listen for key words and phrases and use them Crisis Intervention Goal Is the resolution of an immediate crisis It s focus is on the supportive with the restoration of the individual to his pre crisis level of functioning How far you go in life depends on you being tender with the young, compassionate with the aged, sympathetic with the striving and tolerant of the weak and the strong. Because someday in life you will have been all of these. ~George Washington Carver~ (American scientist, botanist, educator, inventor; ) 14