Working with the Mentally Ill and Substance Abusers: Connections Between Sexual Assault, Mental Illness, and Substance Use

Transcription

1 Working with the Mentally Ill and Substance Abusers: Connections Between Sexual Assault, Mental Illness, and Substance Use Jolene Culbertson, ARNP, SANE-P Advanced Practice Forensic Nurse SANE Coordinator Harrison Medical Center

2 Why we need to understand this connection.. Childhood sexual abuse increases the risk of a wide range of subsequent behavior problems, mental health disorders and adjustment difficulties in childhood as well as the serious long-term sequelae in adult life. Allows us to educate patients about the risk factors related to SA Helps us to understand the short and long-term consequences of SA Child Abuse and Neglect 27 (2003)

3 Risk Factors for Sexual Assault A history of child/adolescent SA can predispose to future assaults Physical and/or emotional abuse Low self-esteem, depression Neglected children (parent with ETOH problem or battered mother) Early sex initiation and/or multiple partners. Prior forced sex Drinking and/or drug use Preventive Medicine 39 (2004)

4 Possible Consequences of SA Missing school and prematurely quitting school Drinking at a younger age Early sexual activity and multiple sexual partners Relationship violence and future victimization Suicidality, depression, anxiety, PTSD Unintended pregnancies, STD s Smoking, weight issues, adult ETOH issues Am J Prev Med 2005;28 (5)

5 Multiple Vulnerabilities Age; women age experience the highest rates of dating violence including sexual assault. 32% of all reported rapes occurred in females aged Substance use; adolescents who use are more likely to engage in unsafe sex, and have multiple partners Mental health; depression, anxiety, PTSD, psychosis Developmental Disabilities; Downs, Tourette s, autism, asberger s, physical or sensory handicaps, etc Perspectives on Reproductive Health, 36;6 (2004)

6 Mental Health Issues Depression Anxiety disorder (social phobia, GAD, panic disorder) Suicidality / Borderline Personality Disorder ( trauma survivors ) Post Traumatic Stress Disorder (immediate reaction or long-term problem) Psychosis (mania, schizophrenia, dementia, drug / medication)

7 Depression Depressed mood Lack of interest or pleasure Weight change (gain or loss) Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or guilt Decreased concentration or indecisiveness Thoughts of death or suicide DSM-IV TR, 4 ed. (2000)

8 Anxiety (various sub-types) Excessive anxiety or worry Difficulty controlling the worry The anxiety/worry causes significant distress; restlessness, fatigue,difficulty concentrating, irritability, muscle tension, sleep disturbance DSM-IV TR, 4 ed. (2000)

9 Personality Disorders (various) Personality style, an enduring pattern of being Unstable and intense interpersonal relationships (a trauma survivor) Impulsivity (relationships, sex, risky behavior) Recurrent suicidal behavior (threats, selfmutilation). They re not able to selfsooth Affective instability. Chronic feelings of emptiness. Inappropriate intense anger Can become paranoid or dissociate DSM-IV TR, 4 ed. (2000)

10 Post Traumatic Stress Disorder Exposure to a traumatic event (past or present) The response involved intense fear, helplessness, or horror The event is re-experienced (dreams, intrusive memories or visions of event) Physiologic reactivity, and arousal (startle, hypervigilant, irritable) Avoidance of similar situations DSM-IV TR, 4 ed. (2000)

11 Psychosis (schizophrenia, mania, drugs, dementia, etc ) Confusion, disorientation Anxious, aggressive, irritable, irrational Hallucinations (abnormal sensory stimulation, most frequently auditory or visual) Delusions (bizarre belief systems not based in reality) Illusions (inaccurate thoughts or beliefs triggered by a real stimulus) DSM-IV TR, 4th ed. (2000)

12 Examining patients with Mental Health issues Is the patient stable enough for you to perform a SANE exam? Can they consent? Do you feel safe to perform the exam? How traumatic will the exam be for the patient? Are they currently in mental health treatment? If not, do they need a referral? Do they generally take meds and do they have access to those meds? Do they have a safety plan in place? Can they follow the safety plan?

13 Substance Abuse Issues Women substance abusers show high rates of dual diagnosis (MH&SA) 30-59%, most commonly from a history of repetitive childhood physical or sexual assault. Is the patient under the influence? (of what?) Are they able to consent to a SANE exam? How do you know this and how do you document this? Do you suspect they will be going into withdrawals when they leave the hospital? How do you assess this? Do they need referrals for CD treatment, a safety plan? The American Journal on Addictions, 6;4 (1997)

14 After the exam, then what?? Explain about PTSD, what is normal, when to get professional help and how this can make a difference in long term outcome. Caution against the use of drugs or alcohol to ease the pain as this can delay the healing process and potentiate PTSD. Explore and encourage any healthy habits they have (exercise, meditation, family and friends, church, etc..)

15 Case Example: 46 yo female came to ED c/o assault that had occurred Thursday or Friday. Believed she and her dogs had been drugged by an intruder. Initially called 911 and reported a break-in, later started thinking she had been sexually assaulted. Has a hx of anxiety and depression, and takes Xanax (12 mg/d), Neurontin (900mg/d), and Ambien. Husband is in Iraq and she is requesting he return home.

16 Case Example 28 yo female came to ED with c/o being raped. Went to Seattle to buy some speed, instead found someone who offered her crack. Took him to her home in Kitsap Co. the next day he wanted payment for the crack, and when she said she didn t have any money, he took sex instead. Current med is buprenorphine. Given Valium 10 mg. in ED. Male friend is with her for support (x-boyfriend)

17 Case Example 2 14 yo girls went AWOL from CD treatment program on New Year s Eve. Picked up (hitch hiking) by 2 adult males, drove to a bar and got 3 more of their friends to join them, and they took the girls to a motel. Significant alcohol use. The girls were dropped off at a gas station where they called a friend to pick them up. He took them to another friends, but they stayed in the car because we were puking, then there were 2 guys in the back seat having sex with us. Picked up by police as runaways and sent to a locked crisis unit in Kitsap County. The girls requested SANE exams the next day.