SOAR- RN

Alissa Lyon, LCSW- Meridian Emergency Dept. Social Worker

Oreana Harless, LCSW- BoiseEmergency Dept. Social Worker

Mental Health Overview

What do you hope to gain from today’s training?

What is your experience with mental illness?

What training did you receive in Nursing School pertaining to mental health?

StatisticsAn estimated 26.2 percent of Americans ages 18 and older —

about one in four adults — suffer from a diagnosable mental disorder in a given year.

When applied to the 2004 U.S. Census residential population estimate for ages 18 and older, this figure translates to 57.7 million people.

Mental disorders are the leading cause of disability in the U.S. and Canada.

Nearly half (45 percent) of those with any mental disorder meet criteria for 2 or more disorders, with severity strongly related to comorbidity.

Axis I (Clinical Disorders): Depression, Bipolar Disorder, Anxiety, Schizophrenia

Axis II (Personality Disorders): Borderline, Antisocial, Dependent, Histrionic

DepressionPersistent sad, anxious, or “empty” mood

Feelings of hopelessness or pessimism

Feelings of guilt, worthlessness, or helplessness

Loss of interest or pleasure in hobbies and activities that were once enjoyable, including sex

Significant weight fluctuation or change in appetite

Decreased energy, fatigue; feeling “slowed down”

Depression (Cont.)

Difficulty concentrating, remembering, or making decisions

Trouble sleeping, early morning awakening, or oversleeping

Restlessness or irritability

Persistent physical symptoms, such as headaches, digestive disorders, and chronic pain that do not respond to routine treatment

Postpartum DepressionPostpartum depression is a period of time of

extreme vulnerability to depression shortly after giving birth.

“Postpartum blues” occur in about 80% of women.

PPD affects 12 to 15% of women.

Bipolar DisorderBipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.

Bipolar- Mood Changes

Manic Mood Depressed Mood

A long period of feeling "high," or an overly happy or outgoing mood

Extremely irritable mood, agitation, feeling "jumpy" or "wired“

A long period of feeling worried or empty

Loss of interest in activities once enjoyed, including sex

Bipolar Disorder- Behavioral ChangesManic Phase Depressed Phase Talking fast, jumping from one

idea to another, having racing thoughts

Being easily distracted

Increase in goal-directed activities

Being restless, sleeping little

Having an unrealistic belief in one's abilities

Spending sprees, impulsive sex, and impulsive business investments

Feeling tired or "slowed down"

Having problems concentrating, remembering, and making decisions

Being restless or irritable

Changing eating, sleeping, or other habits

Thinking of death or suicide, or attempting suicide

Anxiety DisordersAnxiety is a complex combination of the feeling of fear,

apprehension and worry often accompanied by physical sensations such as palpitations, chest pain and/or shortness of breath.

Anxiety disorders are serious medical illnesses that affect approximately 19 million American adults.

About 18% of American adults have anxiety disorders.

Generalized Anxiety Disorder (GAD)GAD is an anxiety disorder characterized by

chronic anxiety, exaggerated worry and tension, even when there is little or nothing to provoke it.

Worries are accompanied by physical symptoms, especially fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, and hot flashes.

Obsessive-Compulsive Disorder

OCD is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions).

Obsessions often have themes to them, such as:

Fear of contamination or dirt

Having things orderly and symmetrical

Aggressive or horrific impulses

Sexual images or thoughts

OCD- Symptoms of Obsessions Fear of being contaminated by

shaking hands or by touching objects others have touched

Doubts that you've locked the door or turned off the stove

Thoughts that you've hurt someone in a traffic accident

Intense distress when objects aren't orderly or facing the right way

Images of hurting your child

Avoidance of situations that can trigger obsessions, such as shaking hands

Replaying pornographic images in your mind

Dermatitis because of frequent hand washing

Skin lesions because of picking at your skin

Hair loss or bald spots because of hair pulling

Compulsions typically have themes such as:

Washing and cleaning

Counting/ Checking

Demanding reassurances

Performing the same action repeatedly

Orderliness

OCD- Symptoms of Compulsions

Hand washing until your skin becomes raw

Checking doors repeatedly to make sure they're locked

Checking the stove repeatedly to make sure it's off

Counting in certain patterns

Making sure all your canned goods face the same way

Panic DisorderPanic disorder is an anxiety disorder and is

characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress.

PTSDPost-Traumatic Stress Disorder is an anxiety

disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened.

Traumatic events that may trigger PTSD include violent personal assaults, rape, sexual molestation, natural or human-caused disasters, accidents, or military combat. 

Social Anxiety People with social phobia have a persistent, intense, and

chronic fear of being watched and judged by others and being embarrassed or humiliated by their own actions.

Physical symptoms often accompany the intense anxiety of social phobia and include blushing, profuse sweating, trembling, nausea, and difficulty talking.

Psychotic DisordersSchizophrenia and Psychosis - What's the Difference?

◦ Psychosis is a general term used to describe psychotic symptoms. Schizophrenia is a kind of psychosis.

◦ Several different brain disorders can lead to psychotic symptoms, including lesions in the brain resulting from head traumas, strokes, tumors, infections or the use of illegal drugs.

◦ Physical testing can rule out medical conditions (seizure disorders, metabolic disorders, thyroid dysfunction, brain tumor, street drug use, etc) that sometimes have similar symptoms.

◦ If a serious depression goes untreated for a long time, psychotic symptoms may develop.

Schizophrenia

Schizophrenia is a serious mental illness that affects how a person thinks, feels, and behaves. The person finds it difficult to tell the difference between real and imagined experiences, to think logically, to express feelings, or to behave appropriately.

Symptoms may include the following: hallucinations, delusions, disorganized speech, grossly disorganized or catatonic behavior, social withdrawal, lack of interest and poor hygiene.

Approximately 2.4 million American adults, or about 1.1 percent of the population age 18 and older in a given year,

have schizophrenia.

Schizophrenia affects men and women with equal frequency. Schizophrenia often first appears in men in their late teens or

early twenties. In contrast, women are generally affected in their twenties or early thirties.

Characteristic Symptoms:

Paranoid delusions, or delusions of persecution, for example believing that people are "out to get" you

Delusions of reference - when things in the environment seem to be directly related to you even though they are not.

Somatic delusions- false beliefs about your body

Delusions of grandeur - for example when you believe that you are very special or have special powers or abilities.

Hallucinations- Seeing or hearing things that don't exist, although hallucinations can be in any of the senses.

Thought disorder. Difficulty speaking and organizing thoughts may result in stopping speech midsentence or putting together meaningless words, sometimes known as "word salad."

Disorganized behavior. This may show in a number of ways, ranging from childlike silliness to unpredictable agitation.

Negative symptoms include flat or and emotion (blunted affect), poverty of speech (alogia), inability to experience pleasure (anhedonia), lack of desire to form relationships (asociality), and lack of motivation (avolition).

Schizoaffective Disorder- Symptoms that meet the criteria for Schizophrenia are present and during which, at some time, there is either a Major Depressive Episode, or a Mixed (Manic) Episode concurrent with symptoms of schizophrenia.

Delusional Disorder- Non-bizarre delusions involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by a spouse or lover or having a disease.

Eating Disorders

Anorexia NervosaAnorexia nervosa is a chronic and severe disorder with a high incidence of

morbidity and mortality (Gowers et al, 2000). Signs and symptoms to look out for include:

-Weight loss-Refusal to eat-Appetite loss-Fear of becoming obese-Self-induced vomiting-Difficulty in swallowing-Use or abuse of laxatives-Constipation-Preoccupation with food, weight loss and/or body image-Lack of menstruation

Physical problems that stem from the condition- some of which can become life threatening- include electrolyte imbalance, bradycardia, hypotension, hypothermia, fatigue, oedema and amenorrhoea.

It is essential to observe patients' nutritional status as eating disorders can be life threatening.

It is essential to monitor patients' elimination pattern as excessive use of diuretics and laxatives is common among patients with eating disorders.

Monitoring skin condition for breakdown and poor healing is an important part of the nurse's role.

Bulimia NervosaRecurrent episodes of binge eating. An episode of binge eating

is characterized by both of the following:

• eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

• a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.

The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.

Self-evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Eating Disorders and Pregnancy

Magnifies eating disorder issues- weight and body concerns

Complications- miscarriage, premature

Increased risk for postpartum depression

Personality DisordersYou’re the best doctor in the world…no one understands me like you…What…no Norco!?? I hate you…

You’re just like all the other terrible doctors!

People with personality disorders tend to have:

• Great difficulty getting along with others

• History of disruptive relationships

• Difficulty regulating feelings/ behavior

• Difficulty learning from experience

• Inability to accept responsibility for their own behaviors/problems

Said another way:Personality disorders are excessively rigid

patterns of behavior or relating to others.

“In most of us by the age of 30, the character has set like plaster, and will never soften again”

William James

Borderline Personality DisorderBorderline personality disorder (BPD) is a serious mental

illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior.

Originally thought to be at the "borderline" of psychosis,

people with BPD suffer from a disorder of emotion regulation.

These patients tend to triangulate and divide staff.

Anti-Social Personality Disorder

Antisocial personality disorder is characterized by an individual's disregard for social rules and cultural norms, impulsive behavior, and indifference to the rights and feelings of others.

Approximately 1.0 percent of people aged 18 or over have antisocial personality disorder.

Dependent Personality DisorderDependent personality disorder is described as a pervasive

and excessive need to be taken care of that leads to a submissive and clinging behavior as well as fears of separation.

The dependent and submissive behaviors are designed to elicit care giving and arise from a self-perception of being unable to function adequately without the help of others.

Histrionic Personality DisorderThe affected individual displays an enduring pattern of

attention-seeking and excessively dramatic behaviors beginning in early adulthood and present across a broad range of situations.

Individuals with HPD are highly emotional, charming, energetic, manipulative, seductive, impulsive, erratic, and demanding.

“Extreme Drama Queen/King”

DementiaDementia is a progressive decline in memory and at least one other cognitive area

in an alert person. These cognitive areas include attention, orientation, judgment, abstract thinking and personality.

Dementia symptoms vary depending on the cause, but common signs and symptoms include:

Memory loss Difficulty communicating Inability to learn or remember new information Difficulty with planning and organizing Difficulty with coordination and motor functions Personality changes Inability to reason Inappropriate behavior Paranoia Agitation Hallucinations

Dementia vs DeliriumDelirium is an acute disorder of attention and global cognition (memory and perception) and is treatable. The diagnosis is missed in more than 50% of cases. The risk factors for delirium include age, pre-existing brain disease, and medications. There are many causes, the most common are:

D Dementia E Electrolyte disorders L Lung, liver, heart, kidney, brain I Infection R Rx Drugs I Injury, Pain, Stress U Unfamiliar enviroment M Metobolic

Prevention of delirium includes the avoidance of psychoactive drugs, quiet environment, daytime activity, dark and quiet at night, visual and hearing assistive devices, orientation devices, and avoidance of restraints

What Causes Dementia?Diseases that cause degeneration or loss of nerve cells in

the brain such as Alzheimer's, Parkinson's and Huntington's.

Diseases that affect blood vessels, such as stroke, which can cause a disorder known as multi-infarct dementia.

Toxic reactions, like excessive alcohol or drug use. Nutritional deficiencies, like vitamin B12 and folate

deficiency.

Infections that affect the brain and spinal cord, such as AIDS dementia complex and Creutzfeldt-Jakob disease.

Certain types of hydrocephalus that can result from developmental abnormalities, infections, injury, or brain tumors.

Head injury -- either a single severe head injury or longer term smaller injuries, like in boxers.

Illnesses other than in the brain, such as kidney, liver, and lung diseases, can all lead to dementia.

Suicide Prevalence in the General Population

The Centers for Disease Control and Prevention recognized suicide as the 11th leading cause of death in the United States among all age groups in 2006.

This staggering number equates to 1 suicide every 16 minutes in the United States alone.

Suicide in the Hospital

General hospital patients are estimated to have a suicide rate that is three times more than the “normal” population.

Roughly 4% of all completed suicides can be attributed to inpatient suicides.

The National Quality Forum has listed suicide or attempted suicide of a hospitalized patients as a “Never Event” meaning an event that is avoidable and therefore should never happen.

1998: Suicide of hospitalized patients recognized as a reportable sentinel event

2007: TJC established a National Patient Safety Goal aimed at identifying patients at risk for suicide and identifying safety risks that might be found within the hospital

2008: TJC recognized a record number of inpatient suicides

2009: Patient suicide ranked as the second most reported sentinel event

Suicide Risk Assessment

What do you think is most important to assess suicide risk?

Suicide Risk Actual attempt vs. verbalization

Method, planned out and means

Rescue was not self-initiated

History of suicide attempts

Previous psychiatric hospitalization(s)

Sense of hopelessness/helplessness

Command hallucinations

SUICIDE: A MULTI-FACTORIAL EVENT

Neurobiology

Severe MedicalIllness

Impulsiveness

Access To Weapons

Hopelessness

Life Stressors

Family History

SuicidalBehavior

Personality Disorder/Traits

Psychiatric IllnessCo-morbidity

Psychodynamics/Psychological Vulnerability

Substance Use/Abuse

Suicide

Involuntary HoldsA few words about involuntary holds and

mental health assessments:

Document observations of patient behavior that lead you to believe the pt will be a danger to self/others if they are discharged?

Be objective – avoid labels or biases

Describe patient’s behavior, mood, affect

Document from whom you are obtaining information

Use quotes when appropriate

Use professional grammar

Mental Health Assessments

-Safety Check- Update Policy Patients on Suicide Precautions Identify Suicide Risk Level (Low, Moderate or High)

◦ Use RN Suicide Screen (done once upon admission or when patient is alert and oriented)

Make Social Work referral Initiate ICMP Safety/Behavioral Health addendum Inform patient of access to telephone as soon as patient is able to understand. Assessment/Documentation: Use Suicide Precautions/Mental Hold Screen (or Form)

◦ Low Risk – assess/document per standard unit guidelines for focused assessment: psychosocial and observation (eg: q4 hrs Med/Surg, q4 hrs Telemetry)

◦ Moderate Risk – assess/document hourly OR provide continuous observation (document family, friend, PSA or staff) and assess/document per unit guidelines for focused assessment.

◦ High Risk and/or Mental Health Hold – Provide continuous observation by PSA or staff (patients on mental health holds must have PSA or staff in their room at all times). Initiate Safety Checklist for Suicide Precautions. Assess/document per unit guidelines for focused psychosocial assessment and observation.

Step 1: Identify Risk FactorsSuicidality

Current and Past Psychiatric Diagnoses

Physical Illness

Family History of Suicide

Psychosocial Stressors

Impulsivity

Hopelessness

Command Hallucinations

Childhood Trauma

Step 2: Identify Protective Factors

Positive Coping Skills

Spirituality

Children or pets in the home

Social Supports/Connections

Step 3: Ask About Suicidal IdeationAsk specifically about suicidal ideation

(frequency, intensity, duration), plans and behaviors

Do you have a specific plan?

Do you have access to firearms?

Step 4: Determine RiskDetermine level of risk and develop an appropriate

treatment setting and plan to assess the risk.

Immediate safety needs begins with the patient’s arrival in the emergency department.

Follow Suicide Precautions- clear room

High Risk Patients include those who:

Have a serious or nearly lethal suicide attempt orhave persistent suicide ideation and/or planning and:

Command hallucinationsPsychosisRecent onset of major psychiatric syndromeRecently discharged from an inpatient psychiatric unitHistory of acts/threats of aggression

The National Institute of Mental Health (NIMH)

http://www.nimh.nih.gov