Transcript mental illness - Preparing Texas

Sylvia Baack, MSN, RN, PhD student at the University of Texas at Tyler
Robin Keene, MSN, RN, PhD student at the University of Texas at Arlington
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By the end of this presentation, the
participant will be able to:
 Recognize signs and symptoms associated with
exacerbations in mental illness.
 State 2 methods for de-escalating an individual
with mental illness.
 Discuss 2 interventions in managing an individual
with mentally illness in a shelter setting.
 Discuss the importance of medication
management in the individual with mental illness.
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Write down the following:
 1. What are the characteristics of mental illness?
 2. Define mental illness.
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“A mental illness is a psychiatric disorder
that results in a disruption in a person's
thinking, feeling, moods, and ability to relate
to others. Mental illness is distinct from the
legal concept of insanity.”
http://www.wordiq.com/definition/Mental_illness
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Mental health, mental hygiene, behavioral
health, and mental wellness are all terms used
to describe the state or absence of mental
illness. http://www.wordiq.com/definition/Mental_illness
 I can't explain myself, I'm afraid, Sir, because
I'm not myself you see.
Alice
 Are we a one-size fits all society?
 The British prophet dressed like a
disciple.
 Are all homeless individuals mentally
ill?
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According to National Alliance on Mental
Illness (NAMI), mental illness affects 1 in 4
families.
How many of you know someone who has a
serious mental illness?
Did you know right away?
What behaviors were displayed that made
you realize there was a problem?
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Some psychiatrists attribute mental illness to
organic/neurochemical.
Treatment may include psychotropic
medication, psychotherapy, lifestyle
adjustments and other supportive measures.
It is important to note that we really don't
know what causes mental illness.
Nature vs. nurture.
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According to the 2003 report of the U.S.
President's New Freedom Commission on
Mental Health, major mental illness,
including clinical depression, bipolar disorder,
schizophrenia, and obsessive-compulsive
disorder, when compared with all other
diseases (such as cancer and heart disease), is
the most common cause of disability in the
United States.
 According to NAMI:
 23% of American adults will suffer from a
clinically diagnosable mental illness in a
given year, but less than ½ will suffer
symptoms severe enough to disrupt their
daily functioning.
 Is sleep deprivation a form of mental
illness? Alcoholism?
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At the start of the 20th century there were
only a dozen recognized mental illnesses.
By 1952 there were 192.
Diagnostic and Statistical Manual of Mental
Disorder, Fourth Edition (DSM-IV) today lists
374.
Why do you think this is?
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Approximately 9- 13 % of children under 18
experience a serious emotional disturbance
with substantial functional impairment, and
5-9% have a serious emotional disturbance
with extreme functional impairment due to a
mental illness.
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Fortunately, many will recover before
reaching adulthood, & lead normal lives
uncomplicated by illness.
What are the implications here?
Is bullying a form of mental illness?
Is depression to the point of despondency
(which may lead to suicide) a form of mental
illness?
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Emotional scars from neglect or abuse?
Ever seen someone spank their child for
hitting other children?
Individuals with aggressive tendencies in their
youth remain aggressive as older adults!
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The treatment success rate for a first episode
of schizophrenia is 60 percent, 65 percent to
70 percent for major depression, and 80
percent for bipolar disorder.
We do not see things as they are, we
see things as we are.
The Talmud
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Depending on perspective-this results from
 medical & technological advances, (research);
 increased incidence of mental illness, due to some
causative agent (diet, increased stress )
 an over-medicalization of human thought
processes,
 Increased tendency of mental health experts to
label individual "quirks and foibles" as illness.
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The subject of mental illness is profoundly
controversial.
Homosexuality was once considered such an
"illness" (see DSM-II), perception varies with
cultural bias and theory of conduct.
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Other controversies (NAMI)
 Epilepsy
 Sleep deprivation
 Drug & alcohol addictions are NOT mental illness
 Others…? Situational depression?
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Question: Where did the term Mad Hatter
come from?
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Autism Spectrum
Disorders
AttentionDeficit/Hyperactivity
Disorder
Bipolar Disorder
Borderline Personality
Disorder
Dissociative Disorders
Dual Diagnosis and
Integrated Treatment of
Mental Illness and
Substance Abuse
Disorder
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Eating disorders
Major Depression
Obsessive-Compulsive
Disorder (OCD)
Panic Disorder
Post-Traumatic Stress
Disorder
Schizoaffective Disorder
Schizophrenia
Seasonal Affective
Disorder
Suicide
Tourette's Syndrome
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Contrary to popular belief, PMS is not form of
mental illness!!
Although some women “may” become
passive-aggressive temporarily!
Interventions:
 Got milk?
 Chocolate is very helpful (lots of it!)
 Heating pad, Ibuprofen, & lots of patience!
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According to NAMI 2/3’s of states have cut
mental health funding.
Implications for first responder’s and health
care personnel?
Implications in shelter ops?
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Let’s throw in the poor economy for good
measure…
 Loss of jobpoor self-esteemdepression?
 Worry, anxiety etc.
 What happened during the great depression?
 Current unemployment for 1-2 years…
 What we need are some good coping skills…
 “Denial is my happy place.”
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What happens when a patient with mental
illness experiences a major disaster &
becomes displaced?
 Traditional counseling suspended
 Medications interrupted
 Coping with loss and grief
 Social distancing
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Natural disasters are on the rise & are
increasing in magnitude and frequency (James,
Subbarao & Lanier, 2008).
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Global warming vs. cyclic changes: increase in
all extreme weather events (Keim, 2008).
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On average a disaster takes place somewhere
in the world every day (Norris, 2005 as cited by Burnett,
Dyer & Pickins, 2007-2008).
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FEMA has spent 6 times more in the last 10
years, than was spent in the preceding
decade on natural disasters (Fox, White, Rooney &
Rowland, 2007).
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Slepski (2005) defines emergency
preparedness as, “the comprehensive
knowledge, skills, abilities, & actions needed
to prepare for & respond to threatened,
actual or suspected, chemical, biological,
radiological, nuclear or explosive incidence,
man-made incident or natural disaster or
other related events.” (Garbutt, Peltier & Fitzpatrick, 2008)
It would be so nice if something made sense
for a change.
Alice
Definition of anxiety:
A significant unexpected threat to a persons
feeling of self esteem or well being
( Peplau 1989)
Anxiety is a subjective, affective experience;
it is felt as an unpleasant uneasiness,
as apprehension, dread or uncanny sensation
Acting out behavior:
 May be overt expression of anger and aggression
 or covert expression of resentment
Somatizing
 Includes psychosomatic disorders. Anxiety is converted to
nervous system function (Peplau, 1989)
Assessment of mild anxiety:
Perceptual field widens slightly
Aware, alert and grasps concepts
Able to recognize and name anxiety
Freezing: may withdrawal (especially with depression)
Intervention:
Encourage individual to use energy the anxiety provides to
encourage learning (keep task simple)
Give specific directions
Ask them to do a simple task to help-do not overwhelm
them. What simple tasks could you ask them to do?
Assessment of moderate anxiety:
Perceptual field is narrowed
Selective inattention
Intervention:
Encourage individual to talk
Focus on one experience at a time
Describe it fully
Then formulate generalizations about the experience (so it
doesn’t seem to bad).
Remember severity is all a matter of perspective.
Assessment of severe anxiety:
Perceptual field reduced to exaggerated detail (tunnel
vision anyone?)
Attention focused on narrow area of event
Intervention:
Encourage to talk
Ventilation of random ideas is likely to reduce anxiety
PANIC
Assessment of
:
Perceptual field reduced to exaggerated detail
Feel as is there is a great threat to their well being
Energy produced may be mobilized as rage
May pace, physically act out or fight
Intervention:
Provide safety
Allow pacing and walk with the individual
Do not touch the individual
Speak fewest possible words
Symptoms reported by patients:
Intense apprehension
Fear, terror
Irritability
Anger or hostility
Fear of loss of self-control
Pacing
Think how you would feel if you felt “boxed in”.
You are on a plane losing altitude with severe
turbulence. ..
Intervene early-At first signs of behavior:
Pacing
Abusive language
Argumentative
Increase in voice volume
Refusal to follow direction
Threat toward others
Damage to property
Aggressive body language
Triggers to violence
(Johnson, Hauser, 2001)
Non-verbal cues
Poor historical response to stress
Inadequate coping mechanisms (nothing you try seems to work).
Environmental influences & triggers:
 Previous hospitalization
 Enforcement of rules
 Perceived unfair treatment
 Long waiting periods
 Crowding environmental practices that “shame” or “humiliate” (don’t be
dismissive).
 Boredom
Current intent to harm others
Past history
Previous physical or sexual assault
Fire setting or property destruction
Group or gang violence
Hallucinations (violent intent toward others)
Substance abuse
Think about the fight or flight response:
Dyspnea (shortness of breath)
Palpitations
Trembling or shaking
Chest pain or discomfort
Cold clammy skin
Chills or hot flashes
Dryness of the mouth
Elevated heart rate and respirations
You are in line at a gas station, a man with a gun
comes in…how do you feel?
De-escalation is the process of helping patients
regain self-control by lowering emotional tension with
the use of therapeutic communication.
(Chabors, Judge-Gomey, Grogan, 2003).
Early identification of anxiety and appropriate
intervention are key.
Lower emotional tension without using restraints (if
possible)
Focus on the “here and now”.
The goal is to restore the individuals’ emotional
stability (Chabora, Gurney, & Grogan, 2003).
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Use calm verbal skills
Empathetic communication skills
 Gentler & less provocative methods of
communication
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Good negotiation skills
Calling the individual Mr. or Mrs.
 Show great respect
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Introducing yourself
 Leave a WIDE margin of personal space
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Provide clear, honest (not brutal) information
Careful listening
Those who convey an attitude of respect,
humility, empathy and self-confidence, have
a greater chance of effective de-escalation.
(Karp, 2002; Hamrin, Lennaco & Olsen, 2009)
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Reduce stimulation
 Remove individual from area
 Dim lights, decrease noise
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Calming room
 Designate a room early in shelters for voluntary
use by patient
 Soft music or quiet
 Soothing physical environment
 Multi-sensory; aroma therapy, music etc.
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Provide support:
 Designate someone (early on), preferably a social
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worker or mental health nurse, psychologist etc.,
Stay with the individual
Encourage coping skills (breathing)
Convey understanding, use non-verbal support
Ask what the individual needs to stay in control
▪ Understand precipitating factors, antecedents &
triggers
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Avoid being judgmental, avoid criticism
Use reflection, restatement for clarification
Establish trust & therapeutic rapport
BE aware of your own behavior and
remember not to take anything personally!
Your behaviors and attitudes will impact the
attitudes and behaviors of the individual.
Document behaviors…
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Don’t forget to obtain a health history if at all
possible
Plan ahead:
 Gliding rocking chair
 Warm, soft, weighted blankets
 Small pressure balls
 Lava lamps
 Large Tupperware with raw rice (sensory)
(Lancioni, Cuvo & O’Reilly, 2002)
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Consider other signs & symptoms or things
that cause confusion:
 Dehydration
 Lack of food
 Fatigue
 Blood sugar (diabetics)
 Elderly
 Oxygen deprivation
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A 42 year old woman in a shelter who has
experienced a forced evacuation due to a
massive tornado, comes to you and states, “I
don’t know where I am, I have to get home.”
She appears confused, has tremors, she is
diaphoretic and is on the verge of crying, vital
signs, BP 154-90, P 104, T 97.0, R 22, BS 62.
What questions would you ask?
What interventions would be most
appropriate?
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A 76 year old man is wandering aimlessly, he
is wringing his hands, and talking to himself.
He will occasionally pick up an item that does
not belong to him.
BP 102/51, P 112, R-24, T-99.0, BS 112, poor
turgor, and dry mouth.
Questions you want to ask? Further
assessment of this individual?
Interventions?
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A 34 year old man, is pacing, he is clearly
anxious and keeps saying, “I’ve just got to get
out of here”. Another man approaches him to
ask if he’s ok-the individual raises his voice,
becomes agitated and yells at him.
V/S BP 138/86, P 92, R 20, T 97.8, BS 122.
How would you handle this situation?
What de-escalation methods would you use?
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You must be able to recognize the
signs/symptoms of mental illness.
You must be able to rule out physiologic
conditions that may mask as mental illness,
or have someone in your shelter that can
(EMT, Paramedic, Nurse, etc.)
S/S may wax and wane, & may not be
apparent immediately and may vary.
Jack Nicholson (Melvin Udall): ...
go sell crazy someplace else, we are all stocked
up here ...
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Schizophrenia-commonly seen in homeless .
Positive Behaviors are:
 Delusions
 Hallucinations
 Disorganized speech
 Disorganized behavior
 Inability to sleep
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Negative behaviors of schizophrenia
 Flat affect
 May talk, but there is truly no content
 Lack of purposeful action
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Types of schizophrenia:
 Paranoid, Disorganized, Catatonic
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Alcohol and substance abuse can alter
symptoms
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Watch closely for violent or suicidal
behaviors
They may obey forces that are not real and
out of their control
Will require patience, additional
communication skills, compassion
Must provide a safe environment
First, rule out a physical problem & ensure
your own safety
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Most common mental illness
Severe mood swings, mania and depression
S/S of depressive phase: loss of self-esteem
Despondent, withdrawal, sadness,
helplessness
S/S of mania: Euphoria, irritable, decreased
need for sleep, constant talking, grandiosity
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Narcissistic; grandiose;
Borderline personality disorder
Anxiety; Depression
Anti-social personality disorder
Passive aggressive
Pleasantly confused: Cleopatra
 Sometimes fantasy is better than reality
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Their goal is to gain control of others by
manipulating them.
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Resiliency is needed in a disaster event
Resiliency is defined as a process by which
persons cope and acquire skills
Resiliency decreases with age
 Pre-existing health conditions
 Compromised immune system
 Higher levels of depression, anxiety and PTSD
(Gerrard et al., 2004, Finklestein et al, 1983; Katz et al., 2004; Somasunderson & Van De
Put, 2006).
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Why foster resiliency?
It minimizes morbidity and mortality
 Through the development of intervention that can
be used in a crisis
 Monitoring persons and their health post crisis
 By encouraging victims to confront their trauma
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Promoting resiliency in the shelter
 Assign someone to “look after” the older adult
and ensure needs are met
▪ Think about the cot they are on
▪ Location of the cot vs. the bathroom
▪ Diet considerations, skin tears, bed sores
 Protect them-they are very vulnerable
 Perceived degree of control over events
(Acierno et al, 2007; Lating & Bono, 2008; Gerrard et al., 2004).
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Hydration makes all the difference.
Disabilities?
Bathroom close without scaling the stairs?
Social isolation
Inadvertent neglect (why would this happen?)
Some older adults have been neglected or
forgotten in shelters.
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Dementia vs. Delirium;
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 Reversible vs. irreversible ; Chronic vs. acute.
Alzheimer's disease most common
 Cause unknown
 If Lewy bodies are present may experience hallucinations
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Vascular dementia, AKA multi-infarct dementia,
 second most common; small blockages in blood vessels cause
strokes that destroy small parts the brain.
 may not know when the strokes occur.
Other possible causes: Parkinson's disease and
Huntington's disease.
 Infection is a less common cause of dementia.
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http://medicalcenter.osu.edu/PatientEd/Materials/PDFDocs/discond/general/dementia-older-adult.pdf
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Be patient…
They may have trouble:
 finding their words or expressing themselves.
 performing routine tasks
 recognizing people and places
 recalling events
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What to do in a shelter?
Dementia
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Re-assure them
Try to ensure that they have their medications
Keep them fed and hydrated
Assign someone to look after them
Delirium
 Investigate & treat the cause, it is reversible
 Try to ensure that a HCP can assess & treat them
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Adverse Drug Reactions are 7x more common
in the elderly.
Account for 50% of all medication-related
deaths.
What are some pre-disposing factors?
 Polypharmacy
 Changes in body & body water
 Changes in metabolism (constipation, transit
time, etc.)
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You are supervising a shelter and have just
received a bus load of older adults from a
shelter 4 hours away, as the older adults are
unloaded at 1 am, the bus driver says that the
bus ride took 8 hours due to the evacuation
traffic. They were unable to stop, he just
wanted to get them “there”.
What are the considerations you will have for
these older adults?
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According to the FDA, 12.3% of deaths are
related to the use of psychotropic medications
http://www.medscape.com/viewarticle/558689_3
Psychotropic meds can have life threatening
side effects
 People are on these drugs for a reason
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 Anxiety, depression, Bi-polar, psychosis
These drugs SHOULD NOT be abruptly
discontinued!!
 Get someone who understands the drugs,
pharmacist, doctor, mental health nurses
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 Try to reconcile the drugs ASAP
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ALL of these drugs have many side-effects,
which will vary depending on the TYPE of
drug.
Consider the drugs function..
What happens when you drink too much
coffee?
Why do people drink coffee?
What happens when you drink alcohol?
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People who are depressed need a “pick-me
up” drug.
 What do you expect the drug to do?
 What side effects would you anticipate?
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People who are too “high-strung” may need a
anti-anxiety type of medication
 What do you expect the drug to do?
 What side effect would you anticipate?
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Just a few side effects:
 Orthostatic hypotension; sedation; anti-
cholinergic effects
 sexual dysfunction (70%), nausea, HA, CNS
stimulation, nervousness, insomnia, & anxiety,
weight gain
 Most serious signs & symptoms: cardio toxicity,
Extra-pyramidal side effects, & seizures.
 CONSIDER other drug-drug interactions!
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A glimpse of possible side effects:
 nausea, HA, CNS stimulation, nervousness, insomnia,
& anxiety, weight gain, orth0static hypotension
 Extrapyramidal side effects: akathisia (restlessness &
agitation), dystonic reactions & tardive dyskinesia.
 Bruxism-clenching & grinding of teeth, bleeding
disorders, hyponatremia, dizziness & fatigue.
 agitation, HA, dry mouth, constipation, weight loss,
GI upset, dizziness, tremor, insomnia, blurred vision,
& tachycardia, seizures, suicide
(Lehne, 2007)
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Considerations in shelter ops:
 They may be “off” their medications
 They may think they need a double dose to “cope”
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Be aware that there are MANY side effects
associated with theses drug & again, will vary
depending on the type of drug.
Many drug will “dry the patient out”, some
will make them hyper, low blood pressure,
etc.
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A key preparedness element is mitigation
which is defined by FEMA (2007) as:
 measures taken to reduce or potentially eliminate
a hazard as well as efforts to reduce the harmful
impact of a particular hazard. (Beaton et al., 2008)
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Community mitigation may include;
mitigation, vaccination, & social distancingfor PanFlu. (Blendon et al., 2008)
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So how do we mitigate the effects of an
individual with mental illness?
 We want to try to know what we are dealing with.
 It is essential to have the right players at the table
during the planning process!
 De-escalate!
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Ensure you have the right people on your
team (credentials do matter)
Begin with assessment (physical, mental,
medications)
Plan ahead, have a contingency plan (Plan B)
Provide a safe, calm environment
Emotional support
Set limits but avoid power struggles
Allow them some control
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Evacuation Shelter with 800 evacuees.
You start to notice a small thin disheveled
male with a back pack that keeps hiding in a
corner, he seems to be talking with someone,
but no one is there.
You notice he is wearing a hospital bracelet.
How do you assess the situation. What do you
do?
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HICS job action sheets
Command Center
Sound disaster plan:
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Mitigation
Preparedness
Response
Recovery
Facilities should be self-sustaining for 96 hours.
Education should be from the TOPdown.
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People on ALL levels need to:
 Know the plan (Education!)
 Know their role in the plan
▪ Be clear about their role
 Speak a common language (ICS)
 Be in on the planning process
 Have clear communication as changes unfold (if possible)
 Create a health history card, Doctor’s name, scripts, meds,
emergency contacts (Cary, 2008)
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Always have a plan B!
If you can’t handle a medically or mentally ill
individual send them to a hospital.
If the hospital is overwhelmed, find a HCP in
your shelter to assist if possible.
If you fail to prepare, you’re prepared to fail
Mark Spitz
The Mad Hatter: “Have I gone mad?”
(Alice checks Hatter's temperature)
Alice: “I'm afraid so. You're entirely bonkers.
But I'll tell you a secret. All the best people
are.”
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American Psychiatric Association (APA),
(2000). Diagnostic And Statistical Manual of
Mental Disorders, 4th edition, Washington:
American Psychiatric Association
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Beaton, R., Bridges, E., Salazar, M.K., Oberle, M.W.,
Stergachis, A., Thompson, J., & Butterfield, P. (2008).
Ecological model of disaster management. American
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471-478.
Blendon, R.J., Koonin, L.M., Benson, J.M., Cetron, M.S.,
Pollard, W.E., Mitchell, E.W., Weldon, K.J., & Herrmann, M.J.
(2008). Public response to community mitigation measures
for pandemic influenza. Emerging Infectious Diseases. 14 (5),
778-785
Bryan, C., Mistovich, J., Krost, W., Limmer, D. (2009). In two
minds: EMS care of the Schizophrenic patient. EMS, 12,6371.
Burnett, J., Dyer, C.B., & Pickins, S., (2007-2008). Rapid
needs assessments for older adults in disasters.
Generations. Winter, 10-15.
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Cary, S. (2008). Disaster Preparedness-Nephrology Nurses were ready.
Nephrology Nursing Journal. 35(6), 547-548.
Chabora, N., Judge-Gorny, & Grogan, K., (2003). The Four S Model in
Action for De-escalation: An Innovative State Hospital-University
Collaborative Endeavor. Journal of Psychosocial Nursing, 41 (1), 22-28.
Cowin, L., Berlin, E., Fitzgerald, M., & Hoot, S., (2003). De-escalating
aggression and violence in the mental health setting. International
Journal of Mental Health Nursing, 12(1), 64-73.
Furnham, A. & Pereira (2008). Beliefs about the cause, manifestation,
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