mental health2 Flashcards
DSM V criteria for PTSD
exposure to actual or threatened death, serious injury, or sexual violence
presence of one or more intrusion symptoms associated with the traumatic events, beginning after the traumatic events occurred
persistent avoidance of stimuli associated with the traumatic events, beginning after the traumatic events occurred
negative alterations in cognitions and mood associated with the traumatic events beginning or worsening after the traumatic events occurred
marked alterations in arousal and reactivity associated with the traumatic events beginning or worsening after the traumatic events occurred
duration of disturbance is more than one month
disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning
the disturbance is not attributable to the physiological effects of a substance or another medical condition
PTSD prevalence: occupation and gender
Occupation
Emergency personal are twice as likely to experience PTSD
It is estimated that 1/6 Canadian veterans experience PTSD
Gender
Women are twice as likely than men to be diagnosed with PTSD
PSTD prevalence based on type of trauma
Prevalence increases based on the type of trauma
Timing – When over the lifespan does the trauma occur?
Childhood: coping skills are not well developed
Older adult: potentially less supports
At an already stressful time (i.e. pregnancy, looking for work)
Duration – Over what time period did the trauma occur?
Short (i.e. an immediate death from a car crash)
Longer (i.e. several years at a fertility clinic)
Intensity – What is the impact?
Car accident with no injuries, bankruptcy resulting in homelessness, military service in a war zone
Other
Layering of Trauma
The trauma begins in childhood (e.g. sexual abuse) and the individual experiences additional trauma across their lifespan (can be related or unrelated to the original trauma)
The trauma can include emotional and physical implications
1 in 6 children are exposed to a traumatic event prior to age 16 (NCTSN, 2013)
Comorbidities
Trauma may be accompanied by physical injuries (e.g. car accident) which may have short or long term effects
Trauma may be complicated by other health diagnosis and related treatments
genetic factors for PTSD
Genetic Factors
Evidence for an inherited component
Presence or pre-disposition of co-morbid and concurrent diagnoses Depression, acute stress disorder, personality disorder Predisposition to stress management
neurobiological factors for PTSD
GABA-Benzodiazepine theory
Benzodiazepine receptors are linked to receptors that inhibit the neurotransmitter GABA
Leads to unregulated levels of anxiety
Hypothalamus-pituitary-adrenal system
fight or flight response
psychological factors for PTSD
Psychodynamic perspective
Unconscious childhood conflicts form the basis for symptom development
Use of defense mechanisms that become maladaptive
Behavioral perspective
Anxiety is a learned response
Modelling of behavior
Cognitive perspective
Result of thought and perceptual distortions
For example, fortune telling, all or nothing thinking, discrediting the positive
amygdala responsibilities
Quickly recognizing danger signals
Determining the emotional importance that is assigned to a fearful experience
Stimulates the hippocampus, so that the brain can recall memories and connect new experiences to previously stored memories
ptsd mse assessment general observation
appearance = self care patterns may not initially be disrupted; as the illness becomes severe ADLs may become more difficult behaviour = becomes increasingly withdrawn and alienated from others and less able to maintain activities that support his/her health cooperation = may become less cooperative and possible triggers increase
ptsd mse assessment affect and mood
affect = may range from blunted to labile depending on the triggers that are present, may not be appropriate to the context, as the individual may have exaggerated responses to what would be considered normal events
mood = usually rated moderate to low, as the individual is usually on higher alert and trying to avoid actual or perceived harm
mood and affect are usually congruent
ptsd mse assessment speech and language
speech = rate, rhythm and inflection are dependent on the context, volume is usually quiet language = vocabulary, comprehension, and fluency are consistent with the individual's education level
ptsd mse assessment thought process
characteristics = poverty of speech, somatization, and may perseverate on the traumatic events, and present of potential triggers
ptsd mse assessment thought content
delusions = need to distinguish between delusional thinking and distorted thinking
suicidal/homicidal ideation/thoughts of self harm = the reliving of the traumatic experience is often intense, and feels inescapable for the individual. as a result the individual may have thoughts of killing themselves or his/her offender (with or without a plan), self-harm is common coping strategy and a significant risk
depressive cognitions = feelings of hopelessness, worthlessness, guilt (self blame) and helplessness are common
anxious cognition = may be worried and preoccupied that the offender will continue to harm (independent of whether the incident is reported or not)
ptsd mse assessment perceptual functioning
hallucinations = should not be confused with triggers and memories of the verbal interaction illusions = not common depersonalization = may occur derealisation = may occur in several cases dissociation = may occur
Perceptual functioning occurs on a continuum and varies depending on
The type, intensity, and duration of trauma,
the individual’s resiliency
Supports
ptsd mse assessment cognitive functioning
orientation = may be altered during a flashback
memory = slight relapse in memory, may not be able to remember detail
concentration = may be intermittent or poor, difficulties engaging in in-depth or lengthy conversations
interests = may be less aware of what is happening to others, or the impact that his/her behaviour is having on others
executive functioning = may be impaired, certain activities may be avoided as they are triggers that have the person relive the trauma, the individual may be able to plan a reasonable course of action but unable to follow through with his/her plan
ptsd mse assessment insight and judgment
Insight
Culturally dependent on what is defined as trauma
Usually aware of what the problem is but may not have a clear understanding of how this impacts his/her functioning
Judgment
Initially
Making good decisions and functioning normally
Over time
Marked errors in judgment due to increased distraction and avoidance
ptsd family assessment what to consider
Who was involved in the trauma?
Who does the individual consider part of their family?
Who lives in the home?
What is the family’s problem solving style?
What are the family’s coping strategies?
What is known about the trauma?
What are the families cultural and spiritual beliefs?
What stage of change is the family in?
ptsd differences across the lifespan and nursing considerations younger children
Developmentally
May not have developed adequate coping mechanisms
Nursing Considerations Need consent from parents to treat Physical assessment May need to call Social Services and police Create a safe environment Need to explain situation Assess and develop coping skills
ptsd differences across the lifespan and nursing considerations adolescents
Developmentally
Puberty
Erikson’s Stages: identity vs. role confusion
Maslow’s Hierarchy: impact on safety, love and belonging, and esteem
Nursing Considerations Risk assessment & Physical assessment Respect independence May need consent to treat Appropriate language Reassurance
ptsd differences across the lifespan and nursing considerations older adults
Context
Less flexible/adaptive to change
Fewer supports
Increased potential of co-morbid conditions
Nursing Considerations MSE Risk assessment Physical Assessment Assess ADLs Assess supports
most common co morbidities for ptsd
adults = arrhythmias, diabetes mellitus children = adjustment disorder, attachment disorder
dissociation
A subconscious defense mechanism that helps a person protect his or her emotional self form recognizing the full effects f some horrific or traumatic event by allowing the mind to forget or remove itself form the painful situation or memory.
Can occur both during and after the event
Becomes easier with repeated use
dissociative identity disorder DSM V criteria
disruption of identity characterized by two or more distinct personality states
recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting
the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
the disturbance is not a normal part of a broadly accepted cultural or religious practice
the symptoms are not attributable to the physiological effects of a substance
did prevalence
Gender
Occurs more frequently in women
Correlates with traumatic history of significant sexual abuse and/or physical abuse
Exists on a continuum
did nursing assessment
Do not want to re-traumatize the patient
In-patient care is provided because there is are serious safety concerns
Do not use suggestive or leading questions
Observe and assess for incongruences in what one personality shares and also between personalities
May include inaccuracies, distortion, manipulation, confabulation of events and details
Assess for SAFETY
A risk assessment should be done with each identity if possible
There is a HIGH incidence of self-harm in individuals diagnosed with DID
did nursing assessment
Mental Status Exam -
Patients may change the following to match the particular identity that presents in the moment
Clothing, make-up
Speech and language (includes accents, profanity, and cadence)
Tone of voice
Eye contact
Engagement with others
Patients may have hallucinations (auditory and visual are most common) but they may not be about self-harm
Patients may experience periods of lost time. This is a significant risk factor for personal safety
The memories of each identity may vary
In an acute state, patients often do not have insight into other identities
Each identity may have a different level of judgement
Other medical conditions Organic causes (brain tumor, traumatic brain injuries)
Substance use Substances may cause alterations in the individual’s perception, but there will not be several independent identities Past medical history Developmental milestones Co-morbidities Chronic illness Family functioning Who are the patient’s supports Does the patient have a safe space
did nursing considerations for children and adolescents
Disruptive and self-destructive behavior
Incoherence in the developmental memory processes
Fluctuating mood (difficulties with self regulation)
Associated also with parental neglect
Compare disruptions in identity to expected achievement of developmental tasks and milestones
Assess the child’s functioning in other environments (i.e. school, daycare, extra-curricular activities)
Assess the family environment
Physical and emotional safety
Psychiatric history of all family members
Assess for co-morbid conditions
Common co-occurring psychiatric disorders include: OCD, PTSD, ADHD, substance use disorders, attachment disorders
Other medical diagnosis (includes lab and diagnostic test results)
addiction definition
“A primary, chronic disease (1), characterized by impaired control over the use of a psychoactive substance and/or behavior. Clinically, the manifestations occur along biological, psychological, sociological and spiritual dimensions (2). Common features are change in mood, relief from negative emotions, provision of pleasure, pre-occupation with the use of substances(s) or ritualistic behaviour(s) despite adverse physical, psychological and/or social consequences (3). Like other chronic diseases, it can be progressive, relapsing and fatal (4).”
substance use
Consumption is infrequent; may be described as experimental, casual or social; minor consequences
physical dependence
Physiological changes that result from a pattern of regular use (substances) or engagement (gambling) that increase tolerance and withdrawal symptoms
Adrenaline (epinephrine) and potentially other endorphins and neurotransmitters may be increased, as a result, a person could experience withdrawal
On CT scans the brain demonstrates similar neurological and biological patterns between gambling and cocaine use
psychological dependence
The emotional and/or mental need to continue taking a drug or gambling to feel normal and to cope.
craving
a strong and intense desire
Cravings are related, in part, to dopamine levels in your brain
The orbital frontal cortex
Is the area of the brain that has the most dopamine
It sits just behind your eyes and is extensively connected to the areas in your brain that process sensory information as well as the limbic system.
As a result, craving can be triggered by any of the senses, as well as just thinking about a pleasurable aspect of using a substance or participating in some aspect of a process addiction
abuse
“A maladaptive pattern (1) of use indicated by … continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem (2) that is caused or exacerbated by the use [or by] recurrent use in situations in which it is physically hazardous (3).’
intoxication
“A condition that follows the administration of a psychoactive substance and results in disturbances in the level of consciousness, cognition, perception, judgement, affect, or behaviour, or other psychophysiological functions and responses (1). The disturbances are related to the acute pharmacological effects of, and learned responses to, the substance and resolve with time, with complete recovery, except where tissue damage or other complications have arisen (2)”
tolerance
How the body adapts (becomes less sensitive) to repeated use (1) of substances or behaviors and needs to increase the amount and/or frequency of the substance or behavior to obtain the desired effect (2)
withdrawal
Unpleasant symptoms that result when an addictive substance is abruptly stopped or significantly decreased, or there is an interruption in an addictive process
four Cs of addiction
Loss of Control
Compulsion
Craving
Use despite consequences
social theory of addiction
Availability
How easy is it to acquire the substance or engage in the behavior
Is the physical environment conducive
Acceptability
Peer pressure
Honor the notion of “private”
Values and Beliefs
People have choices
Treatment
Legal consequences
psychological theory of addiction
Addiction is influenced by an individual’s psychological make-up
Consider attachment theory
Impact of personality traits leaves the person vulnerable and at risk for using substances to eliminate pain or negative feelings
Treatment
Therapy
addiction and biological theory
Addiction is a genetic disease process
In an addicted brain there are structural and functional changes that are different from a non-addicted brain
Functional changes may persist even after the addictive substance/behavior is stopped
Treatment
Abstinence
addiction risk factors
Environmental
Poor coping strategies
Diminished supports
Decreased internal locus of control
Psychological factors
Family history
addictions across the lifespan
Children & Adolescents
Chaotic home life
Learning disorders
Difficulties with social interactions
Experimentation
Older Adult
Require a smaller amount of addictive substance
Potentially fewer supports
Vegetative shifts due to age
Decreased physical functioning
