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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 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. Write down the following: 1. What are the characteristics of mental illness? 2. Define mental illness. “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 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? 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? 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. 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? 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? 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. 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? 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! 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 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. 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. Other controversies (NAMI) Epilepsy Sleep deprivation Drug & alcohol addictions are NOT mental illness Others…? Situational depression? Question: Where did the term Mad Hatter come from? 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 Eating disorders Major Depression Obsessive-Compulsive Disorder (OCD) Panic Disorder Post-Traumatic Stress Disorder Schizoaffective Disorder Schizophrenia Seasonal Affective Disorder Suicide Tourette's Syndrome 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! 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? Let’s throw in the poor economy for good measure… Loss of jobpoor self-esteemdepression? 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.” 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 Natural disasters are on the rise & are increasing in magnitude and frequency (James, Subbarao & Lanier, 2008). Global warming vs. cyclic changes: increase in all extreme weather events (Keim, 2008). On average a disaster takes place somewhere in the world every day (Norris, 2005 as cited by Burnett, Dyer & Pickins, 2007-2008). 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). 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). Use calm verbal skills Empathetic communication skills Gentler & less provocative methods of communication Good negotiation skills Calling the individual Mr. or Mrs. Show great respect Introducing yourself Leave a WIDE margin of personal space 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) Reduce stimulation Remove individual from area Dim lights, decrease noise 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. Provide support: Designate someone (early on), preferably a social 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 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… 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) Consider other signs & symptoms or things that cause confusion: Dehydration Lack of food Fatigue Blood sugar (diabetics) Elderly Oxygen deprivation 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? 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? 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? 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 ... Schizophrenia-commonly seen in homeless . Positive Behaviors are: Delusions Hallucinations Disorganized speech Disorganized behavior Inability to sleep Negative behaviors of schizophrenia Flat affect May talk, but there is truly no content Lack of purposeful action Types of schizophrenia: Paranoid, Disorganized, Catatonic Alcohol and substance abuse can alter symptoms 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 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 Narcissistic; grandiose; Borderline personality disorder Anxiety; Depression Anti-social personality disorder Passive aggressive Pleasantly confused: Cleopatra Sometimes fantasy is better than reality Their goal is to gain control of others by manipulating them. 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). 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 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). 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. Dementia vs. Delirium; Reversible vs. irreversible ; Chronic vs. acute. Alzheimer's disease most common Cause unknown If Lewy bodies are present may experience hallucinations 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. http://medicalcenter.osu.edu/PatientEd/Materials/PDFDocs/discond/general/dementia-older-adult.pdf Be patient… They may have trouble: finding their words or expressing themselves. performing routine tasks recognizing people and places recalling events What to do in a shelter? Dementia 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 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.) 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? 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 Anxiety, depression, Bi-polar, psychosis These drugs SHOULD NOT be abruptly discontinued!! Get someone who understands the drugs, pharmacist, doctor, mental health nurses Try to reconcile the drugs ASAP 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? People who are depressed need a “pick-me up” drug. What do you expect the drug to do? What side effects would you anticipate? 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? 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! 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) Considerations in shelter ops: They may be “off” their medications They may think they need a double dose to “cope” 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. 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) Community mitigation may include; mitigation, vaccination, & social distancingfor PanFlu. (Blendon et al., 2008) 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! 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 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? HICS job action sheets Command Center Sound disaster plan: Mitigation Preparedness Response Recovery Facilities should be self-sustaining for 96 hours. Education should be from the TOPdown. 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) 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.” American Psychiatric Association (APA), (2000). Diagnostic And Statistical Manual of Mental Disorders, 4th edition, Washington: American Psychiatric Association Beaton, R., Bridges, E., Salazar, M.K., Oberle, M.W., Stergachis, A., Thompson, J., & Butterfield, P. (2008). Ecological model of disaster management. 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