Mental Health or Mental illness Part 6

Sleep Patterns: Sleep is necessary for memory encoding and consolidation Emotional memory is susceptible to sleep deprivation (SD) and leads to the retaining of more negative memories SD also leads to impaired cognition and attention Sleep disturbances occur in 30-80% of patients with schizophrenia and from 50-90% in patients with depression and is a core feature of bipolar disorder Sleep Patterns: Trauma: Trauma informed care and practice (TICP) recognises that many people who experience SMI have been exposed to trauma 60-70% of people with schizophrenia have been exposed to several forms of childhood abuse (physical, psychological, sexual) Intellectual Disability: A person with an intellectual disability may have problems expressing their thoughts, putting together sentences, learning new skills, doing day to day tasks, making decisions, and remembering things. Mental health issues may not be identified, as behaviours associated with the presence of an intellectual disability may mask symptoms. Physical Disability: Mental health and physical health are fundamentally linked People living with a SMI are at higher risk of experiencing a wide range of chronic physical conditions Conversely, people living with chronic physical health conditions experience depression and anxiety at twice the rate of the general population Co-existing mental and physical conditions can diminish quality of life and lead to longer illness duration and worse health outcomes. SMI- Comorbidity Risk Factors: Antipsychotic Medication: o Can cause weight gain- clozapine and Olanzapine have the highest incidencegains of 15-20kg over a 6-month period have been recorded o Increases the risk of hyperglycaemia and dyslipidaemia Smoking: o 66% of people with SMI are tobacco smokers compared to 15% of the general population o people with SMI  smoke more cigarettes per day  inhale more deeply o tobacco related deaths account for 50% of the total deaths seen in people with serious mental illness Diet and exercise: o The sedative effect of antipsychotic drugs can cause amotivtion o Disorganisation due to SMI can lead to exacerbation of negative lifestyle factors such as;  Poor diet  Lack of physical activity o People who experience SMI have poorer diets when compared to the general population  Higher caloric intake  Higher in saturated fats  Lower in fruit and fibre  Lower in vegetables, legumes and dairy o People with mental illness are known to;  Engage in less physically activity (PA) than the general population  Engage in long periods of sedentary behaviour o Low levels of PA are risk factors for:  Obesity  Poor cardiorespiratory Sexual Activity: o People with SMI are more likely to be involved with high risk sexual behaviours such as;  Unprotected sexual intercourse  Multiple partners  Involvement in sex work and illicit drug use Drugs and alcohol: o People with SMI were:  Increased risk of consuming risky levels of alcohol in the last 12 month  1.6 times as likely to have recently used an illicit drug  1.6 times as likely to have recently used cannabis  2.1 times as likely to have used meth/amphetamines Trauma: o Psychological consequences of childhood trauma include interpersonal and relational difficulties, shame, embarrassment, guilt, low self esteem, cognitive and perceptual disturbances o These effects impact on both mental and physical health Interventions: All interventions are based on the principles of RECOVERY: o Uniqueness of the individual o Real choices o Attitude and rights o Dignity and respect o Partnership and communication o Evaluating recovery Metabolic Syndrome: Ongoing assessment- at least every 3 months o Monitoring waist circumference o Calculating BMI o Monitoring BP o Monitoring fasting lipids and blood glucose o Monitoring level of physical activity Respiratory: Regular and ongoing respiratory assessment Cessation of smoking Maintaining physical activity Regular influenza vaccination Smoking Cessation: Motivational interviewing/counselling Management of withdrawal symptoms Nicotine replacement therapy Education Physical Activity: Motivational interviewing Face to face and group-based exercise sessions Structured exercise prescriptions Structure the exercise to suit the age, ability and preferences of the client Nutrition: Education on a balanced diet Suggestions for alternate dietary patterns Identifying and reducing the intake of high fat and high sugar foods Assisting/developing food preparation skills Oral Health: Smoking cessation Regular dental hygiene Identify public dental schemes Sleep: Regularly assess sleep patterns Assess for obstructive sleep apnoea Commence a sleep diary Decrease caffeine intake in the evening and abstain several hours before going to bed Medications to promote sleep may be warranted Sexual health: Promote regular screening- breast, prostate, cervical and STD Education on safe sex Drug and Alcohol: Regularly assess/screen for concurrent use of alcohol and drugs Motivational interviewing Formal rehabilitation programs if warranted Trauma informed care and practice: Recognise that recovery is not possible unless, a person feels safe (physically, emotionally and psychologically) from violence or abuse Identify triggers to avoid re-traumatization Adopt a flexible approach to interventions Disability: Ongoing assessment of the effects of the disability Advise/organise support services as needed Differentiate between the presentation of the disability and the signs and symptoms of mental illness VULNERABILITIES IN MENTAL HEALTH THROUGHOUT THE LIFESPAN What contributes to mental health in children & youth: Risk factors: o Genetics o Biochemical o Pre & post-natal influences o Individual temperament o Psychosocial development Protective factors: o Attachment to family o Supportive parenting o Social competence o Basic economic security o Positive school/work environment o Good networks Infancy & Early Childhood 0-12 years: Children’s Mental Health: Childhood focuses largely on individual strengths of the child and the family (considering the influence of school and other social environments) Clinicians need to be aware of behaviour ranges/abilities expected at each age & what is known about child/youth psychiatric disorders Clinicians need to be able to communicate with the child and their family at their level. Determine what a child requires at any age to minimise risk factors and foster protective factors for development Children do not have cognitive skills to process events around them, nor the language skills to express their distress. They express these things through their play and behaviour - this needs to be interpreted. Skills learnt through attentive and caring parenting: Self regulation: o Impulse control o Self soothing o Autonomy o Perseverance and patience o Inhibition Relating to others: o Empathy o Trust o Affection o Expression o Respect Emotional closeness is what an attachment disordered child wants most but it is also what they fear most Attachment disordered children use less language and more behaviours and facial expressions to articulate themselves and how they are feeling They also tend to misinterpret the non-verbals of others, tending to see neutral things as threatening and dangerous Attachment disordered thinking styles: If they have NOT LEARNT TRUST: o Adults are unreliable, unresponsive and cannot be trusted o I must control others to be safe o Being close to others is not pleasant If they have NOT LEARNT SELF REGULATION (e.g. parents have not experienced and contained their emotions with them): o I cannot control myself o When I want something, I should not have to wait for it o Hard things should not be avoided If they have NOT LEARNT SELF SOOTHING: o Feelings are dangerous and should be avoided o If it is not stimulating it is a waste of time o Being alone is scary but I cannot let others know that Children’s Behaviour to Assess: General areas: o Internalising problems- inhibited or over controlled behaviours, anxiety or depression o Externalising behaviours- antisocial behaviours, aggression Specific areas: o Anxious/depressed behaviours o Somatic complaints o Social problems o Withdrawal o Delinquent behaviour o Attention problems o Aggressive behaviour thought disorders MSE for children: Appearance Behaviour Interactions- family and clinician Language/speech Mood/affect Though form/content Perceptual abilities Cognition Insight & judgement Additionally consider: o Developmental stage milestones o Attention/concentration o Concept of self/others o Positive attributes o Resilience o Temperament (overall) o Ability for imaginative play Disorders Diagnosed in Infancy/childhood: Anxiety disorders – generalised, separation, social, selective mutism, phobias, OCD. Depression / adjustment disorders Attachment disorders / relationship problems Post Traumatic Stress Disorder Sleep, feeding and eating disorders – “failure to thrive” Rumination disorder – repeated regurgitation/re-chewing food Feeding disorder – failure to eat adequately Pica – persistent eating of non-nutritive substances (paint, rocks, hair, soil) Autism Spectrum Disorder (Autism/Asperger’s/PDD) Attention-deficit/hyperactivity disorder Language Disorders – receptive and expressive Oppositional Defiant Disorder Tic disorders (Tourette’s, chronic motor or tic disorders) – a sudden, rapid, recurrent, non rhythmic sound or movement. Anxiety Disorders in Childhood: Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat Separation Anxiety Disorder- the individual with separation anxiety disorder is fearful or anxious about separation from attachment figures to a degree that is developmentally inappropriate. There is persistent fear or anxiety about harm coming to attachment figures and reluctance to go away from attachment figures, as well as nightmares and physical symptoms of distress Onset of separation anxiety disorder may be as early as preschool age and may occur at any time during childhood and more rarely in adolescence Children with this disorder may be described as demanding, intrusive, and in need of constant attention Selective mutism is characterized by a consistent failure to speak in social situations in which there is an expectation to speak (e.g., school) even though the individual speaks in other situations. The onset of selective mutism is usually before age 5 years. Specific Phobia Individuals with specific phobia are fearful or anxious about or avoidant of circumscribed objects or situations. The fear, anxiety, or avoidance is almost always immediately induced by the phobic situation, to a degree that is persistent and out of proportion to the actual risk posed. The median age at onset is between 7 and 11 years, with the mean at about 10 years. In social anxiety disorder (social phobia), the individual is fearful or anxious about or avoidant of social interactions and situations that involve the possibility of being scrutinized or being negatively evaluated by others. Median age at onset is 13 years, and 75% of individuals have an age at onset between 8 and 15 years. Autism Spectrum Disorder: ASD is a neurobiological disorder, characterised by persistent impairment in reciprocal social communication and social interaction AND restricted, repetitive patterns of behaviour, interests or activities. (DSM-V) o Increasing prevalence in Australia o 0.5% estimated to be on the autism spectrum (ABS, 2012) o 79% increase since 2009 o More common in boys o Intellectual impairment may be present as a co-morbidity, not part of the ASD. Easily misdiagnosed where trauma or language disorders are present Schools receive additional funding where there is an ASD diagnosis, which means children receive additional support. However, this may increase misdiagnosis and artificially inflate the prevalence statistics. Asperger’s Syndrome: Asperger's syndrome is a condition on the autism spectrum, with generally higher functioning. There has been no delay in speech development. People with this condition may be socially awkward and have an all-absorbing interest in specific topics. Communication training and behavioural therapy can help people with the syndrome learn to socialise more successfully. ASD Aetiology: While the cause of ASD is unknown, there are lots of theories and ideas. Current research suggests biological or neurological differences in the brain may begin during pregnancy or shortly after birth. Research also suggests that there may be a genetic basis in many instances although not all. There is no scientific link between ASD and immunisations. Every person with Autism Spectrum Disorder (ASD) is different to another and has their own way of seeing the world, which makes them interesting and unique. When someone has ASD, it means that their brains are wired differently to other people. However, the symptoms of ASD vary enormously from person to person. Management: These are dependant upon individuals needs: o Therapy for communication, behavioural issues, sensory processing, motor skills, play skills, eating, toileting, social and friendship skills o Parents training and support o Anxiety management o Speech therapy o OT & physical therapy o Medication  Antipsychotics- reduce aggression/violence  Anticonvulsants- reduce aggression/violence  Antihypertensives- reduce violent outburst  Anxiolytics- reduce anxiety What happens over times? Children do not grow out of Autistic Spectrum, they grow with it Core social, communicative and behavioural difficulties persist: Struggle with social interactions and cues Rigid beliefs “Concrete” thinking – no humour or sarcasm Poor problem solving skills Love of routines May be gullible and easily led Unable to express self accurately May appear egocentric Parents may need a ‘booster’ session in management during particular years to help manage a particular stage of life (e.g. teenage years, finishing school etc.) Attention Deficit & Hyperactivity Disorder (ADHD): ADHD is a neurobiological disorder, characterised by persistent pattern of inattention and/or hyperactivity or impulsivity that interferes with functioning or development (DSM-V) It has genetic and environmental contributors. While primarily recognised as a childhood and adolescent disorder it can be a lifetime issue o Genetic – First degree relatives (parents/siblings/children) have a 4 to 5 times elevated risk o Environmental risk factors included pre-natal exposure to tobacco, alcohol and lead Prevalence – difficult to establish due to variations in understanding of diagnostic criteria and possible under and over reporting Attention deficit hyperactivity disorder (ADHD) describes a range of behaviours characterized by forgetfulness, carelessness, inattention, disorganization, distractedness, fidgetiness and/or impulsivity that can result in performance issues in social, educational and/or work settings. More common in boys Onset: usually identified & diagnosed in preschool/school. May be earlier. Symptoms must be present before age 12. Can be over-diagnosed or mis-diagnosed Paediatrician/child psychiatrist Rule out psychological stressors at home or other MH disorders ADHD Management: Management of behaviours is most effective as a combination of pharmacology with behavioural, psychosocial and educational interventions. Behavioural interventions & CBT Lifestyle changes Exercise, diet, sleep, behaviour modification, structure and routine. Pharmacology: methylphenidate (Ritalin/Concerta) or dexamphetamine (Dex/ Vyvance) Reduces hyperactivity, impulsivity and mood lability Side effects: insomnia, loss of appetite, weight loss Nursing considerations for medication: monitor for appetite suppression/growth delays, take after meals, full drug effect can take 2 hours Oppositional Defiant Disorder (ODD): A pattern of angry/irritable mood, argumentative/defiant behaviour, or vindictiveness, lasting at least 6 months (DSM-V) Symptoms usually appear in preschool years and rarely later than early adolescence Slightly more predominant in males (1.4:1) Often comorbid with ADHD, anxiety disorders Environmental factors prevalent in many causal theories of the disorder. Conduct Disorder (CD): A repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated (DSM-V) Symptoms: aggression to people/animals, physical fights, lying, bullies/threatens/intimidates others, use of weapons, arson, vandalism, truancy, property damage, violation of rules. Frequently associated with risky behaviours: poor self control, early onset of sexual behaviours, substance use, reckless/risky behaviour, insensitivity to punishment. Frequently perceive the intentions of others as more hostile or threatening than is the case – then respond accordingly. • Onset for CD usually between 8 – 16 yrs. (but can be younger) and ODD is a common precursor to CD. Younger onset shows more likely to have persistent conduct disorder in youth & can develop antisocial personality disorder as adults • Aetiology: genetic vulnerability, environmental adversity, lower than average IQ, history of abuse and/or violence • Risk factors include: poor parenting, abuse, poor peer relationships, low academic achievement, low self-esteem • Protective factors: family support, positive peer relationships, good health Treatment: Treatment needs to be appropriate to developmental age and can include: Parenting education for family Social skills training Improving peer relationships Improving academic performance Boundaries and consequences must be enforced Youth Mental health 12-24 years: High prevalence & burden of mental ill health Unique challenges that affect their wellbeing and increase their vulnerability Peak period for emergence of mental ill-health; up to 75% mental disorders have onset during early teens to mid 20s o 1 in 4 young people experience mental disorder in 12-month period 45% of Australian’s will experience a diagnosable mental illness at some time during their life related impact on families, communities and society youth mental health is becoming more recognised as a speciality Adolescent Brain Development: There are significant structural and functional changes in the brain. The frontal lobe is responsible for forethought, delay of gratification, consequential thinking, emotion expression, problem solving – it is the “master” of our personality, thinking and communication. During adolescence, the frontal lobe “closes down” while it either prunes or consolidates neural pathways. The amygdala is part of the limbic system and is responsible for emotional responses, some memory and “taking action”. During adolescence, the amygdala is highly active, but doesn’t have the frontal lobe to contain it. Because of this, adolescents have more impulsive and risk taking behaviours and they perceive time differently to adults.They focus on proximal consequences (e.g. peer reactions) rather than distant goals (e.g. finish school) The impact of Mental Illness on Youth: Tasks of adolescence include developing autonomy, individuality, work/social networks, (sexual) relationships, education, starting employment It is a time when three of the great changes of human life occur: o The ability to reproduce o The development of identity and personality o The formal commencement of logical, rational, reasoned thought Ongoing disability contributes to impaired social functioning, poor educational achievement, unemployment, substance abuse, violence Mental Illnesses found in adolescence: Anxiety disorders OCD Major Depression Adjustment disorders Psychosis Eating Disorders Stress related disorders Post traumatic stress disorder Non suicidal self injury Suicide Early Intervention: Preventing mental health disorders has greatest impact when focussed on children and youth (McGorry and Yung, 2003) Aim is to prevent or minimise serious mental illness and the impact this may have on the developing brain. Early stages critical as essential treatment is important to reduce risk of ongoing disability & focus on recovery Symptoms can continue to evolve from childhood through to adolescence and young adulthood Support Services for young people’s mental health: Headspace offers support for those aged 12 to 25 years old on a range of issues including depression, anxiety, stress, alcohol and drug use, sexuality, sexual health, personal or family relationship issues and bullying. Their service is focussed on preventative measure for mild-moderate issues. Other Non-Government organisation (NGO) initiatives include Beyond Blue, Orygen Youth Heath, Intercept, Black Dog Institute, Grow, Lifeline....... Each state health department runs a child and adolescent/youthmental health service, to provide comprehensive support and interventions for young people with serious and complex mental illnesses. Services may include inpatient, community, assertive outreach and day programs, as well as school liaison.They also provide crisis assessment, treatment and containment. Engagement: Crucial aspect of service but very limited timeframe to convince the young person that you are “on their side” – about 3 mins Allow for enough time, patience & effort build trust/rapport Involve Family/carer Be genuine and authentic, show unconditional positive regard Use a strengths based approach (is resilience present?) Reluctance to seek help – explore why Developmental stage of young people – peer reactions Other factors availability/accessibility/awareness of services substance use illness related factors such as paranoia HEEADSSS psychosocial interview for adolescents: H – Home environment E – Education and Employment E – EatingA – Activities (alone and with peers) D – Drugs (including nicotine and alcohol) S – Sexuality & relationships S – Suicide / depression S – Safety from injury and violence For a young person presenting to a mental health service, assessment should additionally include: o Anxiety symptoms o Conduct difficulties and risk taking- legal issues o Psychosis and mania o Early development and illnesses, family history of mental illness