According to the World Health Organisation, suicide is responsible for approximately 2200 deaths per day, which amount to 800,000 deaths per year, or 1 death per 40 seconds (WHO, 2016). In addition, with every successful attempt there are many more attempted suicides. The highest suicide rate can be attributed to the elderly.
4/5ths of individuals who die from suicide have attempted to do it at least once before.
Whilst attempts are three times more often performed by women, men are three times more likely than men to complete it.
Some researchers claim that people with low levels of serotonin are up to ten times more likely to commit suicide than those with normal serotonin levels.
Other researchers claim that 25% of drivers who die in car accidents actually cause them subconsciously, hence the term ‘autocides’, meaning suicides in which individuals crash their cars with the aim of ending their lives.
Psychiatric In-Patient Suicide
Up to 0.4% of suicides take place in a mental health hospital.
Psychiatric inpatients are at particular risk for suicide. Studies show that the inpatients who are most at risk for suicide are those with affective disorders and schizophrenia. Precautions should be taken to reduce the risk of inpatient suicide, and following a suicide, the impact on the individual’s family as well as the other inpatients and staff should be considered.
Level 1 supervision is highly intrusive, but can also be therapeutic. Level 3 supervision is more related to care eg. to prevent falls, not just related to mental health. Based on past observations however, even constant supervision can fail at stopping or avoiding suicide.
Retrieved from http://blog.needymeds.org/2018/09/12/suicide-prevention-awarness/ on 22nd January 2022
Retrieved from https://www.facebook.com/NCSBNLearningExt/posts/10157330874509113:0 on 22nd January 2022
Suicide Nursing Assessment
Suicide nursing assessment depth depends on the setting, ability and willingness of the person to provide information about previous and current mental health state, and availability of further information from other healthcare professionals in relation to the same person.
The SAFE-T card pictured below lists key risks and protective factors to be considered while evaluating the person’s suicide risk level. It provides guidance in conducting a comprehensive assessment and triage, risk estimation, and development of treatment plans and interventions based on the person’s mental health state.
Retrieved from https://store.samhsa.gov/product/SAFE-T-Pocket-Card-Suicide-Assessment-Five-Step-Evaluation-and-Triage-for-Clinicians/sma09-4432 on 22nd January 2022
Suicide enquiry should ideally include questioning about thoughts, plans, behaviours and intent in relation to suicide:
Intent: how the person plans to carry out the act, whether the person believes the attempt will be lethal or injuring, and for what reason/s does the person think he should die
NOTE: In Malta, teenagers from 14 years up can ask for treatment even if parents refuse to accept that their child needs treatment, and this is possible thanks to the Mental Health Act.
Retrieved from https://slideplayer.com/slide/13630104/ on 22nd January 2022
Protective Factors
Protective factors that may help the person during contemplation phase include:
ability to cope with stress
religious/spiritual beliefs
tolerance to frustration
responsibilities eg. children and pets
positive therapeutic relationships with healthcare professionals who can provide guidance and help
social support eg. support groups or family help
Documentation
Documentation should include assessed risk level and the rationale behind the level assigned. It should contain interventions to reduce risk as well as plans for follow-up treatment. Psychotherapy, medication, treatment setting contact with others, and consultation with other past or present healthcare providers should be considered to reduce the possibility of suicide.
Retrieved from https://alea-research.com/suicide-prevention-the-columbia-protocol/ on 22nd January 2022
Are You Contemplating Suicide?
If you landed on this blogpost and you are contemplating suicide, please know that there are people who do care about you and your well-being. Please seek professional support. You can contact Richmond Foundation on 1770, Kellimni.com and Victim Support Malta.
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A psychiatric emergency is when an individual experiences an acute disturbance of behaviour, thought or mood. If untreated, a psychiatric emergency may lead the individual to harm self or others. It may happen anywhere in any person, whether diagnosed with a mental health problem or not, and requires intervention by another person (not necessarily by mental health professionals).
A mental health crisis is a situation in which an individual’s actions, feelings, and behaviors can lead them to hurt themselves or others. During a mental health crisis, the individual is at risk of becoming unable to self-care and function in a healthy way within the community.
Psychiatric Emergency Features
A person experiencing a psychiatric emergency exhibits the following 4 behavioural elements:
change and the person’s response towards it
intolerance towards change and towards other persons involved in the situation
reaction of significant others
behavioural change being an instant one
During a psychiatric emergency:
the person appears to be extremely agitated, possibly tearful, and highly distressed
the person may make extreme demands to others
the person may take irrational decisions which seem to be lacking rational judgement
the person may put self in danger, the consequences of which are not obvious to the person at the time
the person may lack the capacity to relate to the surrounding reality
those present during the psychiatric emergency may experience distress and fear, and may act spontaneously in a way that may cause emotional pain or anger following the event
(Ward, 1995)
Psychiatric Emergency Risk Factors
A psychiatric emergency may be triggered by the following psychological responses:
fear
rejection
frustration
intrusion
inferiority
embarassment
grief
reality conflict
psychiatric disturbance
Additionally, a person is more susceptible to experience a psychiatric emergency when:
experiencing an acute psychological disturbance
experiencing a stressful situation
undergoing a detox program
being admitted to a psychiatric facility
recovering from anaesthesia
in an intoxicated state
medication is being changed
unexpected worsening of physical condition occurs eg. infection
witnessing another person’s psychiatric emergency
being discharged
receiving follow-up community care
being cared for in an unfamiliar culture incl. different religious background
Psychiatric Emergency Nursing
Psychiatric emergency nursing may require different types of interventions:
verbal intervention
physical intervention
background management
As a nurse witnessing a PE, aim to:
provide immediate support to help the person regain control over feelings and actions
be flexible by treating the person as an individual with different needs
reduce any possible environmental triggering factors, moving away from the immediate area if required
provide psychiatric first aid to try to reduce the emotional tension being experienced by the person, steering away from the immediate feelings
protect the person experiencing a PE and yourself from physical harm
evaluate the event in both a concurrent and retrospective way to determine the best possible support required by the person
Ask for help or assistance if needed
PE Nursing Care Cycle
Assessment > Intervention > Resolution > Support
Assessment
The person experiencing a PE should be continuously monitored, assessed and re-evaluated. Focus on what the person wants, whether the person (or anyone else) is in danger, what was the behavioural cause, whether any similar situation occurred to the person before and how it was handled, and what it meant for the person if it happened before.
Intervention
Intervention should be provided as mediation between the person experiencing the PE and what is immediately available. Mediate between danger and safety, acting reasonably and quickly in a concise and unambiguous way. Focus on the person’s immediate thoughts and beliefs about self and what is currently causing the issue. Most importantly, act in a calm and confident way.
Safety
Inform your colleagues about the situation
Do not leave the person alone
Stay at arm’s length from a potentially aggressive or an aggressive person
Do not let the person stand between you and an exit point
Approach slowly
Speak slowly and calmly in a ‘matter of fact’ tone, but show that you care
Expect that the person may not even reply to your questions
Be ‘unshockable’
Do not retaliate, do not manhandle, do not belittle, do not respond to personal abuse, and never strike a person even if provoked
If grabbed by your clothing, move towards the person rather than away
If restraining the person is required, do so in a safe manner for all
Always treat the person experiencing a PE with dignity and respect
Resolution
Resolution occurs when the intervention produces a positive effect and the situation becomes no longer critical. In this stage, provide positive reassurance and affirm that it is safe for the person to feel better and relieved. Avoid patronising – keep acting in a kind and calm way without giving away your authority as a nurse. Make sure you reassess the person’s mental state.
Support
During this stage the nurse should re-evaluate the incident’s effects, and encourage the person to reflect on the incident and any possible triggers that could have led to the PE. The nurse should provide emotional support to the person, as well as seek professional support or support from other colleagues.
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Substance misuse and addictions can be attributed to many reasons other than just an aim of getting high. Studies show that only 20% of individuals who make use of drugs do so with the primary aim of seeking pleasure. Other reasons for substance misuse and addictions include anxiety, depression, anger, boredom, peer pressure, lack of self confidence and lack of self control.
Substance misuse is more probable where there is availability and peer pressure. It is usually obtained either in an illicit way, or else through the chemist (certain drugs such as codeine), shops (such as solvents) and doctors (such as benzodiazepines).
Terminology related To Substance Misuse and Addictions
Acute Intoxication – a transient condition which follows alcohol or psychoactive substance misuse, resulting in disturbances in the individual’s level of consciousness, cognition, perception, judgment, affect or behavior, or other psycho-physiological functions and responses.
Harmful Use – damage incurred by psychoactive substance misuse in the individual as well as the implicated negative effects on the individual’s family and surrounding society eg. at work, in health, etc.
Physiological Dependence – withdrawal symptoms (eg. urgent need for more) and drug tolerance (needing more than before to experience the same ‘high’ effect).
Psychological Dependence – a sense of urgency to take a substance experienced by a drug-dependent individual, even when knowing of its related consequences; social, occupational and recreational activities are usually neglected by an individual with substance psychological dependence. A person with psychological dependence usually becomes addicted to the whole drug-taking process itself – including making sure they’re not being followed.
Diagnosis
Dependence diagnosis requires 3 of the following to be present for at least a year:
increased tolerance to a psychoactive drug
physiological withdrawal symptoms exhibited when drug is reduced or stopped
a sense of urgency to make use of the drug
inability to control substance misuse behaviour
neglecting other social, occupational and recreational activities
increased amount of time required to obtain and make use of the drug, and to recover from its effects
persistent use of drug despite knowing its attributed negative consequences
Experimentation/Recreation Drug Use vs Addiction
A recreational drug user is an individual who has tried the drug, enjoyed its use, may want to re-use it, but does not treat it as a priority.
On the other hand, for a drug addict, the drug becomes the main focus of attention, to a point in which other necessities such as nutrition become unimportant compared to the drug. Addiction is a chronic disorder.
Retrieved from https://greatoaksrecovery.com/cycle-of-addiction/ on 19th January 2022
The Pharmacology of Drugs
Drug pharmacology can be divided into 2 components: desired effects and unwanted effects. Most drug users do not become addicted, dependent or tolerant to the drug. All drugs cause dopamine to be released within the brain‘s nucleus accumbens, which leads to a pleasurable effect. However, it is motivation that may cause cravings for a drug, and drug-seeking behaviour.
Opiates
Opiates such as heroin (illegal), codeine, morphine, and methadone, are analgesic agents which bind to opioid receptors in the central nervous system, causing pain to be reduced or eliminated.
Opiates create a rush sensation of peace followed by CNS depression. Withdrawal symptoms, such as craving, sweating, yawning, diarrhoea, agitation, goose-flesh, abdominal cramping, and flu-like symptoms, can start developing from as early as 24 hours following dose administration.
Retrieved from https://addictionblog.org/infographics/heroin-metabolism-in-the-body-how-heroin-affects-the-brain-infographic/ on 20th January 2022
Retrieved from https://www.colleaga.org/tools/clinical-opiate-withdrawal-scale on 20th January 2022
Opiate Replacement Therapy
Methadone is an opiate receptor agonist which is given as a replacement to heroin and other opioids in the case of addiction. Methadone has a longer half-life when compared with heroin, which means that withdrawal symptoms and cravings are reduced without providing the same euphoric effect that heroin provides, giving opioid users a better chance of weaning off or reducing their dose of opioids.
Buprenorphine is an opiate partial agonist. Together with naloxone, which is an antagonist that blocks the euphoric effect related to opioids, buprenorphine is given in tablet form as Suboxone, with the aim of preventing relapse.
An opioid overdose may cause miosis (pinpoint pupils) and respiratory depression (hypoventilation). Naloxone may be required to rapidly reverse opioid overdose by binding to opioid receptors, thus blocking the effects of the other opioids.
Hallucinogens
Hallucinogens – drugs (such as LSD) which cause dilated pupils, increased temperature, vasoconstriction, and hallucinations (distortions in an individual’s perception of reality), can be found in some plants and mushrooms (or their extracts) or can be man-made.
Hallucinogens do not cause physiological dependence, but rare adverse effects may include flashbacks, psychosis, and seizures.
Ecstasy (MDMA in powder form) can induce hyperactivity, and dehydration which can be fatal.
Flakka is a synthetic drug which has been changing in the past. It is very common, yet very dangerous. Psychosis is a common effect of Flakka.
Magic Mushrooms are similar to LSD with regards to effects.
Stimulants
Amphetamines (stimulant drugs eg. speed) cause euphoria, increased concentration, increased energy, mydriasis (pupil dilation), tachycardia, and hyperreflexia, followed by depression, fatigue and headache.
Cocaine can be sniffed, chewed, or taken through the IV route. Its effects are similar to hypomania, and may include visual and tactile hallucinations. Crack cocaine is a highly addictive form of cocaine with a relatively short ‘high’ effect, which may cause persecutory delusions as a withdrawal symptom.
Retrieved from https://addictionblog.org/infographics/cocaine-metabolism-in-the-body-how-coke-affects-the-brain-infographic/ on 20th January 2022
Cannabis
One of cannabis’s active components is THC, which produces psychological effects such as euphoria, relaxation, an overall well-being sensation, omnipotence and hallucinations. Physiologically, THC causes increased appetite and lowered body temperature.
Cannabis is also associated with depression and schizophrenia. However, to develop schizophrenia, the person using cannabis needs to be at a higher risk of developing it due to factors such as genetic predisposition.
Cannabis may also cause adverse effects such as conjunctival (eye) irritation, decreased sperm production, lung disease, transient psychosis, and apathy. It also causes psychological dependence.
Retrieved from https://addictionblog.org/infographics/marijuana-metabolism-in-the-body-how-marijuana-affects-the-brain-infographic/ on 20th January 2022
Sedatives and Hypnotics
Benzodiazepines such as Ativan and Valium are commonly used addictive drugs which can cause dependence, withdrawal symptoms, and tolerance. They also carry a risk of seizures and respiratory depression. In the hospital setting, Ativan and Valium are two medications that fall under the Dangerous Drug Act (DDAs).
Solvents
Solvents are typically sniffed with the intention of getting high due to the initial euphoria it causes. This however is followed by drowsiness. Chronic solvent sniffing can lead to weight loss, nausea and vomiting, polyneuropathy (widespread malfunction of peripheral nerves), cognitive impairment, and aplastic anaemia (body ceases to produce new blood cells).
Sniffing solvents may cause a red rush around the mouth and nose – this is a good way of detecting sniffing solvent abuse.
Khat
Khat is commonly used by Somali and Yemeni men. It contains cathionone, which is an amphetamine-like stimulant which causes excitement and euphoria. It is typically consumed through chewing.
Alcohol
Alcohol safe drinking limits are 31 units per week in men, 14 units per week in women, with at least 2 drink-free days per week. Whilst rates of alcohol consumption by women and adolescents are increasing rapidly, younger people are more prone to exceed the stipulated safe limits.
Detecting alcohol abuse is important so as to avoid long-term complications and acute withdrawal effects. A good way to detect alcohol abuse is through screening questionnaires such as FAST and CAGE. CAGE is an ideal questionnaire when alcoholism is suspected. Once detected, an alcoholic individual should be referred for counseling.
Retrieved from https://www.researchgate.net/figure/The-Fast-Alcohol-Screening-Test-FAST_tbl2_260423389 on 20th January 2022
Retrieved from http://www.familyvan.org/module-week-9-substance-use on 20th January 2022
Alcoholism-related terminology
Acute Intoxication – a state in which an individual shows signs of slurred speech, impaired coordination, impaired judgement, and labile affect (inappropriate emotion expression). More severe repercussions include hypoglycaemia, stupor and coma.
Acute Withdrawal – following 1-2 days of abstinence, the individual experiences malaise, nausea, autonomic hyperactivity, tremor, labile mood (uncontrollable crying or laughing at an improper time or situation), insomnia, transient (mostly visual) hallucinations, and seizures. In the worst case scenario, delirium tremens, which is a severe withdrawal symptom related only to alcohol withdrawal, may be experienced. This is characterised by altered mental status and sympathetic overdrive that may progress to cardiovascular collapse. Delirium Tremens carries a 15% mortality rate.
Alcohol Dependence – individual experiences cognitive, behavioural and psychological features with compulsion to drink, preoccupation with alcohol, stereotyped drinking pattern, loss in drinking regulation, and tolerance of alcohol intoxicant effect.
Psychotic Disorders – hallucinations with 2nd person threatening voices and at times pathological or morbid jealousy.
Amnesic Syndrome – Korsakoff’s psychosis: a severe, diencephalic amnesia caused by thiamine deficiency, which is typically noted in alcoholic patients with very poor diets.
Alcohol Abuse Residual Problems – residual depression and dementia.
Retrieved from https://addictionblog.org/infographics/alcohol-in-the-body-from-drinking-to-elimination-infographic/ on 20th January 2022
Alcohol Abuse Detection and Screening
collect collateral history
look for signs of alcohol disease eg. jaundice, palmar erythema (a skin condition that makes the palms of your hands turn red), gynaecomastia (a common condition that causes boys’ and men’s breasts to swell and become larger than normal), and spider naevi (swollen spider-like blood vessels on the skin often containing a central red spot and deep reddish extensions)
blood tests should be performed to check for macrocytosis (red blood cells that are larger than normal), high gamma-glutamyltransferase (GGT – indicative of liver disease), and high blood alcohol levels
Complications related to alcoholism are usually encountered in the acute setting. These include:
gastrointestinal complications
haematological complications
cardiovascular complications
wernicke’s encephalopathy (a life-threatening illness caused by thiamine deficiency, which primarily affects the peripheral and central nervous system)
korsakoff’s psychosis
peripheral neuropathy
cerebellar degeneration (a condition in which cerebellar cells a.k.a. neurons, become damaged and progressively weaken in the cerebellum)
erectile dysfunction
social complications
fetal alcohol syndrome (in pregnancy)
Management
motivational interviewing
detoxification (possibly including hospitalisation with administration of benzodiazepines and thiamine)
learning relapse-prevention strategies
referral to self-help groups such as Alcoholics Anonymous
administration of Disulfiram, which causes an unpleasant reaction if the individual consumes alcohol, and Acamprosate, which reduces cravings
public health measures eg. taxation
Retrieved from https://www.verywellmind.com/symptoms-of-alcohol-withdrawal-63791 on 20th January 2022
Synthetic Drugs
Synthetic drugs are manufactured to chemically resemble illicit drugs such as cocaine, LSD, MDMA, or methamphetamines, yet can be purchased legally as the manufacturers continuously change the chemical structure to circumvent drug laws. They are usually not detected in urine tests.
Synthetic Cannabinoids, which are commonly used in Malta, are products that mimic the effect of Cannabis in a more potent way. These can be found as solids or oils. Smoking mixtures with added cannabinoids are mostly sold in metal-foil sachets.
Synthetic Cannabinoids cause psychotic symptoms such as extreme anxiety, confusion, paranoia, and hallucinations.
Other synthetic drug names include:
Spice – synthetic marijuana / cannabinoids
Ecstasy – Molly
Bath Salts – contain one or more synthetic chemicals related to cathinone
Mephedrone – Meow Meow: commonly found in bath salts
Krokodil – cheaper heroin substitute which is a synthetic morphine derivative, commonly used in Russia
NOTE: Psychosis following intoxication can usually be reversed.
The Stages of Change Model
Retrieved from https://researchcor.com/transtheoretical-model-versus-the-health-belief-model/ on 20th January 2022
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An eating disorder is a psychiatric disorder in which severe disturbances in eating behaviours and related thoughts and emotions are experienced. Most often, signs and symptoms of an eating disorder are first experienced in adolescence or early adulthood, with the onset usually being a stressful life event. Eating disorder types include:
Anorexia Nervosa
Bulimia Nervosa
Binge Eating
Pica
Pervasive Arousal Withdrawal Syndrome (PAWS)
An Eating Disorder is NOT a Lifestyle Choice!
Anorexia Nervosa
An individual with anorexia nervosa aims to lose weight deliberately through restricted dietary choices, excessive exercise, induced vomiting, appetite suppressants, and diuretics.
Anorexia Nervosa symptoms include:
muscle weakness
irregular menstrual cycle
hair thinning
dental problems
impaired functioning of the immune system
Common comorbidities of anorexia nervosa include depression, OCD, social phobia, and PTSD.
Bulimia Nervosa
Bulimia Nervosa features similar psychological features in anorexia nervosa. An individual with this eating disorder experiences excessive worry about ways to control body weight, and so, aims to eat excessive amounts of food, followed by induced vomiting. These bingeing episodes usually happen several times a week.
Individuals with bulimia nervosa may have a history of anorexia nervosa, with the switch to bulimia nervosa frequently resulting from worrying of family members or friends.
NOTE: Body weight of individuals with bulimia nervosa may range from slightly underweight to obese.
Pica
Pica, which is an eating disorder that commonly affects children under the age of 6, is the persistent eating of substance which have no nutritional value such as clay, dirt, and flaking paint. Pica can feature as an individual psychopathological behaviour, or as one of the symptoms of another psychiatric disorder, such as autism.
Common causes of Pica include malnutrition and iron-deficiency anaemia.
Diagnosis requires the eating disorder to be developmentally inappropriate, and to persist for at least a month.
Pervasive Arousal Withdrawal Syndrome PAWS
Pervasive Arousal Withdrawal Syndrome (PAWS) a.k.a.Pervasive Refusal Syndrome is characterised by food and drink refusal with sudden onset following a tough health-related situation such as illness, pain or virus, or a traumatic event. PAWS is in fact commonly experienced by child refugees.
Refusal of food and drink may also be accompanied by social withdrawal, partial or complete lack of self-care, and partial or complete mobilisation refusal.
An individual with Pervasive Arousal Withdrawal Syndrome quite commonly resists any encouraging attempts of interaction or food/drink intake.
Eating Disorder Treatment
Psychopharmacology
Anti-depressants
Anti-psychotics
Mood stabilisers
Psychosocial Interventions
Individual psychotherapy
Group psychotherapy
Family psychotherapy
Medical care
Nutritional Counseling
Cognitive Behavioural Therapy CBT
In Malta, individuals with eating disorders can be referred to Dar Kenn Għal Saħħtek, which offers day services as well as in-patient services.
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Obsessive Compulsive Disordera.k.a. OCD is a common chronic long-lasting disorder in which an individual experiences uncontrollable repeated obsessions or behaviours. Children and adolescents may experience Obsessive Compulsive Disorder too, with multiple obsessions and compulsions possibly changing content over time.
Common obsessions include excessive fear of dirt, germs or sickness, excessive fear of a loved one being in danger, obsessions related to religion or sex, as well as an uncontrollable need for symmetry and exactness.
Common compulsions include ritualistic handwashing, repetitions, checking, counting, ordering, hoarding, and touching.
Tic Disorder
Tourette Syndrome (TS) is a condition related to the nervous system which causes individuals to experience tics. Tics are sudden, rapid, non-rhythmic twitches and movements (motor tics) or sounds (vocal tics) that affected individuals repeat over and over, with no control whatsoever. Children who are diagnosed with tic disorder can also exhibit associated behavioural difficulties.
Dissociative Disorder DD
Dissociative disorder is a mental disorder involving disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity. Individuals with dissociative disorders experience problems with day-to-day functioning as they tend to escape reality involuntarily. This disorder has been linked with childhood trauma.
Dissociative disorder symptoms may include amnesia, disturbances in sense of self, trance-like states, rapid mood shifts and behaviour, knowledge-memory-skills access fluctuations, hallucinations (auditory and visual), and vivid imaginary friendships (in children and adolescents). Stress tends to exacerbate these symptoms.
Treatment for dissociative disorders includes a combination of psychotherapy and medication. Although difficult to treat, early identification and intervention increases the chance of affected individuals being able to lead healthy and productive lives.
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One of the top 5 most common mental health disorders in children is depression. Diagnosing depression in children is quite challenging since they may still experience periods of normal functioning despite their underlying disorder. As for diagnosing depression in adolescents, it becomes difficult to distinguish between the normal teen-related mood changes and those that come with depression. Nevertheless, early diagnosis is important since if depression in children is overlooked, it may persist through adulthood.
Signs and Symptoms of Depression in Children
persistent low mood
persistent sadness
lack of interest in activities they used to enjoy
a lingering feeling of tiredness and exhaustion
lethargy
agitation
sleeping too much or too little
eating too much or too little
feeling numb/emotionless
ongoing guilty feelings
poor memory
poor concentration
lack of self-esteem
lack of self-confidence
self-harming thoughts
suicidal thoughts
Anxiety and Depression in Children
Anxiety Disorders in Children
Separation Anxiety Disorder – child experiences fears related to an attachment figure being harmed or dying
Social Phobiaa.k.a.Social Anxiety Disorder – fear of being watched and judged by others
Generalised Anxiety Disorder – worrying on different events or circumstances
Specific Phobia – fear of a particular object or stimulus
Panic Disorder – sudden panic attacks related to somatic and cognitive sensations
Emotional Unstable Personality Disorder EUPD
Emotionally Unstable Personality Disordera.k.a.Borderline Personality Disorder is the most common type of personality disorder. EUPD causes intense fluctuating emotions that may last for a few hours to several days at a time. Emotions experienced may include impulsivity, risky behaviour, suicidal thoughts, and possibly self-harm.
A diagnosis of Emotionally Unstable Personality Disorder is usually given in adulthood as the related symptoms are associated with a lifelong personality disorder.
Substance Abuse
Substance abuse refers to the use of illegal drugs or prescription drugs or over-the-counter drugs or alcohol for purposes other than those for which they are meant to be used, or in excessive amounts.
Alcohol, marijuana and opiates mimic depression symptoms, causing lack of concentration, lack of motivation, and low energy. On the other hand, Amphetamine and Cocaine mimic mania symptoms. Substance abuse tends to trigger social, physical, emotional, and occupational problems.
NOTE: Substance abuse does not rule out a mood disorder.
Self-Harm
Self-harma.k.a.self-injury is a behavioural act in which an individual intentionally harms him/herself, usually without suicidal intention. Adolescents may seek to self-harm as a way of expressing tension, low self-esteem, physical discomfort, and pain. At times, self-harm is sought as a risk-taking act, rebellion against parents, or as an attention-seeking behaviour. However, self-harm can indicate severe psychiatric disorders such as depression, psychosis and PTSD.
Self-harming behaviour is also associated with children having developmental delays, including Autism Spectrum Disorder, and those who have experienced abuse or abandonment.
Suicide
Suicide is one of the main causes of death in children and adolescents. Severe bullying increases the risk of suicide. Additionally, being diagnosed with depression, ADHD, anxiety disorder, Attention Deficit Disorder (ADD), bipolar disorder, or schizophrenia during childhood also puts the child at a higher risk of suicide.
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Conduct Disorder (CD) is the most common psychiatric disorder in the world. It is characterised by persistent anti-social behaviour where social rules are repeatedly broken and aggressive acts are repeatedly performed with the aim of upsetting others. Many children and adolescents with a Conduct Disorder diagnosis grow up into anti-social adults.
Conduct Disorder Signs & Symptoms
repetitive and persistent violation of societal norms, rules, laws, and basic rights of others
aggression, property destruction, theft, and deceitfulness
behavioural severity that leads to significant impairment in various areas of functioning
prolonged behavioural pattern lasting a year or more (thus, isolated criminal acts do not lead to a Conduct Disorder diagnosis)
Oppositional Defiant Disorder (ODD), a disruptive disorder which often accompanies ADHD, features ongoing behavioural patterns that cause significant impairment in a child’s social, academic and occupational life.
Risk Factors for Conduct Disorder & Oppositional Defiant Disorder
anti-social parents
anti-social peers
lack of parental supervision
disruptive family behaviour
child abuse
child neglect
negative parental discipline
cold parental attitude
parental conflict
low family income
low IQ / low academic achievement
impulsiveness
attending high-crime-incidence schools
living in a high-crime-incidence neighbourhood
Treatment for CD & ODD
Psychosocial Interventions
Parental Training
Limit Setting Implementation
Cognitive Behavioural Therapy (CBT)
Family Therapy
Psychopharmacology
Stimulants – help reduce aggression
Anti-Depressants – SSRIs help reduce impulsive and aggressive behaviour
Lithium and Anti-Convulsants – help reduce aggression
Clonidine – help reduce impulsivity and aggression
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Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neuro-developmental disorders related to childhood. Although ADHD is most commonly diagnosed in childhood, it usually lasts well into adulthood. Children diagnosed with ADHD tend to find it hard to pay attention, are prone to controlling impulsive behaviour without any form of reflection, and are usually overactive.
Understanding ADHD – Simulation
Varying Types of Attention Deficit Hyperactivity Disorder
Predominantly Inattentive Presentation – characterised by distractibility, lack of organisational skills, lack of inability to complete tasks, and inability to follow instructions.
Predominantly Hyperactive-Impulsive Presentation – characterised by difficulty in being still, excessive fidgeting and movement, restlessness and impulsivity.
Combined Presentation – characterised by a combination of all symptoms: inattention, hyperactivity and impulsivity.
ADHD Diagnosis
For a child to be diagnosed with ADHD, the following must be evident in multiple settings eg. at home, at school, with friends, with family, even if in varying degrees:
at least 6 months of inattention (distractibility and organisational problems) with or without hyperactivity (lack of behavioural self-control/difficulty remaining still/excessive motor activity) and impulsivity (reacting to surrounding stimuli without thinking/reflecting on possible outcomes)
such behaviour needs to have a direct negative impact on the child’s functionality academically/occupationally or socially
deficit related to inattention, hyperactivity and impulsivity should be over the limit expected per child’s age
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Autism Spectrum Disorder (ASD) is a developmental disorder in which both communication and behaviour are affected. Signs and symptoms tend to start showing up during the first two years of life. A child with ASD exhibits issues related to social interaction, communication and play, and interest restrictions.
Autism Spectrum Disorder is considered to be a chronic disability. Through early intervention, symptoms can be improved.
For an accurate Autism Spectrum Disorder diagnosis, a child’s developmental and behavioural history is required, from which certain criteria can be evident by the age of 3. These include:
inability to initiate and maintain social interaction
inability to initiate and maintain communication
behavioural patterns which are restrictive, repetitive and inflexible
unusual interests or activities which at times may seem excessive
impairment in functional abilities related to self, family, and society, including school/work
Note: Child may still exhibit intellectual functioning and language abilities.
Genetic – having a sibling with ASD, or having certain chromosomal conditions such as tuberous sclerosis (genetic disorder which causes benign tumors to develop in various parts of the body) or fragile X syndrome (genetic condition which causes developmental issues such as learning disabilities and cognitive impairment).
Drugs – intake of certain drugs in pregnancy such as valproic acid (Epilim) and thalidomide (Thalomid)
Parental Age – the older the parents are when a child is born, the greater the risk for the child to develop ASD
Note: There is no scientific evidence suggesting that vaccines cause ASD.
ASD is linked to symptoms such as aggression, repetitive behaviour, irritability, anxiety and depression, hyperactivity, and attention deficit. Treatment for ASD may be prescribed with the aim of targeting such symptoms.
Psychosocial Interventions
Therapy can help a child with ASD to develop life skills, social skills, communicative skills, and language skills. Suggested therapy includes Behavioural Therapy, Psychological Therapy, and Educational Therapy.
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Psychosis is a condition affecting the way in which the brain processes information, causing loss of touch with reality. An individual with psychosis may see, hear, or believe things which are not real, to a point where it becomes hard to dissociate what is true from what is not. Psychosis symptoms include delusions, hallucinations, abnormal behaviour and incoherent speech.
Psychotic Episode Risk Factors
Severe Stress
Lack of Sleep
Alcohol Abuse Withdrawal Symptoms
Psychiatric Conditions – dementia, schizophrenia, severe depression, bipolar disorder
Schizophrenia, Schizotypal and Delusional Disorder
Schizophrenia
Schizophrenia is a chronic severe mental disorder affecting 20 million individuals worldwide. It may affect educational and occupational performance due to its effect on perception, mood, thinking, behaviour and contact with reality.
Individuals with schizophrenia are unfortunately more prone to stigma, discrimination, and violation of human rights, and are up to 3 times more likely to die early than the majority of the population, often due to preventable diseases eg. infections, metabolic disease and cardiovascular disease.
Through appropriate medicinal treatment and psychosocial support, schizophrenia can be treated.
Epidemiology
Negative symptoms onset tends to occur 5 years prior to the initial psychotic episode
Children of individuals with schizophrenia tend to have lower IQ, poor attention skills, poor social adjustment, and symptoms related to thought disorder.
Individuals with schizophrenia tend to differ from their peers in developmental markers throughout childhood, especially when it comes to developmental milestones, cognitive function levels, educational achievements, neurological and motor development, social competence and psychological disturbances.
Schizophrenia Risk Factors
40% increased risk if both parents have schizophrenia
10% increased risk if first-degree relative has schizophrenia
3% increased risk if second-degree relative has schizophrenia
10% increased risk if born in winter
2-4 times higher risk if living in urban areas
having older parents
having an over-protective dominant mother and an over-submissive father
experiencing hostility between parents
experiencing highly expressed emotions
having an infection during the fetal development stage
abnormalities in pregnancy and delivery
2nd trimester maternal influenza
low birth weight
fetal malnutrition
use of cannabis (past or present)
NOTE: A stressful life event may serve as a precipitating factor for the onset of schizophrenia, usually happening about 3 weeks later.
The Dopamine Hypothesis of Schizophrenia
The dopamine hypothesis goes back to the 1960’s and 1970’s when studies involving amphetamine (which increases dopamine levels) showed an increase in psychotic symptoms, whilst reserpine (which depletes dopamine levels) showed a reduction in psychotic symptoms.
The original dopamine hypothesis stated that hyperactivity of dopamine resulted in symptoms of schizophrenia, and drugs that blocked dopamine reduced psychotic symptoms.
There is however little direct evidence that abnormal dopaminergic transmission causes schizophrenia.
Retrieved from https://commons.wikimedia.org/wiki/File:Schizophrenia_brain_large.gif on 11th December 2021
The 3 Phases of Schizophrenia
Phase 1: PRODROMAL PHASE:
75% of individuals with schizophrenia experience the prodromal stage. Signs and symptoms experienced in this phase include:
Decline in normal functioning precedes the 1st psychotic episode
Social withdrawal
Irritability
Physical complaints
Poverty of speech
Peculiar behaviour
Role functioning impairment
Lack of initiative, interests or energy
Personal hygiene and grooming impairment
Unusual perceptions
New interest in religion or the occult, odd beliefs or magical thinking
Management of the Prodromal Phase focuses on the prevention of psychological and social disruption that results from psychosis. Anti-depressants, anxiolytics and mood stabilisers help the individual to deal with the symptoms. Anti-psychotics should be prescribed and started early, since studies indicate better prognosis. Psychoeducation of the individual and main caregivers increase coping mechanisms in relation to dealing with schizophrenia, while education about coping strategies in relation to stress help as prophylaxis against impending psychosis. Observation and monitoring should be performed in frequent intervals.
Phase 2: PSYCHOTIC (ACUTE) PHASE:
Positive symptoms
Perceptual disturbances such as auditory hallucinations
Delusions
Disordered thought process
Auditory hallucinations, which are frequently experienced in schizophrenia, include simple noises, complex sounds, voices, music, single words, whole conversations, commands or running commentary.
Visual hallucinations rarely occur without other kinds of hallucinations, but are less frequent than auditory hallucinations.
Other type of hallucinations may be olfactory (smells that aren’t truly present), tactile (sensation of touch or movement on the skin or inside the body) or gustatory (taste).
Delusions may be classified as primary (occurring occasionally) or secondary (preceded by a hallucination). Persecutory Delusions are delusions in which the person thinks that people are trying to inflict harm; Delusions of Reference are delusions which hold direct reference to the person (eg. television program referring to the individual with schizophrenia); Delusions of Control are delusions in which the person feels or beliefs that he/she is being controlled by someone else; Delusions of Possession of Thought are delusions in which the person feels thoughts are being inflicted, withdrawn or forecast on him/her.
In Disorder of Thoughts, the person has difficulty dealing with abstract ideas, and may experience mystical ideas. The person also features loosening of association (where ideas seem confused), pressure of thought (rapid, abundant and varied thoughts), poverty of thought (slow, few and unvaried thoughts) and blocking of thoughts (where the mind seems to go blank).
Phase 3: RESIDUAL (CHRONIC) PHASE:
Happens between psychotic episodes
Features negative symptoms such as social withdrawal
Odd thinking
Odd behaviour
Negative symptoms include the flat effect, in which reduced expression of emotions on the face or voice can be noted; alogia (reduced speech), avolition (inability to start and sustain activities), anhedonia (inability to experience pleasure), asociality (social withdrawal) and being reluctant to perform daily tasks.
Diagnosis
Schizophrenia can be diagnosed by:
taking a detailed history
excluding other possible conditions
excluding substance abuse and withdrawal
noting positive, negative and cognitive symptoms
noting that symptoms are experienced frequently
noting impaired social and occupational functioning
at least experienced for 1 month
Differential diagnosis include:
F21: Schizotypal Disorder
F22: Persistent Delusional Disorder
F23: Acute Transient Psychotic Disorder
F24: Induced Delusional Disorder
F25: Schizoaffective Disorder
Retrieved from https://www.verywellmind.com/schizotypal-personality-disorder-4689994 on 12th December 2021
Retrieved from https://www.verywellhealth.com/delusions-5113070 on 12th December 2021
Drug-induced psychosis refers to a psychotic episode which is directly related to abuse of an intoxicant, such as an illicit intoxicant, use of prescription medication without GP direction, or excessive use of alcohol or other legal substances.
Drug-induced psychosis happens when a person takes too much of a certain drug, or as an adverse reaction following the mixing of substances, or during drug withdrawal, or if the person has underlying mental health issues.
Drug detox can help reverse the effects of drug-induced psychosis.
Institutional Neurosis is a psychiatric disorder where a person assumes a dependent role and passively accepts a paternalist approach following long-time confinement in a hospital, mental hospital, prison, or such institutions.
In institutional neurosis, the person features signs of apathy, lack of initiative, loss of interest, submissiveness, and at times lack of emotional expression.
Psychosis Management
The APA Guidelines for Schizophrenia divide management in 3 phases:
Acute Phase: treatment for acute psychotic episode lasting 4-8 weeks
Stabilisation Phase: time-limited transition to continuing treatment lasting up to 3 months (in reality, sometimes this phase takes more than 3 months as many individuals with psychosis keep switching from the stabilisation phase to the stable phase over and over)
Stable Phase: stable treatment
Retrieved from https://login.medscape.com/login/sso/getlogin?wcode=102&client=205502&urlCache=aHR0cHM6Ly93d3cubWVkc2NhcGUub3JnL3ZpZXdhcnRpY2xlLzUwNzg1OA&sc=ng&scode=msporg on 12th December 2021
Psychosocial Interventions
Individual Therapy
Social Skills Training
Family Therapy
Vocational Rehab and Supported Employment
Cognitive Behavioural Therapy
Electroconvulsive Therapy (ECT)
ElectroConvulsive Therapy (ECT) induces brain seizure and momentary unconsciousness; this method can be considered for treatment of resistant schizophrenia, such as in catatonic stupor (significantly decreased reactivity to environmental stimuli and events), worsening of symptoms regardless of medication, and in individuals exhibiting high risk of suicide, homicide or physical assault.
NOTE: In Malta this method is not used in the case of schizophrenia.
Psychopharmacology
All persons making use of anti-psychotics need to undergo ECG PR interval monitoring at least every 3 months since these medications may cause heart problems if used long term especially in high doses.
1st Generation Typical Anti-Psychotics eg. Haloperidol (seranace), Chlorpromazine (largactil) and Trifluoperazine (stelazine) act by inhibiting central dopaminergic neurotransmission, whilst producing antagonism at cholinergic, histamine and alpha receptors, causing extrapyramidal symptoms. These drugsmay also be used for their sedative side-effects.
NOTE: In Malta, the use of Chlorpromazine (largactil) led to long-term psychotic patients to be finally discharged after many years in a mental health facility.
2nd Generation Atypical Anti-Psychotics eg. Clozapine (clozaril), Risperidone (risperdal), Quetiapine (seroquel), Olanzapine (zyprexa) and Aripriprazole (abilify) act on both dopamine and serotonin receptors. They are effective at dealing with both positive and negative symptoms, with a lower risk of extrapyrimidal effects.
Retrieved from https://www.slideserve.com/dai/7-clozapine-resistant-schizophrenia on 12th December 2021
Clozapine
Clozapine is only supplied upon prescription and blood results. Baseline blood tests that include full blood count, blood glucose, and liver function, as well as an ECG and weight, should be taken prior to administration of the drug.
Clozapine side effects include agranulocytosis (low number of granulocytes – type of white blood cells – in the blood) and extrapyramidal symptoms (EPS) such as tardive dyskinesia (involuntary neurological movement disorder), parkinsonism (a combination of movement abnormalities as seen in Parkinson’s disease such as tremor, slow movement, impaired speech or muscle stiffness) and dystonias (a movement disorder in which muscles contract involuntarily causing repetitive/twisting movements).
Clozapine administration requires monitoring for side-effects especially in the initiation phase, blood temperature monitoring, as well as weekly blood tests for WBC (number of white blood cells) for the first 18 weeks, every 2 weeks for the first year, followed by monthly testing.
Extrapyramidal Symptoms:
Retrieved from https://nursekey.com/antipsychotics-and-anxiolytics/ on 12th December 2021
Retrieved from https://www.verywellhealth.com/parkinsonism-causes-symptoms-and-treatment-5189631 on 12th December 2021
Neuroleptic Malignant Syndrome
Neuroleptic Malignant Syndrome is a life-threatening reaction to anti-psychotic drugs in which the person experiences fever, altered mental status, muscle rigidity, and autonomic dysfunction within hours or days of exposure to the drug. A patient with NMS may die within a few hours if untreated.
Retrieved from https://www.slideshare.net/AdeWijaya5/neuroleptic-malignant-syndrome-125151824 on 12th December 2021
Psychosis Nursing Approach
immediate goal as in all types of mental health problems is to prevent harm to self and others
establish a therapeutic nurse-patient relationship
notice signs or symptoms of hallucinations
acknowledge that hallucinations and other positive symptoms may be true to the person but not true to others
encourage the person to describe the positive symptoms being experienced, as well as related thoughts and feelings
provide help in the development or maintenance of life skills
offer support to the person and family/caregivers
Psychosis Nursing Care Plan
The following Psychosis Nursing Care Plan is based on the situation shown in the above video…
Immediate Goals
establish a therapeutic nurse-patient relationship based on trust and understanding
compile full history including current psychotic episode and any other similar episodes in the past
compile a list of current medications and other comorbidities to ensure that therapy suggested is suitable for the person
offer support to the person and his mother by providing information about the condition
person should be prescribed anti-psychotics so as to tackle psychotic symptoms
refer for psychological therapy such as CBT or Individual Therapy
suggest Family Therapy if lack of understanding between the person and his mother is evident, so as to promote understanding and support within the family unit
since the person feels safe at his parents’ house, it could be suggested that he moves back in with his parents for the time being until his condition is stabilised and under control; this could also mean that the person starts to eat well again as he may feel safer
Short Term Goals
review situation and make adjustments to the plan accordingly
review medication and see if any changes in dose or type of prescribed drugs need to be adjusted/changed, especially in the case of undesired side-effects
educate about compliance to medication so as to avoid relapse as much as possible
educate the person about the importance of continuing psychological therapy so coping techniques can be learned
review food intake and fluid intake and ensure the person has started eating/drinking again
teach the importance of keeping with follow-up appointments
Long Term Goals
re-assess symptoms
review medication and psychological therapy and their effectiveness
consider change of treatment if need be
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