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ROAD TO WHOLENESS BEHAVIORAL HEALTH

HOME CARE TRAINING FOR

PARAPROFESSIONALS

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PART 3- What is Mental Illness? – Schizophrenia,

Bipolar Disorder and Handling Psych Emergencies

PART 3- What is Mental Illness? –

Schizophrenia, Bipolar Disorder

and Handling Psych Emergencies

C&V Senior Care Specialists, Inc.

Katherine J. Vanderhorst, RN-BC,BSN,CCM

Dr. Amy Craven,PT,MS,DPT

All Rights Reserved C & V Senior Care Specialists 2019

This Photo by Unknown Author is licensed under CC BY

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Webinar Objectives

• Discuss the occurrence of Schizophrenia and Bipolar Disorder.

• Define Schizophrenia and Bipolar diagnoses.

• Describe ways to converse with a patient who is psychotic.

• Explain 4 of the side-effects of antipsychotic medication that you would report to case manager.

• Describe our role in caring for a client with Bipolar Disorder.

• Explain your role in handling psych emergencies.

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Schizophrenia

• Schizophrenia is a mental illness that affects how the brain works. Effects 1.1% of population.

• People with schizophrenia experience psychosis, which means they can have serious problems with thinking clearly, emotions, and knowing what is real and what is not.

• This can include hearing or seeing things that are not there (hallucinations), and having very strange beliefs that are abnormal or not true (delusions).

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Schizophrenia• Schizophrenia refers to a group of severe, disabling psychiatric disorders marked by

withdrawal from reality, illogical thinking, possible delusions and hallucinations, and emotional, behavioral, or intellectual disturbance.

• These disturbances last for at least for six (6) months. The level of functioning in work, interpersonal relationship, and self-care are markedly below the level since the onset of symptoms.

• Have difficulty distinguishing reality from fantasy. Their speech and behavior may frighten or mystify those around them.

• They may have problems understanding other people’s emotions, and may feel depressed or irritable

• People may have trouble getting on with everyday life.

• Suicide is one of the main causes of death for people with schizophrenia.

• People living with schizophrenia have high rates of heart disease and diabetes

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MORE ON SCSHIZOPHREANIA

Pattern of symptoms

Times when symptoms worsen are called relapses. When symptoms improve or disappear, it’s called remission.

When delusions and hallucinations occur or get worse, the person may have trouble with everyday tasks, thinking clearly, solving problems or making decisions.

They may be unable to control their emotions or to get on normally with family, friends or other people, including their health-care team.

Other health problems for people with schizophrenia

• People with schizophrenia often have other problems with their mental health and physical health. These can include:

• anxiety and depression

• problems with drug and alcohol use

• health problems caused by smoking

• physical health problems.

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Common symptoms include:

• hallucinations (such as hearing voices of people who are not there)

• delusions (false beliefs, often based on hallucinations)

• being unable to think and speak clearly

• acting unusually

• being unable to enjoy things

• being unable to feel emotions normally

• losing interest in other people.

Schizophrenia Spectrum and Other Psychotic Disorders-Key Features

Positive Symptoms• Delusions -a fixed false belief (persecutory,

referential, religious, somatic, grandiose)

• Hallucinations – are perception-like experiences that occur without an external stimulus. Most common-auditory- hearing voices.

• Disorganized Thinking (Speech) - person may switch from one topic to another. Responses to questions may be totally unrelated. Severely disorganized speech.

• Grossly Disorganized or Abnormal Motor Behavior (Catatonia) - childlike behaviors, rigid, inappropriate or bizarre behaviors, complete lack of motor responses, excessive motor responses.

Negative Symptoms

Affect Flattening – absence of emotional expression.

Anhedonia – loss of pleasure in activities.

Asociality – social withdrawal isolative behavior.

Alogia – poverty of speech. Avolition – lack of energy and drive. Lack of motivation.

Apathy - lacking in emotion, enthusiasm or interest.

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Cognitive Symptoms• Confused thinking and speech (e.g., incoherent ramblings, loose association, word salad, wandering).• Bizarre behavior include childlike silliness, laughing or giggling, agitation, inappropriate appearance,

hygiene, and conduct.

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Treatment of Schizophrenia

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Medication

• Treats psychotic

• Anxiety

• Depression

• Side-effects of medication

Counseling

Therapy

Community Supports

Social and vocational supports

MEDICATIONS YOU MAY SEE

• Atypical more commonly used today due to less side-effects

• Typical more likely to cause movement disorders

• Newer atypical increase risk of diabetes and heart disease

• ALWAYS report any abnormal movements

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Drug-induced movement disorders (DIMDs), also referred to as extrapyramidal symptoms (EPS)

• Restlessness• Parkinson’s symptoms• Involuntary contractions of muscles

of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures

• Repetitive movements around the face

• NMS-fever, muscular rigidity, altered mental status

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REPORT

Schizophrenia

What Your Person Is Saying:

• There is a car parked on my street that is monitoring me. Every time I leave my house a car drives by marking down the times I left. They follow me around wherever I drive.

• I bought extra locks for my house because they came in the middle of the night and drugged me. All my doors are barricaded to keep them out. The police say they won’t do anything to help me.

• I stay up at night watching and waiting and set up traps in the yard to catch them. I bought a hearing amplification device so I can catch them before they get to my house.

How to Respond:

• That must be SO scary to feel like people are always watching you! You’re saying you can’t go anywhere without them following you? That must be terrible to constantly feel you are being monitored. How do you handle this stress? What are you doing to stay safe? So when do you sleep? And what do you do to get food? If you are always being followed, I imagine you wouldn’t feel too safe leaving the house. Is there anything I can do to help?

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What NOT To Do When Speaking With Someone With Psychotic Thoughts:

• Avoid criticizing or blaming the person for their psychosis or the actions related to their psychosis.

• Avoid denying or arguing with them about their reality “That doesn’t make any sense! Of course the government isn’t tapping our house!”

• Don’t take what they say personally. Paranoia and psychosis can lead to mistrust and suspicion.

• Do not directly confront them.

• Don’t tell them they are psychotic.

• Do not dismiss their concerns or laugh it off.

• Do not encourage their psychosis by confirming their delusions. Just because I am telling you not to argue with them about reality this doesn’t mean you have to agree with what they are saying. You don’t need to comment directly. Often a general, supportive statement will suffice. Some helpful things to say are “I don’t know what happened. It sounds very scary” or “There are lots of things that happen in this world that I can’t explain” or “I don’t know what to make of what you are saying. It’s so confusing and upsetting to hear everything you are telling me. How are you handling it?”

• Do not focus on correcting the reality of delusions. Don’t waste time trying to prove the delusion can’t be true with reason and logic.

• Don’t get angry. They are psychotic because their brain is playing tricks on them. They are not in control of what is happening in their mind.

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What To Do?• Be gentle and calm.

• Make them comfortable to share what is going on in their life.

• Focus on what is troubling them.

• Empathize with their situation “It must be SO scary to see those UPS trucks everywhere monitoring you!”

• Focus on their feelings in what they say, not the actual facts of their story

• Ask them if you can help in any way. “I know you are waiting for that letter with the million dollars. Are you managing to leave the house or are you too fearful you will miss it? Have you been able to get out and pick up your coffee? Can I get you some?”

• Ask about things you know they enjoy.

• Emphasize strengths “Wow! You skipped your cigarette this morning? How did you do that?!”

• Share love in a way they can tolerate. This may simply be by giving your full attention to their thoughts.

• Don’t underestimate the power of human connection

• Contact their treatment team to let them know what you are seeing, especially if it is concerning. If you think they are getting worse tell their providers.

• Call for help if they are making unsafe decisions that are putting themselves or others safety in jeopardy. Someone having a psychotic episode won’t always willingly go with you to the Emergency Room. If you are concerned about safety, then you may need to call 911 to get them

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What Can Do?

1-Support client

2-Encourage healthy diet

3-Use therapeutic communication-establish trust and rapport

❖Don’t touch client without telling him first what you are going to do.

4-Encourage healthy diet-if client thinks food is being poisoned have him/her help with preparation

5-Maintain safety

6-Maximize level of functioning-Avoid promoting dependence by doing only what the patient can’t do for himself

7-Present reality-Don’t argue about hallucinations. Tell them you do not see, hear, smell, or feel it but explain that you know that these hallucinations are real to them.

8-Remind to take medication

9-Document what you observe and do on care plan.

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Bipolar Disorder

• It is a mental illness that causes dramatic shifts in a person’s mood, energy and ability to think clearly. People with bipolar experience high and low moods—known as mania and depression—which differ from the typical ups-and-downs most people experience.

• life-long prevalence rate of bipolar disorder is 0.3 to 1.5%

• the age range is from childhood to 50 years

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This Photo by Unknown Author is licensed under CC BY-SA-NC

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Conditions that may coexist with Bipolar Disorder

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PSYCHOSIS ANXIETY ADHD MISUSE OF DRUGS OR ALCOHOL

EATING DISORDERS

How is Bipolar Treated?

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Medications

• Mood stabilizers-Lithium most common

• Antidepressants

• Antipsychotics-Aripiprazole (Abilify),Asenapine (Saphris),Cariprazine (Vraylar),Clozapine (Clozaril)Lurasidone (Latuda) ,Quetiapine (Seroquel) ,Olanzapine (Zyprexa)Risperidone (Risperdal

• Anticonvulsants-Depakote, Depakene (divalproex sodium, valproic acid, or valproate sodium)Lamictal (lamotrigine)Tegretol (carbamazepine)

• Anxiolytics

Psychotherapy

ECT

Exercise

Charting, daily mood monitoring

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HOW CAN WE HELP?-Bipolar

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1-Use therapeutic communication-establish trust and rapport

- clear sentences when communicating, breaks information into many small segments.

Maintain nutrition/hydration

2-Observe if moods are changing day to day

3-Encourage rest periods

4-Encourage exercise

5-Positive reinforcement/Building self-esteem

6-Remind to take medication at same time every day

7-Document what you observe and do on care plan

8-Ensure safety

• Minimize stimuli

REPORT MEDICATION SIDE-EFFECTS

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Psychiatric Medications

• Anti-depressants

• Major tranquilizers or neuroleptics

• Mood Stabilizers-Lithium

• Anti-anxiety

• Combination of above

Common Side EffectsCONSTIPATION ANXIETY

BLURRED VISION URINARY RETENTION

DROWSY DROOLING

RESTLESS IMPOTENCE

PHOTOSENSITIVE BLOOD PRESSURE MIGHT DROP WHEN STANDING

WEIGHT GAIN DRY MOUTH

SLOW MOVEMENT

REPORT TO NURSE, OFFICE

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Serious Side Effects

VITAL SIGN CHANGES PROBLEMS WITH SPEECH

MUSCLE RIGIDITY STRANGE MOVEMENTS

CONFUSION SWEATING

MUSCLE ACHES EYES ROLL BACK

NAUSEA AND VOMITING TREMORS

SEIZURES SIGNS OF INFECTION

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CALL NURSE, OFFICE AND PHYSICIAN ASAP AND /OR 911

What constitutes an emergency in psych?Patient is in danger of hurting self or others.

Patient is neglecting health-not eating,

drinking or sleeping.

Patient is experiencing a medication side-

effect.

Patient is not able to cope- very psychotic

thinking, panic attacks, overtly aggressive

“A True Emergency requires Emergency care!”

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Suicidal or Self-Destructive Behavior

• STAY WITH THE PATIENT

• STAY CALM

• TELL THE PERSON YOU ARE THERE FOR THEM

• TAKE ALL THREATS SERIOUSLY

• CALL NURSE/OFFICE/911

Homicidal or Aggressive Behavior

C&V Senior Care Specialists, Inc. 2016

• DO NOT STAY IN A DANGEROUS SITUATION

• GET TO SAFETY

• CALL FOR HELP-911

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Escalating Behavior

- Crying - Yelling - Mutism- Arguing - Inappropriate Laughter - Fear - Confusion

Behavioral Signs- Rocking/Swaying

- Rapid Breaths

- Shaking extremities- Pressured Speech

- Tenseness in the body

- Loud or Quiet

- Clenched fists

- Poor Eye Contact

- Pacing - Skittish Behaviors

C&V Senior Care Specialists, Inc. 2016 29

Escalating Behavior What to Do?

• Always back away from

• Give the person space client-at least 2 arm lengths

• Do Not Block Exits

• Lower tone of voice

• Close to door – back facing door

• Ask if the patient needs water, a moment alone, to sit down

• Do not threaten, argue or reason

• Empathize –” I can see that you are upset”

• Give choices when settling down

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Signs of Alcohol Intoxication

• DON'T TAKE INSULTS AND VERBAL ABUSE PERSONALLY

• INTOXICATION SIGNS CAN ALSO LOOK LIKE STROKE, DIABETES

• IF AGITATED, BACK OFF GET AWAY FROM PT

• IF VOMITING, HAVE THEM UPRIGHT OR ON SIDE

• CALL CASE MANAGER ASAP

• OFFER WATER

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Signs of Opioid Intoxication

• small or constricted pupils

• slowed or absent breathing

• extreme fatigue

• changes in heart rate

• loss of alertness

• CALL 911, Patient needs immediate treatment

• Narcan(naloxone) is 1st line treatment

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Common Opioid DrugsCodeine Fentanyl (Actiq, Duragesic, Fentora, Abstral, Onsolis)Hydrocodone (Hysingla, Zohydro ER)Hydrocodone/acetaminophen (Lorcet, Lortab, Norco, Vicodin)Hydromorphone (Dilaudid, Exalgo)Meperidine (Demerol)Methadone (Dolophine, Methadose)Morphine (Kadian, MS Contin, Morphabond)Oxycodone (OxyContin, Oxaydo)Oxycodone and acetaminophen (Percocet, Roxicet)Oxycodone and naloxone

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Questions ?

Katherine Vanderhorst, RN-BC, BSN, CCM716-863-0743

Amy Craven, PT, MS, DPT, CCM716-491-2098

cvseniorcare.com

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