498 Mental Health PTSD

• The lecture covers PTSD and Addictions

Wellness Resources

• The content may trigger unresolved personal experiences.
• Available resources for support:
  • U of C Wellness Center (403) 210-9355
  • Distress Centre (403) 266-4357
  • Calgary Counselling Center (403) 265-4980
• Contact your IOR for support.

Class Objectives

• Identify the combined role of pharmacological agents and psychotherapy in the treatment of PTSD.
• Describe how pharmacological and psychotherapeutic interventions promote patient safety and well-being across the lifespan and throughout the trajectory of PTSD.
• Critique how pharmacological and psychotherapeutic interventions are influenced by the SEDoHs.
• Describe how nurses use age-appropriate communication skills, such as normalizing, active and reflective listening, intervening, injecting doubt and confrontation, with individuals, families, and groups.
• Summarize the nurse's role in Motivational Interviewing (MI).
• Explain how nurses would include Motivational Interviewing (MI) as an intervention to create forward momentum toward wellness for patients and families experiencing PTSD.
• Summarize the five components of empathy, in relation to Motivational Interviewing (MI), and explain how these are implemented in the elicit-provide-elicit cycle.
• Define the principles of change talk using DARN and CAT.

Review on PTSD

• Role of Amygdala in PTSD
• Role of Thalamus in PTSD
• Role of Hippocampus in PTSD
• Role of Prefrontal cortex in PTSD
• Six principles of trauma informed care:
  • Safety
  • Trustworthiness and transparency
  • Peer support
  • Collaboration and mutuality
  • Empowerment, voice, and choice
  • Cultural, historical and gender issues
• Function of the following neurotransmitters:
  • GABA (gamma-amino butyric )
  • Dopamine
  • Norepinephrine
  • Serotonin

PTSD & DID Interventions

• Outcomes are also connected to the Determinants of Health:
• Income & social status
• Social Support Networks
• Education
• Employment/working conditions
• Social Environments
• Physical Environments
• Health Services
• Personal Health Practices/Coping Skills
• Healthy Child Development
• Biology and Genetic Endowment
• Gender
• Culture

PTSD Pharmacological Interventions

• Medications do not decrease flashbacks or feelings associated with the original trauma.
• Medications are usually prescribed to decrease anxiety, depression, panic, difficulty falling asleep, nightmares and increased arousal symptoms.
• Early intervention promotes the best outcomes across the lifespan.
  • Resolve trauma prior to another trauma occurring.
  • Identify maladaptive coping skills and develop healthy adaptable coping mechanisms.
• SSRI are considered 1st line medications.
  • The only approved medication for treatment of PTSD in Canada.
  • It is frequently used in all age groups.
• Medications used for "off-label" indications include:
  • Antipsychotics
  • Benzodiazepines
  • Clonidine (Catapres), Guanfacine (Tenex), Propranolol
• Important to treat any other co-morbid or concurrent conditions:
  • Common mental co-morbid health conditions like Bi-polar and psychotic disorders
  • Common co-morbid physical health conditions like Arrhythmias and diabetes mellitus
• Individuals with PTSD:
  • 50% have an alcohol addiction.
  • 30% have a drug addiction.
• Considerations when medications are prescribed:
  • Lab and diagnostic tests.
  • Education.

Pharmacology: Across the Lifespan

• Children and Adolescents:
  • Use of medications has become more frequent.
    • Early intervention is critical.
    • Relieving even one symptom has a significant positive impact on overall functioning.
    • Medications depend on the parent's, child's, and adolescent's beliefs and values of pharmacological interventions.
  • SSRIs are the most researched medications in children and adolescents.
• Older adults:
  • Caution as medications are metabolized in the liver.
    • Increase risk for drug-to-drug interactions.
    • Decreased liver functioning.

Pharmacology: SSRI

• Address symptoms associated with serotonergic dysregulation.
• Decreased risk of relapse if prescribed for a least a year.
• Side effects include suicidal ideation and behavior.
• SSRIs can increase blood concentration of Warfarin, digoxin, beta-blockers, benzodiazepines.
• Diuretics and alcohol can increase the blood concentration of SSRIs.
• Ibuprofen, naproxen and aspirin can decrease the blood concentration of SSRIs.
• Medications approved by Health Canada:
  • Citalopram (Celexa)
  • Sertraline (Zoloft)
• Additional medications prescribed (off-label):
  • Fluoxetine (Prozac)
  • Paroxetine (Paxil)

Pharmacology: Antipsychotics

• Address symptoms such as agitation, dissociation, hypervigilance, paranoia or brief psychotic reactions (off-label uses).
• Medications include:
  • Risperidone (Risperdal)
  • Olanzapine (Zyprexa)
  • Quetiapine (Seroquel)

Pharmacology: Benzodiazepines

• Intended for short-term management only, i.e. crisis situations.
• Address symptoms of anxiety and hyper-vigilance.
• Medications include:
  • Lorazepam (Ativan)
  • Alprazolam (Xanax)
  • Diazepam (Valium)

Pharmacology: Other Medications

• Clonidine (Catapres)*:
  • Reduces anxiety and arousal.
  • Improves concentration and mood.
  • Decreases behavioral impulsivity.
• Guanfacine (Tenex)*:
  • Reduces nightmares.
• Propranolol*:
  • Reduces arousal symptoms.
  • • Indicates off-label use

Post-Traumatic Stress Disorder: Review Questions

• A nurse is caring for a client who is diagnosed with post-traumatic stress disorder (PTSD). The nurse administered the patient's first dose of an atypical antipsychotic medication this morning. When signing off the medication in the electronic medication recorded, the nurse noticed that he gave the patient twice the amount of atypical antipsychotic that was ordered. The nurse should continue to assess the patient for Neuroleptic Malignant Syndrome
• Jill was part of the Canadian military and served in Afghanistan. When she returned from duty she was diagnosed with PTSD. For the last month Jill has secluded herself in her apartment and states that even the sound of traffic leads to a panic attack. Jill called he health clinic and tells the nurse that she needs a prescription for Ativan (lorazepam) because the antipsychotic she was prescribed isn't working. Which of the following would the nurse include in her conversation with Jill? Explore Jill's strategies for coping with intense feelings.
• A patient has been diagnosed with PTSD and has a history of self-harm. During a recent panic attack the patient was emotionally distraught and suicidal. Which is the most appropriate nursing intervention? Request the patient is placed on 1:1 nursing intervention.

PTSD - Psychotherapeutic Interventions:

• Therapeutic interventions help individuals develop new coping skills and understand their traumatic experience.
• Interventions include:
  • Relaxation and mindfulness techniques
  • Cognitive restructuring
  • Emotional regulation

PTSD - Trauma-Focused CBT:

• Trauma-focused Cognitive Behavior Therapy (TF-CBT) includes three components:
  • Psychoeducation
  • Telling the trauma narrative
  • Restructuring

PTSD - Trauma Narrative:

• Nurses facilitate the patient moving forward while hearing the story. -Be curious about the patients own resources.
  • Acknowledge unique experiences, validate uniqueness. -Inquiry; not advice giving. -Focuses on parts of the experience that are missing in the narrative.

Cognitive Behavior Therapy (CBT)

• Cognitive Traps
  • Catastrophizing: Making it bigger than it is
    • Example: ""I will never feel better""
    • Intervention: Acceptance of feelings, continue with structured activities -Theorizing: Finding a reason for this will make me feel better
    • Example: ""Maybe this happened to me because....""
    • Intervention: Acknowledge that that cannot be changed, but how they react can change.
      -Mood Checking: Testing to see if the problem has really disappeared -Example""I haven't had flashbacks for days"" -Intervention: Stay in the present -Emotions working as a memory filter: One emotion activates other memories -Example: ""That alarm just sounded like evacuation"" -Intervention: Not all alarms are the same, recall the differences (i.e no fire).

CBT

• Generalizations that are accepted for all situations
  • Example: "I have to do everything I am asked to do"
  • Intervention: Identify options and the resources necessary to make those choices.
• Disqualifying the positive: The positive changes don't count as much as the negative choices.
  • Example: "I've only been back to work for one day"
  • Intervention: Explore and commend possible achievements.
• Mind Reading: Imagine what others are thinking
  • Example: "I know my boss doesn't like me"
  • Intervention: Explore the context clues.
• Fortune Telling: Ability to see into the future
  • Example: "Im not going to date again"
  • Intervention: Challenge the notion that nothing can change. Create safety plan
• Labelling: Makes a solvable problem unsolvable
  • Example: "It's my fault" -Intervention: Identify factors that happened.

Post-Traumatic Stress Disorder - Homework:

• Purpose
  • Summarize and consolidate learning.
  • Provide opportunity for patients to practice what he or she has learned.
  • Allows the nurse to provide feedback and encourage problem solving.
  • Should relate to the patient's goals.

Integrated Care:

• Homework may be focused on one or more specific areas:
  • Physical needs
  • Mental status needs
  • Safety needs
  • Functional needs
  • ADLS
  • Medication knowledge and adherence

Communication:

• Nurses can use communication skills such as normalizing, active and reflective listening, intervening, injecting doubt and confrontation with individuals patients, families, groups, across the lifespan.

Family-Patient vs Nurse-Patient

• Nurse-Patient: Focus on specific individual problems and solutions are based on the individual their circumstance. The relationship is integral with the therapist.
• Nurse-Family: Explore relationships as a support system , Nurse is the facilitator using open communication.

Nurse-Group Communication

to learn about “insight’ in relation to outsight

• Explore relationships -Gain new techniques or skills from learning that is acquired from others
  -Provide for healthy emotional experiences -Exploration of dependency
  -Develop social skills -Increase confidence

Review: Groups

• Types of Groups
  • Open vs. closed
  • Homogeneous vs heterogeneous
  • Educational
  • Process

Addictions Pharmacological Interventions

• Two purposes for using medications:
  • Manage withdrawal using Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A).
  • Treatment.
• CIWA-A:
  • Begin monitoring when there is a likelihood of alcohol withdrawal.
  • Stop monitoring when the score is <10 for three consecutive assessments; continue to monitor informally for re-emergence of symptoms.
  • Considerations:
    • Waking the patient
    • Maintaining eye contact
    • Use of Ativan or Valium may not necessarily prevent seizures
• Medications are always used in conjunction with behavioral therapies
  • Benzodiazepines: Ativan and Valium.
  • Methadone: Used for opioid addiction to suppress withdrawal symptoms and relieve cravings.
  • Tobacco:
    • Nicotine replacements
    • Bubroprion (Wellbutrin) -Varenicline (Champix)

Motivational Interviewing (MI)

• Goals:
  • Process Goal: For the patient to use their own voice to discuss concerns, and recognize the argument for change.
  • Outcome Goal: To have the patient resolve ambivalence and increase their motivation and commitment to change.
• Nurse Role:
  • Engage the patient to tell their story.
  • Collaborate to create understanding.
  • Direct attention to potential change.
  • Provide expertise.
• Empathy is:
  • A way of listening and responding to foster understanding
  • Involves aspects of communication:
    • Validation
    • Clarification
    • Inquiry
    • Eye contact
    • Tone of voice

Motivational Interviewing (MI)

• OARS represents the first four components to development of empathy:
  • O - Open ended questions
  • A - Affirmation
  • R - Reflective Listening
  • S - Summarizing
• Change Talk is the fifth component to development of empathy:
  • Listening for discrepancies and expressions of ambivalence
• Eliciting Change Talk:
  • Categories of change talk (DARN)
    • D - desire
    • A - ability
    • R - reasons
    • N - need
  • Facilitates action (CAT)
    • C - commitment
    • A - (taking) Action
    • T - trying (effort)