Mental Health: Eating Disorders, OCD, and DID Module PDF

N497 MENTAL HEALTH EATING DISORDERS OBSESSIVE-COMPULSIVE DISORDER DISSOCIATIVE IDENTITY DISORDER Michelle Cullen RN, MN, BMUS NOTE The content in this module deals with serious mental health challenges. Sometimes these discussions can trigger unresolved personal experiences. The following resource...

N497 MENTAL HEALTH EATING DISORDERS OBSESSIVE-COMPULSIVE DISORDER DISSOCIATIVE IDENTITY DISORDER Michelle Cullen RN, MN, BMUS NOTE The content in this module deals with serious mental health challenges. Sometimes these discussions can trigger unresolved personal experiences. The following resources are available for you to access, if you require support.  NP Mental Health & Wellness Clinic  [email protected]  U of C Wellness Center (403) 210-9355  Calgary Counselling Center (403) 265-4980  Silver Linings Foundation (Support for Eating Disorders)  403-536-4025  Distress Centre (403) 266-4357  Imminent Distress 9-1-1 You can also contact your instructor, or you can connect with me at: [email protected]  AGENDA  Instructions  Class objectives  Eating Disorders  Anorexia Nervosa  Bulimia Nervosa  Obsessive Compulsive Disorder (OCD)  Dissociative Identity Disorders (DID) Unless otherwise indicated, image(s)/icon(s) were obtained from the Microsoft application (PPT/Word) image collection. February 1, 2025. INSTRUCTIONS INSTRUCTIONS  This learning module is intended to guide you through an understanding of eating disorders (Anorexia Nervosa & Bulimia Nervosa), Obsessive-Compulsive Disorder (OCD), and Dissociative Identity Disorder (DID) as it is defined in the DSM 5.  Throughout the module there are a variety of ways that you can evaluate your own learning, including:  Checkpoints at the end of each section  Example questions and answers. The rationale for the correct answer is often detailed in the notes section.  Points for reflection. The answers to these questions are not provided because the learning is in working through the process of analyzing and synthesizing information rather than just reading the correct answer. If you choose to answer these questions, you can email me your response to receive some feedback  You are not required to complete all the questions in the module; however, they are intended to help you articulate pertinent nursing knowledge.  If you have any questions, please email me at [email protected] CLASS OBJECTIVES CLASS OBJECTIVES – EATING DISORDERS  Identify the two types of eating disorders, and summarize the relationship between the diagnostic criteria, physical assessment and mental health diagnoses  Compare and contrast the trajectory of the anorexia nervosa and bulimia nervosa across the lifespan. CLASS OBJECTIVES - OCD  Generate a typical MSE (including the potential for SI/HI), for a client with obsessive compulsive disorder (OCD) and compare and contrast the presentation of OCD across the lifespan  Identify the five assessment categories which are pertinent for the nurse to explore with a patient and family experiencing OCD.  Describe how the assessment data for an individual experiencing OCD informs the nurse’s priorities for care. CLASS OBJECTIVES - DID  Identifyhow the diagnostic criteria, in conjunction with other assessment data, informs the nurse’s approach to, and prioritization of care for the client, family and nurse across the lifespan for dissociative identity disorder (DID) EATING DISORDERS EATING DISORDERS Definitions  Body Image  A mental picture of how one’s own body looks  Body Image Distortion  An individual perceives his/her own body different that the world perceives it  Interoceptive awareness  Describes the sensory response to emotional and visceral cues, such as hunger  Purge  Purposeful evacuation of stomach or bowel contents through artificial means such as vomiting or laxatives White, J. H. (2017). Eating disorders: Nursing care of persons with eating and weight-related disorders. (pp. 425-447) Essentials of Psychiatric Nursing (ed. M. A. Boyd) Wolters Kluwer; Philadephia PA EATING DISORDERS ANOREXIA NERVOSA  DSM 5 CRITERIA ANOREXIA NERVOSA A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5 th ed.). Washington: American Psychiatric Publishing. CHECK POINT List the diagnostic criteria, according to the DSM 5, for anorexia nervosa. PREVALENCE  About 0.5 – 1%  Onset is in early Adolescence (age 14-16)  Females  10x more likely than males  Early menses (age 10/11) is an important predictor  Usually a chronic condition with relapses  Precipitated by distorted body image  Impacted by  Culture  SEDoHs (Decreased socioeconomic status, Decreased education) ANOREXIA NERVOSA Comorbidity Click to edit Master text styles Across Click tothe Lifespan edit Master text styles  Anxiety disorders  Most often begin in childhood  OCD predates anorexia nervosa and adolescence by 5 years  May have serious dieting  Perfectionism before the signs of starvations are noticeable  Depression  Co-morbidities seem to resolve when the anorexia is successfully treated ETIOLOGY – BIOLOGICAL FACTORS  Changes is the orbitofrontal cortex and striatum  The orbitofrontal cortex has the most dopamine receptors in the brain  Decreased dopamine may decrease the pleasure an individual experiences with eating  Genetic Strong Heritability https://pixabay.com/illustrations/deoxyribonucleic-acid-dns-geneti First degree relatives account for 50-80% of cs-1500068/ heritability ETIOLOGY – BIOLOGICAL FACTORS  Neuroendocrine & Neurotransmitter Increase in endogenous opioids Patients exercise excessively Decreased thyroid function Related to malnutrition and chronic stress this puts on the body systems Decreased serotonergic functioning Decreased weight ETIOLOGY – PSYCHOLOGICAL FACTORS  Historically  It has been thought that the underlying psychological factors have been related to unresolved conflict in developing autonomy.  Dieting and weight control were a means to defend against feelings of inadequacy  Internalization of peer pressure Learned from peers Reflect: How is a therapeutic environment created on an in-patient child/adolescent psychiatric unit?  Body dissatisfaction Comparison with others (especially in the media) results in a struggle to develop his/her own identity Implications when the individual falls short of the ideal Reflect: Why is it important for nurses to educate adolescents and families about normal growth and development patterns, in particular the increased weight gain that supports changes during puberty? ETIOLOGY – SOCIAL THEORIES  Societal messages  Appearance  Roles  What roles are women most likely to pursue?  If a women is in a significant leadership role, are there expectations for how they will look and behave?  Achievements  Do we have expectations for what successful people looks like?  Confusion between character and appearance  “It doesn’t matter what is on the outside. It’s what’s on the inside that matters?”  Does this align with values and beliefs about equity?  Do we live out these values and beliefs?  Awareness of obesity  Media awareness of plus sized models  Dedicated clothing stores for particular sizes ADDITIONAL RISK FACTORS Puberty Low self-esteem Dieting/Attitudes about healthy eating Feelings of inadequacy Athleticism SEDoHs CHECK POINT Describe how the biological factors, two psychological factors, social theories, and additional risk factors contribute to a holistic understand of the etiology of anorexia nervosa. ASSESSMENT Anorexia Nervosa ASSESSMENT MSE Risk Assessment Physical Assessment Family SEDoHs MENTAL STATUS EXAM What might you included in your MSE for a patient diagnosed with anorexia nervosa? (Hint: consider how the DSM 5 criteria aligns with each category)  General Appearance  Affect & Mood  Speech & Language  Thought Process  Thought Content  Perceptual Functioning  Cognitive Functioning https://pixabay.com/vectors/writ e-author-pencil-pen-draft-15319  Insight 3/  Judgment CHECK POINT Demonstrate your understanding of the nine components of the mental status exam by categorizing the DSM V criteria for anorexia nervosa. RISK ASSESSMENT  7% - 10 % mortality rate  Suicide is the leading cause of death  Use highly lethal means  Inquire about  A plan (time/date/place)  Access to means (even if there is no plan as insight and judgment are usually impaired)  Protective factors  Collaborative information Reflect - What are some of the barriers to obtaining consent from the patient to talk with family members and other supports? PHYSICAL ASSESSMENT Multiple physical systems are compromised by starvation  Musculoskeletal 1. Loss of muscle mass, fat (leads to osteoporosis)  Metabolic 1. Hypothyroidism 2. Hypoglycemia 3. Decreased insulin sensitivity PHYSICAL ASSESSMENT Physical Assessment Continued  Cardiac 1. Bradycardia and ventricular tachycardia 2. Arrhythmias (atrial and ventricular premature contractions) 3. Hypotension 4. Loss/diminished cardiac muscle 5. Prolonged QT interval (consider potentiated effect with antidepressants like Remeron which further prolong the QT interval) 6. Sudden death syndrome PHYSICAL ASSESSMENT Physical systems continued  Gastrointestinal 1. Delayed gastric emptying 2. Bloating 3. Constipation/diarrhea (outcome of continued laxative use and poor nutrition) 4. Abdominal pain Reflect: How are these signs and symptoms related to the stress response? How might a consistent fight or flight response increase the difficulty of treating a person with an eating disorder? PHYSICAL ASSESSMENT Physical systems continued  Reproductive 1. Irregular menses to Amenorrhea 2. Low levels of luteinizing hormone 3. Low levels of follicle-stimulating hormone Reflect: How might disruptions in a patient’s reproductive system impact their self-esteem? PHYSICAL ASSESSMENT Physical systems continued  Dermatological 1. Dry, cracking skin & brittle nails (dehydration) 2. Lanugo (fine baby –like hair) over the whole body 3. Edema 4. Bluish hands and feet (result of poor nutrition and dehydration –decreased blood volume and decreased iron to carry oxygen) 5. Thinning hair PHYSICAL ASSESSMENT Physical systems continued  Hematological 1. Leukopenia 2. Anemia, 3. Thrombocytopenia 4. Increased cholesterol Reflect: What lab results would help you provide care for a patient experiencing these physical side effects? PHYSICAL ASSESSMENT Physical systems continued  Neuropsychiatric 1. Abnormal taste sensation (related to zinc deficiency) 2. Depression 3. Apathy 4. Sleep disturbances (decreased serotonin) 5. Fatigue (but will continue to exercise) Reflect: How will you assess for and differentiate between apathy that is related to decreased nutrition and apathy that is part of depression? PSYCHOLOGICAL SYMPTOMS  Psychological  Decreased interoceptive awareness  Sexuality conflict or fears  Maturity fears  Ritualistic behaviors  Difficulty expressing negative emotions  Low self esteem  Perfectionism  Body dissatisfaction CHECK POINT Describe how changes in an individual’s physical systems impacts the psychological characteristics related to anorexia nervosa. FAMILY ASSESSMENT  There is no evidence that family interactions are the primary cause of eating disorders.  Behaviors which may contribute to an individual’s need to control eating and weight  Unrealistic attitudes (weight, shape and size)  Decreased affection, communication and time spent together  Inability to manage conflict  Enmeshment (Erikson's stages of development – low autonomy, excessive lack of boundaries intrudes privacy)  Overprotectiveness (decreases the development of autonomy)  Rigidity (maintaining the status quo; change and conflict are avoided) CONSEQUENCES - PATIENT  Alienation from family and friends  Lack of intimate relationships  Additional health problems  Co-morbid conditions  Con-current conditions  Financial  Unable to work  Death CHECK POINT Discuss how multiple assessments (mental status, risk assessment, physical assessment, and data from the Socio-economic Determinants of Health) inform the nurse’s approach to care and prioritization of the patient/family experiencing anorexia nervosa. CHECK POINT Identify actual and potential health patterns and safety concerns that may exist for the patient and others as a result of experiencing anorexia nervosa. EATING DISORDERS BULIMIA NERVOSA  DSM 5 CRITERIA BULIMIA NERVOSA A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5 th ed.). Washington: American Psychiatric Publishing. CHECK POINT List the diagnostic criteria, according to the DSM 5, for bulimia nervosa. PREVALENCE About 1% – 2.3% Onset is between 15-24 years old Females 10x more likely than males Influenced also by Culture SEDoHs COMORBIDITY Anxiety disorders Depression Substance abuse Borderline and avoidant personality History of childhood sexual abuse ETIOLOGY – BIOLOGICAL FACTORS Genetic Biochemical Strong Heritability Decreased serotonin Contributes to vegetative shifts (patterns related to sleep, nutrition, and activity) which may contribute to weight gain Decreased plasma tryptophan Can lead to depressed mood ETIOLOGY – PSYCHOLOGICAL FACTORS Cognitive perspective Cognitive distortions form the basis of binge eating (i.e. all or nothing thinking, discounting positive changes, fortune telling) Psychological triggers can cause physiological responses and therefore are currently seen as an explanation for continuation of the behavior (bulimia nervosa) not as a cause ETIOLOGY – PSYCHOLOGICAL FACTORS Psychological triggers  Increased stress  Negative emotions  Both physical and emotional trigger the opioid system in the anterior cingulate cortex (ACC) to release endogenous opioids. Our bodies do not make an endless supply of endogenous opioids and these can be depleted over a prolonged experience of pain.  Environmental cues  Environmental stimuli can be linked to memories in the hippocampus  In this way, these cues trigger neurochemicals to respond in a way similar to when the initial event was experienced.  As a result, even a visual or the smell of a desired food can cause a increase in dopamine levels. ETIOLOGY – PSYCHOLOGICAL FACTORS Separation-individuation process  Moving between developmental stages  Usually occurs between adolescence and adulthood  Individuals are unprepared for emotional separation  Blurred boundaries  Individuals may feel guilt about making their own decisions ADDITIONAL RISK FACTORS Societal perceptions Dietary restraint Low self-esteem History of sexual abuse Feelings of inadequacy CHECK POINT Describe how the two biological factors, two psychological factors, social theories, and additional risk factors contribute to a holistic understanding of the etiology of bulimia nervosa. ASSESSMENT Bulimia Nervosa ASSESSMENT MSE Risk Assessment Physical Assessment Family SEDoHs MENTAL STATUS EXAM General Appearance Affect & Mood Speech & Language Thought Process Thought Content Perceptual Functioning Cognitive Functioning Insight Judgment CHECK POINT Demonstrate your understanding of the nine components of the mental status exam by categorizing the DSM V criteria for bulimia nervosa. RISK ASSESSMENT High suicide risks Independent of other co-morbid/con-current disorders High risk for self- Increased impulsivity mutilation Legal and Related to increased impulsivity Financial difficulty A plan (date/time/location) Inquire about Access to means (even if there is no plan) Protective factors PHYSICAL ASSESSMENT Physical systems are compromised by the binge-purge cycle Electrolyte abnormalities (hypokalemia, hypomagnesemia Metabolic Increased blood urea nitrogen levels (possible kidney damage) Ipecac-related cardiomyopathy arrhythmias Cardiac Ipecac syrup is used to induce vomiting Chronic vomiting can alter sodium and calcium levels Salivary gland and pancreatic inflammation and enlargement (increased serum amylase) Gastrointestinal Esophageal and gastric erosion/rupture Dysfunctional bowel syndrome PHYSICAL ASSESSMENT Physical systems continued  Dental 1. Erosion of dental enamel (front teeth) 2. Decay *Both 1 & 2 occur because of increased acid in the mouth when the individual is vomiting. The patient’s dentist may be the first care provider to identify concerns about bulimia nervosa.  Integument  Fingers and knuckles may be dry and cracked which is the result of the acidity of the vomit PHYSICAL ASSESSMENT Physical systems continued  Neuropsychiatric 1. Seizures Due to the fluid shift and electrolyte disturbances 2. Mild neuropathies 3. Fatigue 4. Weakness PSYCHOLOGICAL INQUIRY Psychological Assessment  Decreased interoceptive awareness  Sexuality conflict or fears  Related to their perception of their body  Maturity fears  Difficulties with taking responsibility and being accountable  Fear of failure  Low self-esteem  Body dissatisfaction  Could be related to weight, size, and shape CHECK POINT Describe how changes in an individual’s physical systems impacts the psychological characteristics related to bulimia nervosa. FAMILY ASSESSMENT  Behaviors which may contribute to an individual’s need to control eating and weight  Inability to manage conflict  Enmeshment  Erikson's stages of development - excessive boundaries intrudes privacy which may lead to sneaking behavior; lack of boundaries may lead to decreased sense of the individual’s own identity  Overprotectiveness  Impedes the development of autonomy  Rigidity  Maintaining the status quo – change and conflict are avoided CONSEQUENCES - PATIENT Alienation from family and friends Lack of healthy relationships Additional health problems Co-morbid conditions Con-current conditions Financial and legal implications CHECK POINT Discuss how multiple assessments (mental status, risk assessment, physical assessment, and data from the Socio-economic Determinants of Health) inform the nurse’s approach to care and prioritization of the patient/family experiencing bulimia nervosa. CHECK POINT Identify actual and potential health patterns and safety concerns that may exist for the patient and others as a result of experiencing bulimia nervosa. OBSESSIVE-COMPULSIVE DISORDER  DSM 5 CRITERIA OBSESSIVE-COMPULSIVE DISORDER A. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are defined by (1) and (2): 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington: American Psychiatric Publishing.  DSM 5 CRITERIA OBSESSIVE-COMPULSIVE DISORDER B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder The following video is an overview of OCD. https://www.youtube.com/watch?v=ua9zr16jC1M American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington: American Psychiatric Publishing. CHECK POINT List the diagnostic criteria, according to the DSM V, for obsessive-compulsive disorder PREVALENCE  About 1.2 % will develop OCD over a lifetime  Early onset predicts poorer treatment outcomes  Females are diagnosed slightly more than males  Higher rates among individuals who are  Young, divorced or separated, and unemployed PREVALENCE – ACROSS THE LIFESPAN Children & Adolescence 1-3% More males than females Young children are more difficult to diagnose Older Adult Late onset is more likely to occur in females Increased occurrence of PTSD PRACTICE QUESTION  Zac is 6 years old and just finished kindergarten. Zac does not have many friends and prefers to play by himself. Zac’s dad is concerned and thinks that there might be something wrong with his son. What additional information would be important for the nurse to know? Select all that apply. A. Zac spends significant time completing trivial tasks. B. Zac likes certain t-shirts more than others. C. Zac gets very upset when his dad encourages him to play with friends outside. D. Zac counts the stuffed animals on his bed every day when he wakes up and before he goes to bed. E. Zac doesn’t like to share his toys. PRACTICE QUESTION  Zac is 6 years old and just finished kindergarten. Zac does not have many friends and prefers to play by himself. Zac’s dad is concerned and thinks that there might be something wrong with his son. What additional information would be important for the nurse to know? Select all that apply. A. Zac spends significant time completing trivial tasks. B. Zac likes certain t-shirts more than others. C. Zac gets very upset when his dad encourages him to play with friends outside. D. Zac counts the stuffed animals on his bed every day when he wakes up and before he goes to bed. E. Zac doesn’t like to share his toys. COMORBIDITY  Mood disorders  Personality disorders  Particularly depression and  Occurs in about 80% of bipolar disorder individuals diagnosed with OCD  Anxiety and panic disorders  Somatic Disorder  Impulse control disorders  Substance disorders  Eating disorders  Occurs in about 1/3 of individuals diagnosed with OCD  Tourette syndrome  Frequently occurs with OCD REFLECT What are some common traits between OCD and borderline personality disorder? When working with a child in elementary school, how would you distinguish between a developmental delay diagnosis, and an OCD diagnosis? What are some reasons an individual with OCD would begin to use substances, Source: such as, illegal or non-prescribed drugs or https://pixabay.com/illustrations/hatena- think-question-in-trouble-1184896/ alcohol? ETIOLOGY – BIOLOGICAL FACTORS Genetic o Strong Heritability First degree relatives Increased prevalence if relatives also have Tourette’s syndrome, an anxiety disorder, or a mood disorder o Polygenic disease ETIOLOGY – BIOLOGICAL FACTORS Neuropathological o Hyperactivity of the orbitofrontal cortex Has the most dopamine receptors anterior cingulated cortex Part of the limbic system caudate nucleus Part of the basal ganglia where GABA mediates dopamine o Increased cerebral glucose Source: Colorbox/#222796.com metabolism ETIOLOGY – BIOLOGICAL FACTORS Biochemical o The most studied neurotransmitter in conjunction with OCD is Serotonin o This is based on the effectiveness of Serotonin specific reuptake inhibitors (SSRI) o Serotonin is one of the transmitters that o Initiates the fight or flight response o Influences how emotions are prioritized in the amygdala o Influences how meaning is connected to memories in the pre-frontal cortex o Implicated in vegetative shifts REFLECT How does the connection between the neuropathological and biochemical etiology of OCD help you understand the following for individuals diagnosed with OCD?  Decreased stress tolerance  Changes in executive functioning  Vegetative shifts  Increased pain perception (physical and emotional)  Changes in sexual behavior (decreased intimacy with partners) ETIOLOGY – PSYCHOLOGICAL FACTORS Psychodynamic Behavioral Arise form unconscious defense Conditioned stimuli mechanisms Behaviors that would typically be Isolation – separation of affect from considered neutral, provoke anxiety thoughts and impulse To manage anxiety individuals begin to Undoing – performing a behavior to perform other behaviors avoid the consequences of another The more a behavior decreases anxiety behavior the more frequently an individual will Reaction formation – a behavior or engage in the behavior attitude that opposes another behavior or attitude CHECK POINT Describe how each of the three biological factors and two psychological factors, contribute to a holistic understand of the etiology of obsessive-compulsive disorder. ASSESSMENT Obsessive-Compulsive Disorder ASSESSMENT  MSE  Risk Assessment  Physical Assessment  Family  SEDoHs MENTAL STATUS EXAM Based on the DSM 5, what would you expect to observe in each of the MSE categories when assessing an individual diagnosed with OCD?  General Appearance  Affect & Mood  Speech & Language  Thought Process  Thought Content  Perceptual Functioning  Cognitive Functioning  Insight  Judgment RISK ASSESSMENT Assess both the Type obsession and Severity compulsion for Access to means Inquire about Protective factors Allow enough time for the assessment It is importance to: Gather collateral information Consider insight and Is there increased impulsivity? Does the judgment patient feel the need to punish themselves? PHYSICAL ASSESSMENT Dermatological  Includes assessments of skin and Possible Outcomes hair  Osteoarthritis  Behaviors include:  Trichotillomania  Repetitive hand washing  Excessive cleaning (skin breakdown  Body dysmorphic disorder also due to cleaning agents)  Infection  Skin picking  Electrolyte imbalances  Pulling out hair  Particularly if there have been changes in nutrition due to decreased Dental Care enamel.  Behaviors include:  Excessive teeth brushing (leads to *These outcomes would require decreased tooth enamel) additional assessment FAMILY ASSESSMENT Individuals are more likely To remain single Have higher rates of celibacy Evaluate the families understanding of OCD Is education required? Is the family ready to change their behaviors? How much is the family able to adapt? Is the family enabling the patient’s compulsions? Does the family need assistance caring for the patient? FAMILY ASSESSMENT  Impact of SEDoHs  Financial  Can the patient work?  Is the patient safe alone or is constant caregiving required ?  Is funding required and/or available  Outside supports  Does the patient have social supports (friends, volunteer groups, etc.)?  Education  What education has the patient completed?  How does this impact employment?  How does this impact peer groups?  Social Functioning  Is it awkward to participate in social activities? CONSEQUENCES - PATIENT  Alienation from family and friends  Lack of intimate relationships  Additional health problems  Co-morbid conditions  Con-current conditions  Legal  Acting on obsessions  Financial  Unable to work INTEGRATING YOUR ASSESSMENT DATA  Click the link to watch the video.  https://www.youtube.com/watch?v=dSZNnz9SM4g  What assessment data would you collect for each of the following assessments?  MSE  Risk  Physical Assessment  Family Assessment  Stages of Change  SEDoHs  What emerges as the patient’s strengths?  What might the nursing priorities be?  What are the patient’s priorities? CHECK POINT Demonstrate your understanding of the nine components of the mental status exam by categorizing the DSM V criteria for a typical presentation of obsessive – compulsive disorder for populations across the lifespan. CHECK POINT Discuss how multiple assessments (mental status, risk assessment, physical assessment, and data from the Socio-economic Determinants of Health) inform the nurse’s approach to care and prioritization of the patient/family experiencing obsessive-compulsive disorder. CHECK POINT Identify actual and potential health patterns and safety concerns that may exist for the patient and others as a result of experiencing obsessive-compulsive disorder, and contrast how these may change across the lifespan. DISSOCIATIVE IDENTITY DISORDER (DID) DISSOCIATION DEFINITION  A subconscious defense mechanism that helps a person protect their emotional self from recognizing the full effects of some horrific or traumatic event by allowing the mind to forget or remove itself form the painful situation or memory.  Can occur both during and after the event  Becomes easier with repeated use Videbeck, S. L. (2014). Trauma and stressor related disorders. In D. Reilly (Ed.), Psychiatric Mental Health Nursing (pp. 216-231). PA: Lippincott Williams & Wilkins. DID: DSM 5 CRITERIA A. Disruption of identity characterized by two or more distinct personality states, which may be described in some culturesasan experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterationsin affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signsand symptomsmay be observed by othersor reported by the individual. B. Recurrent gapsin the recall of everyday events, important personal information, and/or traumatic eventsthat are inconsistent with ordinary forgetting. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The disturbance isnot a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptomsare not better explained by imaginary playmatesor other fantasy play. E. The symptoms are not attributable to the physiological effectsof a substance (e.g., blackoutsor chaotic behavior duringalcohol intoxication) or another medical condition (e.g., complexpartial seizures). Retrieved from: http://dsm.psychiatryonline.org.ezproxy.lib.ucalgary.ca/doi/full/10.1176/appi.books.9780890425596.dsm07#BABJAEHE DID: PREVALENCE  Gender  Occurs more frequently in women  Correlates with traumatic history of significant sexual abuse and/or physical abuse  Exists on a continuum DID: NURSING ASSESSMENT Do not want to re-traumatize Assess for SAFETY the patient In-patient care is provided because there are A risk assessment should be done with each serious safety concerns identity if possible Do not use suggestive or leading questions There is a HIGH incidence of self-harm in Observe and assess for incongruences in what individuals diagnosed with DID one personality shares and also between personalities May include inaccuracies, distortion, manipulation, confabulation of events and details DID: NURSING ASSESSMENT  Mental Status Exam -  Patients may change the following to match the particular identity that presents in the moment  Clothing, make-up  Speech and language (includes accents, profanity, and cadence)  Tone of voice  Eye contact  Engagement with others  Patients may have hallucinations (auditory and visual are most common) but they may not be about self-harm  Patients may experience periods of lost time. This is a significant risk factor for personal safety  The memories of each identity may vary  In an acute state, patients often do not have insight into other identities  Each identity may have a different level of judgement DID: NURSING ASSESSMENT  Other medical conditions  Organic causes (brain tumor, traumatic brain injuries)  Substance use  Substances may cause alterations in the individual’s perception, but there will not be several independent identities  Past medical history  Developmental milestones  Co-morbidities  Chronic illness  Family functioning  Who are the patient’s supports  Does the patient have a safe space DID: CHECK POINT Compare and contrast the diagnostic criteria for between DID and PTSD. DID: NURSING CONSIDERATIONS FOR CHILDREN & ADOLESCENTS  Children and Adolescents  Disruptive and self-destructive behavior  Incoherence in the developmental memory processes  Fluctuating mood (difficulties with self regulation)  Associated also with parental neglect International Society for the Study of Dissociation (2004). Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children. doi:10.1300/J229v05n03_09  DID: NURSING CONSIDERATIONS FOR CHILDREN & ADOLESCENTS  Nursing Considerations  Compare disruptions in identity to expected achievement of developmental tasks and milestones  Assess the child’s functioning in other environments (i.e. school, daycare, extra-curricular activities)  Assess the family environment  Physical and emotional safety  Psychiatric history of all family members  Assess for co-morbid conditions  Common co-occurring psychiatric disorders include: OCD, PTSD, ADHD, substance use disorders, attachment disorders  Other medical diagnosis (includes lab and diagnostic test results) International Society for the Study of Dissociation (2004). Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children. doi:10.1300/J229v05n03_09 DID: CHECK POINT Identify how a child or adolescent may present with a dissociative identity disorder related to appropriate developmental milestones. THANK YOU You have finished the content for the N497 on-line mental health module! You can email me at [email protected] if you have questions.