PTSD Mental Health: Pharmacology & Interventions - PDF

N498 Mental Health PTSD & Addictions Michelle Cullen RN, MN, BMus Wellness Resources The content we will be talking about today, can be difficult. Sometimes these discussions can trigger unresolved personal experiences. The following resources are available for you to ac...

N498 Mental Health PTSD & Addictions Michelle Cullen RN, MN, BMus Wellness Resources The content we will be talking about today, can be difficult. Sometimes these discussions can trigger unresolved personal experiences. The following resources are available for you to access, if you require support. U of C Wellness Center (403) 210-9355 Distress Centre (403) 266-4357 Calgary Counselling Center (403) 265-4980 You can also contact your IOR. Agenda Class Objectives PTSD Introduction to Addictions Class Objectives 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. Class Objectives Describe how the nurse uses 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). Class objectives Explain how the nurse would include Motivational Interviewing (MI) as an intervention to create forward momentum towards wellness for the patient and family 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 What is the role of the following structures in PTSD? Amygdala Thalamus Hippocampus Prefrontal cortex  What are the six principles of trauma informed care? Safety Trustworthiness and transparency Peer support Collaboration and mutuality Empowerment, voice, and choice Cultural, historical and gender issues Retrieved from: https://www.wehonorveterans.org/wp-content/uploads/Video-1-Teaching-Guide_-Recongnizing- Trauma-and-Symptoms-of-PTSD.pdf What is the function of the following neurotransmitters GABA (gamma-amino butyric ) Dopamine Norepinephrine Serotonin PTSD: Interventions  PTSD & DID: Interventions  Outcomes are also connected to the Determinants of Health  Personal Health  Income & social status Practices/Coping Skills  Social Support Networks  Healthy Child  Education Development  Biology and Genetic  Employment/working conditions  Social Environments Endowment  Physical Environments  Gender  Health Services  Culture World Health Organization (2011) The Determinants of Health. Accessed January 31, 2014 @ http://www.who.int/hia/evidence/doh/en Post-Traumatic Stress Disorder Pharmacological Interventions PTSD: Pharmacology Medications do not decrease flashbacks or feelings associated with the original trauma Medications are Anxiety Depression usually prescribed Panic to decrease Difficulty falling asleep Nightmares symptoms Increased arousal symptoms Checkpoint Identify the goal of pharmacological interventions in PTSD and DID. PTSD: Pharmacology Resolve trauma prior Early intervention to another trauma occurring promotes the best Identify maladaptive outcomes across the coping skills and develop healthy lifespan adaptable coping mechanisms The only approved medication for SSRI are considered treatment of PTSD in Canada 1st line medications Frequently used in all age groups PTSD: Pharmacology Medications used for “off-label” indications: Antipsychotics Benzodiazepines Other: Clonidine (Catapres), Guanfacine (Tenex), Propranolol Important to treat any other co-morbid or concurrent conditions Common mental co-morbid health conditions  Bi-polar and psychotic disorders Common co-morbid physical health conditions  Arrhythmias and diabetes mellitus PTSD: Pharmacology Individuals with PTSD 50% will have an alcohol addiction 30% will have a drug addiction Considerations when medications are prescribed Lab and diagnostic tests Education Reflect An individuals with PTSD is prescribed an antipsychotic, but continues to manage intense emotions with alcohol and illicit substances. Why might this individual use alcohol and illicit substances, such as marijuana? 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  Dependent 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 International Society for Traumatic Stress Studies (2008) Treatment Guidelines for Psychopharmacotherapy for Children and Adolescents. Accessed January 31, 2014 @ Pharmacology: Across the Lifespan Older adults Caution as medications are metabolized in the liver Increase risk for drug-to-drug interactions Decreased liver functioning Checkpoint Identify seven considerations when implementing pharmacological interventions for patients across the lifespan, diagnosed with PTSD and DID. Checkpoint - Answer Identify seven considerations when implementing pharmacological interventions for patients across the lifespan, diagnosed with PTSD and DID. Answer: 1. Early intervention 2. SSRI are 1st line medications 3. SSRIs are the most researched medications for use in PTSD and the only medications approved by Health Canada for PTSD 4. Important to treat other co-morbid disorders 5. Children/Adolescents in particular benefit from relieve of even one symptom 6. Children/Adolescents – inclusion of medication in the treatment plan is largely based on the values and beliefs about medication in child and adolescents 7. Caution when using medications in older adults related to 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 Pharmacology: SSRI SSRIs can increase blood concentration of Warfarin, digoxin, beta-blockers, benzodiazepines Warfarin Increased blood Digoxin SSRI concentration of Beta Blockers Warfarin, digoxin, Benzodiazepines beta blockers, and Benzodiazepines Pharmacology: SSRI Diuretics and alcohol can increase the blood concentration of SSRIs Diuretics Increased blood SSRI concentration of Alcohol SSRI Pharmacology: SSRI Ibuprofen, naproxen and aspirin can decrease the blood concentration of SSRIs Ibuprofen Decreased blood Naproxen SSRI concentration of Aspirin SSRI Pharmacology: SSRI (continued) 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) Reflect When an individual with PTSD has a flashback the stress response is activated and norepinephrine is released from the peripheral nerve endings.  Remember: Norepinephrine is a by product of dopamine. Reflect How would taking an antipsychotic medication decrease the acuity of the stress response during a flashback? Pharmacology: Benzodiazepines Are 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)*  Reduce anxiety and arousal  Improve concentration and mood  Decrease behavioral impulsivity  Guanfacine (Tenex)*  Reduces nightmares  Propranolol*  Reduce arousal symptoms * Indicates off-label use Checkpoint Describe the rationale for using SSRIs, antipsychotics, clonidine (Catapres), guanfacine (Tenex), and Propranolol in the treatment of PTSD and DID. Describe how the use and effectiveness of pharmacological treatment for PTSD and DID are influenced by the socio-economic determinants of health. Post-Traumatic Stress Disorder Review Questions Review Question 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 which adverse effect? A. Serotonin syndrome B. Rhabdomyolysis C. Neuroleptic Malignant Syndrome D. Fall risk Review Question Jill was part of the Canadian military and served in Afghanistan. When she returned from duty she was diagnosed with PTSD. Over 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 the 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? A. Encourage Jill to continue to avoid situations that may cause stress. B. Explore Jill’s strategies for coping with intense feelings. C. Ask Jill if a friend could stay will her overnight. D. Ask Jill when she started taking the antipsychotic. E. Provide Jill with information about how Ativan can be addictive. Review Question 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? A. The nurse should sit with the patient in their room and provide reassurance. B. Administer Ativan 1mg sublingually prn C. Request the patient is placed on 1:1 nursing. D. Administer Seroquel 25 mg orally prn Post-Traumatic Stress Disorder Psychotherapeutic Interventions PTSD: Therapeutic Interventions The purpose of therapeutic interventions is for an individual to develop new coping skills and new ways of understanding his/her traumatic experience. Therapeutic 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: Psychoeducation Normalizing symptoms Learn coping strategies (i.e. relaxation, mindfulness, naming feelings, connecting feelings with thoughts and behaviors) Mindfulness: Becoming aware of one’s thoughts and feelings and accepting them without judgment Interrupt autonomic processing PTSD: Trauma Narrative Hearing the story  Role of the nurse is to facilitate the patient moving forward Curiosity about the patients own resources; not solely about the experience Acknowledge and validate as part of their unique experience Inquiry; not advice giving focuses on parts of the experience that are missing in the narrative Retrieved from: http://www.narrativetherapylibrary.com/media/downloadable/files/links/ 0/2/021Morgan_2.pdf PTSD: Restructuring Move from automatic thinking to conscious thinking Uses CBT to identify negative thought patterns and develop healthy coping strategies Consequences of not restructuring Getting stuck in the past Hypervigilant Risk of burnout PTSD: Cognitive Behavior Therapy (CBT) Examples of thought distortions Cognitive traps Trap Example Intervention Catastrophizing Making it bigger than it is “I will never feel better” Acceptance of feelings Continue with regular activities (importance of structured day) Theorizing Finding a reason for this will make me feel “Maybe this happened to me Acknowledge that you cannot change better because…” past events but you can change how you respond to them Mood Checking Testing to see if the problem has really “I haven’t had any flashbacks for two Stay in the present disappeared days. The flashback were really scary because…(describes vivid detail)” Emotions workingas a memory filter One emotions triggers several other “That alarm sounded just like the Not all experiences are the same. Recall memories one when we needed to evacuate” when the trigger was not related (i.e. fire drill) Source Unknown PTSD: Cognitive Behavior Therapy (CBT) Cognitive Traps(Faulty Assumptions) Generalizationsthat are accepted for all situations “I have to do everything I am asked Identify options and the resources to do” necessary to follow through with the choice Disqualifyingthe positive The positive changes don’t count as much “I’ve only been back to work for one Explore what made the one day possible as the negative choices. day in the last week” and provide commendations for the pt’s insight & achievement. Mind Reading Imagine what others are thinking “I know that my boss doesn’t think Explore the differences between the two I’m a good employee” contexts. Fortune Telling Ability to see into the future I’m not going to date anyone, Challenge the notion that nothing because I’ll just get hurt again.” changes. (create a safety plan) Labelling Inquire about other factors, that the Makes a solvable problem unsolvable “It’s my fault” person has no control over, that influence the outcome Source Unknown Checkpoint Describe the role and responsibilities of the nurse in the three stages of trauma-focused cognitive behaviour therapy, and explain how this approach promotes patient safety and wellbeing Post-Traumatic Stress Disorder Homework Homework in Mental Health Purpose  Summarize and consolidate learning  Provide an opportunity for the patient to practice what he or she has learned  Allows the nurse to provide feedback and encourage problem solving Related 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, administration, adherence) Post-Traumatic Stress Disorder Individual, Family, & Group Interventions Communication  How would you define therapeutic communication?  What are some communication skills you currently use?  Consider how nurses’ roles and skills may be similar and different when working with individuals, families, and groups, as well as, across the lifespan..  Communication Nurse-Patient Nurse-Family Purpose: Focus on specific Purpose: Explore relationships individual problems as a way to approach change Relationship between the within a larger support system patient and the therapist is Nurse is facilitator integral Understand communication Solutions are tailored to the patterns individual and his/her circumstances Communication: Nurse-Group Purpose: 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 Checkpoint Compare and contrast how the nurse uses communication skills, such as normalizing, active and reflective listening, intervening, injecting doubt and confrontation with an individual patient, a family and in a group, and across the lifespan. Addictions: Interventions Addictions Pharmacological Interventions Medications Two purposes for using medications Manage withdrawal Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) Treatment Withdrawal: CIWA-A When to When there is a likelihood of alcohol begin withdrawal monitoring When to When the score is