Transcript for:
Understanding Mental Health Disorders

all right everybody hello hello we're going to be talking about mental health stuff today what do we got going to talk about bipolar stress anxiety disorders trauma and dissociative disorders so let's get into it so when you guys think about bipolar disorder i want to think about these three that we are mainly going to be focused on we've got bipolar 1 bipolar 2 and psychothemic disorder okay don't get confused when you think about bipolar 1 versus bipolar 2 i need you to understand that bipolar 1 will be the one that's more difficult to live with okay bipolar 2 would be it's going to be difficult to live with either of them but bipolar 1 will be the most difficult because we'll see in just a second that folks who have bipolar 1 what they're experiencing not only do they experience the depression that you see here the severe depression but then they go all the way up here on this graph and then they experience mania okay so that's the big distinction between bipolar two and bipolar one bipolar one folks the experience that mania and when a person's in a manic state they are not going to be behaving in a way that's you would consider to be safe okay so looking here at this graph you know this is us you know for those of us who don't have bipolar disorder you know we see our move kind of fluctuating a little bit just kind of going up and down you know no big deal people have psychothermic personality disorder you're going to see a bit more of a rapid cycling they go up down up down but they never really fully hit that first step of depression all the way at the bottom here in between here nor do they experience the hypomania they're kind of like in between you look at folks who have psychothermic disorder these folks they'll come all the way down they'll hit that first step of depression okay they'll come all the way back up to normal they'll hit that first step or that step of hypomania okay they don't generally become manic though they come all the way down so they just keep going back up and down never really hitting that severe depression luckily never going beyond hypomania okay looking at bipolar 2 folks you see they come all the way down they hit that first step of depression they hit that severe depression they come all the way back up when they experience that hypomania you know they feel like they're they got a lot of energy they want to work on some projects around the house clean the car wash the cat watch whatever lots of energy okay um but you know they're able to control it somewhat they're not out of control potentially like you would see with some mania all right and then once again you see them coming all the way back down so when you think about a person who's experiencing bipolar 2 or bipolar 1 uh what do you guys think if they're experiencing this severe depression what's the priority of concern that we would have for our patient you know it would probably be the idea that they might be developing thoughts to hurt themselves right and we need to ensure that we're helping to keep these folks safe when they are experiencing that severe depression okay and we do have this right here unipolar mania where these folks they don't really experience the depressive side they're only experiencing the highs just the hypomania you know getting close to that mania but uh you know the key ones i want you to focus on psychotherapy disorder bipolar two bipolar one all right so looking at bipolar one how we are able to characterize somebody with this disorder versus some with bipolar ii is that we see that they would have a manic episode that lasts for at least seven days or longer within a given period of time if that happens that person would likely be categorized or diagnosed with having bipolar one technically you could have someone who has bipolar two they may go into a manic state for a short period of time maybe a day or two a few days but they would still be diagnosed with having bipolar 2 if um you know if it's less than if it goes less than seven days okay um right so when you think about bipolar ones go back to bipolar one when we think about folks with bipolar one we know that they can experience that mania we know that they're going to be going full steam because that's when you're manic you're just you just keep going right you have almost like an unlimited level of energy but you're still a human being you still require what sleep you still require food do you guys think that these folks are going to be feeling very hungry when they're manic do you think they're going to be feeling sleepy they probably won't be so with that in mind we're going to have to prompt them to say hey jerry why don't you go lay down and take a nap for a little bit want you to go lay down and relax or here jerry here's a here's a ham sandwich here's a chicken sandwich something with meat something with uh you know high caloric value behind it okay you really want one you really would not want to give them something like you know carrots and celery we're not trying to help them lose weight but um right the key thing i want you to know is this they can experience psychosis and one of the reasons why they could experience the psychosis is when you're manic and you go day after day after day after not sleeping very well right could you become psychotic yeah you're gonna probably start hearing things seeing things happen delusional thinking etc and um we have to be mindful about that when we work with our folks okay all right so looking right here at the slide this is the mania and when we look at books of mania what do we see we see this extreme drive in energy they'll have an inflated sense of self-importance noticing this idea that they are going to have a reduced sleep requirement you know for them they can lay down go to sleep for like a half an hour 90 minutes wake back up and then be right back into the action you know whereas you and me you know if you were to only get what maybe an hour of sleep you know on a monday night and then you know you wake up tuesday you're probably gonna feel pretty pretty poopy right um and then imagine tuesday night you only get another one hour of sleep you know how are you gonna be feeling by wednesday right wednesday night get an hour of sleep thursday how are you gonna be feeling you're gonna be like you're going to feel like you're dead almost right you're going to be so tired so messed up from that lack of sleep you'll barely be able to function but these folks they just keep going they'll have the energy they'll be able to wake up and they get right back into this you know right back into things the problem is you know your brain is not going to be functioning very well when you're not sleeping and um you know that's the thing that can lead these folks into that psychosis so it like i said it's a really important idea for us to prompt them to say hey jerry why don't you go lay down take a nap why don't you go lay down and relax before uh before we do our group therapy session et cetera okay uh you'll see a folks who have mania they're gonna be talking um you know with this pressured speech and for those of you who get to go to clinicals and meet these folks in person um you're going to see folks who have bipolar disorder when they're in the manic state you're not really going to be talking with them more so they're going to be talking at you not much of a back and forth in between conversations mostly just them talking at you um so you're gonna see that these folks are gonna be very easily distracted uh they can become obsessed you know over certain goals or things that they think have to be done or accomplished you know you might get a patient coming up to you you know if you work night shift come on two at two in the morning hey i need to talk to the doctor right now it's really important to call you gotta call the doctor and talk to them right now really what is it that you wanna talk about you know and they'll say i need to take i need to make sure that i have a dietary supplement in the morning for breakfast you know they'll be really fixated over these whole things and uh you know as a nurse you need to make sure that you know what it is they're talking about you have to acknowledge their complaints you have to acknowledge their concerns but you need to be mindful about calling the doctor at two in the morning simply because the patient wants to have access to dietary supplements etc okay uh you'll see this purposeless arousal movement many of these folks have racing thoughts and one of the key things that we need to be mindful of too with the mania high risk behavior okay these folks they will engage in activity such as gambling uh having sex with people who they don't know without any protection um many stories you know i've been told for folks who go into a manic state where they have access to their parents you know retirement funds or their own retirement funds and then they just dump it all into you know whatever they think is the hottest thing or really you know cool investment or whatever and then they lose all their money and that is the thing that happens sadly with these folks because when they're in this manic state are they thinking clearly are they making good executive decisions you know over their care over their own self you know being one self well-being well not not really okay they genuinely will have difficulty making good decisions and uh you know it can they can really screw their lives up when they're in a manic state with some of their behavior that they're doing okay all right so here is a acronym called dick fast you guys can use to help yourselves remember mania all right you're seeing that distractibility indiscretion grandiosity okay they'll think that they can do things that no others can do they may think that they're all powerful okay they're having the flat of ideas you're seeing an increase in their activity the sleep deficit very talkative okay so looking at depressive characteristics when these folks who have bipolar become depressed you know what do you see a flat blunted label affect possibly tearfulness crying energy and adonia okay lack of energy inability to experience joy or pleasure you may see that they experience psychomotor retardation uh they may develop these uh you know physical reports discomfort and pain and that's you know once again due to this idea of somatic issues when you have depression when you have this negative you know feeling or this mindset for some period of time you know it can lead to development of pain discomfort throughout the body okay we'll talk more about somatic symptoms later in the term so uh you may also see that when folks are experiencing their depression these characteristics with their bipolar difficulty concentrating difficulty focusing problem solving they're probably not doing really well with their adls okay and you're also seeing a disturbed sleep pattern and disturb eating patterns as well okay here's the slide there depression assessment yeah i don't really use this but it's something so okay so psychothermic disorder hold on one second okay so psychedelic disorder when we think about psychotic disorder this disorder it can be a bit difficult to distinguish between this disorder and bipolar ii um you know we see the similarity traits with the hypomania okay we see the depression okay the thing with the psychothema disorder though is that you don't see folks developing the severe depression that more commonly see with folks who have bipolar too patients with disorder tend to have more irritable hypomanic episodes uh children this disorder can cause sleep disturbances and irritability okay uh just the symptoms that we see with this disorder it can be you know difficult you know living with this disorder and it can impair some folks as occupational um you know their occupational or their social uh activities so next looking at the epidemiology another among children and teens bipolar disorder has a rate of about one percent uh it's often very difficult to diagnose in children with children because they're still developing we still don't you know know exactly how they're gonna turn out and what's considered to be normal for this person uh many psychiatrists kind of hold off on giving a child the diagnosis is bipolar because also it could be something else it could be something maybe like conduct disorder uh so there are sometimes a bit hesitant to give them a diagnosis unless they are for certain exactly what's going on with them okay bipolar one tends to become a depressive episode in women seven five percent of time bipolar ii disorder is more commonly seen among females uh bipolar one tends to begin with a depressive episode in men 67 of the time and bipolar one disorder seems to be common among males when we think about the onset of age for someone with bipolar uh a bipolar one usually we might see around the age of 18 bipolar 2 right around 20 but that's i don't want you guys to think oh it has to be oh when you're 18 that's when you have bipolar when you're 20 that's when you hit bipolar 2. that's not exactly the case because you know you can become a bit older uh maybe in your early 20s mid-20s or even a little bit later in life and you can still develop perhaps bipolar um you know become somewhat manifested but um you know that that's just kind of how it goes uh i do want you guys to understand this idea when we think about bipolar one bipolar ii some spokes would normally ask this question professor could you have bipolar 2 disorder and then become diagnosed with bipolar 1 yeah you can um you know people who may have bipolar 2 you know they may have never really experienced being here before maybe they only get it for a day or two possibly but then later in life uh or things change maybe they do have that full one week you know episode of mania and you know once they do develop that that's when they would likely be diagnosed with bipolar one okay um that's how it goes so among children researchers are actively sudden differences between adhd um and bipolar since the symptoms like you know they can become or appear to be very similar women with bipolar disorder more likely to abuse alcohol drugs commit suicide you know folks who are using uh this medication called lithium you know they're more likely to develop hypothyroidism okay um men with bipolar disorder they're more likely to have legal problems more likely to commit acts of violence so looking at the comorbidity you know if you have bipolar disorder do you have anything else you probably might you know and that's only going to make you know their quality of life even more difficult but you got bipolar you could have you know panic attacks eating disorder personality disorder et cetera and more than half people with bipolar disorder will likely also have an additional or other psychiatric disorder as well so really important this slide here interventions when we're working with a patient who is experiencing acute mania we need to make sure that um we need to make sure that we are keeping these folks safe okay we need to focus on their safety we need to maintain their physical health all right when they're in the manic state they will not be doing a very good job of either of these okay um we will be constantly asking them you know we ask our patients every shift you know if they're having any thoughts or hurting themselves you know it also hurts people but particularly with folks who are experiencing mania we might ask them you know more than once during the shift you know we need to keep a close eye on them all right do what you can to try to reduce stimuli offer them quiet time you know try to keep them away from the nurse's station because when you think about the nurse's station is the nurses station nursing station very busy is there a lot of commotion going on over there yeah naturally to someone who is manic they're going to be drawn to that you know to that um that noise that activity you know all that tension that's going on over there they're going to want to go see what's going on and we want to give them an opportunity to relax to rest okay when we talk with these folks use short simple sentences you know we can use a you know calm voice you know somewhat quiet very loud we're not gonna be yelling or shouting at them okay speaking of very matter of fact uh you know what method and um when you give them explanations make sure they're very concise use consistent staff of the same sex and orientation uh have them go for a walk okay you're going to think that why anyone to go for a walk professor why is that appropriate well you know when they're in the manic state do you think they're going to be able to sit down and watch a movie with you do you think they're going to be able to sit down and read a book they're not going to be able to do that all right when they're manic there's going to be keep going away what's hey how you doing my name's jared what's going on hey why are you here they are not going to stop okay they just keep going and um you know because they have this level of energy would it be appropriate to have them go and exercise you know uh on an elliptical or a exercise bike i don't think so because if you give them that opportunity to go on there they're gonna go pedal to the middle uh they're probably gonna exercise to the point where they may even hurt themselves okay they can lead this can lead them when they're in this manner state this can lead them to you know go into a level of physical exhaustion okay they can literally end their own life because they just keep going full steam like this and uh you know the idea of taking them for a walk it's appropriate it is an appropriate action because you're letting them burn up some of the excess energy right the idea is that if you are going for a walk with the patient if you're with them you are going to ensure that they stay safe okay you're going to do your job as a nurse keep your patients safe and um you know that's that's the idea staying with the patient when they're manic you are doing a good job as a nurse because you are going to ensure that they are safe okay uh that the staff member maybe that you say hey to the cna or to the lbn or even to your uh your your buddies hey go stay with this patient for a while that's good okay staying with the patient is a good thing to do to keep your patients safe to keep them alive so we're going to implement breast periods we're going to tell them to go lay down to go relax try to take a nap okay it's appropriate to provide them some outlets for physical activity we're not going to say you know no physical activity at all that's like overboard okay but we need to make sure that the physical activity is appropriate and safe not just for that patient but other patients around them i would not want to have my manic patient play ping pong because i know darn well they're going to spike that ping pong and if someone who's not paying attention walks by they're going to get nailed in the head with that paddle okay so you know if you want to have them do some stretching activities that's fine uh but nothing too nothing too vigorous okay um also when you're doing activities with them don't make them play a game that's very complicated or very heavy in terms like the rules or instructions like i wouldn't want these folks to play monopoly monopoly is too complicated too complex for someone to act for someone to engage in if they're manic they're not going to want to sit there and wait till their turn etc they're gonna want to just you know roll the dice play do everything you know because they'll think it's their turn every time it's someone else's turn i have to play something simpler okay like checkers okay um maybe maybe chess but probably not just you know something more straightforward okay uh we're going to ensure that the nutrition is being met by providing them foods that they can eat on the run you know finger foods okay but they're going to be high calorie finger foods all right many of the times the patients will want to complain about you know things that are going on and that's fine uh you know we'll listen to and we'll act on legitimate you know grievances that they have um you know that's fine uh we need to reinforce non-manipulative behaviors okay sometimes these folks when they become manic they can be very manipulative they'll say things they'll do things to try to get you the nurse to do what is they want you to do and when they start doing some not you know some inappropriate you know manipulative type of behavior we got to shut that down okay otherwise this is going to persist and it's going to make your uh it's going to make your job a lot more difficult so okay like i was saying physical exhaustion death are things that could potentially happen okay uh like i said they're not stopping they're not moving they won't feel the need to eat or drink or sleep this can lead to a medical emergency so we need to ensure that we're preventing the patient from self-harm whether it's intentional or accidental try to decrease that patient's physical activity level ensure that they are having adequate fluid and food intake promote adequate amounts of sleep each night assist the patient with any self-care needs manage their medications appropriately okay so you got a patient here uh he's coming down from automatic period he says i feel bad about cheating on my wife there's what would be the nurse's best response when you think about what is the nurse's best response remember it's always going to be something that sounds therapeutic just because it says what is done versus best response in the back of your head you're thinking okay what is also very therapeutic are you going to say oh don't worry you can't help it it's part of your i don't think that's good are you gonna say let's discuss your feelings with your wife i don't know if she wants to discuss this with you the nurse and the three of you so um how about uh see hypersexuality is part of her illness let's discuss early signs of a manic episode that sounds okay let's look at the last one last one says you better be your wife will divorce you well that's not therapeutic or appropriate at all so i think you guys can see that c would be the best response okay so now we're looking at medications okay and when we think about bipolar disorder the main thing that we're going to help to give these the main medication class meds we get to help them will be our mood stabilizers okay and one of the go-to meds that we're going to consider is going to be lithium all right lithium it's a really powerful effective medication uh very helpful for you know our patients who are experiencing mania okay lithium produces neurochemical changes in the brain including serotonin receptor blockade decreases neural atrophy or it increases neuronal growth for condom maybe it does this maybe it does not uh controls episodes of acute mania helps prevent the return of mania or depression decreases the incidence of suicide which is a really good feature from this medication patients are having thoughts to hurt themselves you get some lithium in them once it gets to a therapeutic level that you know that those thoughts of suicide kind of go down pretty quickly this medication though it is teratogenic so we don't want to give this medication to our patients who are pregnant um nor do we want to breastfeed while they're on this medication and like i'm saying long-term use folks would like to develop hypothyroidism and possibly they may develop regional complications as well so when we think about folks who are taking lithium understand that the medication it is not addictive okay uh if it was then i'll be taking this medication and you know that's not that's not the case it's on the addictive medication uh we need to make sure that we're taking a look at the following labs all right um when folks are on lithium we need to ensure that they are not uh going overboard with their fluid intake the lithium itself may make them feel uh you know thirsty that's kind of like an effect of the medication but if they start chugging a bunch of water um that's not going to you know enable them to be in a therapeutic level with this medication so try to restrict you know their um you know their fluid intake to one and a half to three liters a day make sure that when it comes to their sodium intake you know just as long as they follow a regular sodium intake diet like a regular you know amount of sodium each day that they would normally consume they'll be fine uh do not let them take less than their regular amount of sodium per day nor do we want them to take more sodium per day okay um now if we see a decreasing sooner if we see them having you know not enough sodium in their system uh this can lead them to develop toxicity and um you know that's one of the key things that we have to be careful of lithium is that the lithium level in their system can become toxic if they are you know if they are not having enough sodium in their system if they're having issues where you know they're having you know a high level of sodium coming out of the system such as from what vomiting diarrhea okay faculty then to become toxic as well and the problem is when folks become toxic with lithium that will likely make them want to vomit and experience diarrhea so you can have someone who's taking lithium and maybe they're taking the medication like as you know written by the provider but at some point in time they start having the vomiting or diarrhea you know why is that is that because the dosage was too high another and now they are at a toxic level with their with their lithium or maybe they ate some food that wasn't prepared appropriately and maybe that's the reason why they're having the vomiting and diarrhea either way if they experience vomiting and diarrhea well on lithium we're going to tell that patient to say hey jerry hold your next dose let's come have you see the provider immediately so we can check out and see what's going on okay they might be experiencing the vomiting or diarrhea for some other issue okay or they could be experiencing it because the lithium levels just simply i mean the lithium dose was simply just too high okay all right so make sure that folks who are on lithium make sure that they take the medication this medication with food okay otherwise they're going to experience gi upset and uh you know you have to empower them with this education that they experience is vomiting and diarrhea and they need to stop the med okay so here are the lithium indications uh when we think about folks who are on lithium you know a normal range that we'd like to see folks at you know it could be you know 0.5 1.2 right that's normal that's fine um the whole the main thing is that we don't want them to get to which number 1.5 because they are 1.5 they are now toxic okay and when they're toxic what do you see you're going to see the diarrhea you're going to see the vomiting you'll also see nausea you're going to see them having you know issues of thirst you know polyuria muscle weakness fine hand tremors should say fine not bind some type of there about slurred speech lethargy okay you may have folks who are experiencing advanced signs of toxicity uh you'll see their lithium levels 1.5 to 2.0 you're going to see that they're going to have mental confusion sedation poor coordination coarse tremors worsening gi distress regarding their diarrhea and their vomiting okay uh severe signs of toxicity 2.0 to 2.5 they're seeing extreme polyuria of dilute urine they may have tinnitus giddiness jerking movements blurred vision ataxia seizures severe hypotension you know stupor leading possibly to a coma um they can eventually go into they can possibly die from this they can go to a coma and they can die once they get to 2.5 you know 2.5 or higher all right so other medications that we could use to help our folks we got carbomazepine valproic acid uh we've got the metrogene all right and you see how difficult acid is uh golden and red i want you guys to look up alphoric acid and i want you guys to know what kind of uh lab value we're going to be looking at while a patient is on this medication okay want you guys to look it up in your books and uh know that for next week or the following week when you get tested okay so uh these medications they still the entrance of sodium and calcium back into the neuron uh thus extending the time it takes for the nerve to return to its active state potentiates the inhibitory effects of gamma nutrient acid inhibits glutamic acid which in turn suppresses cns and excitation other medications that we could use we have our anti-convulsants um like glonazepam okay we can use gabapentin to pyramid we may use benzos other benzos such as lorazepam okay antidepressants these can be used mainly when they are in that depressive state all right we'll get ssris but we have to be mindful that we're not giving them these ssri medications when they are in a manic state because that can prolong their mania all right so we don't want to take these ssri meds if we begin to see or if we determine that yeah they're manic at this point okay all right so other interventions we could use we spoke about this in the previous week you know some folks they potentially may benefit from uh you know ect but um you know in my experience i think i've only seen patients you know for cbct uh for their depression at glendale venice but um whatever completely that you know this will work for patients with bipolar i just personally never got to see that though okay next we're on to understanding and managing responses to stress okay think about stress what comes to mind right uh it could be your neighbors it could be your family right it could be your children okay it could be your work maybe you're relocating um all right all these things can lead to stress all right so we think about stressors it could be you know something that's physical response a psychological response um we have our fight versus flight uh response and when you think about fight versus fight you know people maybe they're in this maybe if there are costco and some guy comes up to you and you know starts to threaten you and wants to get into a fight well if you're a guy you're gonna be like all right bro let's go right and ladies you're smarter than us what you guys are going to do you got like uh-uh i just got my nails done my hair's done i'm not doing any of this stuff you guys are going to be smart you're going to just get the heck away from that person and save yourself a lot of trouble so different responses between fight or flight all right key terms i want you to understand when you think about distress distress you know it's the root word itself it's you know it's an unpleasant kind of issue to be stuck in right it's very distressing to take an exam which you haven't studied for right it's very distressing the term here called eustress this is something that's uh you know quite the opposite of distress with e-stress you know you're feeling stressed but the idea is that the end result will be something beneficial or something that you'd like or something that's good okay maybe you're packing up to go on your vacation and you're worried about okay who's going to take care of the dog okay i got to deal with this i got to make sure that the water plants are going to be watered and etc you know all that kind of stuff that's more in line with you stress the end result of something that's going to be happening will be something really great you're going to get on vacation um you know as opposed to distress oh my god i'm going to fail this class or oh my god i'm going to get fired or oh my god you know that's that's the difference between the two okay so thinking about stress you know we have folks who can experience acute stress all right that's you know in the short term uh maybe they're experiencing apprehension unhappiness sorrow decrease in their appetite increasing their respiratory rate their heart rate cardiac output blood pressure increase in their metabolism glucose use depressed immune system people that experience prolonged stress okay stress that goes on longer than it you know then they would like it to they're going to possibly develop issues with chronic anxiety or panic attacks maybe they are going to experience depression chronic pain sleep disturbances you might see weight gain or weight loss these folks will be at an increased risk for mi or stroke more likely they will exhibit signs of diabetes poor diabetes control hypertension fatigue irritability decreased ability to concentrate these folks who experience prolonged stress they are going to be at increased risk for infection okay now we have a general adaption center by han celia that's stage one the alarm reaction stage two resistance stage three exhaustion that's neat okay and we get the management of stress all right so what do we do to help manage stress well we can do some cognitive techniques like cognitive reframing um this is a technique that consists of identifying and then disputing irrational or maladaptive thoughts we have behavioral techniques where we help the patient learn how to relax we have them engaged in meditation guided imagery breathing exercises okay uh progressive muscle relaxation maybe they can engage in some physical exercise right what else can we do well we can have them engaged in journal writing they can do priority restructuring they can use some biofeedback maybe engage some mindfulness they can you know use some assertiveness training sometimes uh you know folks maybe let's say you're a waiter uh working in a restaurant and um the manager fires all the other waiters okay or for whatever reason you're the only way to work in there um is that a sustainable way in which that person could work as the only waiter or waitress in that in that restaurant no right they need to be assertive and they say hey boss look you got to hire more people this is ridiculous i can't do this all on my own you know assertiveness training is something that folks may need to engage in you know some folks may be you know naturally more assertive than others uh it can't this can be something where we see that it could be a cultural thing too um you know but uh yeah we need to be we need to consider that sort of this training could be a good um option for some folks given their situation okay other stress reduction techniques maybe they can engage in you know their individual hobbies i like magic the gathering but i haven't been able to play matches with gathering because uh you know covered 19 so that's a real bummer for me for the last year and a half but you know so you know hopefully folks can engage in their you know their hobbies um that will definitely help them with managing their stress some folks will engage in you know music therapy um pet therapy right physics really music is a really good thing early listen to some good music recently so it's good so uh the the neurotransmitter we're looking at um regarding this topic here with serotonin okay and we see that it's affecting our mood sleep sexuality or sexual drive uh appetite metabolism uh we said it's more active in stressful situations okay so mediators of this first response uh you know some things can be more of a stressor to others you know i kind of discovered that as i get older you know certain things that used to stress me out when i was younger um don't stress me out so much now now that i'm older i think too like if you encounter the stressor before and now it's rearing its ugly head and coming back for you to deal with it again the third or fourth time you know it's probably not shouldn't be as stressful you know the third or fourth time going around on it you know but um you know we're all different key thing though too i think it's your perception on the matter some people see a given stressor as like the end-all be-all to their existence almost and that can cause them to become or experience you know more stress perhaps than you know somebody else who sees that stressor much differently okay who perceives the situation maybe more realistically okay your own individual temperament uh will be a mediator to your stress response having social support that's a big thing when we think about mental health and uh you know anybody who has health issues if you have a really strong social support group you know friends and family um you're probably likely to do or handle things better compared to people who have no social support at all okay some folks may participate in support groups okay and when we look at our culture you know cultures are going to be different and uh you know it could be a cultural thing in the way in which people will respond to you know stress and some folks may have spirituality or religious beliefs maybe they think that uh you know it's uh maybe maybe they think that god's challenging them god wants them to child god wants them to uh deal with this you know truly stressful event but to overcome it right god's challenging you and they'd like you to um you know basically overcome it and show your strength and etc uh could be seen in a negative way maybe some folks will think that god is punishing them and that they deserve to be punished and that this is what they get for you know fill in the blank right uh so it's kind of it can be a bit of a double-edged sword sometimes but it depends on how you know people use you know you know depends on how their spirituality their religious beliefs uh are utilized um you know when it comes to particular stressors okay all right next round to anxiety and obsessive-compulsive related disorders okay so when you guys think about anxiety you know people you know we're generally seeing some kind of threat to our biological self okay or maybe our self concept and uh when people have you know anxiety they can have you know a realistic threat you know they're perceiving they're perceiving this realistic threat as something to be you know mindful about um you know their response to it will be proportionate it'll be appropriate we're not really seeing any dysfunctional behavior folks who have neurotic anxiety they perceive an unrealistic threat their reaction will be out of proportion to that given threat and uh even if that threat is removed or taken away from their position or from them uh they're still going to be responding to that you know that stimuli even though it's not there anymore okay folks with neurotic anxiety you're going to be seeing impaired functioning too so looking at the levels of anxiety we got mild we got moderate we got severe we got panic okay and when you think about mild anxiety we probably all experience mild anxiety at some point during life you know it's no big deal before your final exam your proctor etc uh you're gonna maybe experience what feelings of discomfort restlessness irritability maybe patient a bit apprehensive okay what do you do some folks maybe they bite their nails maybe they do some foot finger tapping fidgeting lip chewing you know nothing too serious something to no cause for alarm with mild anxiety okay then you get the folks who have moderate anxiety so for these folks you know you're seeing difficulty with their concentration maybe they're going to be pacing around the floor or pacing around the you know around the unit or on their home okay maybe they're reporting feeling tired if you were to check their you know vitals you're going to see an increase in their pulse the respiratory rate perspiration maybe they even start to have a bit of shaking okay um maybe they'll see that they have gastric discomfort headaches backache uh urinary urgency maybe difficulty sleeping changes in their voice pitch and maybe some vocal tremors okay then you got folks who have severe anxiety and for folks who have severe anxiety these folks they're not gonna be doing pretty good okay they're gonna be pretty uh not gonna be in a good place so uh they may appear to be dazed and or confused you know maybe they're going to say or maybe they'll have this feeling of impending doom or dread maybe they experience a withdrawal maybe they're talking in a loud or in a rapid manner you'll see this endless activity maybe they're kind of like washing it looks like they're washing the dishes but they're just kind of like you know smearing grease on the plate because they're not really washing it they're just you know maybe they maybe it looks like they're folding clothing but they're just kind of like flopping them over or they're just they're not really doing anything but it looks like they're doing something that's kind of like that aimless activity uh maybe they're they'll say that their hearts pounding out of their chest maybe they are appearing uh to be hyperventilating okay uh this stays confused you know they'll maybe they're talking when they're talking you know they they may not be talking in a way in which they're completely like you know flipping out right um they might be talking loudly because you know how they're feeling um you know or they could be saying i i i don't i don't know why my wife i don't know why my wife left me uh i don't understand you know um but if they're reporting you know physical ailments right like their their heart's pounding out of their chest okay that's severe but there's something beyond severe that's panic and when we think about panic these folks they're really off the deep end okay these folks you're going to be seeing a dysfunction in their speech they will be showing irrational thinking um maybe they become you know what appears to be somewhat psychotic you know they're gonna say my dad my dad he he's gonna he's coming into town i know he's gonna he could read my thoughts so i had to have to be really good if i don't think if i'm not thinking the right thing you know he'll know he'll know what i'm thinking and i'm like wow you know unless you became jean grey or professor x you know no you can't read other people's thoughts you don't know what they're thinking but when they're saying something like this you can hopefully recognize yeah that's delusional thinking there okay they're not uh they're they're clearly beyond severe at this point okay you're seeing this extreme fright or horror severe hyperactivity you know flight response the they can get to the point where they become straight up immobile they don't move okay and i think that's like one of the worst things people can experience when they experience this panic level of anxiety all right um you know with all the you know all the mass shootings and things like that happening you know in the united states you have to be you have to be able to move okay you can't just freeze up like that but you know hopefully you know we don't experience that but we do see that when people experience panic they will literally become immobile they'll just stand there you'll see that they may have dilated pupils severe shakiness this inability to sleep okay so when we assess these folks we're trying to work with them we're trying to understand you know what is their level of anxiety what caused their anxiety you know if that if something that caused their anxiety something that we can identify maybe we can remove that thing that's causing their anxiety maybe they can remove it away from them and that will help them okay are they having any kind of cognitive distortions are they you know what type of coping behaviors have they used in the past um is what they're feeling is it fear or is it anxiety and when you think about fear fear is a response to a perceived threat that is consciously recognized as a danger anxiety you know it's an emotional response to anticipation of danger even though they don't know exactly what it may be okay next we're on to mild moderate anxiety intervention so we're going to use active listening we want to demonstrate to the patient that we have a willingness to help them that we are going to use specific communication techniques you know to de-escalate them to help them feel you know more comfortable or safe we're going to evaluate um you know past couple mechanisms what they've done in the past to help with them you know to help keep themselves calm when you engage these folks provide a calm presence recognize that the patient is in distress okay try to explore alternatives to problem solving situations try to encourage patients to participate in activities such as exercise or something that may temporarily relieve feelings you know within their of their inner attention looking at severe panic but these folks um are these are what do you think do you think they're going to be safe when they're in panic mode or when they're in severe you know anxiety mode probably not so but these folks if you have the opportunity to stay with them that's going to be pretty good actually you know if you have a patient who's having any level of anxiety whether it's mild to moderate severe or panic if you have an opportunity to stay with that patient would that be the best thing for you to do i think it would be because if you stay with the patient what are you doing are you keeping them safe are you keeping them alive are you fulfilling your prime directive as a nurse if you do that yes you are okay but particularly with the folks who are having severe and panic you want to stay with them you got to ensure that they keep them so that you're helping to keep themselves safe okay um they may do something maybe they lash out at somebody or they you know wig out or do whatever you got to make sure that they're not hurting themselves or hurting other people or hurting somebody else who might beat the poop out of them you know that i've seen situations like that so okay um try to provide a might try to provide a quiet environment trying to minimize the stimulation if you're able to use medications in restraint but only after less restrictive interventions have failed okay just because you know they are clearly you know in panic mode doesn't mean you get to throw them in restraints just like that always try something else before we do restraints restraints are like the last thing that we try to do you can encourage gross motor activity such as walking or other forms of exercise set limits by using a firm short simple statements understand that repetition will likely be necessary because they're not processing very well you may need to tell them 10 20 30 times you know about what's going on before they can really process it and understand it okay try to direct the patient to acknowledge reality focus on what is presence in the environment um that's a good intervention for these folks okay so when we think about anxiety um you know understand that when folks have anxiety if they don't you know kind of like deal with it if they're not able to resolve what's called causing them to be anxious it can develop into other things it can develop into an anxiety disorder okay um maybe they're having panic attacks uh phobias okay maybe it can go into somatoform disorder where they think or they feel that there is um you know something going on with them physically you know but when we check them out look at them there's no organic cost in their pain or the discomfort of what they're feeling okay all right they may develop a dissociative disorder and we'll talk about the social disorders in just a bit okay so here are some of the anxiety disorders we're going to cover really quick we got acute stress disorder ptsd separation anxiety disorder panic disorder generalized anxiety disorder phobias a cystic compulsive disorder body dysmorphic disorder hoarding disorder hair pulling and skin picking disorders okay so um first up we got acute stress disorder okay so when you think about acute stress disorder um versus ptsd you know we understand what causes ptsd right it's going to be a really traumatic terrible event being present at a mass shooting right that's definitely a thing that can you know cause ptsd the thing is you know how do we say that this person has ptsd versus acute stress disorder and um when it comes to ptsd versus acute stress disorder they are a bit different so let's say it's monday i was at a tragic event you know this place you know at the park whatever now i experienced this traumatic event and two weeks later you know i'm having issues where i'm detached i'm having difficulty you know thinking about you know what happened or maybe i'm having horror or flashbacks you know all this fun stuff but it's not been it's only been two weeks so within that time frame we would recognize that this person is experiencing what acute stress disorder okay if these symptoms persist and they go beyond beyond 30 days what would you say that this is that this would then become ptsd okay um you know and when we think about ptsd ptsd can last for years um you know and looking at the individual you know some people are just kind of hardwired you know on their brains a little bit differently you have two people who are both present at this traumatic event in the park right uh one person has acute stress disorder and then the other person develops ptsd the other person you know they're able to resolve you know the issue and what happened with it they don't develop ptsd you know um it's just you know we're all unique we're all different but not everybody will develop things you know similarly um even though they were right there they pretty much you know shared the same experience and all that stuff um you know we are unique so next topic we have separation anxiety disorder and this starts usually before the age of 18. um and we're seeing folks develop this excessive anxiety when they become away or when they are away from their home or a significant other and to be diagnosed it must last for at least four weeks in children adolescents in six months or more in adults uh we're seeing this developmentally inappropriate and or excessive fear or anxiety concerning the separation either from that individual or from that location okay recurrent uh excessive distress when anticipating or experiencing the separation from the home or from that person persistent in excess of worry about losing that major attachment you may see that they will become reluctant they will maybe not want to leave the house or maybe they don't want to leave that person's presence okay maybe they'll develop sleep disturbances and nightmares you're probably going to be seeing some physical symptoms gi disturbances pain nausea vomiting headaches okay next we're on to panic disorder so for someone to have panic disorder we need to see four or more of the following um during their panic attack palpitations shortness of breath feelings of being choked or smothered right chest pain nausea feelings of depersonalization maybe the fear of dying or losing their own mind okay chills or hot flashes so what are we going to do with these folks well we're going to do some interventions we're going to us you know basically do what we can to try to reduce their anxiety promote safety stay with the patient that's always going to be a good option because if you do that you're keeping them alive keep them safe take their vital signs maybe their vital signs are getting up there okay maybe there's a maybe there might be a medication that would be appropriate to give them if their vital signs are spiking that eye okay maintain a calm manner make sure that the patient you know um it has a paper back possibly to breathe into if they're hyperventilating you can use short simple sentences be firm you know whether with a voice that's somewhat directive um try to refocus their energy make sure the stimuli is low try to decrease noise if we're able to direct other patients to head off to the room for a little bit or have this patient go to their room okay thinking about general anxiety disorder [Music] with generalized anxiety disorder we're seeing this uncontrollable the successive worrying uh for six months or longer okay and the key thing is this is is the excessive worry all right uh folks who have this disorder it can cause you know significant impairment in their ability to do their work do their job studying and school work um and uh you know for folks to have this you know diagnosis we're gonna be seeing three or more of the following okay once again feeling nervous the irritability being on edge having the sense of impending danger or doom uh having this increased heart rate breathing rapidly sweating trembling feeling weak or tired difficulty concentrating having trouble sleeping experiencing gi problems folks who have gid because this is an ongoing issue uh they're not likely to basically wake up one day and say oh my generalized desire disorder's all gone like that's that's not likely going to be the case um these folks are going to be living with us more likely probably forever um so what do you think do you think you want to give these folks benzos like lorazepam whatever they're feeling anxious well the rise of pam's pretty heavy hitting isn't it uh do you think you just get people lorazepam willy-nilly whenever they feel like they want it or need it these folks they're going to be feeling anxious when how often like all the time i don't really think it would be a good idea for these folks to be using uh benzos um you know as their primary way of dealing with their anxiety maybe they can have a prn dose of once a day or once every other day or something like that hopefully that's how often they would take it we don't like our patients taking benzos you know willy-nilly every single day of the week that's not appropriate that's not what it's intense uses for more likely we're going to get this person who has this disorder maybe something like bispro and beast bar um this medication that that's a you know just medication that's given daily and um that would probably more that would probably be more appropriate to get them than to get them benzes okay right so interventions working with these folks which teach activities that promote relaxation okay maybe they can do warm shower do some exercising teach them progressive relaxation they can use imagery uh help them structure their day that's an appropriate uh you know activity for them to do um they can use positive self-talk they can do reframing they can do prioritizing they can use humor yoga meditation uh pr medications you know those would be kind of like a specific last resort um only for when they feel like they are losing control or things they you know it's too much fun to handle should we have to use um pear and meds like menses okay scheduled meds like beast prone those would be fine that's appropriate that's good okay next we got phobic disorders so uh phobia it's an irrational fear of a specific object activity or situation that results in compelling desire to avoid a particular object or perhaps a situation uh people with phobias will likely experience panic terror dread when they come into contact you know with that phobic you know element all right so here are some of the phobias that uh you know more commonly seen uh we have social phobias we have agoraphobia sorry agoraphobia acrophobia okay uh aerophobia arachnophobia nectophobia thanatophobia sounds like a marvel character right we got astrophobia glossophobia monophobia mysophobia pyrophobia and zoo there are many other movies out there but these are the ones that are more commonly seen the ones that bold and red i think you really want to be familiar with those with those because i feel like those are pretty they're pretty commonly seen uh within the population um yeah i think i think i probably have acrophobia i don't like heights like you know like oh it's not gonna impair my ability to do my job but um what do you guys think you think if you worked uh for the like the telephone repair folks or powerline folks uh do you think they can do their job if they have acrophobia probably not no they're gonna have to have uh they're gonna have to get this stuff under control if they have acrophobia and they want to continue with their job so all right so what do we do with these folks who have phobias well one of the best things we're going to do is systematic desensitization okay uh exposes them to a series of increasingly anxiety-broken situations beginning with the least threatening okay visualizing is usually the least anxiety-provoking uh thing that we're doing with these hooks we can have them engaged in reciprocal inhibition where their anxiety or fear is paired with another opposite feeling okay we could do cognitive restructuring i like this one a lot too this helps to reframe reframe or re-label a frightening situation or object we can do flooding or implosion we're basically exposing them we're bombarding them with a lot of that particular content or material whatever it is that they have appointed to obviously when we do flooding or implosion we're doing so with the patient's consent we're not going to just dump a bucket of spiders on them and be like haha flooding like that would be terrible okay uh we can do thought stopping and uh thoughts off is pretty good because this helps them to basically you know help them in their own minds try to stop what it is that they're feeling um you know have them maybe think you know about something different but you know it's it's a it's an option um don't get confused the terms thought stopping versus thought blocking okay don't want to get tripped up on that make sure you know your terminology uh if you're not getting the terminology well if you're not able to recall it or keep it in your mind you know proctor exam is going to take advantage of it on that so make sure we remember our vocabulary here's a practice question you got a patient with a somatic symptom disorder uh they even started on relaxation and has identified how their negative assumptions make their symptoms worse currently he believes his palpitations in his chest are due to a heart attack okay he thinks he's having a heart attack he has a high pulse rate the nurse is teaching him cognitive reframing so which of these examples demonstrates cognitive reframing if you were to say i must have very high blood pressure due to blocked arteries for me to feel like this that's not cognitive framing he still thinks that you know he's having a heart attack he's still you know he's he's still like not thinking correctly about what's really going on with him if he were to say i might consider the pharmacy could have made a very critical mistake oh no what if he were to say this and said um a good explanation of how i'm feeling might be the extra coffee and the stress i'm under at work yeah that's probably more accurate as to what's going on you're not having a heart attack uh it's you know but that would be a that would be an appropriate action or appropriate answer this one here i'm sure there's something wrong but i can tell for that because my family doesn't die of heart attacks no he's not though not c is going to be the most appropriate to recognize that this patient is now using cognitive reframing okay next we've got obsessive compulsive disorder we have when it comes to the trauma when it comes to these terms here obsession this is basically their recurring thoughts that they're having compulsion is their feeling where they are compelled to act and uh you know they may engage in particular rituals and when they engage in these rituals it could be them uh washing their hands all right it could be them flipping a light switch on or off or something these rituals that they are doing they are doing these to basically you know reduce their own anxiety that's what's really going on when they do this okay um it's a way for them to exhibit some control over their life but is it really practical do you guys think it's appropriate like i'm gonna go wash my hands guys i'm jerry i'm gonna wash my hands for half an hour i'll see you in half an hour no you got you got stuff to do you don't have time to wash your hands for half an hour that's like not appropriate right um but if you give these folks that opportunity they will do it they will wash their hands they will do that kind of uh you know activity like that so different types of obsession um could be something words can you know they think it's you know they're contaminated maybe it's sexual nature aggressive maybe they're engaging in hoarding activity they're saving their money okay but they won't they won't spend it even though the house needs you know money to be spent on it for repair work they ain't spending their money okay maybe it's uh you know related to religious issues uh ideology or et cetera um often seeing though that it could be something that's uh exactly everything has to be displayed just correctly that the forks and the knives are just like this this wall painting is displayed properly other types of compulsive symptoms can include them cleaning checking repeating counting you know ordering putting things in particular order uh hoarding um you know reassurance taking and uh yeah so it's it's difficult because these folks once once the obsessive compulsive behavior starts it doesn't really stop and then as it persists and goes on longer and longer without intervention it only becomes more and more difficult for these books to stop okay but uh good news is that there are some medications that we use to help these folks and um you know when we think about the medications that we're going to use we're thinking what ssris let's go ahead and take a look at your medication list that i gave you guys and you'll see that on the list under antidepressants you get to the anti-obsessional medless section you're going to see that almost all the medications are literally ssris okay so when you get these patients who are engaging in this type of activity this behavior um you know they're maybe they're turning their light switch on and off repeatedly or they're washing their hands uh you know they gotta wash their hands for half an hour um what do you think you're gonna say okay go ahead wash your hands for half an hour i'll be back i'm gonna take a lunch break i'll come back are we gonna do that no that's totally not appropriate right um why don't we say jerry why don't you wash your hands for let's wash your hands for five minutes instead okay or something that's more practical like 30 minutes is that's a bit much 10 minutes i feel like we're giving them too much time maybe but the goal will be that you work them down you know to a smaller and smaller amount so if they're maybe if they're used to washing their hands for 30 minutes maybe you can cut it down to 15 minutes okay but try to cut it down quick because you know we're not gonna go like okay you get 29 minutes instead of 30. like that's no that's not even doing anything i'm doing it like that so it's important also don't interrupt them from the ritual they're washing their hands you're not going to grab them pull the patient away all right jerry you had enough time to wash your hands like that's that's not appropriate you're only going to make them feel they're willing to make them more anxious um you know and you're not helping the situation okay we know that when they become more stressed out their desire the you know for them wanting to do their rituals will increase uh so it'll be appropriate for us to provide them with structure provide them with you know routine activities for them to engage in um they would definitely benefit from cognitive behavioral therapy and uh you know one thing i like to think about too is you know when i have folks who have this kind of ocd kind of behavior what's going to help them in the long run do you think it's going to help them in the long run if they continue to only do these rituals no because the rituals it's not a [Music] it's not an appropriate means to try to deal with the problems that they have in their life okay i think that if i were to have a person who's like this i would like to have this person engage in some social activity with another patient or other patients or other people okay i think that would be more appropriate because we want to get these folks back to behaving you know the way in which human beings behave and that is what being social we are social creatures we like to you know talk to other people engage people maybe not you know maybe not you know for long periods of time okay but you know to have that social interaction uh i think that's going to be a big that'll be probably a bigger help uh for them definitely compared to them just continuing their ritual activity okay um but we're not gonna interrupt the ritual we'll try to say all right jerry you have two more minutes okay and then we have to go and start doing our daily activities for the day okay cool next we got body dysmorphic disorder so folks who have this disorder they're gonna have this preoccupied idea they're gonna think that there is a defect within their physical appearance or that something maybe you know out of proportion or is considered to be an abnormality for them the belief will be considered to be extreme but they are understand this they are not considered to be delusional okay they could maybe experience social isolation you know maybe they become very self-conscious um you know for some folks depending on how they have to put themselves together to make them feel comfortable before they go outside the house this could become a very time consuming issue okay many of these folks may seek cosmetic surgery to correct uh this perceived defect that they think that they have so i'm sure if i say hey guys who can you tell me what type of what celebrity uh do you think you can think of who has this disorder i'm sure a lot of you guys are going to write a lot a bunch of names of people i've never even heard about but i know for sure i could say who i know likely had this disorder probably michael jackson right with his nose and uh yeah he just you get kept basically muted in his nose nothing was wrong with his nose but um yeah but for these folks you know they think that uh you know they think that their you know their appearance they think that it's not appropriate or that there's something wrong with it so most of the time there's nothing wrong what sucks next we got hoarding disorder okay so when it comes to hoarding disorders uh generally i have you guys watch an episode of hoarders but um you know that's right but uh yeah hoarding disorder it's it's a thing and you know you're not gonna get to see these folks in the hospital because they're probably not going to require inpatient care often but um when they when these folks are hoarding they're going to be hoarding things that have little to no value okay their problem is that they can't it's extraordinarily difficult for them to throw things away from the give up these possessions that for the most part a lot of it could be equivalent to straight up trash like they are some folks who hoard they are literally hoarding trash like the you know the the rappers from you know fast food place or whatever just hoarding garbage you know somebody's folks sometimes you might see people who hoard things they'll try to hoard things that may have some value and that's you know but often it's going to be things that have like little to no value so when they are getting these things and they're trying to to get them discarded they're going to experience severe anxiety when trying to discard out these items um great difficulty categorizing or organizing things to be you know what's to keep what's to throw away what's to donate uh very indecisive about what to keep or where to put them uh they're gonna experience distress when people you know come over to the house to see their living conditions and their living conditions are going to be really terrible okay they're going to be pretty gnarly uh if it's not overrun with the mice rats bugs etc it may be difficult for you to simply navigate and walk around throughout the house because there's just so much stuff okay they're going to experience very high levels of suspicion when other people are in the house touching their items okay they may have obsessive thoughts where they think they're going to run out of a particular item okay they'll even check the trash because they accidentally think that there were things that were accidentally discarded and they may end up keeping the whole trash bag the whole everything in there it's pretty pretty messed up so yeah functional impairments the loss of living space social isolation family or marital discord financial difficulties health hazards uh you know all that fun stuff i think my dad he was i'm pretty sure he was a hoarder yeah he was a horrible kid he was a hoarder and uh he would go around like trying to collect things that were like literally of no value like to me or to anybody else you know but he would collect them or get them because he thought or he would say he could use this or that and the acquisition of said things made him feel more comforted okay that made him feel it made him feel good about himself and about what he had just you know gotten i remember one day he came home with something and then showed it to her mom and she's like what the hell are you gonna do with this you know and it was basically it was like a it was a square one foot by one foot quarter inch thick piece of copper like a big piece of copper and uh it's like what what are you doing with this and he's like this is worth forty dollars and copper is worth money copper does have value you know and it's like really she's like it's worth forty dollars like yeah and she's like why don't you go and sell it and go buy some go buy some damn dinner look on his face he got so bad you know i'm laughing i don't know so they have funny but um you know that's that's the thing with these folks they're going to hoard things they're going to accumulate and acquire more and more you know things but the reality of it is that these things are likely to be of no value so um am i a hoarder you know papers are you a hoarder i don't think so i mean i i like to collect things so like i like to collect uh magically after cards then i could nothing makes you feel more accomplished than buying something for like 100 or 200 bucks and then watching the value go up to like a thousand to two thousand dollars because it's you know it's it's a collectible right uh it'll never be reprinted or etc so i like that but i don't think i'm a hoarder but um i think having grown up you know with my dad uh observing his behaviors and stuff i'm pretty sure like i'm gonna like not become a hoarder like you know i just don't like the idea of living my life where i'm constantly like on the go looking for stuff like that but um yeah so anyways moving on here's an example of what a hoarder would look like here she is living in her house with all the stuff there and she's like this is fine this is fine you can just imagine a little all the little critters that are just hiding in there you know running it out eating all that uh rotted food that's sitting in the kitchen sink and just uh right but for these folks you know they they consider this to be okay they consider this to be uh normal or appropriate and um yeah sucks so next we're going to be looking at hair pulling and skin picking disorders we have tricholonia this is a disorder that causes people to pull hair from their scalp or their eyelashes the eyebrows pubic area underarms their beard chest legs anywhere brother's hair they're going to rub it off and um next we've got dermatomania this is where we're seeing this compulsive picking of the skin and this can result in tissue damage and i knew a co-worker going down a court worker who's the medical doctor i used to work with at the glendale venice he um he would pick at his nose and um it happened many years ago basically he was picking his nose picking his nose and then basically he just ended up losing the entire nose because he would just pick at it so much you know what was left of it had to be removed um and the reason you know what caused this was that uh his wife divorced him and um that's when they said this that's what then they said that upon the first divorce you have with this woman that's when they said that he started doing this dermaltomania he picked up his nose um the wife divorced him and then she ran into the arms of another man and that other man was her biological cousin and i'm pretty sure the medical doctor he was pretty devastated over that but then she got tired of her cousin and she married him again she went back she married the doctor again and then things were great and then she was with him for a while and she divorced him again and then she went back to the cousin you know and then that's when this their little managers went overboard and then he literally self-mutilated and ruined his nose his nose is like completely gone so he has to put a bandage over his nose and uh when he talks thoughts because he doesn't have a nose and um yeah so it's it's pretty tragic sucks but so here's some pictures here um the triclomania and the dermatomania and uh yeah so this is what happens when we have issues you know with uh you know with our anxiety and you know we're not uh you know handling it appropriately this is what some folks may engage in so um yeah i just thinking about this if i was a nurse and i was doing med surg there was no no way i would not be like triple gloved up right because you know all the potential infections you get from handling anybody like yes but some people like you know some nurses you know one of my when i was doing my rotations i think for med surg uh or critical care is what we what they call the north program uh i did remember meeting a nurse who appeared to have this disorder because uh whenever i got to see her with her gloves off her fingers looked just almost like this you know and um stress right so what are we going to do with these folks what can we do to help them we can give them ssris ssris they are kind of our first line defense or trauma or stressor related issues um secondary benefit of treating comorbid depressive disorder uh so ssris we go what we got peroxine fluoxetine the cilipram fluffoxamine circulating okay uh we might also give them maybe maybe some maois okay this is reserved for treatment treatment resistant conditions because of the life-threatening hypertensive crisis that we know can follow if they don't maintain that appropriate dietary restriction try to avoid those foods high in tyramines right so what meds we got phenoxine uh we've got translac for me right those generic names hard to pronounce so we try to treat somatic and psychological symptoms of our patients you know who have anxiety disorders we can give them benzos but like i was saying guys benzos they are meant for temporary use temporary and short period time frames overthinking uh we do not want our patients to be on benzos for a long period of time um that's generally not the case maybe the only exception i would say that i've seen you know um would be for folks who have bipolar disorder who you know need the medication to help keep them somewhat stable you know that's like a scenario where we can get the long-term use benzos but for everyone else we try to avoid benzos because long-term use of benzo guys you need to be mindful about is that patients can like they're going to be at increased risk for developing dementia okay if they're doing long-term use benzos all right so benzos would not be appropriate for folks who are pregnant or for folks who have issues with substance abuse problems because this medication does become addictive you'll you get into this medication you're on it for a month or longer or two weeks long i think it's like at least two weeks or longer uh but usually a mother longer using this you're gonna become dependent on it and uh you guys note that when patients are on benzos uh if they were to stop using benzos when they've been on it for a long time um you know that can that can lead to benzo withdrawal that's life-threatening okay um so we have to be careful about that so ben's as we got librazepam clonazepam diazepam a prozalem all right other medications that we could use for anti-anxiety like i was saying earlier beast bro and b-spur all right that's a good medication that they can take that's scheduled that they'll take it every day and then we have hydroxyz visceral this medication is going to be used as a prn and hydroxyzine is basically um an antihistamine medication uh it's not going to be nearly as powerful i guess you could say as the benzos but it's an option it's you know it's something that can help with anxiety and definitely something to be you know probably more appropriate for some of our patients um don't want to just pop so here benzodiazepine they are again these benzos uh chlorides epoxide we're going to be talking about that later in the term when we talk about uh alcohol withdrawal but uh yeah we'll get into so here's that blue chlorodiox this medication binds to serotonin dopamine receptors less potential for dependency it can be used for panic disorder we see system compulsive disorder social anxiety disorder ptsd along with generalized anxiety disorder okay here's a little picture you guys you know slightly take a picture of if you'd like um i thought it was cool i'm not going to um but good stuff let you guys take a look at that for a few more seconds all right so when it comes to defense mechanisms we've been kind of covering defense mechanisms throughout the term so there's nothing really new so much that i need to say on this stuff um you know we really want to make sure we're building up our understanding regarding defense mechanisms because you will be seeing them like i said throughout my quizzes and on the proctor and on the vinyl so here they are for you one more time remember this is a video you guys can pause it go back and forth whenever you like okay i like this picture here at displacement you know you um see that guy up there he's mad at some maybe maybe his boss yelled at him and then uh you know when he's angry and upset what did you do he goes and takes out that anger on something that's less uh you know not as threatening right he goes and takes down the dog and goes and kicks the dog okay common uh defense mechanism we see there all right so this is all terminology and i gave you guys that information i think already for this stuff so nothing new here yeah projections a really common defense mechanism uh we see this a lot people are attributing their own unacceptable motives or characteristics to another person or to a group uh often you know but this appears to be like they're blaming okay um so it's kind of common that we see with projection um reaction formation this is where like you know imagine there's this uh dude and he's in high school he's got a crush on this girl and that girl she has a boyfriend already you know normally people like that guy who has the crush on the girl that guy would see that boyfriend he would think man that guy sucks he's a loser oh man look at his hair or whatever he'll find something to say that he doesn't like about that person okay that's normal that's how human beings would generally you know operate people who are doing reaction formation that guy would look at the boyfriend and say if he's this is reaction information he'd say man that guy's pretty cool yeah i know he's dating that girl like but man he's a cool guy right being really kind of like friendly towards that person but in reality you know we know that he doesn't like him because you know that's that's how he should be another example another good example of reaction information would be like a patient comes up to you and jerry goes out to says nurse there's kevin i hate my roommate he's terrible he farts he snores he he's just the worst and he's so loud and obnoxious i hate him so much i hate him you know i hate terry he's just the worst person ever then here comes terry walking past me and jerry terry says oh hey jerry and then jerry says to terry oh hey hey terry hey man here you want some of my cookies have some of my cookies and i'm watching this i'm like dude you just told me how much you hated terry and now you're giving them your cookies man i don't share my cookies with nobody but you're sharing this cookies jerry right that's another example of reaction formation okay cool uh sublimation this is where people you know um instead of doing something inappropriate uh back towards somebody else you know or you know because something bad happened to them um maybe they go do something productive maybe they go write a short story about something or maybe they go to the gym to go work out okay uh instead of doing something inappropriate like because they got yelled at at work or something to that effect right cool splitting we think about splitting um you know let's say you go to work with a patient one night and you give them their medications early and then they say oh you're the best there so you're so great you're so wonderful you you're just the best right and then the next night you work again the patient's there but you're getting an admission and discharge patients are flipping out out of control so now when you get the patients the medications this patient gets the medication last right they're going to save you you're the worst nurse ever you abandoned me you betrayed me you're the worst right that's this idea of splitting you're either all great or all terrible um and we need to make sure the team members on the staff on the unit know that this patient is engaging in this behavior because if they don't understand or don't know it they're going to think that the complaint that the patient's making they might think that it's legitimate okay and um you know so we need to make sure that the team is aware of this kind of behavior so it's it can be really unpleasant dealing with patients who are engaging in splitting activity okay uh suppression you know this is where they are consciously think of like alright guys i'll give you an example the jack-in-the-box suppression is you standing on that jack in a box with your hands like nope you're deliberately not letting that jack-in-the-box you know pop out that's this idea of suppression you're actively controlling it actively denying this uh impulse this idea of this thing from coming out undoing i think i gave you guys this example earlier too where you know you're working with uh i'm sorry this uh mom comes home from work and then she yells at her kid and she feels bad so she goes and buys the kid a bunch of toys right thus undoing that negative uh you know interaction that they had but could it be the opposite maybe she goes and buys this kid a bunch of toys and the kids like yay they're so happy wee toys right and the next day she looks at the kids like man screw this kid she goes and gets all those toys and throws them away right that's an example of undoing okay cool so don't just think it's only don't just think you're something bad then do something good you can do something good and do something bad thus undoing that initial action all right next trauma stressor related dissociative disorders okay so when it comes to trauma related disorders in children we know that they might develop what ptsd okay we know they could develop reactive attachment disorder um where it's consistent pattern inhibited emotion withdrawn behavior due to a lack of bonding experience with the caregiver by the age of eight months maybe they have disinhibited social engagement disorder where they have no normal fear of strangers they seem unfazed in response to being separated from their caregiver they will willingly just go off of people who they don't know and go home with them like they are their new dad you know and i know you guys know this example you guys all remember being young little boys and girls going just going to the grocery store right you're walking around the grocery store and then you uh you're walking next to your mom or dad or you think you know you think it's something and then you stop and you look up at him you're like oh my god you're not my mom or you're not my dad right what feeling would you get you'd be like horrified you'd be scared right you'd be terrified like who are you right but for these kids you know they'll look up and they'll be like all right i guess your dad now let's go get some give me some chicken tenders or something right that's what you're seeing with this is disinhibited social engagement disorder uh they will just they'll go with that person they'll walk right up into their car hop up into a vehicle they've never been in they'll go home with them that's this disinhibited social engagement disorder okay some folks have what's called adjustment disorder and it's usually going to be precipitated precipitated by a stressful event diagnosed it can be diagnosed immediately or within three months of the exposure to that event what we're seeing are cognitive emotional behavioral symptoms that negatively impact their ability to function another type is called complicated grief it's manifested by this intense yearning longing for the you know for the deceased person maybe intense sorrow or emotional pain or preoccupation with that deceased person uh adjustment disorder itself it's an emotional or behavioral reaction to a stressful event or change in a person's life the reaction is considered to be unhealthy or excessive possible response to the event or change within three months of it happening stressful events or changes in the life of a child or adolescent may be something like moving okay could be a divorce could be separation maybe the loss of a pet uh maybe the birth of a sibling okay maybe a sudden illness or restriction in a person's life due to a chronic illness this can also result in has an adjustment response to this particular disorder okay once again ptsd um main thing i want you guys to remember with ptsd in order for it to be ptsd how long does it have to be greater than 30 days okay if it's less than 30 days we know it's going to be acute stress disorder all right so events that we know that are likely to be associated with ptsd rape and partner violence combat uh sexual harassment okay if you're in a serious motor vehicle accident or some other kind of accident where something hurt you or injured you uh man-made or natural disaster okay being the victim of someone who stalks you okay experiencing a robbery or mugging um so many folks with ptsd you know they're often going to engage in some form of coping sadly that can be you know through abusing alcohol and or becoming aggressive later as time goes on okay so for ptsd um you know if we're able to have mental health counselors available at the time of the traumatic event this can be very helpful may not be possible in certain areas of the world obviously but right health objectify i'm sorry help objectivity by identifying of areas of no control a system to regain control by identification identifying past situations that they were able to handle successfully have these folks engaged in support groups group therapy you know the idea that back in the day um during world war ii they would call this combat fatigue you know and uh nowadays we know exactly what's really going on but um yeah common exposure can also be depression provide safety uh with these folks the idea that you know what they thought was really kind of cool interesting was that if you're able to get paper morphine if you can give people morphine roughly at the time of that traumatic event or shortly after that traumatic event has happened they are going to be at a lower risk for developing ptsd you know and uh not that nurses and everybody running around is out there in the you know the public area just packing you know morphine just dispense like you know pests and whatnot but uh you know if we're able to get these folks morphine shrill afterwards the cool thing is that they may not develop uh ptsd or you know may not be severe uh you know in their future so right next we're going to talk about dissociative disorders and these are characterized by involuntary escape from reality um you know basically you know between their thoughts their identity their consciousness and their memory there's this dissociation and when folks are experiencing this disorder you know they might be aware of sound and smell but they won't be able to link it to the actual event itself depending on the type of dissociation they have going on um there are videos that you'll see on the slides when we get to this when we get to that slide you can pause the video and then basically type out the the link into your computer that way you guys can watch the video at your at your leisure okay um or i'll just have it posted online for you guys to click on so uh whatever however you want to do it give us the like professor okay you'll get the link don't worry so the social disorders we got dissociative identity disorder we got the social diffuse dissociative amnesia and depersonalization disorder so first up we got dissociative identity disorder so this is also used to be called multiple personality disorder and with folks who have this disorder we're seeing two or more distinct different personalities within these individuals and when these personalities you know are there they're gonna be able to take control over that person over their behavior and basically they're gonna like become active in a sense and um you know in the video that you're gonna watch there on this link you know the mom she was afraid that social services were going to come in and come take away her child and watching and observing a person who has this disorder with these different alters these different personalities taking over and taking control i could see why child protective services were concerned um there's one personality that's really like movie i would not want to deal with that person because they're really like they seem to be kind of out of it you know they're hyper fixated into this religious ideology and they're saying things such as evil daughter right she died she was a good just saying all this weird random stuff you know and as a young girl who's hearing her mother muttering these kinds of things she might think is she talking about me am i the evil daughter like you know i don't know just watching that uh video it's like yeah i could see definitely why they wanted to come over and come take come take her away but it's a good video uh it'll really give you the insight to see how these folks behave and you know what not but the reality of it is you know work with working in mental health for these years i've never actually ever met a person who has this personality just i'm sorry this dissociative identity disorder um this disorder it's extraordinarily rare one of the psychiatrists i've worked with at glendale venice she's worked in the la area for almost over 40 years and her entire time working she's only ever met two patients that she know could be diagnosed with this disorder all that are patients that she's met no they don't they don't have this disorder it's so it's it's pretty rare the idea is that when people experience sexual abuse or chronic traumatic events it can lead to this dissociation where the splits become fixated uh and then it basically leads to this development of these different alters these different personalities when it comes to us treating these folks one of the end goals that we would have for them would be to reduce the number of their alters to go from maybe like 10 maybe to get it down to four or five or three if we're really lucky most of the time these folks are going to need a lot of therapy um we can give them some medications like ssris but uh you know for the most part there's not like one magic medication to treat this particular disorder it's a really rare disorder interestingly enough it would seem that folks who have this disorder they can live at home and work if they're able to work at home um kind of a job like they can still do things on their own but you know more likely they might need some kind of assistance you know they're going to live at home with somebody who have care for them uh et cetera but um in the video them it turns out that the mom and the you'll see in the video she's a artist she makes uh art projects and art you know paintings and this kind of stuff and you know she makes really good money and she was able to sell that stuff and that's how she was able to support herself and her daughter uh all those years so fast forward to today the daughter she i think just graduated from law school she's a lawyer so she's she's doing good the mother is doing great you know her alters they take over and it's interesting because the ultras would take over when they're taking over they'll do their own art they'll do their own drawings and uh you know that they did it because of you know who they are in terms of the altar you know in terms of their different different personality uh that you see but um it's really cool it's really interesting so like i said pretty rare you're not going to be seeing them pretty you're not going to see them very often if at all next we've got dissociative fugue so folks who experience the social diffuse these are folks who are going to be you're going to see them experience probably some kind of traumatic event maybe somewhat recently there's a trigger for it they probably had some kind of traumatic event earlier in their life okay so when this trigger happens maybe they get caught cheating on their spouse or something like that or they get fired from their job whatever you know some traumatic event like that happens they're going to wander they're going to go away from their home they're going to go into this state where they'll recognize themselves as who they are uh you might see me if any of you could recognize me in real life you might say hey professor bosefield you see me at target i'll look you dead in the eye and i'll say i'm not professor rosefield i don't know you and you'll be like what and then you'll walk away from me i'll walk away from you and then maybe then work you know if we're still in target and i'm checking out i'm paying for my uh my purchase and then you're gonna see me bust out my target red car with my name on it and i'm going to pay for it and you're going to look at me you're like what the hell you're you're a liar right that's what you'll think but the reality is i can i'll use things that are kept in both fields you know things but i don't recognize myself as kevin bosefield okay that's what you're seeing they are not able to recognize themselves as who they are and um when they go into this feud state the puke state may last a few days it may last a few weeks um sometimes these folks they'll will come too and they'll be like where the hell am i they're going to be in a completely different city completely different town altogether perhaps and uh sometimes folks who have this associative fugue you know they may get themselves into trouble they may you know they may get into things that they shouldn't be getting into uh the video that you see right there that you can watch uh the woman in this video she oh my gosh uh one of the times where she was she goes into a few state and when she came out of it they were pulling her out of the uh out of a river like face down you know and uh so i don't know what the heck is going on with her this isn't something that you get to see very often on the unit uh you know because most of the times when patients who have this disorder when they have dissociative fugue they will walk right by you you're not gonna think there's anything wrong with them you're gonna think they're fine unless you know them unless you are a close friend or a fan member you are not going to think there's anything wrong with this person because they are not going to appear to be in any form of distress and it's only when maybe a person who goes into this [ __ ] state they get brought in by a fan member or a friend who knows that they're not well that they're in a few state perhaps because they know their history maybe then i'll get to work with them and care for them but um you know other than that it's they're they're not gonna they're not gonna be in a good place you know they can you think they're okay you think they're doing all right care of themselves but watch that video you're going to see that not always is the case for these folks okay next we got dissociative amnesia and you know what we're seeing here are one or more episodes of memory loss of important personal information at some point they just become completely unaware of you know who they were they can't remember you know things about them over a particular you know their lifetime uh in the video you guys can watch there this woman she's 40 years old she wakes up and she wakes up remembering only herself when she was like in her teens as a 16 or 17 year old sharing a bunk bed with her sister that's the last thing that she's able to remember at that age being this age 16 being a teenager the reality is she wakes up she has a teenage son who lives with her but she doesn't recognize the son she doesn't even know where the heck she's at she only knows herself as a teenager being 16 years old of age everything else from then on to you know act to that current time none of that's recallable to them and uh you know so it's it's pretty trippy uh sadly like i said you know the folks just such a few not met any patients who've experienced dissociative amnesia kind of a trip next we have depersonalization disorder this is a disorder where you know folks may have feelings of being detached from their body from their own mental process maybe having a feeling of being on the outside you know observing their own life being detached from their surroundings um this disorder is often triggered by severe stress diagnosis is based on symptoms after other possible causes of rolled out treatment consistent psychotherapy uh drug therapy ssri medications um that's that's gonna be that's more likely gonna help them but uh interesting disorder depersonalization so once again treating these folks we can use anti-suppressants um ssris maybe we'll give some anxiolytics but uh like benzos but uh ssris are gonna be our primary go-to when they are experiencing this dissociative crisis uh if they're not in a safe place we need to make sure that we keep them safe maybe we're going to be making decisions for them to ensure that we're keeping them safe okay we'll let them make more decisions when they become you know more when they're able to become more dependent i'm sorry more independent but you know in the beginning we may need to do quite a bit to help ensure that they feel safe and supportive for us okay we can have them utilize grounding techniques have them be in the here and now have them utilize mindfulness physical exercise okay these are good activities maybe take a shower hold an ice cube counting beads deep breathing ground techniques will be very helpful for these folks okay here's a question 22 year old woman is seen in the outpatient mental health clinic complaining of frequent nightmares feelings of guilt and poor concentration during the intake assessment the nurse learns that the patient was physically abused as a child this history and symptoms are most consistent with which anxiety disorder what do you guys think do you guys think this is a panic attack uh with agoraphobia do you think this is a phobic reaction is this uh obsessive compulsive disorder what do you think maybe this looks more like ptsd yes i think it looks more like ptsd okay so i did this lecture pretty quick i guess that's what happens if i just go nonstop without taking breaks and letting you guys give me any feedback so what i'm going to do is i i will post i'll post the links for you guys to check out the videos um i want you guys to be able to see you know some of these folks and how this how these disorders kind of play out uh i think i'll give you some good insight so um so hopefully you enjoyed this lecture until i see you in person again take care bye bye