Psych Unit Two

Sleep Priority Healthy people 2030

Increasing public knowledge of how adequate sleep and treatment of sleep disorders improve health, productivity, wellness, quality of life, safety on roads and in the workplace

Sleep requirements in adults

Most adults require 7-8 hours of sleep. Long sleepers require more than 10 hours a night, short sleepers can function on 5 or fewer hours of sleep

Major consequence of sleep loss

Excessive sleepiness that impacts functionality and increases risks of accident or injury

Sleep deprivation: discrepancy between hours of sleep obtained and hours of sleep required for optimal functioning

Short term consequences of sleep loss

Increased stress responsively, somatic pain, reduced quality of life, emotional distress, mood disorders, cognitive, memory, and performance deficits, safety risks

Long term consequences of sleep loss

Cardiovascular disease, weight related issues, metabolic syndrome, Type 2 DM, colorectal cancer, safety issues, financial burden

Types of poor sleep

sleep deprivation, irregular sleep, too much sleep

Regulation of sleep

complex interaction between two processes. Homeostatic process of sleep drive and circadian drive

Sleep drive

production of melatonin enhances sleepiness and promotes sleep

Circadian drive

promotes wakefulness, influenced by endogenous and exogenous factors

Insomnia Disorder

dissatisfaction with quantity or quality of sleep. Results in clinical distress or impairment. Symptoms exist 3 times a week for at least three months

Symptoms of insomnia

Difficulty initiating sleep, difficulty maintaining sleep, Early awakening

3P model of insomnia

Model that is used to comprehensively assess the causes of insomnia, suggest appropriate interventions, and providing rationales for treatment.

The 3Ps are…

* Predisposing
* Precipitating
* Perpetuating factors

Predisposing factors 3P model

Individual factors that create a vulnerability to insomnia. Included prior history of poor sleep, depression, anxiety

Precipitating factors 3P model

External events that trigger insomnia. personal and vocational difficulties, medical and psychiatric disorders, changes in role or identity

Perpetuating factors 3P model

Sleep practices and attributes that maintain the sleep complaint. Excessive caffeine, alcohol, excessive daytime napping

Hypersomnolence Disorder

Chronic excessive daytime sleepiness that begins in young adulthood. Impairs social and vocational functioning as it may impair concentration and memory. Increases risk for anxiety and irritability

Treatment for hyper-somnolence disorder

maintaining regular sleep-wake cycles with ample sleep opportunity. Stimulant-based pharmacotherapy may help

Narcolepsy

Uncontrollable urge to sleep. Persons with narcolepsy may find themselves falling asleep in the middle of activities such as driving or working

Symptoms narcolepsy

disturbed nighttime sleep with automatic behaviors and memory lapses, uncontrollable attacks of sleep, cataplexy, hypnagogic hallucinations, not rested regardless amount of sleep

Cataplexy

brief episodes of bilateral loss of muscle tone while maintaining consciousness. episodes are usually triggered by strong emotions

Obstructive sleep apnea

repeated episodes of upper airway collapse and obstruction. Results in sleep fragmentation. Cannot breathe and sleep at the same time

Diagnosis of obstructive sleep apnea

Clinical evaluation and polysomnography

Treatment for sleep apnea

continuous positive airway pressure(CPAP)

Central sleep apnea

Cessation of breathing during sleep caused by instability of respiratory control system. Related to aging, cardiac or pulmonary disease, neurologic disorders

Sleep related hypoventilation

sustained oxygen desaturation in sleep. No apnea or respiratory events. Associated with morbid obesity, lung disease, pulmonary vascular pathology, COPD

Circadian Rhythm Sleep Disorders

Misalignment of normal circadian rhythm timing and external factors affecting the timing or duration of sleep

Types of circadian rhythm sleep disorders

Delayed sleep phase, advanced sleep phase, irregular sleep-wake, non 24 hours sleep-wake, shift work

Delayed sleep phase

A delay of more than 2 hours between desired time of sleep and actual sleep. Results in delays in waking

Advanced sleep phase

Sleep begins several hours early and ends several hours earlier than desired

Irregular sleep-wake cycle

sleep is sporadic and fragmented. Longest sleep period lasts about 4 hours and tends to occur between 2 am and 6 am.

Non 24 hour sleep wake cycle

mismatch of the 24-hour environment and the persons internal clock. Sleep tends to occur later and later, eventually leading to daytime sleeping. Significant problem for up to 70% of blind individuals

Shift work circadian dysfunction

working outside of the normal work hours results in excessive sleepiness at work and impaired sleep at home

Non-raid eye movement sleep arousal disorders

Sleepwalking, sleep terrors

Comorbidities of sleep disorders

Multiple symptoms are impacted by sleep disorders. Neurological disorders, depressive disorder, bipolar disorder, sleep disorders can increase the risk for suicidal ideation

Nursing assessment of sleep disorders

General assessment-sleep patterns. 2 week sleep diaries, identifying sleep wake disorders, functioning and safety, epworth sleepiness scale

Nursing goals: Insomnia

Improved sleep, successful sleep induction, appropriate hours of sleep, consistant sleep pattern, minimal awakening

Nursing goals sleep deprivation

adequate quanitity of sleep; balance between work and sleep, minimal awakening, feeling restored after sleep, sleeping between 7 and 9 hours

Impaired sleep

adequate quantity and quality of sleep, minimal awakening, feeling restored after sleep

Nursing planning, sleep wake disorders

Treatment is in community, multifaceted considerations(occupational, social, interpersonal, medical and psychiatric conditions), team approach under sleep disorder specialist,

pharmacotherapy for insomnia

used mostly with comorbidities, antianxieties(benzdiazepines) antidepressants(SSRIs, SNRIs)

Somatic interventions for anxiety

Cereve sleep system: significantlt reduced sleep latentcy. software controlled bedside device that is placed on the forehead. A fluid filled pad cools the forehead and reduces anxiety in the cerebral cortex

Impact of culture in psychologic care

Nonverbal communication and etiquette will change between cultures, deviance from cultural expectations can be defined as an illness by other members of the group.

Cultural barriers to mental health services

communication barriers, stigma of mental illness, misdiagnosis, cultural concepts of distress

Eastern traditions

idenity is based on the family, body-mind-and spirit are one entity, time is circular and recurring. Individuals are born into duty they must perform. Disease is caused by fluctuations in opposing forces

five construts of culturally effective care

cultural awareness, cultural knowledge, cultural encounters, cultural skill, cultural desire

Cultural awareness

examine belifs, values, and practices of ones own culture. recognize that during a cultural encounter, three different cultures are intersecting(culture of the nurse, the patient, and the environment)

Cultural knowledge

learn by attending cultural events and programs. Forge friendships with diverse cultural groups. Learn by studying,

Cultural encounters

deter nurses from stereotyping, help nurses gain confidence in cross cultural interactions. Helps nurses avoid or reduce cultural pain

Cultural skill

ability to perform a cultural assessment in a sensitive way. Use professional medical communication, use culturally sensitive assessment tools

Goal of cultural skill

a mutually agreeable therapeutic plan. this plan must be both culturally acceptable and capable of producing positive outcomes

Cultural desire

Genuine concern for patients welfare. Willingness to listen until a patients viewpoint is understood. Patience, consideration, empahy

Adverse Childhood experiences

Sesitize people to stress later in life. These experiences include

* Any form of psychological physical or sexual abuse
* Violence against a parent, particularly the mother
* Living with people with substance use disorders, mentally ill, or incarcerated

Distress

Negative draining energy that results in anxiety, depression, confusion, helplessness, hopelessness, and fatigue

Eustress

Normla physiological positive energy that motivates individuals and results in positive feelings and purposeful movement

General adaptation syndrome

Syndrome that results from an attempt to adapt to anxiety situations. Has three stages

Three stages of GAS

1. Alarm or acute stress stage: activates the sympathetic nervous system, activates HPA axis to stay on alert “fight or flight” mode
2. Resistance or adaptation stage: sustained and optimal resistance to the stressor, recover, renewal, and repair may occur
3. Exhaustion stage: resources are depleted, the stress may become chronic. This can result in chronic health conditions

Mild Anxiety

Day to day tension. Keeps a person alert and motivated, problem solving and grasping information is increased. Can be considered Eustress

Moderate anxiety

Selective inattention, clear thinking is hampered, problem solving is less than optimal but still possible, SNS symptoms begin. Engaging a patient can bring them back from this.

Severe anxiety

Perceptual field greatly reduced. Difficulty concentrating on the environment, confused and automatic behavior. Somatic stress symptoms increase. Patient is unable to take in the “big picture” physical symptoms of stress develop

Panic

Markedly disturbed behavior such as running, shouting, screaming, pacing. Unable to process reality. Impusivity. Patient will be in danger of harming themselves or others, not able to judge their space

Crisis

Stressor in life that requires an individual to adjust to the unexpected and to adapt to an unpredicted situation or event.

Three types of crisis

* Maturational: Crisis that occurs due to transition into another stage of life
* Situational: events that are unusually distressing and unanticipated. Affects only the person experiencing the crisis
* Adventitious: Traumatic and external event that happens unexpectedly. Will typically affect many people. Ex: natural disaster

Phase 1 of the crisis response

Serious stressor results in increased anxiety. Stimulates the usual coping mechanisms to address the problem and decrease anxiety. Minor anxieties can be respolved here

Phase 2 of the crisis response

Defense mechanisms fail, threat persists, anxiety increases which results in feelings of discomfort, disorganized functioning, and trial and error attempts at problem solving. Person will be desperate and disorganized in attempt to resolve issues

Phase Three crisis response

Trial and error fails resulting in increased anxiety to severe or panic level. Automatic relief behaviors are mobilized(withdraw, flight, etc). Some form of resolution may be devised such as compromising or redefining the situation

Phase 4 Crisis response

Problem is unsolved and coping skills are ineffective. Overwhelming anxiety can lead to personality disorganization, confusion, violence, and self injury

Assessment of crisis situation

Assessing perception of the precipitating event. Assessing the situational support(who can help them through the crisis), assessing coping skills(how can they help themselves through the crisis)

Steps in crisis intervention

Planning

* devise a plan to restire client to previous level of functioning

Intervention

* Help pt gain understanding of the crisis, explore coping mechanisms

Resolution

* Restore to previous level of functioning. Anticipatory planning for next crisis

Levels of Crisis prevention

* Primary prevention: promotes mental health and reduces mental illness to decrease incidence of crisis
* Secondary prevention: intervention during an acute crisis to prevent prolonged anxiety
* Tertiary prevention: Provides long term support for those who have experienced crisis

Stress debriefing

Tertiary prevention tool. allows for a group to discuss a stressful event and express their emotions on it

Post-Traumatic stress disorders

Persistent re-experiencing of a highly traumatic event. This event will involve actual or threatened harm or death to self or others. Can begin a month after exposure, but symptoms may not arise for months to years

Major features of PTSD

Flashbacks: re-experiencing the trauma through intrusive recollections of the event

Avoidance: of stimuli associated with trauma

Hyper-vigilance: exaggerated startle response

Alterations in mood: chronic depression, lack of interest

Biological treatment for PTSD

SSRI’s, Sertraline(zoloft), Paroxetine(paxil), benzodiazepines

Psychological therapies for PTSD

Exposure therapy, cognitive reconstructing, EMDR therapy, CBT

Acute stress disorder

may develop after exposure to a highly traumatic event. Diagnosed 3 days to 1 month after exposure.

Adjustment disorder

Milder, less specific version of ASD and PTSD. Precipitated by a stressful event. Symptoms may include all forms of distress

PTSD in children and adolescents

Manifests in reduction in play, self blame, estrangement loss of interest in significant activities. Children are more resilient than adults and more able to return to previous levels of functioning after treatment

Interventions for children with PTSD

use interactive process, establish trust, developmentally appropriate language, regulate emotional response, art and play, coordinate with social work

Evaluation for children with PTSD

Treatment is effective when: safety is ensured, anxiety is reduced, eReamotions are appropriate

Reactive attachment disorder

Childhood condition: Consistent pattern of inhibited emotionally withdrawn behavior unresponsive to caregiver efforts to offer comfort

Disinhibited social engagement disorder

childhood disorder; no normal fear of strangers, seemingly unfazed by separation from caregiver

Dissociative disorders

Occur after significant adverse experiences/traumas. Individuals respond to stress with severe interruption in consciousness. Results in disturbance in memory, consciousness, self identity, perception

Dissociative amnesia

inability to recall important personal information. Often of a traumatic event

Dissociative Fugue

Subtype characterized by sudden, unexpeted travel and inability to recall ones identity/information about the past

Depersonalization

Focus on self-extremly uncomfortable feeling of being an observer of ones own body or mental process

Derealization

Focus on outside-recurring feeling that ones surroundings are unreal or ditant. Person feels as if walking in a fog

Dissociative Identity Disorder

Presance of two or more distinct personality states. Each alternate personality has its own pattern of perceiving, relating to and thinking about self and environment.

Manifestations of DID

History of multiple physical and psychiatric diagnoses, violent trauma. Inconsistencies in behavior, pattern of psychophysiological complaints, experiences of voice inside the head talking to one another(NOT psychosis)

Biological treatment DID

No specific medications, some may be used to hyperarousal and intrusive symptoms

Psychological therapies DID

CBT, psychotherapy, exposure therapy, EMDR, neurofeedback, somatic therapy,

Adaptive defense mechanisms

Lowers anxiety for acceptable achievement of goals

Maladaptive defense mechanisms

Immature defenses that can eventually make anxiety worse

Altruism

Motivation to feel caring and concern for other and act for the well being of others. Can be adaptive(Running an AA meeting) or maladaptive(hoarding dogs to “give them a better life”)

Compensation

Used to counterbalance perceived deficiencies by emphasizing strengths. Can be adaptive or maladaptive

Conversion

Unconscious transformation of anxiety into a physical symptom with no organic cause. Always maladaptive(CONVERSION DISORDER)

Denial

escaping unpleasant anxiety causing thoughts, feelings, wishes, or needs by ignoring their existence. Can be adaptive or maladaptive

Displacement

Transference of emotions associated with particular person, object, or situation to another nonthreatening situation or person. Can be adaptive or maladaptive

Dissociation

Disruption in consciousness, memory, identity, or perception of the environment that results in compartmentalizing uncomfortable or unpleasant aspects of oneself. Adaptive or maladaptive

Identification

attributing oneself to the characteristics of another person or group. Adaptive or maladaptive

Intellectualization

a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing. Adaptive or maladaptive