mikayla0813

I just feel like a jerk because we have no psychologist or social worker to refer her to while she's here. If she wants to talk, there's no one appropriate. No group therapy, either. Seems like that is a big disservice to the patients, but maybe I'm just spoiled because of the way the facility I work at is set up. I would have her keep a journal of all these thoughts that she wants to "talk" about so she will have a point of reference when she is discharged and ready to speak with a therapist. Keep encouraging her to seek a therapist upon discharge but also let her know that you are probably not the best one to speak with her regarding abuse issues and try to change the subject. Her stay is probably going to be 3-5 weeks long. When she's discharged, she has the option of being treated by our outpatient team, which includes dr.'s, nurses, an MSW and a psychologist. Which is free, because we're in Canada. We have social workers who come in with dogs that the patients pet and brush, but they aren't allowed to talk to the social workers about their lives... Pet therapy is excellent!! She doesn't talk to the other patients at all. The RN I'm working with says we shouldn't get her out of bed, because she needs "rest" while adjusting to her new SSRI, and the inpatient stay is for physical and emotional rest.. But it's been this way for almost a week. When do we start paying attention to her ADLs? The RN will ask her to shower, and she'll do it w/o complaint, but doesn't make her come to meals or anything, so she's basically not eating. The drill on this unit for a missed meal is that if you do, there's a table with juice on it, and you can have as much juice as you want. I'm sure her weight is monitored? Her labs are also probably drawn on a regular basis since she is on meds? If these values stay WNL, I wouldn't be too worried. If she is borderline, making an issue of the eating may actually worsen the symptoms. If she is depressed, as soon as the meds start working, she will more than likely begin eating again. You sound like you really care and the facility you're at is lucky to have you!

I understand your frustration! Patients with personality d/o are some of the most frustrating to deal with. It is difficult at times to remain therapeutic. My advice to you is if you ever start to feel that you can no longer be therapeutic, take a break! Chances are at times that you may be "triggering" the behavior if you are not being therapeutic. I have found that it is useful to do Empathy Training with these individuals. Any time they become aggressive ask them how they would feel if that were done to them. If they give inappropriate responses, tell them how YOU would feel if it was done to YOU. This is an example of the old adage, "fake it till you make it"! In time, they will know the right responses, even if they don't mean it. Eventually, maybe, some of them might start to at least consider how their behaviors affects others adversely. People with antisocial behavior have a "messed up" brain. Their limbic system is all out of whack. Their transmitters are firing every which way, and making inappropriate connections. It is with overlearning that the "holes" in the limbic system can be "fixed" again. Make yourself a "broken record" about empathy training and setting limits. A good limit-setter is "Nothing else happens until...(insert phrase). Keep repeating this phrase until you get the desired result. Worth a try, anyway. Be sure to understand the history of the patient with personality disorder. Usually there is a background of severe abuse or neglect. Make sure you know what their triggers are. Is it loud noises? Delay of requests? Women with long black hair? Find out...and try to keep these triggers away. Find out what their early warning signs for aggression are. Do they pace? Do they grind their teeth? Find out and intervene EARLY, before the aggression can begin.

Conversion disorder is classified as a somatoform disorder. It is, however, much less common than the classic somatization disorder. Also important to note is that conversion disorder is almost always preceded by a traumatic, anxiety producing event. Somatization, as mentioned above, is a chronic condition. Another difference: Persons who suffer from conversion disorder are said to be dissociative, while those suffering from somatization are not.

:up:True....couldn't IMAGINE my kids on these types/dosage of meds!

So, this patient continues to say that she doesn't feel like she's receiving help. Does this patient have an AXIS II diagnosis? Sounds a lot like Borderline Traits to me, but could be wrong...I've seen many, many patients (especially female) try to get attention with these maneuvers, especially those who have abuse histories. She understands why she was placed on a psych hold after a suicide attempt, but she feels like she needs counselling. This is an inpatient facility with no psychologist/social worker? Odd...Is she not in any kind of group therapy? Again, her penchant for "needing to talk" may be a plea for attention. Negative attention is better than no attention. Her family is in a different city, she's new to this city and doesn't have friends here, or school, or a job, or anything. I really think isolation led was one of the key factors in her depression, and as one of the most high functioning pts. on the unit, she can't relate to the people around her. She could try to figure out if there's a way to get counselling on the unit - ie. having a private counsellor come in to talk to her. Her dr. would have to okay it, and she'd have to pay this counsellor probably upwards of $100/hr. She's also not getting out of bed, and probably not really up for going through the phone book and interviewing potential counselors. Even if her meds haven't kicked in, her depression should be treated in her plan of care, i.e. not allowing her to sleep all day, making it a goal for her to interact with her peers, or perhaps playing a game with her peers to draw her out of her self-imposed shell. How do you usually address a hopeless sense of isolation in a pts plan of care? Part of it is definitely that she needs to have more internal emotional resources for dealing with stress or sadness, but the girl also has old abuse issues, etc. and probably does need to talk to a therapist. I feel really bad that our facility has no way to address this. I've been emphasizing that her time on the inpatient unit is a time of physical and emotional rest, and that it's not a time to tackle big issues. But she just seems lonely, and her affect is getting flatter, and she's getting out of bed less. An inpatient facility is really not the place to address these old abuse issues unless she expected to remain there for a while (months). Opening up that can of worms if she's just there for stabilization will actually make the presenting problems more severe. The plan is usually to stabilize, then the social worker should have some type of continuity of care planned for her to visit with her local MHMR or therapist. This sense of isolation can be addressed by having the patient journal, locking her door during the day so she can't sleep all day (sounds harsh, but it works), having her work on coping skills on a daily basis. Ask her what 5 coping skills might be for her and see what she comes up with. If they are appropriate, have her practice these. If they are not appropriate, try to come up with some together. Above all, don't try to tackle her BIG issues with her (big red flag for manipalation). If she attempts to try to talk to you about abuse, refer her to the psychologist i hope you have on your unit.

The kiddos on my unit are taking these medications: Lithium, Geodon, Trileptal, Seroquel, Depakote, Tenex (not a "psych" med, but still used), Clonidine (same). These are what the Dr. on this unit has ordered most of these kids. I have seen Abilify and Risperdal used an awful lot too. Of course, then you have the stimulants, such as Adderall, Concerta, Ritalin, Strattera (used for ADHD but not a stimulant, per se). My doctor likes Zyprexa Zydis, Risperdal M-tab's, and Vistaril as PRN. If very aggressive, they usually receive a "cocktail" of sorts...mainly Haldol, Ativan, Benadryl IM. Prozac is also used very effectively with kids who have anxiety disorders/obsessions.

I work at a state hospital and my pay is comparable to what other RN's make at the medical hospital in town. I also get great benefits.

1. University of Alabama at Birmingham 2. I'm going to be a Family Practice Mental Health Nurse Practitioner when I grow up! 3. Working full-time 4. Going to school full-time (i'll be done in 17 months! yay!) 5. And it's going to be tough...