A Nurse's Guide To Women's Mental Health 5ew40

A Nurse’s Guide to

WOMEN’S MENTAL HEALTH

Michele R. Davidson, PhD, CNM, CFN, RN, holds a PhD in nursing istration and health care policy from George Mason University and has practiced in the area of women’s health nursing for more than two decades. She is currently an associate professor of nursing and an faculty member for the Women’s Studies Program at George Mason University. Dr. Davidson received an associate degree from Marymount University and then a baccalaureate nursing of science degree from George Mason University in Fairfax, Virginia. Upon graduation, Dr. Davidson worked in a variety of women’s health settings including labor and delivery, postpartum, neonatal intensive care unit, reproductive endocrinology, and inpatient gynecology at Columbia Hospital for Women, formerly in Washington, DC. Dr. Davidson completed a master’s of nursing and science from Case Western Reserve University and obtained her certification as a certified nurse midwife (CNM) with a special interest in high-risk obstetrics. She has delivered more than 1,000 babies during her career as a nurse midwife and has treated women with a variety of mental health disorders. She has subsequently developed an interest in postpartum mood disorders and women’s mental health issues. She formulated a postpartum depression group and provided ongoing treatment to indigent women battling postpartum depression. Her doctoral dissertation, “Care of High-Risk Women Cared for by Certified Nurse Midwives,” brought national attention to the potential care that midwives could provide to a high-risk obstetrical population. She received an honorary award from the March of Dimes for her ongoing care to pregnant women. Over her years as a nurse midwife, she has continued to develop an interest in women’s clinical obstetrical and mental health issues, including PTSD, postpartum depression, and postpartum psychosis. She has published more than 50 papers, contributed more than 17 chapters to textbooks, and published an additional 15 textbooks that she has cowritten, including the international bestseller Olds’ Maternal-Newborn Nursing and Women’s Health Across the Lifespan (9th ed.), which is translated into nine languages and used throughout the world. She is a member of the American College of Nurse Midwives (ACNM) where she served as past vice president of the Washington, DC, chapter and has served as an item writer for the ACNM National Certification Examination. She is also

an educational of the American College of Obstetricians and Gynecologists (ACOG). She is a long-time member of Sigma Theta Tau, the International Honor Society of Nursing. Dr. Davidson holds an additional certification as a certified forensic nurse (CFN) and is a member of the American College of Forensic Examiners International (ACFEI). She is also a member of the International Society of Psychiatric-Mental Health Nurses (ISPN) and the Marcé Society. In 2002, Dr. Davidson established the Smith Island Foundation to provide rural health care education, screening programs, and children’s programming to this small island community in the Chesapeake Bay. She subsequently developed an immersion clinical practicum for students to participate in rural community health on Smith Island. She is also the author of the children’s book, Stowaways to Smith Island.

A Nurse’s Guide to

WOMEN’S MENTAL HEALTH

Michele R. Davidson, PhD, CNM, CFN, RN

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Davidson, Michele R. A nurse’s guide to women’s mental health / Michele R. Davidson. p. ; cm. Includes bibliographical references. ISBN 978-0-8261-7113-9—ISBN 978-0-8261-7114-6 (e-book) I. Title. [DNLM: 1. Mental Health—Nurses’ Instruction. 2. Women’s Health—Nurses’

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To my family, who has taught me the joys of living well, finding inner strength, pursuing happiness and making me believe that happily ever afters can come true . . .

Nathan . . . For my husband, who has ridden the ride with me through good and bad and never wavered.

Hayden . . . For introducing me to the wonder of first motherhood, always making me smile, and enabling me to laugh.

Chloe . . . For showing me the true delight in having a daughter, whose beauty and strength inspire and delight me every day of my life.

Caroline . . . For bringing sunshine, happiness, and hope to the world, for making motherhood the thrill of a lifetime.

Grant . . .

For showing me that disabilities are just challenges to be celebrated and proving that love can conquer all.

Contents

Preface Acknowledgments

SECTION I: INTRODUCTION TO WOMEN’S MENTAL HEALTH

1. Statistics on Mental Health of Women

2. Stressors Affecting Women

3. Role of Culture in Mental Illness

4. Violence Against Women

SECTION II: SPECIAL POPULATIONS IN WOMEN’S MENTAL HEALTH

5. Childhood and Adolescence

6. Mental Health for the Aging Woman

7. Physical Disabilities and Mental Health

8. Lesbian and Transgender Women

9. Female Veterans

10. Women and Forensic Mental Health Issues

SECTION III: CHILDBEARING AND WOMEN’S HEALTH ISSUES

11. Menstrual-Related Issues

12. Infertility and Psychological Implications

13. Antepartum and Intrapartum Psychological Issues

14. Postpartum Mood Disorders and Lactation Issues

SECTION IV: PSYCHIATRIC ISSUES COMMON TO WOMEN

15. Anxiety Disorders

16. Mood Disorders

17. Eating Disorders

18. Grief and Loss

19. Personality and Dissociative Disorders

20. Schizophrenia

21. Psychotic Disorders

22. Sexual Dysfunction

23. Sleep Disorders

24. Substance Abuse Disorders

Index

Preface

I always, always wanted to be a nurse! Although I am the only nurse in my family, nursing surrounded me throughout my childhood. My nursing career began at the young age of 3 with the daily schedule in our household that involved caring for my maternal great uncle who was chronically ill. Watching my mother, a “lay nurse,” care for him provided me with the motivation and direction that guided my professional life. We spent many days at hospitals, clinics, and physicians’ offices. Since that time, I was inspired to become a nurse. I recall being mesmerized by the stark, white uniforms and, years ago, the starched hats. It was not until I entered nursing school and had my first obstetrical clinical that my love for women’s health emerged. The excitement of seeing a birth, holding a mother’s hand, or breathing through contractions with that laboring mom, have always provided a great sense of joy for me. Even after years as a certified nurse midwife and having delivered more than 1,000 babies, it has never grown old. When I began my nurse midwifery practice, I became acutely aware of the issues surrounding women, mental health, and illness. As an advanced practice nurse, not a day ed that I hadn’t provided mental health care services to women in my practice. As I began to research the issue of women and mental health, it was apparent that little had been published on the topic. Most mental health professionals engage in the care of the mental illness without respect to gender. The more I studied and treated women affected with mental illness, the more differences I encountered. As a nurse midwife, most people would assume that the women for whom I cared were all happy and joyous; after all, isn’t having a baby the greatest joy of all? In reality, 25% of the population suffers from a mental illness; many are specific disorders that are more common in women than in men. Women have unique biopsychosocial factors that make them more vulnerable to mental illness. Many of these mental illnesses can elicit enormous physical, emotional, financial, and social barriers.

Mental illness can affect any woman; it knows no racial, ethnic, educational, social, economic, or geographic boundaries. Many women have risk factors for mental illness; whereas other women have none. Mental illness continues to carry a negative stigma in our society, making seeking treatment difficult. Some women may be embarrassed to seek treatment; others may not have the financial resources to do so, and still others may not know they have a mental health issue at all. During my fourth pregnancy, I gave birth to a little boy after my physician failed to come to the hospital to perform an emergency Cesarean delivery despite severe fetal distress. My son finally was delivered after a 90-minute delay but suffers from severe cerebral palsy as a consequence of the delay. During the subsequent months, while my son’s brain injury and multiple disabilities were being evaluated, I suffered from several postpartum mood disorders. It was during this time that I realized the potential depth of postpartum mood disorders and how significantly such disorders can impair one’s family and one’s entire life. During my journey to recover the life I once knew, I experienced a growing ion to become an advocate for women suffering from mental illness. I have had the opportunity to meet many women, both personally and professionally, who struggle with mental illness. I truly believe that nurses make a difference, can be that single voice that is heard, and can change the course of lives. I sincerely hope that this book will serve as a resource for all nurses caring for women and to all those nurses who can and do make a difference!

Acknowledgments

This project was truly a labor of love, and like giving birth, I have complete awe for the people who have inspired me along the journey, became my coaches, and partnered with me until the end. I would like to acknowledge and sincerely thank my mother, Geri Lewis, whose and encouragement never waiver; who believes in me no matter what the task; and is always there to provide advice, lend a hand, or a shoulder to cry on through good and bad times. My father, Harry Mhee, has provided ongoing encouragement throughout this process. In 1991, I met and married my husband, Nathan Davidson RN, CFNP, MSN, who is perhaps one of the best practitioners I have ever met. Nathan’s knowledge, experiences, and guidance have provided a wealth of knowledge that only helped to enrich this project during the year we celebrated our 20th anniversary! My earliest nursing adviser, Dr. Charlene Douglas, has provided ongoing since the time I was an undergraduate student at George Mason University and, 20 years later, remains an inspiring mentor. Dr. Douglas is, without a doubt, the smartest woman I have ever known. She is the quintessential woman, nurse, educator, and friend. When the going gets tough, she gets going! Thank you for years of encouragement, , and love; I am proud to call you a friend. I want to thank Margaret Zuccarini, my publisher at Springer Publishing Company, who wholeheartedly embraced this book from day one and provided the guidance and to bring it to life. My colleagues at George Mason University, School of Nursing, have provided and encouragement throughout the writing process. To the many George Mason University nursing students who have enabled me to do what I love every day, thank you! To Dean Shirley Travis, thank you for your . Mike and Angela Westbrook and Elizabeth “Buffy” Dougherty, RN, have been friends ’til the end. Many thanks to my many neighbors, friends, and adopted family on Smith Island, who provided much encouragement and , specifically the Reverend Rick Edmund and Ewell United Methodist Church! Many mental health providers have inspired and taught me during these past few

years, and to them, I remain forever grateful. Dr. Arthur Rosecan is a knowledgeable, caring, and gifted psychiatrist specializing in geriatrics who brings comion, knowledge, and skill to the field and who I met briefly when our paths crossed several years ago. I remain thankful to have met him. Dr. Sharon Furari, a forensic mental health psychologist, offered hope and comion and taught me a great deal during the brief time we collaborated together. Dr. Laurence Levin, a practitioner in a state mental health facility, has years of experience dealing with forgotten souls, who guided and expanded my knowledge base. Dr. Victoria Lyle is a forensic specialist who is a generator of hope, a practitioner of caring, and a role model to all psychiatric practitioners. Jennifer Greene, LCSW, continually offered guidance and . Dr. Mohammed Nasr taught me the value of patience and that all things will come. Perhaps one of the most comionate nurses I have ever had the privilege of meeting was a new graduate practicing in a psychiatric mental health field named Rae Leach, RN. Her comion remains an inspiration, and I think of her almost every day when I teach eager young nursing students. Caroline Chevalier, Katie Huffman, and Dr. Lisa Lindley all provided for this project. Finally, Violet Taylor, S, provided remarkable insight into this book. Violet, a certified peer specialist, made the experiences of mentally ill women come alive and continues to serve as a role model who embraces recovery in every sense of the word! During my treatment for postpartal mood disorders, I encountered some amazing young women who were inflicted with mental illness. Many of them have suffered for years and some have spent years in and out of mental health facilities. They offered amazing , encouragement, and befriended me in the darkest of times. I will always be thankful to have met and will fondly Jackie Spaw and June Rosales. I will never forget the many women who have entrusted themselves and their families in my hands over the years, you have touched my life in such an intense, positive way, thank you for allowing me to participate in your care, your births, your good times and bad. For the women I have treated for mental illnesses, thank you for never giving up and believing in yourselves. I cannot thank enough my four beautiful children who have endured much and complained little during their young lives. They have walked with me on this path of life through good times and bad. They have seen postpartum mood disorders firsthand and, as a result, have developed comion, patience, and

hope. My son Hayden, an honor student, has decided he would like to pursue a career path in medicine as a result of seeing how people with physical disabilities and mental illnesses are treated. My daughter Chloe is forever the cheerleader, peacemaker, babysitter, and all around wonderful great big sister. My youngest daughter, Caroline, remains best friends with Grant and believes that, with love, all things are possible. My youngest son, Grant, who has spastic quadriplegia cerebral palsy as a result of a birth injury, has been our family’s greatest joy and taught us about hope, love, and faith. He has created an environment of laughter, positivity, and strength that we have all grown and strengthened from. It is my hope that, as they grow and mature, they will encounter a world where mental illness is no longer a disease of embarrassment to be hidden and denied. For the brave women that fight mental illness and its stigma, thank you for allowing us to walk this journey by your side.

I

Introduction to Women’s Mental Health

1

Statistics on Mental Health of Women

Women’s mental health is a great public health concern that includes women of all races, ethnicities, cultures, education levels, sexual orientations, and socioeconomic statuses. More women are diagnosed with mental health disorders than men. In fact, women are more likely to be diagnosed with a mental health disorder even in situations where men have the same objective scores on standardized testing, and are more likely to be prescribed psychotropic medications. It is estimated that 29% of women are treated for mental health disorders compared to 17% of men ( World Health Organization [WHO], 2011 ). The difference may be because health care professionals may view women as overemotional. Additionally, women may seek treatment of mental health– associated symptoms more frequently than men ( Hattery & Smith, 2007 ). Table 1.1 describes major mental illnesses in women.

Table 1.1 ■ Major Mental Illnesses in Women

Mental Illness Depression Bipolar Disorder Anxiety Post traumatic stress disorder (PTSD) Eating disorders Autism Borderline Personality Disorder Schizophrenia

Incidence Twice as common in women Equal in men and women Twice as common in women Twice as common in women Three times as common in women Four times as common in men but more severe symptoms in women Twice as common in women Equal in men and women; women have later onset

Most women with mental health disorders are diagnosed by primary-care providers; for this reason, the need for education regarding screening, diagnosis, and treatment of the primary-care and advanced-practice nurse is imperative. The diagnosis of mental health disorders presents a significant challenge when compared to physical disorders because there are no blood tests or neurological scans that can confirm a diagnosis. Instead, diagnosis is based on clinician observation and subjective reports from the patient. Women may underreport mental illness symptoms because of fear, stigma, family values, or cultural factors. Societal issues play an important role in the diagnosis and treatment of mental health disorders in women. A diagnosis of a mental illness can be stigmatizing even in today’s society and can result in delay or avoidance of treatment. Most mental health disorders go untreated and are not identified by health care providers. Women frequently report more somatic complaints rather than specific mental health illnesses, such as depression or anxiety.

Clinical Pearl

Depression is the most common mental health disorder affecting women.

INEQUALITIES IN WOMEN’S MENTAL HEALTH

There is a large body of research showing that gender inequality in society is a leading factor related to the increased incidence of mental illness diagnosis in women. Women’s role in society places them in a more vulnerable state: They are more prone to abuse, rape, and various acts of violence than men (WHO, 2011). In most societies, women have a tendency to internalize their feelings and emotions, which can lead to specific mental health problems; men, however, commonly externalize their feelings and emotions, leading to syndromes more externally related, such as aggression, substance abuse, alcoholism, and antisocial personality disorder (WHO, 2011). In some cultures women are seen as being inferior to men, a situation far more pronounced in some parts of the world than others. Gender gaps lead to inequality that commonly manifests in psychological ways. Women suffer more stress than men, partly as a result of conflicting societal roles. Women are also negatively impacted by the health care system. Access to services, prompt and accurate diagnosis when mental health issues are present, financial barriers, and lack of insurance all play roles in women’s mental health care (Figure 1.1). In some countries, it is forbidden for anyone to receive mental health care services, and therefore many women go untreated (WHO, 2011). Biological and developmental factors also play a role.

Figure 1.1 ■ Multiple variables, including individual, environmental, and system-based factors can impact women’s mental health care. Source: Surgeon General’s Workshop on Women’s Mental Health, 2005.

BIOLOGICAL FACTORS

Research is just beginning to uncover gender differences in neurobiology, neurochemistry, sex steroids, endocrine sex reactivity, and psychosocial stressors that make women more prone to psychological illnesses. Increased levels of progesterone and estrogen have shown that women develop a greater susceptibility to mental illness during times of hormonal fluctuations, such as puberty, pregnancy, menstrual-cycle changes, and menopause (Vigod & Stewart, 2009). Altough women’s brains are smaller than men’s, women have larger frontal lobes, which are responsible for judgment, language, and problem solving (Surgeon General’s Workshop on Women’s Mental Health, 2005), possibly explaining why some genetically based specific mental health disorders occur more commonly in women than in men.

STATISTICS ON MENTAL ILLNESS

Currently, 26.4% of Americans over the age of 18 are living with a mental health diagnosis. Of them, 6% are suffering from a major mental illness that results in significant impairment and are therefore classified as “chronically mentally ill” (WHO, 2011). “Chronically mentally ill” patients have a major mental illness that impacts work, social, and family interactions and interferes with thought processes. Chronic mental illness is diagnosed by a licensed medical professional and includes Schizophrenia, Major Affective Disorder, and Posttraumatic Stress Disorder (PTSD). Federal law further states that the individual must have at least one documented hospitalization within 2 years as a result of the disorder; have documentation via a standardized test that evaluates mood, thought processes, and/or impairments with work or family relationships; or have documented symptomology (U.S. Code of Federal Regulations, 1977). Chronically mentally ill patients have shortened life expectancies by up to 25 years, with poor health practices identified as the main causative factor. Women who meet the criteria for chronic mental illness are more likely to be substance abs; participate in more high-risk sexual behaviors; have a higher incidence of sexually transmitted infections (STIs), such as HIV infection; and are more likely to participate in survival sex, the performing of sexual acts in return for food, shelter, or money (American Psychological Association [APA], 2010). In addition, these women may be less apt to understand the process of HIV transmission.

CULTURAL DISPARITIES AND MENTAL ILLNESS

The mental health disparities among various cultural groups are not clearly defined. It is well documented that minorities experience more mental health disorders than their Caucasian counterparts. African Americans are more likely than White Americans to experience a mental health disorder but are more unlikely to seek help for that disorder. While Whites and Hispanics suffer equally from mental health conditions, Hispanic women suffer higher rates of depression than Hispanic men. Puerto Ricans have significantly higher rates of depression than other Hispanic groups. American Indians and Alaska Natives suffer significantly higher rates of depression and substance abuse. In of suicide, Blacks are half as likely to commit suicide as Whites (Office of the Surgeon General, 2000). The disparity of treatment of minorities related to mental illness is widespread. In general, minority populations have less access to mental health services. Minorities are less likely to receive mental health services even when they have been identified as being in need of services. Furthermore, minorities who do receive care often receive poorer quality services, and minorities continue to be underrepresented in mental health research. Barriers to care include lack of access, financial considerations, limited availability, and social stigma. Struggles with discrimination and racism remain viable barriers to receiving needed services. It is also common for Blacks to be labeled as mentally ill when indeed they are not, particularly with the diagnosis of Schizophrenia (Hattery & Smith, 2007).

DISABILITY FROM MENTAL ILLNESS

Although more than two-thirds of individuals with a mental illness are defined as having a mental disability, few receive federal benefits as a result. It is estimated that 3.5% of individuals have a mental health disability that results in compensation from the U.S. government. Individuals with a mental health disability are 20% to 30% more likely to be unemployed than individuals without a mental health disability (Social Security istration, 2010). Mental health disorders are the leading cause of disability in both the United States and Canada. Individuals are said to have a mental health disability if they are unable to work or attend school and have limitations on their functioning that impact daily activities. Major mental health disorders that meet these criteria typically include Bipolar Disorder, Major Depressive Disorder, Schizophrenia, Paranoid Personality Disorder, Delusional Disorder and other personality disorders. Depression is twice as common in women as in men and is forecasted to become the greatest cause of disability by 2020. Nearly half (45%) of individuals with a mental illness suffer from more than one mental disorder (Social Security istration, 2010). Individuals with a major mental illness of long-term duration may receive disability payments through two federal programs: Social Security Disability Insurance (SSDI) and the Supplemental Security Income (SSI). SSDI is indicated for women who have previously worked and paid Social Security taxes. SSI is for low-income women who have not paid Social Security taxes in the past. SSI beneficiaries are eligible to receive medical services through statefunded Medicaid programs, and SSDI beneficiaries can receive Medicare after a two-year waiting period. Vocational rehabilitation services may also be available to women who receive Social Security benefits.

Clinical Pearl

Women considered to have long-term mental health disorders should be referred to the local Social Securit

GLOBAL PREVALENCE OF MENTAL ILLNESS

The prevalence of mental illness is not isolated to the United States, although the United States leads the world in the percentage of mental illness within its population. While the incidence of mental illness in the United States is 26.4%, globally it is estimated to be 6.5% (WHO, 2011). This number may not be a true reflection of actual rates, however, because some cultures are more prone to deny mental illness because of the cultural stigma plus a reluctance to confide in researchers studying mental illness in developing countries. Despite barriers to research, it is estimated that worldwide 450 million people have a mental health disorder (WHO, 2011). The most common mental health disorders worldwide are anxiety disorders. In countries such as the Ukraine, where hunger and unemployment are widespread, depression is the leading cause of mental illness. It appears stigma from mental illness is a worldwide phenomenon that crosses all borders. In developing countries, it is estimated that 76% to 85% of individuals with serious mental disorders are untreated compared to 36% to 50% in developed countries (WHO, 2011). In developing countries, 20% of the patients who solicit physical health services from primary care clinics also have an underlying mental health disorder (WHO, 2011). It is common practice to avoid seeking help from health care providers of mental illness or for mental-illness–associated symptoms. In some cultures, physicians who diagnose mental health disorders are seen as incompetent for not identifying a physical disorder instead. Worldwide, it is estimated that 80% of the people impacted by civil wars, natural disasters, and displacement are women and children (WHO, 2011). Globally, violence against women is on the rise and is a major contributor to mental illnesses. Women in certain cultures are more likely to be victimized, especially in societies where violence against women is an accepted norm. As mentioned, depression is the leading cause of illness in women and this is true in both developed and developing countries. Depression is the third leading cause of disease worldwide, second only to infections and parasitic diseases. Suicide is the leading cause of death worldwide, with women more likely to attempt

suicide than men (WHO, 2011).

MENTAL ILLNESS AND COMORBIDITIES

Women with chronic health problems have a higher incidence of coexisting mental illness. Heart disease, now the leading cause of death among American women, may coexist with major mental illness. One-third of individuals who have a myocardial infarction also have depression. Individuals with diabetes are twice as likely to be depressed as individuals without diabetes. HIV/AIDS is the leading cause of death worldwide for women during the reproductive years. Women with HIV or AIDS have twice the number of mental health issues compared to those without the disease. It is estimated that 50% of individuals with cancer suffer from severe mental health disorders, including Depression, Adjustment Disorder, and anxiety (Koester, 2007). Table 1.2 lists the leading causes of death in American women.

Table 1.2 ■ Leading Causes of Death in American Women, All Races, All Ages, 2007

Cause Heart disease Cancer Stroke Chronic lower respiratory diseases Alzheimer’s disease Unintentional injuries Diabetes Influenza and pneumonia Kidney disease Septicemia

Percent* 25.8 22.0 6.7 5.3 4.2 3.5 3.0 2.5 1.9 1.5

Source: Centers for Disease Control and Prevention, 2007.

HEALTH CARE EXPENDITURES AND MENTAL HEALTH

It is estimated that of the total health care expenditures in the United States, 6.2% is spent on mental health and 1.3% is spent on substance abuse disorders (Substance Abuse and Mental Health Services istration [SAMHSA] 2010). The majority of mental health treatment in the United States is paid by federal and state agencies in the form of Medicare, Medicaid, and local programs. Private insurance s for 4% of the costs. Many mental health consumers are uninsured or underinsured and are of the working poor or the unemployed. Substance abuse treatment is funded by government sources for 76% of patients, with private insurance covering only 24% (SAMHSA, 2010). By 2014, it is estimated that the treatment of mental health disorders will cost more than $203 billion per year (SAMHSA, 2010). The majority of spending is allotted to providing medication management to patients; however, it is expected to slow as a result of the greater availability of generic medication. There is also an expectation that the use of inpatient settings will continue to decline in years. It is estimated that by 2014, substance-abuse services will cost approximately $35 billion (SAMHSA, 2010). There is an expected shift in expenditures from speciality treatment centers to a community-based treatment model of mental health care as the amount of services being paid for by private insurance companies is expected to continue to decrease. Mental illness costs are also seen in the workplace. It is estimated there is a $193.2 billion loss in earnings annually resulting from mental health conditions (Kingsbury, 2008). Individuals with mental illness earn an estimated 40% less than those without a mental illness, and it is estimated that 5 to 6 million individuals cannot find employment as a result of a mental illness (Kingsbury, 2008). Mental health costs are often not covered to the same degree as physical condition by insurance as well, making it more costly for individuals seeking treatment. Many workers do not seek treatment at all because of these limitations.

SUMMARY

Mental illness in women is a worldwide epidemic that results in major alterations in lifestyle and social relationships. Minority women are more likely to experience mental illness and less likely to have access to quality care to treat it. Mental health disorders are the lea`ding cause of disability in the United States and Canada. While some federal programs assist in providing financial compensation to women with disabilities, often applicants do not receive needed services. Worldwide, depression is the third leading cause of mental illness in women. Global issues, such as war and violence against women, make mental illness more common in women. Many women suffer from both physical and mental illnesses; comorbidity is common in women. As more women face mental illness issues, rising health care costs will continue to consume the gross national product of the United States.

Case Study

Regina Robertson is a 34-year-old African American woman who was diagnosed with schizophrenia at the age of 19. Regina was attending a local community college and doing well when she began experiencing delusions about her English professor following her around town and home from school. Shortly thereafter, she began experiencing auditory hallucinations. Regina had worked part time at a local clothing store in the mall during her senior year of high school but has not worked since that time nor has she been able to attend school. She attends the county mental health services program where a mental health nurse reviews her medications and treatment management as part of each visit. She currently qualifies for free services based on her lack of income but has no health insurance or other health care services. What services may be available to Regina based on her mental health disability?

Questions to Consider

How can nurses identify risk factors in women who may be prone to mental illness? How do cultural differences impact the presentation of mental illness? How can health care expenditures for the treatment of mental illness be reduced in the United States?

REFERENCES

American Psychological Association. (2010). APA practice guidelines for the treatment of psychiatric disorders. Washington, DC: Author. Centers for Disease Control and Prevention. (2007). Leading Causes of Death in Females United States, 2006. Retrieved from http://www.cdc.gov/women/lcod Hattery, A., & Smith, E. (2007). African American families. Thousand Oaks, CA: Sage. Kingsbury, K. (2008). Tallying the cost of mental illness. Time Magazine. Retrieved from http://www.time.com/time/health/article/0,8599,1738804,00.html Koester, S. (2007). Mental illness affecting half of cancer patients. Health & Wellness. Retrieved from http://www.associatedcontent.com/article/376550/ mental_illness_affecting_half_of_cancer.html Office of the Surgeon General. (2000). Mental health: Race, culture, and ethnicity. Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/cre/execsummary-2.html Social Security istration. (2010). Benefits for people with disabilities. Retrieved from http://www.socialsecurity.gov/disability/index.htm Substance Abuse and Mental Health Services istration. (2010). National expenditures for mental health services and substance abuse treatment: 2004– 2014. Retrieved from http://csat.samhsa.gov/IDBSE/spendEst/reports /MHSA_Est_Spending2003_2014.pdf U.S. Code of Federal Regulations. (1977). Title 38: Pensions, benefits, and veterans relief. 38 CFR 61.1. Retrieved from http://cfr.vlex.com/vid/61-1definitions-19777562#ixzz138PbFppb

U.S. Surgeon General’s Workshop on Women’s Mental Health. (2005). Workshop report. Retrieved from http://www.surgeongeneral.gov/topics/womensmentalhealth/ Vigod, S., & Stewart, D. (2009). Emergent research in the cause of mental illness in women across the lifespan. Current Opinion in Psychiatry, 22(4), 396–400. DOI: 10.1097/YCO.0b013e3283297127 World Health Organization. (2011). Gender and women’s health. Retrieved from http://www.who.int/mental_health/prevention/genderwomen/en/

2

Stressors Affecting Women

Women historically experience more stressors than men—typically twice the stress levels—and have more complex roles within the family ( American Institute of Stress, 2010 ). Women experience more stress on a daily basis as a result of competing roles, including raising children, work demands, and the care of aging parents. Today’s women are attaining higher levels of education, making higher wages, staying single longer, and having children later in life. These modernizing factors have also led to higher stress levels and more demands on American women. There are two types of stress: eustress or good stress and distress or bad stress.

■ Eustress motivates individuals to strive for more. Eustress can be associated with feelings of boosted energy and feeling more awake and alert. ■ Distress occurs when uncomfortable situations arise in which an individual does not have the proper coping mechanisms to manage them.

Stressors can be short or long term. They can be situational, such as a motor vehicle accident, or maturational, such as pregnancy or menopause. Certain risk factors increase stress levels for women (Kenney & Bhattacharjee, 2000) and may include the following:

■ Homelessness ■ Drug abuse ■ Economic difficulties ■ Socialization problems

Strain from their many roles makes mental health issues more prominent in women with these risk factors. Gender-specific risk factors for common mental disorders that affect women include lower socioeconomic status, lower income or income inequality, and greater responsibility for the care of children or aging parents (Davidson, London, & Ladewig, 2012). Interestingly, unmarried women have higher rates of depression than married women (Ahmed, 2005).

THE BODY’S STRESS RESPONSE

During times of stress, the body compensates through a comprehensive response system. The brain first responds with a fight-or-flight reaction in which physiological events occur. The body responds in predictable ways through the following physiological changes:

■ Increased heart rate ■ Increased blood pressure ■ Increased respiratory rate ■ Diversion of blood from less important to more vital organs ■ Increased glucose levels from noncarbohydrate sources ■ Breakdown of glycogen stores within the liver and muscles to elevate glucose levels

Next, the body responds to stress when the endocrine system increases levels of cortisol, growth hormone, and norepinephrine. Continued exposure to these stress hormones can lead to multiple physical and psychological abnormalities. Stress is responsible for 70% of office visits to primary care providers and 85% of serious illnesses (Camacho, Ng, Bejarano, Simmons, & Chavira, 2010). These physiological changes can result in either physical or psychological stress in women. Responses from women show that besides the fight-or-flight response occurring during times of intense stress, women also have a strong response to protect their young and to form alliances. This has been termed the “tend and befriend” response. Researchers equate the release of oxytocin during times of stress as the basis for this response (Taylor, Klein, Lewis, Gruenewald, Gurung,

& Updegraff, 2000). Women tend to have more physical symptoms associated with stress than men (American Institute of Stress, 2010). Common symptoms may include stomach complaints, headaches, backaches, general aches and pains, insomnia, and difficulty ing or concentrating. Stress also results in physiological changes within a woman’s body (Figure 2.1).

Figure 2.1 ■ The effects of stress. Source: American Institute of Stress, 2010.

These physiologic changes vary with the type of stress experienced: stress can be acute, such as that experienced during a physical assault, or chronic, such as stress caused by caring for an aging family member for a long period of time. Acute stress occurs when there is a perceived physical, emotional, or psychological threat. Although the threat may only be perceived, it is the individual’s response to the threat that creates a biophysical response. Chronic stress occurs when there is an ongoing state of physiological arousal, and the body does not appropriately recover from the physiological stress-response mechanism. The physical and psychological disorders commonly associated with chronic stress are included in Exhibit 2.1.

Exhibit 2.1

Physical and Psychological Disorders Associated With Chronic Stress

Irregular or absent menses Growth abnormalities in adolescence Hypertension Gastric disturbances, including worsening ulcers Depression Anxiety Posttraumatic Stress Disorder (PTSD)

Attention Deficit/Hyperactivity Disorder (ADHD) Impaired cognitive functioning Alterations in blood sugar Reduction in bone density Abnormalities in thyroid functioning Decrease in muscle mass Lower immunity Lower inflammatory response Headaches, including migraines Neck, shoulder, and back pain

RELATIONSHIP ISSUES

Relationships are a normal part of every woman’s life and may include family relationships, friendships, parent-child relationships, business relationships, social relationships, and romantic relationships. All mutual relationships involve interactions between individuals and can have the potential to produce or reduce stress. Romantic relationships can be negatively affected by internal stressors related to the relationship itself, such as martial discord over finances, or external factors related to stress outside of the relationship, such as work-related stressors. Both can negatively impact the relationship. Women who are in happy marital relationships suffer less stress and fewer mental health issues than those who are unmarried or in unhappy marriages (Kenney & Bhattacharjee, 2000). Marriage provides both economic stability and social . Women in unhappy marriages may be impacted negatively by inequalities within the relationship and intimate partner violence. Despite suffering less stress as a result of being married, women in marital relationships do experience more stress than men in relationships regardless of the quality of the relationship (Ahmed, 2005). Women tend to form stronger relationships with female friends and share more intimate details of their interpersonal relationships with their peers than men do (Taylor et al., 2000). This serves as a means for reducing stress levels. There is some evidence that the relationships formed between women are similar to the bonding that occurs between a mother and her young. Hormones identified as mothering hormones, such as oxytocin, play pivotal roles when females are forming bonding relationships with others (Taylor et al., 2000). Further research shows friendships act as buffers against stressors and may lower a woman’s stress levels, with multiple health benefits associated with women having close same-sex bonds with other women (Taylor et al., 2000) that include the following:

■ Lower levels of stress

■ Longer lives ■ Fewer physical dysfunctions ■ Better immune system functioning ■ Higher levels of happiness

Individuals with strong systems are more likely to reap the benefits of both mental and physical health. Friendships have been studied as an effective means to reduce depression in elderly women (Taylor et al., 2000). It is well established that a strong system aids in recovery from mental illness. Modern changes in society have resulted in a reduction of social in many ways. The traditional family that lived in close geographic proximity to each other is now often spread out and may lack strong community ties and social .

Clinical Pearl

Referrals to groups, school functions, civic organizations, special-interest groups, and mothering g

PARENTING STRESSORS

All women who choose to have children will experience stressors at some point in their lives as a result of raising children. Raising children is a large responsibility, and with it comes common stressors and worries. Parental stressors are normal—parents worry about the physical safety, growth, and development of their children. Despite today’s family dynamics, women still provide 76% of child care to dependent children (Mistry, Stevens, Sareen, De Vogli, & Halfon, 2007). Mothers of young children experience significant stressors related to raising them. It is estimated that 19% of mothers with young children experience two or more depression symptoms (Mistry et al., 2007). Parental stressors include social stress, financial stress, and child health care stressors. Making arrangements for child care can be a significant stressor for women, regardless of their external work status. Stay-at-home mothers as well as working mothers face unique stressors. Stay-at-home mothers may feel isolated and removed from their previous systems. They may lack adult interaction and friendships, feel a sense of boredom, and sometimes yearn for their previous life. Women working outside of the home may have feelings of guilt, feel disconnected from their children, and often feel as if they have more responsibilities than time allows them to handle. Families with teenagers face unique stressors as these children strive to gain independence. Mothers need to realize it is normal for teenagers to want to spend time alone and with their friends. Struggles over rules and authority are common during this stage. As teenagers strive to meet developmental milestones, parents often struggle with the unique changes associated with their growing up. Research has shown individuals with children have higher depression levels than those who are not parents. Parents at risk for depression are those with adult children living at home, those with adult children who have recently left home, and those who do not have custody of their minor children. Married parents seem to experience less stress and depression than unmarried parents and single parents. Women who have their children living with them have the lowest stress levels. Women sharing custody experience more stressors. Single-parent mothers

tend to have less social and financial resources than married mothers (Ahmed, 2005). It is important for parents to build ive peer relationships with other parents. Working mothers with minor children living at home experience higher cortisol levels than those without children at home (Mistry et al., 2007). Women who have raised their children and then have children leave home are known as “empty nesters.” Empty nest syndrome encomes feelings of loss, loneliness, depression, or grief related to the process of a child leaving home and is more common in women. The syndrome can also occur when children marry, and parents then play a less pivotal role in their children’s lives. The empty nest years often represent a period of major adjustment as the woman strives to redefine her life and her activities. It may occur during a major life transition, such as menopause, or in crucial years when the woman is dealing with the aging and care duties warranted by her own parents. Empty nest syndrome is worse in Western societies and has become more common in modern times with children moving away for college and not returning home. Working women seem to experience a milder form of empty nest syndrome than stay-at-home mothers although the closeness of the child to the parent seems to be the greatest indicator of severity. Internal stress factors related to mothering come from internal sources and include a woman’s attitudes, perceptions, beliefs, and expectations. When she falls short of these expectations, the woman often blames herself. External parenting stressors come from an individual’s environment and include interaction with others. Often, external stressors may come in the form of external expectations of how one’s child interacts with others in certain situations. Families raising children with disabilities experience more stress than those who do not have a disabled child. Marital relationships are more likely to suffer in families with disabled children. For example, parents with a child with Attention Deficit/Hyperactivity Disorder (ADHD) are twice as likely to divorce than parents without an affected child (Doheny, 2008). Often, the role of caregiver falls upon the mother in these circumstances. Women with children with disabilities often experience guilt, anger, and frustration about their child’s disability.

Clinical Pearl

Women with disabled children can be encouraged to groups specially designed for families co

WORK AND FINANCIAL STRESSORS

The number of working women is approaching 82% (Jacobe, 2010). When women work, they are expected to take on the same amount of responsibility in the workplace as their male counterparts while maintaining the ideal homemaker and mother role in the home setting. These societal expectations can lead to extreme pressures and stressors for working women. Although the husband of a working woman puts in an average of 7 hours of housework per week, the woman still triples that rate in today’s average dual-earner family. Fathers are more involved than ever before with child care, devoting three times more hours to family functions than they did during the 1960s. Despite these gains, working women are still the primary care providers for children even when both parents work equal hours outside the home (Kelleher, 2007). Despite equalities in education, occupation, and qualifications, women earn less than men for the same work. It is estimated that women earn 77 cents compared to men’s one dollar for the same work. Despite the Equal Pay Act of 1963, women have never caught up. In 2009, President Barack Obama signed the Lilly Ledbetter Fair Pay Act into law, making it easier for women to sue employers who participate in unfair pay practices for women (Stolberg, 2009). Minority women face even greater disparities with Black and Hispanic women earning even less. Nearly half of Black and Hispanic women have negative wealth, meaning their debt outweighs their assets. Financial stress affects as many as 70% of Americans and can lead to higher rates of depression and sleep disturbances (Jacobe, 2010). Women with financial stressors are more likely to have a reduction in coping mechanisms, less money for self-care activities, insomnia, and depression symptoms (Ahmed, 2005). Women and families living in poverty experience higher stress levels and more depression than those in higher socioeconomic categories. Financial stressors put strain on marital relationships and parenting, and are associated with higher levels of family dysfunction (Ahmed, 2005). Current economic conditions within the United States and the resulting higher incidences of bankruptcy and foreclosure add additional stressors to women and their families.

Minority female populations, including Blacks and Hispanics, often have lower income levels than Caucasians. Women with financial strain and those who have problems at work have more frequent crisis mental health visits and more acute psychiatric hospitalizations (Camacho, et al., 2010). Many working women face difficulties balancing work, marriage, home, and other required duties. For some, work situations themselves may create stressors and pressures. Work stress affects approximately 62% of all Americans (Amagada, 2009). In times of economic turbulence, threats of job loss and layoffs increase work-related stress levels to 73% (Amagada, 2009). Job burnout affects almost 33% of American workers (Amagada, 2009). Some female workers face additional stressors, such as sexual discrimination, sexual harassment, and even workforce violence. Studies show women are more vulnerable to stresses encountered at work. Some women may utilize alcohol as a coping mechanism to deal with stress at work, whereas other women internalize negative feelings and commonly have resulting somatic complaints.

RETURNING TO SCHOOL AS A NONTRADITIONAL STUDENT

A nontraditional student is one who returns to the school setting after the age of 25. There are approximately 45 million American adults who have returned to school after the age of 25, with women as 45% of these students. Women returning to the college setting face more barriers than their male counterparts. Many of them already have families and are responsible for household duties, and some continue to maintain employment for financial reasons. Studies have shown that men who return to school have more social and family than women who do so. Women report the main obstacle to returning to school to be lack of family . When a woman does return to school, other family often have to become responsible for household tasks. Without a ive partner and children, many women have difficulty finding enough time to do it all (Mbilinyi, 2006).

STRIVING TO BE THE “PERFECT WOMAN”

Women are often faced with societal pressures to be the “perfect woman.” While most women now engage in full-time employment outside the home, they are still tasked with raising children, maintaining the home, cooking, being engaged in children’s social activities and school functions, and being the perfect wife, all while maintaining adequate health and fitness. The constant push to meet this stereotype in itself creates stress for many women. One woman explained, “I have to be a workaholic at work; a picture-perfect mother at home, cooking homemade nutritious meals; the dutiful daughter to my parents; the active parent-teacher organization member at the kids’ school; the giving volunteer in the community; the sexy wife every man desires; and all as a size seven jean size. ” In American society, obesity is profound, yet women are judged negatively and perceived as less desirable in many facets of their lives for being overweight. Some women encounter a great deal of pressure to maintain the size and shape they possessed prior to marriage and childbirth, creating yet another social stressor.

THE SANDWICH GENERATION

Women aged 45 to 56 years make up the sandwich generation and for one in eight American women who are caring for a child under the age of 21 while providing financial assistance and care to an aging parent. It is estimated that 9% of women in this age group are caring for an ailing parent within their home at the same time as raising a child under the age of 21 (National Women’s Health Information Center, 2010). Most sandwich-generation women have a higher-than-average education level (14.1 years), are married, are employed outside the home, and are ing children and elderly parents either financially or through the provision of housing, college expenses, or other living expenses (National Women’s Health Information Center, 2010). Sandwichgeneration women are exposed to more stressors as a result of their dual roles within the family.

CAREGIVER STRESS

A caregiver is anyone who provides physical and/or emotional care for an ill or disabled individual, usually a loved one. The most common caregivers are women caring for parents, spouses, adult children, or other family . Women who provide continuous care to others are at risk for caregiver stress. Caregiver stress includes both the physical and emotional strain of providing care to another individual. Caregiver stress impacts women more than men, probably because it is much more common for women to be the primary caregiver. There are 44 million caregivers within the United States. Of them, 61% are women. Most caregivers are middle-aged, and 13% of caregivers are over the age of 65. Approximately 75% of caregivers report symptoms such as guilt, frustration, anger, and exhaustion (National Women’s Health Information Center, 2010). Although in most cases caregiving is a full-time job in itself, many caregivers frequently have jobs outside of their caregiving duties. Of the 59% of caregivers who have outside jobs, many have to compensate by making changes at work in their schedules or hours worked (National Women’s Health Information Center, 2010). Many caregivers provide care at the expense of their own health. Female caregivers are less likely to maintain their own preventive health care and are less likely to fill prescriptions, get immunizations, receive annual mammograms, and engage in healthy activities. Caregivers experience increases in physical illness rates, including slower wound healing; higher levels of obesity; and greater incidences of chronic health problems, including diabetes, heart disease, cancer, and arthritis (National Women’s Health Information Center, 2010). Women caregivers have higher rates of anxiety and depression when compared to women who are not caregivers. Many caregivers lack and report feelings of isolation. Women caregivers have greater mental decline, more memory problems, and more difficulty paying attention to details than women who are not caregivers (National Women’s Health Information Center, 2010). The nurse is in a key role and can provide essential health care education for women who act as caregivers. Specific interventions should be discussed. Stress-

relieving measures are imperative to maintain the health and well-being of the caregiver and to assist in her demanding role. The nurse should provide the following suggestions as interventions to decrease caregiver stress levels:

■ Encourage a proactive approach to caregiving in which the woman caregiver actively plans her activities and duties, prioritizes, and sets realistic goals. She should be conscious of limitations, and that she does not always have to be perfect. ■ Advise the woman to ask other family to do their share of the physical and financial care of the dependent family member. ■ Encourage the caregiver to learn to say no to extra activities, such as hosting holidays or carpooling activities. ■ Alert the woman to the existence of community-based groups. ■ Instruct the woman to maintain outside interests and peer relationships. She should be advised to take time for herself and keep her sense of humor. ■ Provide the caregiver with a list of caregiving resources, including meal preparation and delivery, transportation services, home health services, home services (cleaning, cooking, home maintenance), and legal and financial services. ■ Offer alternative care resources, including respite in-home care, short-term nursing home services, adult day-care centers, and day center programs.

The nurse plays a crucial role in providing resources for the caregiver. Available resources are listed in Exhibit 2.2.

Exhibit 2.2

Community Resources for Caregivers

istration on Aging Phone number: (800) 677-1116 Internet address: http://www.aoa.gov, http://www.eldercare.gov

Centers for Medicare and Medicaid Services Phone number: (800) 633-4227 Internet address: http://www.cms.hhs.gov

Family Caregiver Alliance Phone number: (800) 445-8106 Internet address: http://www.caregiver.org

National Alliance for Caregiving Internet address: http://www.caregiving.org

National Family Caregivers Association Phone number: (800) 896-3650 Internet address: http://www.nfcacares.org

Source: Adapted from the National Women’s Health Information Center, 2010.

INTERVENTIONS FOR COPING WITH STRESS

Women with dual roles and societal pressures need reassurance that stress is a normal part of life. Although everyone encounters stress, women’s reactions and how they cope with that stress can vary significantly and impact their emotional and physiological responses. Nurses should assist women in learning positive ways to deal with stressors. These may include the following:

■ Advise the woman to eliminate stressors if possible. Some stressors cannot be eliminated, but with others, it may be possible. ■ Encourage a low-stress lifestyle that includes flexibility, setting limits, making goals, and becoming more organized. Encourage women to let go of the “perfect woman” persona. ■ Utilize stress-reduction strategies and relaxation techniques, such as deep breathing, guided imagery, yoga, meditation, journaling, and massage. ■ Encourage proper eating and daily exercise and activity. ■ Promote healthy sleep patterns, including getting 7–9 hours of sleep nightly, going to bed at a regular time, establishing nighttime rituals, and eliminating caffeine intake in the evening. ■ Encourage positive relationships with partners, friends, and social and business acquaintances. Avoid destructive or negative relationships whenever possible. ■ Promote the use of a system, and encourage women to maintain relationships with other women, to talk about stressors with friends or family, to volunteer in the community to improve her self-image, and to engage in counseling as needed.

■ Bio is an effective tool for some women. ■ Counseling with a health care professional can aid a woman in determining her sources of stress, suggest interventions to deal with that stress, and teach healthy coping mechanisms. ■ Self-medicating with alcohol or other substances should be avoided, and any discussion should focus on the negative aspects of these behaviors. ■ Alternative therapy herbs, such as St. John’s wort, kava kava, and Siberian ginseng; homeopathic remedies, such as ignatia amara (Ignatia) and phosphorus; and vitamin therapy including B-complex vitamins, vitamin C, omega-3 fatty acids, and magnesium, can be used to decrease stress levels after consultation with your health care provider as alternative therapies sometimes have adverse reactions with medications and over-the-counter products. ■ A detailed physical examination should be conducted to rule out physical etiologies of stress. ■ A psychological assessment should be performed to identify the presence of an underlying mental health problem, such as depression or anxiety.

Complementary and alternative therapies dealing with stress can also provide women with additional tools for dealing with stressors (Exhibit 2.3).

Exhibit 2.3

Alternative and Complementary Therapies That Can Reduce Stress

Acupressure/acupuncture

Aromatherapy Breathing exercises Chiropractic therapies Diet/nutrition therapies Exercise Herbs Homeopathy Guided imagery Kinesiology Massage Meditation Naturopathy Progressive relaxation exercises Reflexology Yoga

SUMMARY

Women face a number of stressors throughout their lives, more stressors than most men. As female roles continue to grow and expand, the number of stres sors also multiplies for women. Nurses play a key role in assisting women with identifying stressors and developing interventions to reduce stressors in their daily lives. Stress can negatively impact a woman’s physical and mental health; stress-reduction interventions are therefore important in preventive medicine.

Case Study

Jennifer Canfield is a 27-year-old teacher who lives in an urban area in the Midwest. Jennifer is married to her college sweetheart and has a 13-month-old son who is in day care during the day while she is at work. Jennifer’s husband is a wonderful father but does little to help around the house. Jennifer presents to her primary-care provider for frequent headaches, feeling overwhelmed much of the time, and physical exhaustion. She tells the nurse she works all day, comes home in the evening and cares for her son, cooks dinner, cleans up, baths her son, puts him to bed, and then cleans house and grades school papers each evening. Jennifer feels intense pressure “to be able to do it all.” Her parents live nearby, but her mother is constantly telling Jennifer she doesn’t keep her home as neat as she should and that when Jennifer was growing up, her mother always kept a spotless home. Jennifer feels intense pressure to do everything well and feels guilty because she cannot meet the expectations of her parents and herself. In addition, she has not lost all her baby weight and feels her husband does not find her attractive. What nursing interventions would you advise for Jennifer? What stress-reduction strategies can Jennifer engage in to reduce her stress levels?

Questions to Consider

How does the physiological stress response impact the woman with acute stress? What are the physiological and psychological characteristics associated with stress? How do financial stressors impact a woman’s mental health? What interventions can you identify to decrease mental stressors for women caregivers?

REFERENCES

Ahmed, Z. S. (2005). Poverty, family stress, and parenting. Retrieved from http://www.humiliationstudies.org/documents/AhmedPovertyFamilyStressParenting.pdf Amagada, J. (2009). Stress statistics: Where do you fit in? American Chronicle. Retrieved from http://www.americanchronicle.com/articles/view/92786 American Institute of Stress. (2010). Effects of stress. Retrieved from http://www.stress.org/topic-effects.htm Camacho, A., Ng, B., Bejarano, A., Simmons, A., & Chavira, D. (2010). Crisis visits and psychiatric hospitalizations among patients attending a community clinic in rural Southern California. Community Mental Health Journal. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20924788 Davidson, M. R., London, M. L., & Ladewig, P. A. W. (2012). Old’s maternalnewborn nursing and women’s health across the lifespan, (9th ed.). Upper Saddle River, NJ: Pearson. Doheny, K. (2008). Divorce more likely in ADHD families. Retrieved from http://www.emedicinehealth.com/script/main/art.asp?articlekey=93680 Jacobe, D. (2010). Could we see a negative wealth effect? Gallup Poll. Retrieved from http://www.gallup.com/poll/5377/Could-See-Negative-Wealth-Effect.aspx Kelleher, E. (2007). In dual-earner couples, family roles are changing in U.S.: As women’s earnings boost household income, men pitch in more at home. Retrieved from http://www.america.gov/st/washfileenglish/2007/March/20070321162913berehellek0.6708338.html#ixzz13PLeZO7e Kenney, J.W., & Bhattacharjee, A. (2000). Interactive behavioral model of women’s stressors, personality traits, and health problems. Journal of Advanced Nursing, 32(1), 249–258.

Mistry, R., Stevens, G. D., Sareen, H., De Vogli, R., & Halfon, N. (2007). Parenting-related stressors and self-reported mental health of mothers with young children. American Journal of Public Health, 97(7), 1261–1268. Mbilinyi, L. (2006). Degrees of opportunities: Adults’ views on the value and feasibility of returning to school. Minneapolis: Capella University. National Women’s Health Information Center. (2010). Caregiver stress. Retrieved from http://www.womenshealth.gov/faq/caregiver-stress.cfm Stolberg, S. G. (2009, January 29). Obama signs equal-pay legislation. The New York Times. Retrieved from http://www.nytimes.com/2009/01/30/us/politics/30ledbetter-web.html?_r=1 Taylor, S. E., Klein L. C., Lewis, B. P., Gruenewald, T. L., Gurung, R. A. R., & Updegraff, J. A. (2000). Biobehavioral responses to stress in females: Tend-andbefriend, not fight-or-flight. Psychological Review, 107(3), 411–429.

3

Role of Culture in Mental Illness

Culture, a major contributing factor to one’s sense of self and wellness, is defined as “the beliefs, values, attitudes, and practices that are accepted by a population, a community, or an individual” ( Davidson, London, & Ladewig, 2012 , p. 33). Ethnicity is defined as the “social identity that is associated with shared behaviors and patterns” (p. 33). A woman’s cultural background and ethnicity play key roles in her perception of her physical and mental well-being. With an increasing rate of immigration, a country becomes more diverse, and the ability to assign ethnicity becomes increasingly difficult. Women who immigrate to a new country must change and adapt to a new cultural environment. Immigration is a time of great stress and can result in a loss of system, loss of language proficiency, physical and emotional isolation, financial hardship, and even culture shock. Culture shock is defined as the difficulty encountered when moving to a new culture where cultural norms differ significantly from one’s own cultural background. Acculturation occurs when individuals must adapt to a new cultural norm within their environment. When an individual becomes part of the culture around them, assimilation has occurred (Davidson et al., 2012). Understanding the culture of diverse clients is essential to the nurse’s understanding of women’s perceptions of their own mental health. Cultural variations can directly impact how a woman defines and identifies herself and her own mental status. Even in the United States, where mental illness has greater acceptance as a credible disorder, stigma still exists and is prominent. In some countries, mental illness is viewed as a curse, and the woman can be isolated and even tortured. Because of these varying factors, the need for cultural competence among health care providers is essential (Leininger & MacFarland, 2006). Cultural competence is “a set of congruent behaviors, attitudes, and

policies that come together as a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in crosscultural situations” (Sutton, 2000, p. 58).

CULTURAL COMPETENCE IN MENTAL HEALTH

There are a number of ways in which health care providers can convey acceptance of cultural differences to the women they care for. The first is to embrace cultural differences as strengths. Nurses can conduct a self-assessment of cultural ideas so they can become aware of their own opinions and values. Cultural acceptance should be embraced on a macro level throughout health care organizations. Variations in practice may need to be employed to meet the diverse cultural needs of caring for women from different cultural backgrounds. In order for cultural competence to be truly obtained, clinician behaviors and skills, as well as organizational acceptance, need to be achieved (Bhui, Warfa, Edonya, McKenzie, & Bhugra, 2007). Cultural competence is important for health care providers for multiple reasons. Women presenting from diverse cultures may express themselves differently and may report symptoms of mental illness differently. Language barriers may exist, making reporting symptoms of mental illness through an interpreter difficult or embarrassing for some women. Many women from diverse backgrounds face greater health disparities. The U.S. Department of Health and Human Services Healthy People 2020 program aims to achieve two broad goals; one is to reduce health disparities (U.S. Department of Health & Human Services, 2010). Cultural competence should be viewed on a continuum rather than as an endpoint for clinicians.

INEQUALITY IN MENTAL HEALTH SERVICES

In 1999, the Surgeon General of the United States issued a report titled “Mental Health: A Report of the Surgeon General.” At that time, it was acknowledged that minorities and individuals from diverse populations received unequal mental health services. The report highlighted that these individuals were less likely to receive quality mental health services and were often misdiagnosed, over diagnosed, or not diagnosed at all when it came to mental illness. The availability of services, utilization of services, and outcomes of services were poorer for ethnic minority groups when compared to the White population (Table 3.1).

As the population of the United States continues to evolve and become more ethnically diverse, the need for diversity in mental health care services is essential. According to projections from the U.S. Census Bureau, African Americans, American Indians, Asian Americans, and Latinos will make up roughly 50% of the total U.S. population by 2050 (National Alliance on Mental Illness, 2010). Communication between health care providers and patients from diverse backgrounds is becoming a major health care issue. It is estimated that, currently, less than 50% of ethnically diverse patients had access to a language interpreter as needed during routine health care appointments. In addition, onethird of Hispanics and one-quarter of Asian Americans report difficulty communicating with their care providers (National Alliance on Mental Illness, 2010).

RACE AND CULTURAL IMPLICATIONS OF MENTAL ILLNESS

The causes of mental illness include genetic, physical, psychosocial, and cultural factors. Specific disorders have a greater tendency to be caused by varying contributions from these factors. Some cultural and societal norms may contribute to mental illness. For example, patriarchal cultures are more likely to engage in intimate partner violence, which is a causative factor of depression, anxiety, and PTSD (Baldry & Winkel, 2008). Some disorders, such as Anorexia Nervosa and Dissociative Identity Disorder, are only seen in industrialized countries (Lu, 2006). Culture influences how a woman identifies, voices, and manifests her symptoms. Culture frequently impacts a woman’s individual coping mechanisms and her system. Culture is also directly linked to a woman’s comfort level in seeking treatment. Some cultures view mental illness very negatively, making it socially unacceptable to seek treatment. The availability of ethnically diverse care providers also impacts an individual’s willingness to seek treatment. Asian Americans, for example, are less likely to seek treatment from non-Asian providers (U.S. Surgeon General’s Office, 1999).

POVERTY AND MENTAL HEALTH IMPLICATIONS

Poverty is more common in ethnic and racial minorities than it is in Whites and is a risk factor for mental illness. Poverty affects many more women than men. Women living below the poverty level are reflected in the phrase feminization of poverty, which was coined by Diana Pearce in 1993. The number of women and children living below the poverty level, $22,050 or less, in the contiguous United States, is increasing (Davidson et al., 2012). Women in lower socioeconomic groups have two to three times higher rates of mental illness than those in higher socioeconomic groups and are more prone to intimate-partner violence (U.S. Surgeon General’s Office, 1999). Individuals exposed to violence also have higher rates of mental illness. African American and Hispanic women are more likely to have higher rates of poverty and earn less than their White counterparts, despite equivalent education and job skills. African American women also have higher rates of heading single-parent families, an additional stressor. The homeless population consists of 20% to 40% of individuals with a mental illness (California Psychiatric Association, 2010).

RACISM AND DISCRIMINATION

Racially and ethnically diverse women are exposed to more racism and discrimination, which yield a higher incidence of physical and mental illness as well. Being exposed to constant stressors, including discrimination and racism, make mental illness more prominent.

Clinical Pearl

Asian populations encom more than 30 Asian subgroups and 21 Pacific Islander populations (Lu, 2006

CULTURAL BARRIERS TO SEEKING MENTAL HEALTH CARE SERVICES

There are multiple barriers that exist among minorities and culturally diverse women when seeking treatment for mental illness. Many women in these groups have fear or distrust of the system. Many women have varying ideas, directly related to their cultural beliefs, about what constitutes wellness and illness. Perceptions of symptoms that we commonly associate with mental illness may be viewed as normal under their spectrum of wellness. Women living in rural areas encounter greater difficulties than those living in more populated suburban or urban areas. Language issues continue to play a major role in limiting access to services. Even when interpreters are present, ineffective communication can still result. Lack of medical insurance and poverty are also significant barriers to health care services. In addition, undocumented and illegal aliens may fear deportation or other legal involvement if mental health or other health care services are sought out. Many individuals from diverse populations desire a culturally similar care provider. The lack of multicultural care providers in the United States creates additional barriers for mental health services. Lesbian, bisexual, and transgendered women may feel uncomfortable revealing their sexual orientation or gender identity to health care providers and may be reluctant to seek needed mental health services. The lesbian, bisexual, and transgendered population has a higher incidence of mental illness than their heterosexual counterparts, possibly as a result of the stress associated with discrimination they face (Huygen, 2006). Many lesbian, bisexual, and transgendered women are afraid to disclose their illnesses within their own communities as well and find the community judgmental and unive (Huygen, 2006). Women often fear discrimination resulting from multiple factors, including race, age, gender, religion, class, and sexual orientation. Women with physical disabilities often face discrimination and are often thought to be less intelligent even though their disability may have no impact on their cognitive abilities or

intelligence level (Davidson et al., 2012). All of these factors can provide barriers when seeking mental health care services. The need for cultural competence when providing services is essential. Interventions for culturally competent care are provided in Exhibit 3.1.

Exhibit 3.1

Culturally Competent Mental Health Care Strategies

Appropriate strategies for providing culturally competent care include the following:

■ Inquire about an individual’s cultural identity and values in a respectful manner ■ Assess the family unit, power differentials within the family, and key decision makers within the family unit ■ Ask open-ended questions ■ Avoid making generalizations about a cultural group; instead, explore the culture of the individual woman ■ Provide culturally sensitive intake, assessment, and discharge information ■ Provide written materials in a woman’s own language ■ Offer racially and ethnically diverse care providers within an organization ■ Utilize interpreters and language lines when needed ■ Provide cultural sensitivity training to all staff and care providers

■ Identify and utilize community-based resources ■ Provide questionnaires to patients on how to meet their culturally diverse needs

Source: Davidson et al. (2012).

CULTURAL ASPECTS LEADING TO MISDIAGNOSIS

The misdiagnosis of individuals resulting from cultural variations has not been well researched in many areas but has been reported in the literature. The bias of diagnosing African Americans with Schizophrenia is well documented in the literature (U.S. Surgeon General’s Office, 1999). Biases and prejudices occur and can be intentional or unintentional; therefore, it is essential that clinicians reflect on their own values when evaluating an individual and be cognizant of their cultural beliefs and varying norms. It is important to know a woman’s cultural identity, including acculturation and assimilation variables. The role her culture may play related to her symptoms are also important, as well as cultural factors relating to her environment and level of functioning. The relationship between the woman and the provider is an important consideration, as is an overall cultural assessment. Another crucial factor for practitioners is the need to recognize a woman’s individuality when providing mental health services. Although a woman may identify with a specific cultural or ethnic group, her own views may vary significantly. While it is important for providers to be aware of cultural norms, the need to recognize variations and individuality is essential. Table 3.2 provides some cultural beliefs regarding mental illness in various populations. The clinician is cautioned that this is an overview and reminded that all women present with varying customs, beliefs, and values.

Table 3.2 ■ Cultural Beliefs Regarding Mental Illness

Type of Culture Pacific Islander Chinese Japanese Vietnamese

Beliefs Regarding Mental Illness Emotional and psychological disorders are viewed as an imbalance of the individual’s family, community Mental illness results from a lack of harmony of one’s spirit or as a direct result of the presence of evil sp A condition caused by akuma (evil spirits); the concept of shame or hazukashii is common regarding me Seen as a form of sadness (depression)

Korean Hispanic Arab

Caused by disharmony, a deceased spirit coming back to haunt someone, misfortune, or payback for a wr Associated with danger and may be the result of a lack of character or a direct punishment from God. Sy Belief that the mentally ill may be attempting to manipulate family , wrath of God, and onset of

Source: Adapted from Lu, G. (n.d.).

CULTURALLY COMPETENT TREATMENT STRATEGIES

The initial step in treating any woman from a culturally diverse background is to obtain a transcultural assessment to determine a woman’s specific cultural identity (Exhibit 3.2). A transcultural assessment includes the woman’s perception of her own cultural identity and includes communication, space preferences, social interactions, perceptions of time, environmental control, and biological factors that may impact her cultural identity. While there are specific tools available for specified populations, a generic tool can be used according to the health practitioner’s preferences.

Exhibit 3.2

Transcultural Assessment Model

CULTURALLY UNIQUE INDIVIDUAL

1. Place of birth

2. Cultural definition What is . . .

3. Race What is . . .

4. Length of time in country

COMMUNICATION

1. Voice quality A. Strong, resonant B. Soft C. Average D. Shrill 2. Pronunciation and enunciation A. Clear B. Slurred C. Dialect

3. Use of silence A. Infrequent B. Often C. Length

(1) Brief (2) Moderate (3) Long (4) Not observed

4. Use of nonverbal communication A. Hand movement B. Eye movement C. Moves entire body D. Kinesics (gestures, expressions)

5. Touch A. Startles or withdraws when touched B. Accepts touch without difficulty C. Touches others without difficulty

6. Ask these and similar questions: A. How do you get your point across to others? B. Do you like communicating with friends, family, and acquaintances? C. When asked a question, do you usually respond (in words or body movements or both)?

D. If you have something important to discuss with your family, how would you approach them?

SPACE

1. Degree of comfort A. Moves when space invaded B. Does not move when invaded

2. Distance in conversations A. 0 to 18 inches B. 18 inches to three feet C. Three feet or more

3. Definition of space A. Describe your degree of comfort with closeness when talking with or standing near others B. How do objects (e.g., furniture) in the environment affect your sense of space?

4. Ask these and similar questions: A. When you talk with family , how close do you stand?

B. When you communicate with coworkers and other acquaintances, how close do you stand? C. If a stranger touches you, how do you react or feel? D. If a loved one touches you, how do you react or feel? E. Are you comfortable with the distance between us now?

SOCIAL ORGANIZATION

1. Normal state of health A. Poor B. Fair C. Good D. Excellent

APPLICATION: EXAMINE YOUR CULTURAL INFLUENCES

1. Ask these and similar questions: A. How do you define social activities? B. What are some activities that you enjoy? C. What are your hobbies or what do you do when you have free time? D. Do you believe in a supreme being?

E. How do you worship that supreme being? F. What is your function (what do you do) in your family unit/system? G. What is your role in your family unit/system (father, mother, child, advisor)? H. When you were a child, what or who influenced you most? I. What is/was your relationship with your siblings and parents? J. What does work mean to you? K. Describe your past, present, and future jobs. L. What are your political views? M. How have your political views influenced your attitude toward health and illness?

TIME

1. Orientation to time A. Past-oriented B. Present-oriented C. Future-oriented

2. View of time A. Social time B. Clock-oriented

3. Physiochemical reaction to time A. Sleeps at least 8 hours a night B. Goes to sleep and wakes on a consistent schedule C. Understands the importance of taking medication and other treatments on schedule

4. Ask these and similar questions: A. What kind of timepiece do you wear daily? B. If you have an appointment at 2 p.m., what time is acceptable to arrive? C. If a nurse tells you that you will receive a medication in “about a half hour,” realistically, how much time will you allow before calling the nurses’ station?

ENVIRONMENTAL CONTROL

1. Locus of control A. Internal locus of control (believes the power to affect change lies within) B. External locus of control (believes fate, luck, and chance have a great deal to do with how things turn out)

2. Value orientation A. Believes in supernatural forces

B. Relies on magic, witchcraft, and prayer to affect change C. Does not believe in supernatural forces D. Does not rely on magic, witchcraft, or prayer to affect change

3. Ask these and similar questions: A. How often do you have visitors at your home? B. Is it acceptable to you for visitors to drop in unexpectedly? C. Name some ways your parents or other persons treated your illnesses when you were a child. D. Have you or someone else in your immediate surroundings ever used a home remedy that made you sick? E. What home remedies have you used that worked? Will you use them in the future? F. What is your definition of good health? G. What is your definition of illness or poor health?

BIOLOGIC VARIATIONS

1. Conduct a complete physical assessment noting the following: A. Body structure B. Skin color C. Unusual skin discolorations

D. Hair color and distribution E. Other visible physical characteristics (e.g., keloids, chloasma)

2. Ask these and similar questions: A. What diseases or illnesses are common in your family? B. Describe your family’s typical behavior when a family member is ill. C. How do you respond when you are angry? D. Who (or what) usually helps you to cope during a difficult time? E. What foods do you and your family like to eat? F. Have you ever had any unusual cravings for the following: (1) White or red clay or dirt? (2) Laundry starch? G. When you were a child, what types of foods did you eat? H. What foods are family favorites or are considered traditional?

NURSING ASSESSMENT

1. Note whether the client has become culturally assimilated or observes her own cultural practices.

2. Incorporate data into a plan of nursing care:

A. Encourage the client to discuss cultural differences; people from diverse cultures who hold different world views can enlighten nurses. B. Make efforts to accept and understand methods of communication. C. Respect the individual’s personal need for space. D. Respect the rights of clients to honor and worship the supreme being of her choice. E. Identify a clerical or spiritual person to . F. Determine whether spiritual practices have implications for health, life, and well-being (e.g., Jehovah’s Witnesses may refuse blood and blood derivatives; an Orthodox Jew may eat only Kosher food high in sodium and may not drink milk when meat is served). G. Identify hobbies, especially when devising interventions for short or extended convalescence or for rehabilitation. H. Honor time and value orientations and differences in these areas. Allay anxiety and apprehension if adherence to time is necessary. I. Provide privacy according to personal need and health status of the client. (Note: The perception of and reaction to pain may be culturally related.) J. Note cultural health practices (1) Identify and encourage efficacious practices. (2) Identify and discourage dysfunctional practices. (3) Identify and determine whether neutral practices will have a long-term ill effect. K. Note food preferences (1) Make as many adjustments in diet as health status and long-term benefits will allow and that the dietary department can provide. (2) Note dietary practices that may have serious implications for the client.

Source: From Giger, J. N., & Davidhizar, R. E. (2008). With permission from Elsevier.

Clinical Pearl

For clinicians who work with one specific population frequently, an individualized tool specific to that div

The use of culturally competent treatment strategies can increase treatment success rates, overall patient satisfaction with mental health services, and compliance. Women identified as having a mental health disorder should be offered culturally appropriate treatment interventions that are adapted to fit their needs. For example, if a Chinese woman also wants to utilize Eastern medicine practices, such as acupuncture, she should be ed in using the resources and treatments she feels comfortable using. Examine if religion or spirituality would provide a basis of in her treatment plan. If this is the case, refer her to community resources that her religious views and needs. Various cultures identify spirituality and religion as major components of their wellbeing. In addition, family plays a key role in the care of women. The clinician should utilize family s whenever possible. For many women, social goes beyond the traditional family framework and includes friends, church , group peers, and elders within the community (Hays, 2001). Clinicians need to recognize power differentials within the family unit. For example, in many Arab cultures, the man provides the dominant role within the family, and family revert to him for decision making; therefore, treatment planning should include him to increase compliance with treatment plans. In other cultures, the family looks to the elders for permission and advice when making health care decisions. The use of a same-culture or like-culture group environment can provide women from diverse populations an opportunity to obtain , learn effective coping strategies, and develop a social network with their peers. When treating a woman with medications, the clinician needs to be aware of age-related and ethnic variations in metabolism rates. Exploration of a woman’s expectations can also vary from culture to culture and should be explored prior to initiating a pharmacological intervention (Hays, 2001).

SUMMARY

Culture plays a key role in determining how a woman with a mental illness will view herself. In some cultures, mental illness is viewed negatively and as a source of weakness or shame. Some women may be reluctant to seek treatment for psychiatric symptoms and may present with vague complaints that actually are indicative of mental illness. Examination of one’s own cultural beliefs can provide the nurse with a basis for providing care to ethnically and culturally diverse women. Use of a cultural assessment is an important tool to identify a woman’s cultural beliefs and values. While it is valuable to understand specific cultural norms, it is important to that each person is an individual with unique perspectives and needs.

Case Study

Fatimah Ali is a 32-year-old woman from Iraq who presents to the Family Practice Clinic with insomnia, fatigue, lack of interest in family get-togethers, and persistent sadness following her move to the United States 7 months ago. Her sister, who has lived in the United States for 6 years, states she brought Fatimah in today “secretly, so no one would know that she is seeking treatment for these things.” How might her culture impact her plan of care? What assessments need to be performed to best meet her medical needs?

Questions to Consider

Why is it important to perform a cultural assessment on all women seeking mental health care services? What role can culture play in developing a treatment plan for a woman newly diagnosed with a mental illness? Why is it important to evaluate the role of family when planning health care services for a culturally diverse woman?

REFERENCES

Baldry, A. C., & Winkel, F. W. (2008). Intimate partner violence: Prevention and intervention. The risk assessment and management approach. New York: Nova Science Publishers. Bhui, K., Warfa, N., Edonya, P., McKenzie, K., & Bhugra, D. (2007). Cultural competence in mental health care: A review of model evaluations. BMC Health Services Research, 7, 15 DOI:10.1186/1472-6963-7-15 California Psychiatric Association. (2010). Homelessness and mental health. Retrieved from http://www.calpsych.org/publications/access/homelessness.html Davidson, M. R., London, M. L., & Ladewig, P. A. W. (2012). Olds’ maternalnewborn nursing and women’s health across the lifespan, (9th ed). Upper Saddle River, NJ: Pearson. Giger, J. N., & Davidhizar, R. E. (2008). Transcultural nursing: Assessment and intervention (5 ed.). St. Louis, MO: Mosby/Elsevier. Hays, P. A. (2001). Addressing cultural complexities in practice. Washington, DC: American Psychological Association. Huygen, C. (2006). Understanding the needs of lesbian, gay, bisexual, and transgender people living with mental illness. Medscape General Medicine, 8(2), 29. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1785208/ Leininger, M. M., & MacFarland, M. R. (2006). Cultural care diversity and universality: A worldwide theory of nursing. Washington, DC: National League for Nursing Press. Lu, F. G. (n.d.). Cultural assessment in mental health: DSM-IV TR outline for cultural formulation. Retrieved from www.oleha.com/sites/.../communities_of_color_plenary_lu.ppt

Lu, F. G. (2006). DSM-IV outline for cultural formulation: Bringing culture into the clinical encounter. Focus, 4, 9–10. National Alliance on Mental Illness. (2010). Cultural competence in mental health care. Retrieved from http://www.nami.org/Content/NavigationMenu/Find_/Multicultural_/ Cultural_Competence/Cultural_Competence.htm Sutton. M. (2000). Cultural competence. Family Practice Management, 58–63. Retrieved from http://www.aafp.org/fpm/20001000/58cult.html/ U.S. Department of Health and Human Services. (2010). Healthy People 2020. Retrieved from http://www.healthypeople.gov/About/goals.htm U.S. Surgeon General’s Office. (1999). Mental health, culture, race and ethnicity: A supplement to mental health: A report of the surgeon general. Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/cre/execsummary-1.html

4

Violence Against Women

Unfortunately, violence is common in today’s modern society. Nearly every woman has been affected one way or another by a violent incident whether she has experienced it personally or peripherally in some way. Family violence, including physical and sexual abuse of a child, child neglect and maltreatment, intimate partner violence (IPV), and elder abuse, affects 2.1 per 1,000 victims annually ( U.S. Department of Justice, 2005 ). It is estimated that 1 in 10 violent crimes that occur in the United States involves abuses perpetrated by a family member. More than 73% of victims of family violence are women with an average age of 34 years ( U.S. Department of Justice, 2005 ). Family violence differs from stranger violence in that 90% of violent incidents occur within the home. Whites and Blacks are more likely than Hispanics to become victims of family violence with the highest incidence occurring in Native Americans and Alaskan Natives ( U.S. Department of Justice, 2005 ).

INTIMATE PARTNER VIOLENCE IN UNITED STATES

It is estimated by the Department of Justice that IPV affects 32 million Americans or 10% of the population (Black & Breiding, 2008). The reported figures on IPV, also known as domestic violence, spousal abuse, or domestic abuse, vary widely. It is well known that IPV is underreported within all groups of women, with approximately only one-third of cases reported in the United States and the United Kingdom. It is estimated that one-third of American women will experience IPV at some time in their lives. Although there are male victims, women are much more likely to be victimized by men, with an incidence of female victimization at 92%. Female-to-male abuse results in less than 3% of all IPV cases (Black & Breiding, 2008). IPV includes physical, emotional, financial, verbal, or sexual abuse and affects both heterosexual and homosexual relationships. There is far less research on lesbian IPV, which tends to focus on psychological issues such as control issues and the presence of jealousy versus physical abuse (Neeves, 2008). IPV occurs between individuals who are dating, socializing, married, or cohabitating. Women who are ending a relationship with their partners are more likely to be victimized than at any other time. Black women are 22 times more likely to be victimized by an intimate partner than White women and 35 times more likely to be victimized than any other race (Campbell, Webster, Koziel-McLain, Block, Campbell, Curry et al., 2003). Lifetime IPV prevalence rates are higher in multiracial, non-Hispanic, and American Indian/Alaskan Native women (Rape, Abuse, and Incest National Network, 2009).

STALKING

Stalking is another form of abuse in which an individual’s conduct makes another individual feel uncomfortable. It is estimated that there are 3.4 million Americans who are victims of stalking (National Center for Victims of Crimes, 2010a). Women tend to be victimized by stalking more than men. In 75% of cases, stalking involves a person the woman knows; in 25% of cases, the stalker is a previous intimate partner. Stranger stalking is rare and occurs in only 10% of all stalking cases. The most common victims are females aged 18–24 years. Almost half of victims experience one or more unwanted encounters per week with their stalkers (National Center for Victims of Crime, 2010a). Women who are victimized by stalkers experience long-term chronic stress as a result. Nearly half of them live in fear and experience fears of the unexpected and the unknown. Victims commonly suffer from mental health disorders including anxiety, insomnia, social dysfunction, and major depressive disorder. Victims commonly encounter occupational interruptions, such as lost time from work, and many are forced to move their residences (National Center for Victims of Crime, 2010a).

HOMICIDE BY MALE PERPETRATORS

In the U.S. it is estimated that, each year, more than two million women are threatened with a firearm (Tjaden & Thoennes, 2000). Women with partners who own firearms are more likely to be the victim of a homicide. In fact, if a woman has been previously threatened with a gun, her risk of being a homicide victim increases 20-fold. Those who have previously had a death threat made against them are 15 times more likely to be killed. In 2005, nearly 1,500 individuals were killed by their intimate partners; of these, approximately 1,200 were women. Women are nine times more likely to be murdered by a man they know than by a stranger. It is estimated that 61% of female homicide victims were murdered by their husbands (Reckdenwald & Parker, 2008). Homicide is the leading cause of death for Black women aged 18–45. It is the seventh leading cause of death for all American women. The average age of a female homicide victim is 36, with only 10% under the age of 18, and 10% of victims over the age of 65 (Reckdenwald & Parker, 2008). Women who are more economically disadvantaged are more likely to be victims of homicide. Other risk factors include having a partner who has extreme jealousy issues, a partner with a past history of choking a woman, or a man who has forced a woman to have sex. When a woman believes her partner is capable of murdering her, when violence levels continue to rise, or when the partner has daily control over her, the risk of homicide rises (Reckdenwald & Parker, 2008). Use of illicit drugs by the perpetrator is also a risk factor. Women with physical disabilities are more likely to be physically abused than able-bodied women (Davidson et al., 2012). Feminist theorists have long associated gender inequalities as a risk factor for female homicides.

Clinical Pearl

Healthy People 2020 identified injury and violence among the top ten health indicators that present Americ

BEHAVIORAL CONSEQUENCES OF INTIMATE PARTNER VIOLENCE

Victims of IPV suffer physical, psychological, and behavioral adverse effects as a direct result of abuse. Abused women are continually exposed to physical and psychological stressors within their daily lives, and behavioral consequences such as substance use and abuse result. Victims of violence are more likely to smoke tobacco. Approximately 50% of women who are victims of IPV smoke compared to 23.5% of women who are not (U.S. Department of Health and Human Services, 2010). Teens who have witnessed or have been victims of IPV are more likely to use tobacco, and those who have themselves been victimized are more likely to use marijuana. Women who have been victims of IPV are more likely to develop a substance-abuse issue and are more likely to drink alcohol, often being coerced into drinking alcohol or using illicit substances. Sexual abuse during the adolescent years increases the risk of drug and alcohol abuse by 50% (U.S. Department of Health and Human Services, 2010). Women in abusive relationships are often coerced or forced to perform sexual activities that they might otherwise avoid and have higher rates of abortion, sexually transmitted infections, and HIV infection. Women who are victimized also have higher rates of pelvic inflammatory disease, invasive cervical cancer, and preinvasive cervical neoplasia. They are more commonly victims of sabotaged birth control, which then results in unintended pregnancies, with estimates that as many as 40% of women who have been victims of IPV have experienced unintended pregnancies compared to 8% of non victims. Adolescents who have been victimized have higher numbers of nonmonogamous male sexual partners, and 50% do not use condoms consistently (U.S. Department of Health and Human Services, 2010). While victims of violence utilize more health care services and have higher costutilization rates than women who have not been victimized, they are less likely to utilize preventive health care services (U.S. Department of Health and Human Services, 2010). And one-third of IPV victims lack health insurance. Women who are victims of IPV are also less likely to obtain health care and

immunizations for their children and obtain prenatal care or to do so only in the third trimester of pregnancy. Battering during pregnancy is likely and is one of the primary causes of prenatally related disabilities in children (U.S. Department of Health and Human Services, 2010).

MENTAL ILLNESS AND INTIMATE PARTNER VIOLENCE

Of the victims of IPV, 56% are diagnosed with a mental health disorder. They have a 37% to 60% incidence of depression, a 46% incidence of anxiety, and a 45% incidence of Posttraumatic Stress Disorder (PTSD) (U.S. Department of Health and Human Services, 2010). Women also commonly suffer from Generalized Anxiety Disorder and Panic Disorder and report more incidents of Sleep Disorder and more nightmares. Approximately one-third of women who attempt suicide are victims of IPV. Suicide ideation and attempts are six to nine times higher in women who have been abused by a partner (U.S. Department of Health and Human Services, 2010). Women are more likely than men to suffer from a major mental disorder as a result of IPV (Coker, Davis, Arias, Desai, Sanderson, Brandt et al., 2005). Specific mental health disorders prevalent in women and related to IPV will be reviewed in chapters specific to those disorders.

PHYSICAL ILLNESS RELATED TO INTIMATE PARTNER VIOLENCE

Victims of IPV experience higher rates of physical symptomology than nonvictims. Each year, IPV s for one-third of emergency department visits by women (National Center for Victims of Crime, 2010b). Injuries include lacerations, broken bones, lacerated organs, and internal bleeding. A woman is more likely to be victimized during pregnancy than at any other time in her life. IPV during pregnancy can result in spontaneous abortion, preterm labor, premature birth, injury to the fetus, and fetal death. Multiple chronic health problems have been associated with IPV, including arthritis, headaches, irritable bowel syndrome, pelvic pain, excessive fatigue, essential hypertension, and chronic pain. Diabetes, asthma, strokes, hypercholesterolemia, myocardial infarction, and heart disease all occur in higher incidences in women who are victims of IPV (U.S. Department of Health and Human Services, 2010). Chronic illness is more common in women who have been victims of IPV (Coker et al., 2005) and female victims also report higher rates of activity limitations and utilize more disability-related equipment than non victims (U.S. Department of Health and Human Services, 2010). Women who are victims of domestic violence are more likely to be morbidly obese than women who have never been abused (U.S. Department of Health and Human Services, 2010). Obesity is directly linked to a variety of adverse health conditions. Many of the physical health conditions associated with IPV are also experienced with chronic stress. These similarities exist because IPV victims are under constant stressors within their environment, most of them living in fear of when the next attack or violent event will occur.

CHARACTERISTICS OF PERPETRATORS

There are multiple theories on why men abuse women. It is estimated that 80% of abs suffer from a psychological disorder, most commonly personality disorders, such as Antisocial Personality Disorder (Fowler & Westen, 2010). According to a study by Fowler and Westen (2010), abs fall into three categories: psychopathic, hostile/controlling, and borderline/dependent. The first type of ab is typically violent in multiple circumstances and most often has exhibited violent behavior toward others since childhood. These men are often lacking remorse or empathy and are impulsive. They commonly have been abused as children, have a family history of criminality, are commonly juvenile offenders, and animal torture and fire setting in their past (Fowler & Westen, 2010). These men are also sometimes referred to as antisocial perpetrators (Nauert, 2010). The hostile/controlling ab is typically more prone to rage and anger. These men are often suspicious, over-reactive, and lack friends outside of their partnership. They commonly abuse illicit substances and are often children of alcoholic parents. They have a higher incidence of familial mental health disorders but lack a family history of criminality. These men are sometimes referred to as low-pathology perpetrators and are more likely to only abuse their partners (Nauert, 2010). The final category comprises the borderline/dependent ab, who is often depressed, unhappy with life circumstances, and on the edge of “spiraling out of control” (Fowler & Westen, 2010, p. 25). These men are overly dependent on their partners to meet their emotional needs and often fear abandonment by their partners. These men become the most violent when there is a threat or potential for their partner to leave. There is rarely a history of violence or aggressiveness in childhood; instead, these men were viewed as vulnerable and needy during childhood. Family history often includes internalizing feelings and drug and alcohol abuse. Familial criminality is rare. These abs are also known as dysphoric perpetrators and often have depression, anxiety, or other mental illnesses (Nauert, 2010).

Characteristics common in abs include poor impulse control, a sense of inadequacy, low self-esteem, and anger-control issues. Men who abuse use power as a means to control their victims (Figure 4.1). Power and control result from a variety of behaviors, including isolating the victim, financial control, intimidation, humiliation, denying, and blaming. Offenders commonly use their children as a means to obtain and maintain control over their partners. When a man feels the need to dominate another individual, abuse is more likely to occur (Reckdenwald & Parker, 2008). Men who harbor resentment toward others— known as misogyny when the hostility and resentment are directed toward women or misandry when directed toward men—are often abusive toward others.

Figure 4.1 ■ Cycle of violence. Source: From Helpguide.org (2011).

Other theorists feel an ab profile develops from one’s environment, culture, family structure and values, societal influences, and personal stressors. It is well established that many men who abuse have been previously abused as children, and there is some speculation that, combined with unresolved family conflict, this may serve as a trigger. Male-dominated cultures more commonly have a higher prevalence of IPV partly as a result of the acceptability of violence against women. It is estimated that in Pakistan up to 80% of women experience IPV, and it is viewed by many to be socially acceptable to beat one’s wife or daughter into submission (Reckdenwald & Parker, 2008). In many families, the cycle of violence transcends generations and repeats itself time and again. Men with financial pressures and those living in poverty are also more likely to become abusive. Women exposed to IPV as children are more likely to be victims of IPV (U.S. Department of Health and Human Services, 2010). In cultures and family structures where the woman is more dependent on the man for economic resources and social , the incidence of abuse is higher. Additional risk factors for perpetrators are included in Exhibit 4.1.

Exhibit 4.1

Characteristics Common to Perpetrators

Low self-esteem Sense of identity tied to their partner Want to control or dominate partner

Bullying behaviors Anger issues Substance and alcohol abuse Young age Unemployed Poor social skills Victims of childhood violence Poor impulse control Excessive jealousy Abuse authority

Source: Davidson et al. (2012)

SEXUAL ASSAULT AND RAPE

Sexual assault is sexual that excludes intercourse. Rape is forced intercourse, i.e., that occurs against the victim’s will. It is estimated that one out of eight women will experience rape during their lifetimes (National Center for Victims of Crimes, 2010b). Black and White women are victimized almost equally. It is estimated that more than 17 million American women have been the victims of rape or attempted rape. It is estimated that American Indian and Alaskan natives have the highest incidence of rape of any other ethnic group (Exhibit 4.2). While men can also be victims of rape, the incidence is much lower with males representing approximately 10% of victims (National Center for Victims of Crimes, 2010b).

Exhibit 4.2

Lifetime Rate of Rape/Attempted Rape for Women by Race

■ All women: 17.6% ■ White women: 17.7% ■ Black women: 18.8% ■ Asian/Pacific Islander women: 6.8% ■ American Indian/Alaskan women: 34.1% ■ Mixed-race women: 24.4%

Source: From National Institute of Justice and Centers for Disease Control and Prevention. (1998).

The incidence of rape in girls under the age of 12 is 15% (Rape, Abuse, and Incest National Network, 2009). Children under the age of 7 for 30% of child sexual assault victims. In cases of child rape, family or acquaintances are the perpetrators in 93% of cases; stranger rape is extremely rare in child rape. Approximately 80% of rape victims are under the age of 30, with the highest risk among girls ages 16–19; they are four times more likely to be raped than the general population (Rape, Abuse, and Incest National Network, 2009). Victims of sexual assault and rape are more likely to develop mental illness disorders as a direct result of the traumatic event. It is estimated that women who have been raped have three times more likely to suffer from depression, six times morelikely to suffer from PTSD, 13 times more likely to abuse alcohol, and 26 times more likely to abuse drugs. Women who have been raped have four times the risk of contemplating suicide (Rape, Abuse, and Incest National Network, 2009). It is estimated that pregnancy results from a rape incident 5% of the time (Rape, Abuse, and Incest National Network, 2009). This may be a low estimate for several reasons, including lack of reporting of the rape incident and the pregnancies when a rape has occurred. Many women may hide the pregnancy regardless of their plans to terminate or continue the pregnancy. Pregnancy likely doesn’t occur as often as one would suspect because of multiple factors, including the woman’s use of hormonal birth control or an intrauterine device (IUD), the use of condoms by perpetrators to hide DNA detection, and an inability to become pregnant because of medical-related factors or age (Rape, Abuse, and Incest National Network, 2009).

ELDER ABUSE

Elder abuse is a growing national crisis in the United States. Like many forms of family violence, elder abuse is underreported. Some statistics approximate its occurence in up to 10% of the elderly population, but fewer than one in five cases are reported (National Center on Elder Abuse, 2010). There are multiple forms of elder abuse (Exhibit 4.3). Elder abuse is commonly perpetrated by caregivers or family , such as a spouse or children. Often the elder person is emotionally hurt, afraid, or embarrassed to report the abuse to a health care provider or the authorities. If the provider encounters tense conversations between an elderly patient and the caregiver or frequent arguments, a detailed assessment is warranted. In order to appropriately conduct an assessment for elder abuse, the individual should be interviewed in a safe and secure environment alone with the provider. Elder abuse, much like IPV, occurs across all races, ethnic groups, socioeconomic groups, and cultures. Women seniors are more likely to be victimized than males. Risk factors include dementia, mental or physical health issues, intellectual disability, isolation, and poor social for caregivers. Substance abuse by the caregiver is another risk factor (National Center on Elder Abuse, 2010).

Exhibit 4.3

Types of Elder Abuse

Physical abuse–Use of force to threaten or physically injure a vulnerable elder Emotional abuse–Verbal attacks, threats, rejection, isolation, or belittling acts that cause or could cause mental anguish, pain, or distress to a senior

Sexual abuse–Sexual that is forced, threatened, or otherwise coerced upon a vulnerable elder or anyone who is unable to grant consent Exploitation/financial abuse–Theft, fraud, misuse or neglect of authority, and use of undue influence to gain control over an older person’s money or property Neglect–A caregiver’s failure or refusal to provide for a vulnerable elder’s safety or physical, or emotional needs Abandonment–Desertion of a frail or vulnerable elder by anyone with the duty of care Self-neglect–An inability to understand the consequences of one’s own actions or inactions, which leads to, or may lead to, harm or endangerment

Source: National Center for Elder Abuse (2010).

In the United States, all states, the District of Columbia, and the U.S. territories require medical professionals to report suspicions of elder abuse. The professional does not need definitive proof; rather, suspicion is enough to warrant mandatory reporting. In most states, Social Services, Adult Protective Services, or local law enforcement agencies are ed. The nature of suspected abuse should be provided to the appropriate agency.

Clinical Pearl

When there has been a previous report of abuse, worsening conditions should also be reported. Much like I

Health care providers should assess each elderly patient for signs and symptoms of abuse. Physical abuse should be assessed through visual inspection during any physical examination. Unexplained bruising, abrasions, slap marks, pressure marks, burns, or blisters are all common symptoms and warrant exploration into the etiology. Signs of neglect include pressure ulcers, lack of proper grooming and hygiene, unattended medical needs, and nutritional deficiencies, such as dehydration and malnutrition (National Center on Elder Abuse, 2010). The examination and documentation of physical abuse and neglect is the same as the examination of victims of IPV (to be discussed later) and should be followed as detailed. Sexual abuse is often evident from physical signs of abuse, such as bruising or bite marks around the breasts and genital area. Sexual abuse warrants immediate transfer to a sexual assault nurse examiner (SANE) or forensic examiner for a detailed forensic sexual assault examination. Emotional abuse is often characterized by a change in mood, symptoms of depression or anxiety, behavioral changes, and changes in mental status. Because these symptoms can be related to many biopsychosocial changes in this population, careful assessment via direct questioning is warranted. Financial abuse is most commonly associated with changes in an individual’s financial assets, withdrawals from checking or savings s, loss of property, alteration of an individual’s will, and checks that are being written as gifts or loans (National Center on Elder Abuse, 2010). Often, the only sign the health care provider may observe is verbalization of financial worries. Statements from the elderly about financial concerns should be followed up with direct questioning about the source of their anxieties or worries. If financial abuse or exploitation is suspected, reporting to Adult Protective Services is warranted. One of the most common reports to Adult Protective Services involves selfneglect, i.e., when an elderly individual is neglecting his or her own basic care needs. They may be unable to live alone independently and meet their minimum daily needs of living. Self neglect is commonly associated with declining health, a reduction of physical abilities, Dementia or Alzheimer’s disease, or substance abuse. When possible, community resources are arranged, so that the elderly patient can remain as independent as possible. Varying types of elder abuse are listed in Exhibit 4.3.

CARING FOR THE WOMAN EXPERIENCING TRAUMA OR VIOLENCE

Because many women do not seek out medical attention for injuries or attacks, it is important for primary care providers to assess women at each encounter to screen for IPV, sexual assault, or exposure to violence. Although the U.S. Preventive Services Task Force does not recommend routine screening for all women, many medical and nursing organizations disagree and recommend screening at every patient encounter (U.S. Preventive Services Task Force, 2004; Exhibit 4.4). This discussion is pertinent to victims of IPV and elder abuse.

Exhibit 4.4

National Organizations That Endorse Routine Screening for IPV

American Academy of Family Physicians American Academy of Pediatrics American College of Emergency Room Physicians American College of Obstetricians and Gynecologists American College of Nurse Midwives American Dental Association American Nursing Association

American Medical Association American Nurses Association Association of Women’s Health, Obstetric, and Neonatal Nurses t Commission on Accreditation of Healthcare Organizations U.S. Department of Health and Human Services

Source: World Health Organization (2010).

There are multiple assessment tools designed for health care professionals to assess the possibility of violence in their female patients’ lives (Thompson, Basile, Hertz, & Sitterle, 2006). Although some studies have shown that women who are victims prefer self-completed questionnaires compared to direct questioning, direct questioning remains the prominent mode of assessment in the primary care setting (Barclay & Vega, 2006). Victimization inventories include physical, sexual, psychological, and stalking assessment scales. Many primary care providers prefer shorter assessments (Exhibit 4.5). Longer assessment strategies should be utilized for at-risk women (Krieger, 2008). There are also perpetration scales that screen for risk factors for abs.

Exhibit 4.5

New York State Department of Health Domestic Violence Assessment Survey

■ “Do you ever feel unsafe at home?”

■ “Are you in a relationship in which you have been physically hurt or felt threatened?” ■ “Have you ever been or are you currently concerned about harming your partner or someone close to you?”

Source: New York State Department of Health (2002).

Clinical Pearl

A woman who feels more comfortable with her health-care provider is more likely to disclose abuse. Ques

Once a woman has been identified as a victim of violence, she should be reassured that the abuse is not her fault and that what she is describing is abuse. The immediate needs include assessing for physical injury and treating those injuries appropriately, then a treatment plan should be developed. The woman should be reassured the purpose for assessing for abuse is not law-enforcement involvement, which should not be initiated, except in cases of mandatory reporting, unless the victim desires intervention. Women seeking assistance and attempting to leave relationships have a higher incidence of violence escalation (Association of Women’s Health, Obstetric, and Neonatal Nurses, 2007). Regardless of whether the woman is or is not pursuing law enforcement intervention, a forensic examination should be performed to document both major and minor injuries. Provider interactions should include all pertinent data that would be needed if court interventions are pursued in the future (Exhibit 4.6). Appropriate documentation of IPV injuries results in higher prosecution rates and better criminal justice outcomes, as well as better clinical outcomes for abused women (Baker & Sommers, 2008). Nongenital injuries should be assessed through direct visualization. Body maps, photos, and a complete description of the injuries should be included in the health provider’s progress note and documented on special forms when possible. Genital injuries require an expert forensic examiner and therefore referral to a SANE or other forensic specialist who can utilize application of topical dyes and colposcopy imaging (Baker & Sommers, 2008). If IPV rape has occurred, a rape kit should be completed and emergency contraception should be offered along with STI treatment and STI/HIV testing.

Exhibit 4.6

Pertinent Data Included in Progress Notes on Documentation of Violence

Demographic data of patient Name and information of anyone accompanying her to the visit Name of ab and victim’s relationship to the ab Chief complaint in victim’s own words and in quotes Detailed description of injuries, including nature, amount, size, location, severity, and cause of injury Placement of injuries on a body-mapping form Photographs taken and a written release signed Documentation that you asked victim about IPV and her answers Documentation of use of a weapon if used in abusive event Documentation of all laboratory or radiographic examinations If other providers supplied services, include name, type of provider, and services provided in the care of the patient If legal intervention was initiated, include name, badge number, and information for the law enforcement officer who responded to the call Documentation of all resources given, including brochures, hotline phone numbers, social services interventions, and shelters Discharge and follow-up plans

Source: World Health Organization (2010).

Assessments of psychosocial history should include an assessment for signs and symptoms of anxiety, depression, PTSD, and substance abuse. If available, a

counselor should meet the woman at the initial visit or as soon as possible to perform a complete assessment and determine future needs for ongoing psychosocial . The nature of the IPV and extent of the danger should be evaluated. Individuals with knowledge of IPV should explain the options involved in court ex parte or offer protection orders, victim’s services, and legal assistance options. If child or elder abuse has occurred, mandatory reporting should be explained and executed as required by state law (Agency for Healthcare Research & Quality, 2010). Finally, a safety plan should be discussed and implemented. A safety assessment should be performed on every victim prior to discharge. Questions should be specific and focus on the woman’s home situation, status of the ab, and her current mental status (Exhibit 4.7). Interventions should include referral to a domestic violence counselor, domestic violence shelter, hotline phone numbers, a social worker, and a scheduled follow-up appointment for health care services.

Exhibit 4.7

Safety Questions Prior to Discharge for Victims of IPV

Patient Safety Checklist:

Does the patient feel safe going home?

Yes

No

Is there a gun in the home?

Yes

No

Is the ab there now?

Yes

No

Is the patient suicidal?

Yes

No

Is the patient homicidal?

Yes

No

Is the ab suicidal?

Yes

No

Is the ab homicidal?

Yes

No

Is the violence increasing in severity or frequency?

Yes

No

Is the ab also abusing the children?

Yes

No

Are the children safe now?

Yes

No

Does the abusive partner abuse alcohol or drugs?

Yes

No

Is the patient being stalked?

Yes

No

Source: World Health Organization (2010).

A safety plan should be formulated and discussed with the patient. Caution should be used when providing a copy of the plan in writing if the victim does not have a safe place to store it. Immediate interventions should include identifying a code word for others to know that she is in trouble; identifying a trusted neighbor to call authorities if violence erupts; and teaching her children how to call for help if violence occurs. The victim should know where she can go and what she will do if a violent incident occurs. Keeping the car keys in the immediate vicinity is essential. The woman should be ready to leave at any time it is warranted. Advise her to keep an overnight bag ready, packed with clothing, medications, essential documents, money, spare change, and banking information. If the woman is preparing to leave the ab, additional counseling is warranted. Optimally, preplanning is performed in order for the woman to obtain essential documents and money and to line up services that will be needed in order to leave the abusive relationship. The woman should keep vital records for her and her children in a safe place and should be encouraged to open a separate savings , so money can be set aside for when she does decide to leave. Other options should be explored, such as identifying a friend or family member or IPV resource that will let the woman stay with her until other housing arrangements are made; personal resources for borrowing money, such as family and friends; and obtaining a protective order. A copy of the protective order should be kept with the victim at all times and should also be filed with the local law enforcement agencies in her area. If the ab owns a firearm, police should be notified because some states allow search and seizure of the weapon in these circumstances. The woman should be encouraged not to tell her ab in a faceto-face interaction that she is leaving but, instead, should leave a note or call later. Because cell phone records and phone cards can be traced, alternative phone options should be employed. If the woman is staying in her own home, she should have all locks changed immediately, wooden doors should be replaced with steel or metal doors, and

other security measures should be implemented. Neighbors should be advised the partner no longer lives there, and that they should notify the police if the partner is observed in the area. If financially possible, the woman should install motion-detector lights. Children should be taught how to make collect calls in the event they are abducted by the ab so they can phone for help.

SUMMARY

Family violence and IPV affect millions of women and elders annually. The need for comprehensive, empathic care services is essential. The nurse plays a key role in assessment, planning, and intervention. An established trusting relationship between the patient and care providers ensures the victim feel comfortable divulging information and obtaining resources. Nurses need to familiarize themselves with mandatory-reporting requirements, social services availability, and resources for victims within their state and jurisdiction.

Case Study

Miriam Antione is a 28-year-old biracial woman who has been in an abusive relationship with Dylan, her boyfriend of 4 years. The couple have an 18-monthold daughter whom Dylan has begun to threaten in efforts to gain control over Miriam. The daughter has been taken to the local emergency department multiple times for injuries sustained from physical altercations with Dylan. Miriam has threatened to leave Dylan, but he now states he will steal their daughter and harm her. Miriam has stayed because of her fears associated with these threats. Miriam presents to the clinic when her daughter was pushed by Dylan and sustained bruises on her buttocks as a result of the incident. Miriam has a laceration on her face and periorbital bruising around her right eye. Miriam states she would now like to see the social worker for resources on how to leave Dylan, although she remains deathly afraid of him. What interventions does the nurse need to take regarding their injuries? What steps should be taken for a woman who desires to leave an abusive partner?

Questions to Consider

Which types of women should be screened for elder abuse? Which referral services should be utilized for the woman who has been sexually assaulted or raped? How can nurses increase the safety of a woman who is planning on leaving her partner?

REFERENCES

Agency for Healthcare Research & Quality. (2010). Intimate partner violence (IPV) Clinical pathway: Treatment after disclosure (initial visit only). Retrieved from http://www.ahrq.gov/research/domviolria/dvriafig3.htm Association of Women’s Health, Obstetric, and Neonatal Nurses. (2007). Mandatory reporting of intimate partner violence. AWHONN Position Statement. Retrieved from www.awhonn.org/.../Documents/pdf/5H1_PS_IntimatePartnerViolence.pdf Baker, R. B., & Sommers, S. M. (2008). Physical injury from intimate partner violence: Measurement strategies and challenges. JOGNN, 37, 228–233. DOI: 10.1111/j.1552-6909.2008.00226.x Barclay, L., & Vega, C. (2006). Self-completed questionnaires preferred for intimate partner violence screening. JAMA, 296, 530–536. Black, M. C., & Breiding, M. J. (2008). Adverse health conditions and health risk behaviors associated with intimate partner violence: United States, 2005. Mortality and Morbidity Weekly, 57(5), 113–117. Campbell, J. C., Webster, D., Koziel-McLain, J., Block, C. R., Campbell, D., Curry, M. A., Gary, F., McFarlane, J., Sachs, C., Sharps, P., Ulrich, Y., & Wilt, S. A. (2003). Research results from a national study of intimate partner homicide: The danger assessment instrument. National Institute of Justice Journal, 250, 14– 19. Coker, A. L., Davis, K. E., Arias, I., Desai, S., Sanderson, M., Brandt, H. M., et al. (2005). Physical and mental health effects of intimate partner violence for men and women. American Journal of Preventive Medicine, 24(4), 260–268. Davidson, M. R., London, M. L., & Ladewig, P. A. W. (2012). Olds’ maternalnewborn nursing and women’s health across the lifespan, (9th ed). Upper Saddle

River, NJ: Pearson. Fowler, K. A., & Westen, D. (2010). Subtyping male perpetrators of intimate partner violence. Journal of Interpersonal Violence, 25(11), 1–34. DOI: 10.1177/0886260510365853 Helpguide.org. (2011). Retrieved from http://helpguide.org/mental/domestic_violence_abuse_types_signs_causes_effects.htm Krieger, C. L. (2008). Intimate partner violence: A review for nurses. Nursing for Women’s Health, 12(3), 224–234. National Center for Elder Abuse. (2010). Fact sheet: Why should I care about elder abuse? Retrieved from http://www.ncea.aoa.gov/NCEAroot/Main_Site/pdf/publication/NCEA_WhatIsAbuse2010.pdf National Center for Victims of Crimes. (2010a). Stalking facts. Retrieved from http://www.ncvc.org/src/main.aspx?dbID=DB_statistics195 National Center for Victims of Crimes. (2010b). Mental health consequences of crime. Retrieved from http://www.ncvc.org/ncvc/main.aspx? dbName=DocumentViewer&DocumentID=47699 National Institute of Justice and Centers for Disease Control and Prevention. (1998). Prevalence, Incidence and Consequences of Violence Against Women Survey. Nauert, R. (2010). Personality types in domestic violence cases. Retrieved from http://psychcentral.com/news/2010/08/13/personality-type-for-domesticviolence/16772.html Neeves, S. (2008). An examination of power differentials and intimate partner violence in lesbian relationships. (Master’s thesis). Retrieved from http://filebox.vt.edu/s/seneeves/IPV%20in%20lesbian%20relationships%20THESIS%20 DOCUMENT.pdf New York State Department of Health. (2002). Guidelines for integrating domestic violence screening into HIV counseling, testing, referral, and partner

notification. Retrieved from http://www.health.ny.gov/nysdoh/rfa/hiv/guide.htm Rape, Abuse, and Incest National Network. (2009). Who are victims? Retrieved from http://www.rainn.org/get-information/statistics/sexual-assault-victims Reckdenwald, A., & Parker, K. F. (2008). The influence of gender inequality and marginalization on types of female offending. Homicide Studies, 12(2), 208– 226. DOI: 10.1177/1088767908314270 Thompson, M. P., Basile, K. C., Hertz, M. F., & Sitterle, D. (2006). Measuring intimate partner violence victimization and perpetration: A compendium of assessment tools. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Tjaden, P., & Thoennes, N. (2000). Full report of the prevalence, incidence, and consequences of violence against women: Findings from the national violence against women survey. Washington, DC: U.S. Department of Justice, Office of Justice Programs. Publication No. NCJ183781. U.S. Department of Health and Human Services. (2010). Healthy People 2010. Fact sheet: Intimate partner violence and Healthy People 2010 fact sheet. Retrieved from http://www.endabuse.org/files/file/Children_and_Families/ipv.pdf U.S. Department of Justice. (2005). Family violence statistics. Retrieved from http://bjs.ojp.usdoj.gov/content/pub/pdf/fvs02.pdf U.S. Preventive Services Task Force. (2004). Screening for family and intimate partner violence: Recommendation statement. Annals of Internal Medicine, 140(5), 383–386.

World Health Organization. (2010). Intervening with perpetrators of intimate partner violence: A global perspective. Retrieved from http://www.who.int/violence_injury_prevention/publications/violence/intervening/en/index.htm

II

Special Populations in Women’s Mental Health

5

Childhood and Adolescence

Mental health and illness cannot be adequately discussed without reviewing the issue of mental health in young girls before and during adolescence. Some etiologies of women’s mental health, such as abuse, have their roots in childhood and adolescence and become risk factors for mental illness later in a woman’s life. Although the occurrence of mental health disorders in childhood versus adulthood is close in number, many children grow out of mental disorders in their adolescent years. However, mental health disorders occurring during childhood and adolescence are often overlooked because hormonal changes can also impact a girl’s sleep patterns, moods, and appetite. Therefore, a young girl’s emotional health should be assessed at every primary care appointment and should include a complete assessment of psychosocial stressors, coping mechanisms, and risk-taking behaviors in addition to the availability of a system. The clinician should be aware of signs of neglect and abuse, which are often associated with negative behavior patterns in children.

ONSET OF MENTAL ILLNESS

There are a variety of disorders that are more prevalent in women than men, and many are rooted in childhood or adolescence. The most common mental health illnesses affecting young girls are Anxiety Disorder, Disruptive Behavior Disorder, Mood Disorder, and substance abuse. The onset of mental health disorders in adolescent females, on average, happens at approximately age 14. So during these developmental years, it is important for young girls and adolescents to be screened appropriately for the potential of evolving mental health disorders. It is estimated that approximately 20% of American children have a mental illness that results in some type of impairment. Despite this, only 1 in 50 children receive mental health care services (National Institute of Mental Health, 2010a). Children with more acute mental disturbances are categorized as seriously emotionally disturbed, meaning they have more severe functional limitations. It is estimated that 5% to 9% of children ages 7 to 19 would fit this category (National Institute of Mental Health, 2010a; Table 5.1).

Table 5.1 ■ Prevalence of Mental Health Disorders in Children Ages 7 to 19 Years

Type of Disorder Anxiety Disruptive Disorders Mood Disorders Substance Disorders

Prevalence 13% 10.3% 6.2% 2.0%

Source: Adapted from U.S. Surgeon General (2000).

The need to identify and treat children who may be developing mental health issues is essential because childhood psychiatric disorders can impact an individual’s entire life. Children who have a mental health diagnosis are more likely to encounter school-related problems and are twice as likely to drop out of school (National Institute of Mental Health, 2010b). They have more difficulty with peer relationships and may encounter stressors with their parents. In addition, children whose parents have been diagnosed with a major mental illness are at higher risk of developing a mental illness themselves.

ANXIETY IN CHILDHOOD AND ADOLESCENCE

The most common mental illness affecting children and adolescents is anxiety, which affects up to one in eight children (Anxiety Disorders of America, 2010). While some anxiety is a normal part of a child’s growth and development and comes and goes in phases throughout childhood, more pronounced fears that interfere with normal functioning should be examined by a professional health care provider. Children with an anxiety disorder experience intense fear, shyness, and nervousness and may avoid going specific places or doing things out of fear. In general, children with Anxiety Disorder do not perform as well in school, frequently miss important social experiences, and are at higher risk of developing substance-abuse problems (Anxiety Disorders of America, 2010). All of the subtypes of anxiety disorders can affect children.

GENERALIZED ANXIETY DISORDER

Generalized Anxiety Disorder (GAD) can be diagnosed when children exhibit excessive worries or concerns related to school performance, school activities, sports, or issues at home. These children may seek constant approval from their parents, teachers, and peers and may struggle to be perfect in all aspects of their lives. The prevalence of GAD is approximately 2.9% to 4.6% although the disorder is more common during adolescence (Nutter, Larson, & Sylvester, 2010). At least 50% of people who have been diagnosed with GAD report an onset that occurred during childhood or adolescence (U.S. Surgeon General, 2000).

OBSESSIVE-COMPULSIVE DISORDER (OCD)

Obsessive-Compulsive Disorder (OCD) is seen more frequently in boys than in girls. The disorder is characterized by recurring intrusive or unwanted thoughts (obsessions). Individuals with OCD often feel compelled to repeatedly perform rituals and routines (compulsions) to try and ease their anxiety. The average age of diagnosis occurs at approximately age 10 although the condition can be seen in children as early as 2 or 3 years of age. Girls with OCD often tend to develop it in the adolescent years or in their early 20s, and boys tend to develop it earlier, between the ages of 6 and 15 years (Anxiety Disorders Association of America, 2010). The incidence is approximately 0.3% to 1% in children, and in as many as one-third to one-half of adults with OCD, the onset first occurred during childhood.

PANIC DISORDER

Panic Disorder is diagnosed when a child “suffers at least two unexpected panic or anxiety attacks—which means they come on suddenly and for no reason— followed by at least one month of concern over having another attack, losing control, or ‘going crazy’” (Anxiety Disorders Association of America, 2010). Girls are more likely to suffer from Panic Disorder than boys. The incidence of Panic Disorder in young children is thought to be rare, but it can occur during adolescence. As with adults, children who have Panic Disorder may also experience symptoms of depression (Perlmutter, 2008).

POSTTRAUMATIC STRESS DISORDER (PTSD)

Posttraumatic Stress Disorder (PTSD) can occur when a child witnesses or experiences a traumatic event, such as an accident or death involving a parent or caregiver. Those who lack an adequate network and those who had a mental health diagnosis prior to the event are more likely to develop PTSD. Children with PTSD may exhibit intense fear and anxiety, may become irritable, or may show emotional numbness or avoidance behaviors regarding places, people, or activities that were experienced or are associated with witnessing the traumatic or life-altering event (Anxiety Disorders Association of America, 2010). PTSD is more common in girls with an estimated prevalence rate of 6.3%, and is frequently associated with sexual or physical abuse (U.S. Department of Veterans Affairs, 2010).

SOCIAL ANXIETY DISORDER

Social Anxiety Disorder is characterized by intense fear of social situations and may include fears of being called on in class or having to perform during activities with peers. The incidence of social anxiety disorder is 2% to 4% in preadolescents and 1.3% to 4.7% in adolescents. It is more common in girls than boys (Anxiety Disorders Association of American, 2010). The intense fear experienced by children and adolescents with social anxiety disorder can impact school attendance and activities. Children with this disorder have a higher incidence of school drop-out rates. They may also have difficulty initiating and maintaining relationships with peers. Common psychiatric comorbidities, including Depression, occur in 33% of children, and Disruptive Behavior Disorder occurs in 27% of those diagnosed (Anxiety Disorders Association of America, 2010).

SEPARATION ANXIETY DISORDER

Separation Anxiety Disorder occurs when children, most often ages 7 to 9, experience an intense fear, an inability to separate from their parents or caregivers, an inability to adapt to a new environment, a general sense of dread and misery when separated from parents or caregivers, and intense homesickness. While it is normal for toddlers and preschoolers to cry or become anxious when left by their parents, they typically adapt to new circumstances after a period of time. However, children with this disorder typically cannot let go of their intense fears that something will happen to their parents during a period of separation. They frequently fear going to school, social events, and sleepovers. The incidence of Separation Anxiety Disorder in children ages 7 to 11 is approximately 2% to 4%. In adolescents aged 14 to 16, the incidence is higher at 4.1% to 4.7% (Bernstein, 2008). This disorder is often a precursor for an adult-onset anxiety disorder.

SELECTIVE MUTISM

Children who display Selective Mutism become silent and expressionless in certain situations. They may also appear motionless or may engage in a behavior such as hair chewing or twirling. Children with this disorder may be talkative, alert, and engaging in situations where they feel comfortable, and often the diagnosis comes as a surprise to parents who learn of the symptoms from caregivers or teachers. Selective Mutism affects seven out of 1,000 children and is typically diagnosed between the ages of 4 and 8, commonly when a child is starting school (Wong, 2010). It is sometimes mistaken for a Pervasive Developmental Disorder, such as autism. It commonly coexists with other psychological disorders, including depression and OCD (Wong, 2010).

SPECIFIC PHOBIA

Like adults, children can experience a Specific Phobia—an intense, irrational fear of a specific object, such as a dog, or a situation, such as flying. Specific Phobias affect 7% to 9% of children and have a higher incidence in girls (Chakraburtty, 2009). Phobias that are common in children include fear of the dark, animals, thunderstorms, heights, blood, bodies of water, and medical procedures. While many adults come to realize their fears are irrational, children maintain their fears are real and warranted. Children experience intense anxiety that may manifest as crying, tantrums, avoidance behaviors, or clinging to their parents or caregivers. They may also report headaches or stomachaches. The incidence of Specific Phobias is higher in children who have a parent with an anxiety disorder, possibly related to a learned behavior in the child’s environment.

TREATMENT OF ANXIETY DISORDERS IN CHILDHOOD AND ADOLESCENCE

Children with anxiety disorders of all types must be evaluated by a mental health professional who specializes in the treatment of children and adolescents. Various tools exist that can confirm these diagnoses. Cognitive behavioral therapy (CBT) can provide an effective tool to manage symptoms. It can help children learn about their anxiety and face and master anxiety-provoking tasks while learning effective coping mechanisms. CBT is recommended for children regardless of whether pharmacological agents are subsequently prescribed. Sertraline hydrochloride (Zoloft), a selective serotonin reuptake inhibitor (SSRI), has been used with promising results in children with anxiety. However, Zoloft should not be used in children under the age of 6. The dosage for children with social anxiety, Panic Disorder, PTSD, or OCD is typically 25 mg once per day in children and 25 to 50 mg per day in adolescents. As with adults, dosages can be increased weekly up to 200 mg/day (Monthly Prescribing Reference, 2010). Combination therapy that includes CBT along with an SSRI has been shown to be an effective treatment combination and may be superior to individual drug or therapy regimens (Walkup, Albano, Piacentini, Birmaher, Compton, Sherrill, Ginsburg, Rynn, McCracken, Waslick, Iyengar, March, & Kendall, 2008). Commonly used SSRIs include the following:

■ Fluoxetine (Prozac) ■ Sertraline hydrochloride (Zoloft) ■ Paroxetine (Paxil) ■ Fluvoxamine (Luvox) ■ Citalopram (Celexa)

■ Escitalopram (Lexapro)

The Food and Drug istration (FDA) has approved the use of fluoxetine (Prozac), sertraline hydrochloride (Zoloft), fluvoxamine (Luvox), and clomipramine (Anafranil) for the treatment of pediatric OCD. Specific dosage guidelines should be followed for pediatric and adolescent populations.

Clinical Pearl

In 2004, the FDA issued a warning, stating that antidepressant therapies may increase suicidal ideation in c

DISRUPTIVE DISORDERS

Disruptive Behavior Disorders consist of patterns of behavior that consistently break the rules. They include Attention Deficit/Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, and Conduct Disorder. This type of behavior may be a normal part of growth and development in toddlers and in some adolescents to limited extent, but behavior that involves constant, extreme opposition or defiance may be a sign of an underlying mental illness. ADHD, the most well-known and common of the disruptive disorders, is often overlooked and underdiagnosed in girls. ADHD has two distinctive types of symptoms: inattentiveness and hyperactivity/impulsivity. Inattentive symptoms include lack of attention to detail, difficulty maintaining focus on a task, difficulty following instructions, organizational difficulties, loss of items needed for task completion, and being distracted easily. Examples of hyperactivity/impulsivity include fidgeting, leaving one’s seat frequently when staying seated is expected, inappropriate running or climbing, excessive talking, an inability to stay still in most settings, an inability to wait one’s turn, answering a question before the entire question has been asked, and frequently interrupting other people’s conversations. In addition to displaying symptoms, children with ADHD must show impairment in two settings, such as both home and school. Also, their behaviors need to have consequences directly resulting from them and need to have been present prior to age 7. ADHD is three times more common in boys and presents very differently in boys than in girls (Gurian, 2010). While boys tend to exhibit hyperactivity, impulsivity, and disruptive behaviors, girls tend to have more inattentive behaviors. Girls have a missed-diagnosis rate of 50% to 75%, and the average age of diagnosis for girls is 12, 5 years later than boys, who are commonly diagnosed at approximately age 7 (Hinshaw et al., 2006). During adolescence, some girls may demonstrate more irritability and activity while others have a decrease in symptomology. During the premenstrual phase, they may have an increase in certain symptoms, such as irritability, inattention, and emotional instability.

The need to screen and identify girls at risk for ADHD is imperative. Serious social, family, and educational consequences exist for girls who are left untreated. While many girls function adequately during their elementary school years, the additional educational stressors and advanced social skills associated with middle and high school typically result in difficulties for girls in this age group. Girls with ADHD are more likely to develop depression, anxiety disorders, low self-esteem, and Conduct Disorder (Gurian, 2010). Substance abuse is more common in girls who have ADHD because of their inability to interact effectively with their parents, teachers, and peers. Risk taking is more common in girls with ADHD, which can result in higher teenage pregnancy rates and higher incidences of motor vehicle accidents (Nadeau, 2004).

TREATMENT OF ADHD

Education is imperative for the young or adolescent girl diagnosed with ADHD. Parents and their daughters must be taught the implications of the disorder. Because comorbidities with other psychiatric disorders are common, a complete psychological assessment by a knowledgeable mental health professional is essential. Stimulants are the first-line treatments for ADHD. Commonly used stimulants include the following:

■ Methylphenidate (Ritalin, Concerta, Metadate) ■ Dextroamphetamine (Dexedrine, Adderall) ■ Dexmethylphenidate (Focalin)

Dosages are carefully calculated and, in general, start with the lowest dosage. Dosages increase until therapeutic effectiveness is achieved. Side effects vary depending on which medication is used, but can include restlessness, headaches, upset stomach, nervousness, and disruptions in sleep patterns and appetite. It should be noted that this class of medications is commonly abused for performance enhancement, recreational use, appetite suppression, promotion of wakefulness, and increasing focus and attention (National Institute on Drug Abuse, 2010). Strict monitoring of prescription is required by law. Misuse or abuse can result in hypertension, sleep deprivation, tachycardia, and increased body temperature. Prolonged abuse can lead to malnutrition, cardiac complications, and stroke (National Institute on Drug Abuse, 2010). Other medications used to treat ADHD include the following:

■ Atomoxetine (Strattera) ■ Tricyclic antidepressants (TCAs), such as amitriptyline (Elavil) ■ Bupropion (Wellbutrin)

Individual and family therapy can also be beneficial tools for girls with ADHD. Parenting training is sometimes recommended for parents who are dealing with the exhaustion from raising a child with ADHD. Coaching and groups have also been shown to be beneficial.

OPPOSITIONAL DEFIANT DISORDER

Symptoms of Oppositional Defiant Disorder (ODD) include defiance of authority, parents, teachers, and other adults; frequent temper tantrums; seeking revenge; fighting; harboring resentment; an inability or unwillingness to take responsibility for inappropriate behavior; and continuous arguing in situations that include both the home and school environment. ODD can occur at any time in childhood and affects 1% to 6% of children. Typically, signs and symptoms tend to occur by age 4 or 5. The disorder is more common in preadolescent boys, but once adolescence is reached, the gender disparities cease. Untreated, ODD can result in Conduct Disorders; not every child with ODD develops Conduct Disorder, but it is a risk factor. Treatment of ODD involves a variety of therapeutic interventions. The child is best referred to a medical center or physician who specializes in the treatment of ODD. Typically, individual and family therapy is the mainstay of treatment. Additional options include parent-child interactive therapy, in which a therapist provides parenting coaching and oversees parent-child interactions. CBT and cognitive problem solving therapy are also commonly used to get the child to identify problem behaviors and make changes. Social skills training and parenting classes are also commonly used interventions (American Academy of Child and Adolescent Psychiatry, 2011). Many children with ODD have psychiatric comorbidities and may require pharmacological intervention to treat those disorders.

CONDUCT DISORDER

Conduct Disorder involves the breaking of socially set rules and laws. The aggressive behaviors involved with this disorder are typically worse than those associated with ODD. They include threatening or harming people or animals; property destruction, such as setting fires, graffiti, breaking windows, and damaging automobiles; stealing; lying; sexual coercion; bullying behaviors; and serious violation of statutes, including truancy and substance abuse. Girls with Conduct Disorder frequently run away from home and become involved with prostitution. The disorder affects 1% to 4% of children age 7 to 17 years old, but it is more common in adolescents and in older children. The disorder occurs more often in boys than girls. Preadolescent onset is much more prominent in boys and children living in urban areas and generally carries a worse prognosis. Individuals diagnosed with Conduct Disorder have a 25% to 50% chance of being diagnosed with Antisocial Personality Disorder in adulthood. Approximately 50% of individuals with Conduct Disorder also have ADHD (Tynan, 2010). Individuals with Disruptive Behavior Disorder have a higher incidence of continuing psychopathology into adulthood when compared with other diagnoses (Reef, van Meurs, Verhulst, & van der Ende, 2010). The connections with criminality among these disorders are high. Risk factors for Disruptive Behavior Disorder include low birth weight, neurological disorders or injury, coexisting ADHD, poverty, alterations in maternal-child attachment, neglect, physical or sexual abuse, and mothers who ignore their children and fail to meet their basic psychological needs. Treatment for these disorders includes enrollment of parents in parenting classes, social skills training, academic at school, CBT, individual therapy, and home and family therapy. Medical intervention is sometimes utilized, but there is no specific pharmacological treatment that is approved for the disorder. When ADHD is present, the main pharmacological treatment is the stimulant group of medications. Methylphenidate (Ritalin, Concerta, Metadate) has been used as a front-line treatment for aggression. Anticonvulsants are considered to be the

second group of medications to be used in the presence of nonspecific aggression, and lithium is the third choice (Tynan, 2010).

MOOD DISORDERS

Mood Disorders include those disorders that result in an alteration in mood. The two main disorders in this category are Major Depressive Disorder (MDD) and Bipolar Disorder (BD). Girls are more likely to experience MDD than boys (Alakus, Conwell, Gilbert, Buist, & Castle, 2007). Diagnosis during adolescence occurs equally between boys and girls, and the incidence of BD is equal in males and females in adulthood as well, although childhood diagnosis occurs more commonly in boys during the teen years but in adulthood is equal between both groups (Hellander, 2008).

DEPRESSION

Depression is marked by persistent sadness that interferes with an individual’s functioning; it affects approximately 5% of children. Depression rates in young children and early adolescents remain approximately equal between males and females until they near age 15; after age 15 girls are twice as likely as boys to experience depression with hormonal changes contributing to the increased occurrence (National Institute of Mental Health, 2010c). Girls are also more likely to be the victims of sexual abuse, another common cause of depression (National Institute of Mental Health, 2010c). In addition, girls experience higher incidences than boys of poverty, poor education, and other trauma. It is estimated that 70% of girls diagnosed with depression endured a stressful or traumatic event prior to onset compared to 14% of boys (National Institute of Mental Health, 2010c). Exhibit 5.1 lists common symptoms girls and teens may experience as a result of depression.

Exhibit 5.1

Common Symptoms of Depression in Girls and Teens

Irritability Disinterest in friends, school, and social activities Denial of symptoms Constant crying

Persistent sadness Isolation Pessimism Restlessness, irritability Fatigue Difficulty concentrating in school Alterations in sleep habits (excessive sleeping, insomnia, waking at night) Changes in eating habits (overeating or not eating) Physical discomforts and complaints Suicidal ideations

Source: Adapted from National Institute of Mental Health (2010d).

Because depression commonly coexists with other psychiatric comorbidities, clinicians should complete a comprehensive psychological assessment of girls presenting with depressive symptoms. Common comorbidities are listed in Table 5.2.

Table 5.2 ■ Common Comorbidities That Exist in Girls With Depression

Class of Comorbid Condition Anxiety Disorders

Specific Disorder PTSD

Eating Disorders Alcoholism Substance Abuse

OCD Panic Disorder GAD Social Phobia Bulimia Nervosa Anorexia Nervosa

Source: Adapted from the National Institute of Mental Health (2010d).

TREATMENT OF DEPRESSION

Depression is commonly treated with individual therapy, pharmacological therapy, or a combination of both approaches. Family therapy is sometimes indicated as well. While mild depression may respond to individual therapy alone, medications are commonly used to treat more serious symptoms. Because relapse rates can be as high as 50%, ongoing treatment is usually indicated. SSRIs are typically the first line of treatment for children and adolescents.

■ Fluoxetine (Prozac) is currently the only approved medication for childhood and adolescent depression although other SSRIs are commonly prescribed. ■ Citalopram (Celexa) or sertraline hydrochloride (Zoloft) may be effective and are sometimes used with this population. ■ Atypical antidepressant medications, such as bupropion (Wellbutrin), have also been used with success. ■ TCAs and monoamine oxidase inhibitors (MAOIs) have been used in the past but are no longer routinely prescribed because of the side effects and risk factors associated with these medications.

BIPOLAR DISORDER

Bipolar Disorder (BPD) is characterized by exaggerated mood swings, most commonly the extremes of mania and depression. There are five different types of BPD, including BPD Type I, BPD Type II, Cyclothymic Disorder, Mixed Episode BPD, and Rapid-Cycling BPD (Table 5.3). Girls and women are most likely to experience Rapid-Cycling BPD; however, unlike adult women who may experience symptoms of exaggerated mood swings over a period of days or weeks, adolescent girls may experience mood swings over the course of a number of hours. Girls also often have symptoms that correlate with their menstrual cycle, and yet girls with BPD seem to have more menstrual irregularities, including anovulation, menorrhagia, longer-than-normal cycles, and excessive pain with menses (Hellander, 2008). They often have symptoms of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD), and other gynecological disorders, such as hyperprolactinemia, can occur. Other symptoms, such as acne and weight gain, can be of concern for teenage girls. Adult women with BPD are more likely to develop cardiac disease, diabetes, and obesity (Hellander, 2008).

Table 5.3 ■ Types of Bipolar Disorder

Type of BPD Bipolar I Bipolar II Cyclothymia Mixed-Episode Rapid-Cycling

Symptoms Associated With Specific Type of BPD Both manic and depressive episodes Less severe manic symptoms but depressive symptoms are the same Chronic, milder form of BPD with symptoms of hypomania and depression lasting for at least 2 years Depression and manic episodes occurring simultaneously Four or more mood episodes within a 12-month period

Symptoms associated with manic episodes can be a concern for adolescent girls with BPD. Hypersexuality is present in 43% of girls with BPD and can lead to unintended sexual advances and suspicions of child sexual abuse, and can draw attention from child predators (Hellander, 2008). Sexually transmitted infections, unintended pregnancy, prostitution involvement, and attempted and completed rapes occur more often in girls with BPD (Hellander, 2008). Women with BPD are seven times more likely to develop substance abuse problems. Early cigarette smoking has been shown to play a key role in future addiction and should be taken seriously in adolescent girls with BPD. Periods of depression in young girls can mimic the normal mood swings of adolescence. Girls with depressive symptoms frequently have sadness, complaints of physical pain, and changes in sleeping and eating patterns. However, depression associated with BPD can quickly lead to suicidal ideation in girls and should always be taken seriously. Self-injurious behaviors, such as cutting, may also be present.

SUICIDE AND ADOLESCENCE

Adolescents who have been diagnosed with a psychological disorder at the time of their death comprise 95% of suicides annually (Centers for Disease Control and Prevention [CDC], 2010a). Girls with depression and BPD are more likely to commit suicide than girls without a mental health diagnosis. Suicide is relatively rare in young children, but occurs with increasing frequency among adolescent populations. Suicide is the third leading cause of death among teens in the United States (CDC, 2010a). It is estimated that one in five adolescents have seriously considered suicide, and 9% report at least one suicide attempt. Girls are twice as likely to engage in suicidal ideations and attempts, and boys are four times more likely to succeed. Boys also tend to employ more lethal methods of committing suicide, such as firearms, hanging, or jumping from heights. While boys do actually commit suicide successfully more often than girls, these numbers are dropping, and numbers of girls who succeed in harming themselves are rising (CDC, 2010a).

Clinical Pearl

Teenagers with firearms in the home are 60% more likely to commit suicide than those living in homes wit

Girls in distress who exhibit signs of hopelessness or worthlessness, those who lack a network, and those who have previously attempted suicide are at greatest risk. A family history of suicide and a history of physical or sexual abuse also increase the likelihood that a girl will attempt or commit suicide. Among the gay, lesbian, transgender, and bisexual adolescent populations, coming to with one’s gender identification and sexual orientation when family and peers are unive is a causative factor of suicidal behaviors (Kitts, 2010). Adult suicide rates have historically indicated Alaskan Natives/American Indians have the highest rates of suicide followed closely by White females (CDC, 2010a). New research, however, conflicts with these statistics and shows evidence that, while the problem of suicide can cross racial boundaries, Black girls are more likely to commit suicide than those of other races even if they have never been diagnosed with a mental health disorder. By the time they reach the age of 18, 7% of Black girls have attempted suicide. Girls of Caribbean descent have the highest rates of suicide ideation although Black girls have the highest rates of suicide attempts. Having an anxiety disorder is the most common correlation between Black girls and suicide attempts (Joe, Baser, Neighbors, Caldwell, & Jackson, 2009).

SUBSTANCE ABUSE

Substance abuse appears in 2% of girls age 7 to 17 years old who have a mental health disorder (Substance Abuse and Mental Health Services istration [SAMHSA], 2008). Most girls who have substance-abuse issues report their first use of an illegal substance as occurring between the ages of 12 and 14 (SAMHSA, 2008). It is estimated that 8% of individuals over the age of 12 are substance abs, and marijuana is the most commonly abused illegal substance. Marijuana and alcohol for 80% of the abused substances in adolescent girls presenting for treatment (SAMHSA, 2008). Girls are more vulnerable to substance abuse and addiction than boys, and they are more likely to turn to illegal substances to self-medicate. Girls tend to abuse drugs for different reasons than boys. Girls often use drugs as a means to cope with school issues, problems with peers, symptoms of depression, and other stressors (Partnership for a Drug-Free America, 2010). They typically become addicted more quickly and suffer negative consequences earlier than boys (Office of the National Drug Control Policy, 2010). Girls also view alcohol and ecstasy as nonaddictive substances that can be used appropriately to deal with daily stressors (Partnership for a Drug-Free America, 2010). Women and girls abuse drugs less frequently than their male counterparts. The rate of substance abuse for individuals age 12 and over is 6.4% for females and 11.5% for males (Office of the National Drug Control Policy, 2010). Of teens age 12 to 17, girls for 30% of issions to substance abuse centers compared to 70% who are teenage boys; however, girls commonly receive treatment at a younger age than boys. In addition, girls are more likely than boys to suffer from a psychiatric diagnosis in addition to substance abuse, which is known as a dual diagnosis. Boys are more likely to enter substance-abuse treatment because of criminal justice involvement, whereas girls are more likely to enter as a result of a family member asking them to get assistance (Substance Abuse and Mental Health Services istration, 2007). Still, it is not uncommon for girls with substance abuse issues to experience conflicts with the

criminal justice system. Girls with substance abuse issues must be referred to treatment at a facility that specializes in working with adolescents as they need additional and education, and need to be counseled on pregnancy prevention (Substance Abuse and Mental Health Services istration, 2008). Underlying mental health disorders have to be treated because dual diagnosis is common. Family therapy may be needed as well, because parents and family play an important role in treatment. Initial detoxification is typically done in an inpatient setting although there are some facilities that offer outpatient management. Treatment options range from day treatment centers, intensive residential therapy centers, therapeutic boarding schools, wilderness/boot camp programs, and residential treatment schools. Therapy is commonly recommended and may include individual, family, group, behavioral, and cognitive therapy in addition to participation in a 12-step program for addiction. Dual diagnosis groups specialize in treating patients with comorbidities.

EATING DISORDERS

Eating Disorders occur when one has severe disturbances in an eating behavior, either extreme reduction in food volume or extremes in overeating. Individuals with Eating Disorders typically experience distress over their body image or their weight (National Institute of Mental Health, 2010b). These disorders are much more common in girls than in boys. The incidence of Eating Disorders in boys compared to girls is only 5% to 15% (National Institute of Mental Health, 2010b). The two main types of Eating Disorders are Anorexia Nervosa and Bulimia Nervosa. There is also a third category known as Eating Disorders Not Otherwise Specified that covers behaviors that include overeating and binge eating (Table 5.4). Eating Disorders commonly develop during adolescence or early adulthood. Comorbidities with other mental health illnesses are common and frequently include anxiety, depression, PTSD, OCD, and substance abuse. Girls with Eating Disorders are more likely to engage in self-injurious behavior rituals with an incidence of approximately 41% within this population.

Table 5.4 ■ Classifications of Eating Disorders

Eating Disorder Anorexia Nervosa Bulimia Nervosa Binge-Eating Disorder

Symptoms Disturbed eating patterns and behaviors; emaciation; unwillingness to maintain a proper weight; s Recurrent and frequent episodes of eating large amounts of food followed by purging activities, su Recurrent binge eating episodes; loss of control over eating patterns; guilt, shame, and distress acc

Source: Adapted from National Institute of Mental Health (2010b).

AUTISM-SPECTRUM DISORDERS

Autism-Spectrum disorders (ASD), also known as Pervasive Developmental Disorder (PDD), are a group of disorders characterized by delays in the development of basic functions, including socialization and communication patterns. Odd, repetitive motions are also common manifestations. The typical onset of symptoms occurs around age 3, but symptoms can develop as early as infancy and can persist through childhood, adolescence, and adulthood. The most common ASD is autism, which is recognized by alterations in socialization and communication and results in a limited number of activities and interests (National Institute of Neurological Disorders and Strokes, 2010). Autism affects three to four people per 1,000 and is four times more common in boys (National Institute of Mental Health, 2010c), although girls with autism are frequently underdiagnosed or misdiagnosed. The number of girls with autism is estimated to be 140,000. Of those, 42% have normal intelligence with no cognitive impairment (Centers for Disease Control and Prevention, 2010b). Typically, girls with autism have more acute symptomology and higher degrees of cognitive impairment than their male counterparts (National Institute of Mental Health, 2010c). Other types of ASD include Asperger’s Disorder, Childhood Disintegrative Disorder, and Rett’s Disorder. Asperger’s symptoms are usually milder than those of autism and involve social awkwardness and all-absorbing interest in specific topics. It occurs in 0.024% to 0.36% of children, is more common in boys, and is typically diagnosed between the ages of 2 and 6 (WebMD, 2010). Childhood Disintegrative Disorder, also known as Heller’s syndrome, results in a loss of previously acquired social, communication, and other skills. It typically develops later than autism and is more severe. In addition, the condition is much rarer, occurring in one per 100,000 children with autism. There is a higher incidence in boys, and the condition may be associated with tuberous sclerosis, lipid-storage diseases, and subacute sclerosing panencephalitis. Investigators are currently researching if the disorder could have an autoimmune or infectious neurological etiology.

Rett’s Disorder, a rare genetic disorder typically diagnosed during infancy, is the only ASD that is almost exclusive to girls. Girls with Rett’s Disorder have increasing problems involving their movement, mobility, and coordination, including use of their hands, and communication patterns. In addition, girls with Rett’s Disorder have a shortened life expectancy and tend to live only into their 40s and 50s. Treatment for ASDs typically includes early intervention services, specialeducation services for school-age children, social skills training, CBT, and medications aimed at treating other symptoms. Girls with Rett’s Disorder need varying resources, including physical therapy, occupational therapy, speech therapy, and assistance with daily living activities.

SUMMARY

While most mental health disorders do not begin in early childhood, risk factors that can predispose a young woman to mental illness can be rooted in her upbringing and childhood experiences. Some mental health disorders do begin in childhood and can present with vague symptoms that require close assessment by a health care provider specifically trained in treating children and adolescents. Young women are also at risk for a variety of mental health issues that can begin in adolescence. Parents need to obtain educational information from nurses to help identify adolescent girls who may be experiencing a mental illness. Ongoing therapeutic treatment is indicated for the young girl or teenager who is identified as having a mental health issue.

Case Study

Veronica Jeffers is an 8-year-old Caucasian girl who lives at home with her mother, father, and 4-year-old brother. Veronica went to the zoo approximately 6 months ago and saw an alligator in a display there. Since that time, she has developed a severe fear of alligators and becomes increasingly anxious when the topic arises: She becomes hysterical and begins crying and displays a temper tantrum. Her parents do not mention the subject. Occasionally, Veronica brings it up, and her anxiety escalates until she devolves completely. She develops stomachaches and cries nonstop until she wears herself out. What is the likely diagnosis? How can Veronica’s parents attempt to help her with this reaction?

Questions to Consider

What signs and symptoms may be displayed by an adolescent with a Conduct Disorder? What risk factors would predispose a young or teenage girl to PTSD? What interventions should be immediately employed for an adolescent girl with suicidal ideations? What information should be considered before starting a regimen of SSRI therapy for a young girl with depression?

REFERENCES

Alakus, C., Conwell, R., Gilbert, M., Buist, A., & Castle, D. (2007). The needs of parents with a mental illness who have young children: An Australian perspective on service delivery options. International Journal of Social Psychiatry, 53(4), 333–339. American Academy of Child and Adolescent Psychiatry. (2011). Children with oppositional defiant disorder. Retrieved from http://aacap.org/page.ww? name=Children+with+Oppositional+Defiant+Disorder&section=Facts+for+Families Anxiety Disorders Association of America. (2010). Retrieved from http://www.adaa.org/living-with-anxiety/children/childhood-anxiety-disorders Bernstein, B. E. (2008). Anxiety disorder, separation anxiety, and school refusal. Retrieved from http://emedicine.medscape.com/article/916737-overview Centers for Disease Control and Prevention. (2010a). National suicide statistics at a glance. Retrieved from http://www.cdc.gov/violenceprevention/suicide/statistics/aag.html Centers for Disease Control and Prevention. (2010b). Autism spectrum disorders. Retrieved from http://www.cdc.gov/ncbddd/autism/facts.html Chakraburtty, A. (2009). Specific phobias. Retrieved from http://www.webmd.com/anxiety-panic/specific-phobias Gurian, A. (2010). Girls with ADHD: Overlooked, underdiagnosed, and underserved. NYU Child Study Center. Retrieved from http://add.about.com/gi/o.htm? zi=1/XJ&zTi=1&sdn=add&cdn=health&tm=12&gps=189_434_1020_567&f=00&tt=2& bt=1&bts=1&zu=http%3A//www.aboutourkids.org/articles/girls_adhd_overlooked_ underdiagnosed_underserved

Hellander, M. (2008). Impact of bipolar depression on girls. Retrieved from http://www.healthyplace.com/bipolar-disorder/children/impact-of-bipolardisorder-on-girls/menu-id-67/page-2/ Hinshaw, S., et al. (2006). Girls with ADHD overlooked, underdiagnosed, and underserved. Journal of Consulting and Clinical Psychology, 34, 825–839. Joe, S., Baser, R. S., Neighbors, H. W., Caldwell, C. H. S., & Jackson, J. (2009). 12-month and lifetime prevalence of suicide attempts among black adolescents in the National Survey of American Life. Journal of American Academy of Child & Adolescent Psychiatry, 48(3), 271–282. Kitts, R. L. (2010). Barriers to optimal care between physicians and lesbian, gay, bisexual, transgender, and questioning adolescent patients. Journal of Homosexuality, 57(6), 730–747. Monthly Prescribing Reference. (2010). Zoloft. Retrieved from http://www.empr.com/zoloft/anxietyocd/drug/3920/ Nadeau, K. (2004). Understanding girls with ADHD. Retrieved from http://www.addvance.com/help/women/high_school.html National Institute on Drug Abuse. (2010). NIDA InfoFacts: Stimulant ADHD medications: Methylphenidate and amphetamines. Retrieved from http://www.drugabuse.gov/Infofacts/ADHD.html National Institute of Mental Health. (2010a). National survey confirms that youth are disproportionately affected by mental disorders. Retrieved from http://www.nimh.nih.gov/science-news/2010/national-survey-confirms-thatyouth-are-disproportionately-affected-by-mental-disorders.shtml National Institute of Mental Health. (2010b). Eating disorders. Retrieved from http://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml National Institute of Mental Health. (2010c). What are the autism spectrum disorders? Retrieved from http://www.nimh.nih.gov/health/publications/autism/what-are-the-autismspectrum-disorders.shtml National Institute of Mental Health. (2010d). Women and depression:

Discovering hope. Retrieved from http://www.nimh.nih.gov/health/publications/women-and-depressiondiscovering-hope/complete-index.shtml National Institute of Neurological Disorders and Strokes. (2010). Pervasive developmental disorders. Retrieved from http://www.ninds.nih.gov/disorders/pdd/pdd.htm Nutter, D. A., Larson, L. H., & Sylvester, C. (2010, January 27). Anxiety disorder: Generalized anxiety. Retrieved from http://emedicine.medscape.com/article/916933-overview Office of the National Drug Control Policy. (2010). Women, girls, and drugs: Facts and figures. Retrieved from http://www.whitehousedrugpolicy.gov/drugfact/women/women_ff.html Partnership for a Drug-Free America. (2010). National study: New data show teen girls more likely to see benefits in drug and alcohol use. Retrieved from http://www.drugfree.org/newsroom/national-study-new-data-show-teen-girlsmore-likely-to-see-benefits-in-drug-and-alcohol-use Perlmutter, S. J. (2008). Childhood anxiety disorders. Neuropsychopharmacology–5th Generation of Progress. Nashville, TN: American College of Neuropsychopharmacology. Reef, J., van Meurs, I. Verhulst, F. C., van der Ende, J. (2010). Children’s problems predict adults’ DSM-IV disorders across 24 years. Journal of the American Academy of Childhood and Adolescent Psychiatry, 49(11), 1117– 1124. Substance Abuse and Mental Health Services istration. (2007). Substance abuse treatment findings show risks for girls. Retrieved from http://www.samhsa.gov/newsroom/advisories/070524teengirls1426.aspx Substance Abuse and Mental Health Services istration, Office of Applied Studies. (December 11, 2008). The TEDS Report: TEDS Report Definitions. Rockville, MD. Tynan, W. D. (2010). Conduct disorder. Medscape. Retrieved from http://emedicine.medscape.com/article/918213-overview

U.S. Department of Veterans Affairs. (2010). Epidemiology of PTSD. Retrieved from http://www.ptsd.va.gov/professional/pages/epidemiological-facts-ptsd.asp U.S. Surgeon General. (2000). Mental health: A report of the Surgeon General. Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/chapter1/sec1.html Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J., Ginsburg, G. S., Rynn, M. A., McCracken, J., Waslick, B., Iyengar, S., March, J. S., & Kendall, P. C. (2008). Cognitive-behavioral therapy, sertraline and their combination for children and adolescents with anxiety disorders: Acute phase efficacy and safety. New England Journal of Medicine, 359, 2753–2766. WebMD. (2010). Asperger’s Syndrome. Retrieved from http://www.webmd.com/brain/autism/mental-health-aspergers-syndrome Wong, P. (2010). Selective mutism: A review of etiology, co-morbidities, and treatments. Psychiatry, 7(3), 23–31.

6

Mental Health for the Aging Woman

The majority of adults in the United States are between the ages of 18 and 65 with an average age of 36.1 years ( U.S. Census Bureau, 2008 ). For most women, the middle years mark a time when they continue to grow and mature and establish a life for themselves. During their 30s, 40s, and 50s, women likely will encounter multiple stressors, including the dual demands of families and out-of-the-home work obligations. Developmental tasks during this period in life include generativity verses stagnation. Women who have progressed well through this stage wish to leave their mark on the world and are concerned about the welfare of others. They display caring attitudes toward others and freely give of themselves. Women who have not developed generativity tend to be stagnated and may feel bitter and find little meaning in their lives. They may easily become overwhelmed or overextended. Mental illness typically has an onset in young adulthood or early middle adulthood. Despite this, a recent large-scale study in the United Kingdom found the prevalence of mental health disorders were most common in women aged 45 to 64 who were included in the sandwich generation. (See Chapter 2 on sandwich-generation stressors.) Because mental illness is not considered curable, many disorders that had an onset in childhood or during early adulthood persist into the middle years. In general, many middle-aged adults who do have a mental illness have learned effective coping mechanisms by middle age (Boyd, 2008). In some studies, midlife quality of life improvements are noted around the age of 40 when many women have developed financial security and established satisfying marital relationships.

MIDLIFE CRISIS

Although a midlife crisis is not a DSM-IV-TR category, the incidence of psychological symptoms associated with midlife transitions has become well known through popular culture. Struggles with these transitions are a normal part of development and include worry, sadness, and uncertainty. The midlife period may be a time marked by numerous transitions for women, including perimenopause and menopause, children leaving the home, and concerns regarding the needs and challenges of aging parents. During this stage, many women begin to fear deterioration of their health and financial instability that may occur after retirement. For some women, young adult children may continue to be financially dependent, or they may unexpectedly need to raise grandchildren. When women are unable to meet these transition changes and react in maladaptive ways, an Adjustment Disorder may be diagnosed. When an Adjustment Disorder is diagnosed, there is an abnormal or excessive reaction to a life event. Adjustment Disorders are typically associated with agitation, conduct disturbances, depression, anxiety, physical complaints, heart palpitations, trembling, or twitching. Treatment typically involves therapy interventions, such as cognitive behavioral therapy (CBT), individual therapy, family therapy, or group therapy. If anxiety or depression symptoms are present, pharmacological therapies may also be initiated. “Midlife crisis” incidences occur in approximately 25% of the population (Boyd, 2008). Adjustment Disorders typically respond well to therapy and resolve without complications.

AFRICAN AMERICAN WOMEN DURING MIDLIFE

African American middle-age women are at an increased risk for mental illness because of multiple stressors, including “caregiver strain, social isolation, bereavement, exposure to traumatic events (violence, living in crime-ridden neighborhoods), and poor access to health care” (Ward & Heidrich, 2009, p. 480). They frequently have less access to care services and lower utilization rates. The most significant barrier in this population remains stigma. Middle-age African American women are less likely to seek treatment than older African American women and are more likely to use avoidance behaviors when compared to older women (Ward & Heidrich, 2009).

PERIMENOPAUSE

Perimenopause, also known as menopausal transition, marks a time of hormonal changes for women in their late 30s and 40s when their bodies begin a natural transition toward menopause as estrogen and progesterone levels fluctuate. The perimenopause state typically lasts 8 to 10 years and ends with menopause, the cessation of a menstrual period. The most prominent symptoms during this time are menstrual changes, but various psychological changes also occur. Women may become irritable and suffer from depression symptoms, anxiety, and mood swings. Some women even report feeling cloudy or confused or having difficulty focusing. Women with depression and anxiety symptoms have more cognitive symptoms than those without these symptoms (Seritan, Iosif, Park, DeatherageHand, Sweet, & Gold, 2010). Sleep deprivation is common during this period because of hot flashes and night sweats, making psychological symptoms more prevalent. For some women, their declining state of fertility marks a time of relief from concerns about becoming pregnant at this stage of their lives. For other women, it marks a time of great sadness. Women who have a history of infertility, who have not found a partner, or who remained career driven and did not have children may feel regret and despair at this time in their lives. For these women, psychological adjustments can be more difficult. Women may be three times more likely to develop depression during the perimenopausal years. For some women, perimenopause can bring on the first episode of Major Depressive Disorder (MDD). Women with vasomotor symptoms have a six-fold increase in their likelihood of developing depression. Women with a previous history of MDD have a five times higher rate of developing depression (Clayton & Ninan, 2010). Women during early and late perimenopause are at the highest risk while postmenopausal women experience an improvement in depression symptoms (Clayton & Ninan, 2010). Women with premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are also more likely to develop depression during the perimenopausal years (Frey, Hall, Attard, Yucel, Skeltin, Steiner, & Soares, 2010). Women who took combined oral contraceptives during the perimenopausal period had a significant reduction in depression symptoms (Clayton & Ninan, 2010). Estrogen therapy

alone may be protective against cognitive changes in younger perimenopausal women (Maki, Freeman, Greendale, Henderson, Newhouse, Schmidt, Scott, Shively, & Soares, 2010). Because of the increased risk of physical, psychological, and cognitive changes associated with perimenopause, the National Institutes of Health and the North American Menopause Society now recommend routine depression screening for all perimenopausal women (Maki et al., 2010).

MENOPAUSE

Menopause is marked by the absence of menses for a 12-month period with an average age of menopause onset at age 52. Postmenopausal women may also experience depression and anxiety symptoms during this stage in life. Some women may have risk factors that make depression during the postmenopausal years more likely. Magnetic resonance imaging (MRI) has demonstrated actual brain changes that may impact a woman’s emotional regulation tract. These changes may help explain why, during the menopausal years, women are more prone to anxiety and depression symptoms (Frey et al., 2010). Women who undergo early menopause (occurring under the age of 39 years), those who have never had children, those with irregular menses, those with only a primaryschool education, and women with a previous history of mental illness are at a greater risk for postmenopausal depression (Unsal, Tozun, & Ayranci, 2010). It should be noted that risk of suicide increases at the time of menopause in women (Halverson & Walaszek, 2010). The use of antidepressant therapy has been shown to be effective in treating this population (Kornstein, Jiang, Reddy, Musgnung, & Guico-Pabia, 2010). Some studies have examined the differences in women who take hormone replacement therapy (HRT) and those who do not. Women who take HRT in the postmenopausal years experience fewer depression symptoms. They tend to have better physical functioning, fewer melancholic features, and less sympathetic arousal compared with women not taking HRT (Kornstein, Young, Harvey, Wisniewski, Barkin, Thase, Trivedi, Nierenberg, & Rush, 2010). The perception of the menopause experience can also vary among different women. Lower-income women, women with high perceived stress levels, and those with a negative view of aging tend to have more psychosocial symptoms associated with menopause than women who have a positive attitude toward the menopausal experience (Nosek, Kennedy, Beyene, Taylor, Gilliss, & Lee, 2010). In general, the more negative a woman’s view of the menopausal period, the more symptomology is observed (Ayers, Forshaw, & Hunter, 2010). Women from varying cultural groups may also experience menopause differently

based on cultural beliefs. For example, many African American women believe they should suffer silently and not complain about their symptoms to others. They are often raised to be strong and independent women and feel they should be more focused on other family matters than on their own discomforts related to menopause and aging. Many women in one study voiced the need for more educational information about menopause but were reluctant to bring it up to their health care providers (Im, Lee, & Chee, 2010). In contrast, in Japanese culture, menopause is thought to last approximately 20 years and is termed a time of rejuvenation and redistribution of energy. There are no negative connotations, and fewer Japanese women report adverse symptoms compared to those from Western societies (Mills, 2010). In many African countries, the time of menopause is viewed as a time marked by increasing knowledge and wisdom and is something to be celebrated (Mills, 2010).

OLDER WOMEN

As the baby boomers continue to age, the population of older women will continue to grow. In 2009, the over-65 population comprised 12.9% of the United States population (U.S. Census Bureau, 2008). In 2011, the first baby boomers turned 65. By 2020, it is estimated that 20% of the U.S. population will be over the age of 65. With these projections, the population of over-65 people will double over the next 30 years (U.S. Census Bureau, 2008). In addition, people are now living longer lives. The life expectancy rate for women is 80.2 years. Since 1990, there has been a 97% increase in the centenarian (over 100 years of age) population. As more and more women begin to live into their advanced years, the need for awareness of psychological changes and needs is imperative to the primary care clinician.

DEPRESSION AND OLDER WOMEN

Depression is not a normal part of aging. It is estimated that 8% to 20% of women over the age of 65 experience depression symptoms although they do not meet the criteria for MDD (Halverson & Walaszek, 2010). The incidence of MDD in the elderly varies with their living conditions. Elderly women living in the community have the lowest incidence (1% to 4%), and those living in longterm care facilities have the highest incidence (12% to 20%) (Halverson & Walaszek, 2010). The lifetime prevalence of a mood disorder, including depression and Bipolar Disorder, is 12.2% in individuals over the age of 60 (National Co-Morbidity Survey, 2005). Older women are two times more likely to experience depression in comparison to their male counterparts. The incidence of MDD actually decreases with age despite the fact that symptoms of depression actually increase. Despite a reduction in the rate of depression, depression in older women is frequently a chronic condition with more recurrences and fewer periods of remissions. The major risk factor for depression in this age group is the presence of physical health problems that interfere with mobility and increased pain levels, in addition to depression as a side effect of medications (Exhibit 6.1). Women with chronic health problems are more likely to experience depression, including Dementia (Huang, Wang, Li, Xie, & Liu, 2010). Women with depression are at an increased risk for suicide.

Exhibit 6.1

Medications Associated With Depression as a Side Effect

Opiates Steroids Arthritis medications Hypertension medications Cardiac medications Sedative-hypnotics Interferon Antibiotics Antiparkinsonians

Late-onset depression is referred to as depression that has its initial onset after the age of 60 (Halverson & Walaszek, 2010). It is estimated that six million people are affected by late-onset depression, but only 10% will receive treatment (Depression and Bipolar Alliance, 2010). Late-onset depression affects approximately 10% of adults over the age of 60 (Halverson & Walaszek, 2010). Late-onset depression has higher recurrence rates than typical MDD and is often associated with widowhood, poor educational attainment, impaired functional status, and chronic alcohol use (Halverson & Walaszek, 2010). Another risk factor for late-onset depression is Insomnia. Insomnia is often a chronic problem for up to 5% to 10% of elderly women. Living in long-term care facilities increases the risk of sleep problems resulting from frequent interruptions by staff and other residents. Late-onset depression should be carefully evaluated because it is sometimes associated with the onset of Dementia. Certain social behaviors result in a reduction in mental health functioning. In a large-scale study of older women in Australia, women who smoked, drank alcohol, or ingested caffeine had higher rates of anxiety and depression and had a lowered sense of mental well-being. Women with a high body mass index

(BMI) also experienced a lower sense of mental well-being (Xu, Anderson, & Courtney, 2010). Older women being treated for depression have response rates of 60% to 80% although response time is often longer in this population (Halverson, & Walaszek, 2010). Treatment of the aging woman with depression is important. Some clinicians may be reluctant to prescribe selective serotonin reuptake inhibitors (SSRIs) because of comorbidities that are common in this population; however, when left untreated, depression can cause multiple symptoms, decrease the quality of life, and increase the risk of suicide. Depression can be treated with antidepressants, psychotherapy, or a combination of both. All these options have been successful in treating older women (National Institute of Mental Health, 2010). Reduced dosages of medications may be indicated in elderly women because of a reduction in body mass size. Tricyclic antidepressants (TCAs) are contraindicated in the elderly because of the anticholinergic side effects and high sedation rates (Williams, 2002). SSRIs are commonly used because of the reduction in side effects and the lower incidence of drug interactions. Of the SSRIs, the likelihood of drug-drug interaction is highest in fluoxetine (Prozac), paroxetine (Paxil), and fluvoxamine (Luvox) (Halverson & Walaszek, 2010). Hyponatremia occurs in as many as 25% of treated individuals in the elderly population (Smith, 2010). There is some research that reveals older women who took SSRIs experienced higher rates of bone loss and hip fractures (Diem, 2008). The use of baseline bone mineral density may be indicated to monitor bone loss and initiate supplementary bisphosphonate therapy as needed (Diem, 2008).

SUICIDE IN OLDER WOMEN

Almost one-fifth of all suicides are committed by older adults. Suicide s for the death of 14.3 in 100,000 elderly adults (National Institute of Mental Health, 2011). Although suicide attempts are higher in women, they are more successfully carried out by men. Women commonly overdose on prescription medications. Incidences of suicide increase with age, with adults over the age of 85 having the highest rates. Elderly Native Americans, Alaskan Natives, and Whites have the highest rates, whereas Asians, Hispanics, and Blacks have the lowest rates (National Institute of Mental Health, 2011). Women in this age group typically plan their suicides over a long period of time, thus possibly offering clues that a plan is in place. Saying goodbye to family or friends and giving away treasured objects is a warning sign. Hopelessness, history of an affective disorder, previous suicide attempts, a family history of suicide attempts, past history of childhood abuse, and poor self-esteem are all risk factors that should be evaluated by the woman’s care provider or family. Women with other chronic diseases and comorbidities and those living with chronic pain are at a higher risk for suicide.

ANXIETY

Anxiety Disorders in older adults have been linked to hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis (Lenze, Mantella, Shi, Goate, Nowotny, Butters, Andreescu, Thompson, & Rollman, 2010). It is estimated that 17.6% of older adults (over the age of 60) suffer from any type of Anxiety Disorder (National Co-Morbidity Survey, 2005). The leading Anxiety Disorders in older adults are Specific Phobias (7.7%), Social Phobia (6.8%), Generalized Anxiety Disorder (4%), and adult Separation Anxiety Disorder (3.1%) (National Co-Morbidity Survey, 2005). Many older adults worry about disability, finances, adult children, and health problems. Many clinicians are reluctant to prescribe benzodiazepines because of the increased incidence of falls and cognitive impairment within this population. Recent studies have noted that SSRIs, specifically escitalopram (Lexapro), have some effectiveness in treating symptoms related to anxiety without producing adverse side effects. CBT has also been shown to be effective in treating Anxiety Disorders in this population. Combination therapy, consisting of SSRIs and CBT, has shown to be the most effective means to treat Anxiety Disorders in elderly women (Wetherell, Stoddard, White, Kornblith, Nguyen, Andreescu, Zisook, & Lenze, 2010). Healthy habits, such as regular exercise, have also been shown to be effective in reducing levels of anxiety.

DEMENTIA

Dementia refers to a combination of symptoms that impacts social and cognitive functions resulting from cerebral changes affecting two or more areas of functioning, such as cognitive skills and language (National Institute of Neurological Disorders and Stroke, 2010). Although Dementia is not a normal function of aging, it is more common in older adults. It is estimated that 5% to 8% of people over the age of 65 have Dementia, with that number doubling every five years. Approximately 50% of women over the age of 85 will have Dementia (National Institute of Neurological Disorders and Stroke, 2010). Memory loss is a common characteristic of Dementia. Other signs are noted in Exhibit 6.2.

Exhibit 6.2

Common Signs of Dementia

Alterations in communication Organizational difficulties Personality changes Inappropriate behavior Hallucinations Delusions

Agitation Paranoid behaviors Inability to reason Coordination problems Difficulty with motor functions Unable to learn new information or recall recent information

There are multiple causes of Dementia. The primary causes are Alzheimer’s disease (AD), Lewy body disease, and Pick’s disease. Immune alterations, medication side effects, hormone imbalances (hypothyroidism), nutritional deficits (B12 and folate deficiencies), tumors, subdural hematoma, and substance abuse may cause Dementia that is reversible; however, most forms of dementia are progressive and irreversible. Dementia can also result as a complication of an infectious process, such as HIV or Creutzfeldt-Jakob disease. Dementia can be caused from neurological diseases, such as Parkinson’s disease and Huntington’s disease. In both diseases, the underlying neurological disease can negatively affect brain tissue, leading to Dementia (Torpy, Lynm, & Glass, 2008). Dementia can also occur as a result of developmental abnormalities and injuries and as a result of head injury related to intimate partner violence. There are more than 50 identified causes of Dementia, but many are quite rare (Torpy, Lynm, & Glass, 2008). AD is the most common cause of progressive Dementia, ing for 50% to 70% of all Dementias (Mayo Clinic, 2010). AD typically occurs after the age of 60 and has a slow course of 7 to 10 years during which the individual progressively declines in function, including those involving memory, movement, language, judgment, behavior, and abstract thinking. With AD, two different types of neuron damage occur: plaques and tangles. Plaques involve formation of clumps of a normally harmless protein called beta-amyloid, which may interfere with communication between brain cells. Tangles involve the internal structure for brain cells and depend on the normal functioning of a protein called tau. In people with AD, threads of tau protein undergo

alterations that cause the tangles to become twisted. Treatments for Dementia are aimed at slowing down the progression of the disease, decreasing symptoms, and maximizing the quality of life for the individual. (Table 6.1).

Table 6.1 ■ Medications Used to Treat Alzheimer’s Disease

Drug Name Donepezil (Aricept) Rivastigmine (Exelon) Galantamine (Razadyne) Memantine (Namenda) Tacrine (Cognex)

Indications Mild, moderate, and severe AD Mild to moderate AD Mild to moderate AD Moderate to severe AD Mild to moderate AD

Side Effects Diarrhea, vomiting, nausea, fatigue, insomnia, and weight los

May have increased effectiveness when combined with other Nausea, vomiting, diarrhea, abdominal pain, skin rash, indige

Lewy body dementia is characterized by abnormal clumps of proteins called Lewy bodies that are found in the brains of affected individuals. This Dementia varies from AD in that women with this disorder have alterations in behavior that include normal functioning followed by periods of Dementia symptomology. Lewy body dementia is the second most common form of Dementia after AD and s for 20% of all Dementias. They also are prone to Parkinson-like tremors and rigidity. REM sleep behavior disorder characteristics include acting out dreams, thrashing during the night, and kicking during sleep. Multi-infarct or vascular Dementia is caused by arterial damage to the vessels of the brain resulting from disruption of blood flow. These disruptions are commonly referred to as “silent strokes” (National Institute of Neurological Disorders and Stroke, 2010). They are common in hypertension, myocardial infarction, and strokes. It may also be caused from endocarditis and amyloid angiopathy. Multi-infarct Dementia is more common in men of advancing age and may coexist with other forms of Dementia. Because the etiology is so complex, symptoms vary widely and may include a progressive worsening or marked improvement. Symptoms may include confusion, difficulty with shortterm memory; wandering or getting lost in familiar places; walking with rapid, shuffling steps; losing bladder or bowel control; inappropriate emotions; having difficulty following instructions; and having difficulty managing money (National Institute of Neurological Disorders and Stroke, 2010). Treatment of this type of Dementia is aimed at preventing future strokes, which cause further impairment. Pick’s disease, also known as frontotemporal Dementia (FTD), is a rare form of Dementia that occurs in approximately 5% of all cases. The incidence is slightly higher in women and occurs at a younger age with a mean onset of 50. Unlike AD, changes in brain tissue occur in focal areas rather than in a generalized fashion, which is consistent with AD. Pick’s disease affects the frontal and temporal lobes and involves brain atrophy of that region. With Pick’s disease, the presence of abnormalities in brain cells, called Pick bodies, are present and differ from the tangles consistent with AD. Symptoms of Pick’s disease Dementia vary from other forms because initial symptoms are related to frontal lobe involvement and typically include social and emotional alterations. Mood changes involving a sense of euphoria, disinhibition, and deterioration of social

skills are common. Unlike with AD, there are no drugs available to treat Pick’s disease. The progression of the disease is 2 to 10 years with a slow deterioration.

SUBSTANCE ABUSE IN OLDER WOMEN

Prescription medications and over-the-counter agents are most commonly prescribed to women over the age of 65. In 2010, hydrocodone was the most commonly prescribed substance, which resulted in 131.2 million prescriptions (Rubin & Rubin, 2011). The incidence of substance abuse in the elderly population is approximately 10% in individuals over the age of 60 and 9% in elderly individuals over the age of 75 (Naegle, 2008). It is estimated that 11% of women over the age of 59 misuse psychoactive drugs (Naegle, 2008). Substance abuse, alcohol abuse, and tobacco use have all increased in the elderly population. Aging baby boomers are more likely to misuse substances than previous generations. In one study of elderly women over the age of 65, 13% were at risk for alcohol-related drinking patterns, and 3% were identified as binge drinkers (Blazer & Wu, 2009). Women who once drank infrequently may increase alcohol usage as a result of social isolation, loneliness, loss of partner, reduction in social , or boredom. Alcohol is commonly viewed as a socially acceptable substance and may be viewed as harmless by the elderly population. Alcohol use is more common in unmarried or widowed women, women with a family history of alcohol abuse, those living with chronic pain, and women with a comorbidity of depression (Naegele, 2008). Substance abuse in the elderly most commonly involves the misuse of prescription medications that become abused as a result of tolerance or misuse. Providers often feel uncomfortable screening elderly women for substance abuse and are fearful that direct questioning will produce outrage or that these women will become offended by the questioning. When elderly women are identified as having an alcohol or substance-abuse issue, many times their children or friends experience embarrassment as a result of the diagnosis. Elderly women commonly do not present with symptomology that is consistent with the DSMIV-TR criteria, so extensive assessment is needed. A straightforward approach that is nonjudgmental in nature and empathetic is most likely to illicit honest answers.

SCREENING

Many women have regular encounters with health care providers for physical ailments. A mental status examination along with a psychological assessment at each encounter can identify potential mental health illnesses and symptoms. The woman should be asked about her living situation, financial concerns, social interactions, and present and past moods. Specific behaviors should be assessed to determine if anxiety or depression symptoms are present. Screening for elder abuse (discussed in Chapter 4) should occur at each clinical encounter. A minimental examination can be performed to assess for changes in cognitive functioning. Elements of a mini-mental status exam are included in Exhibit 6.3.

Exhibit 6.3

Components of a Mini-Mental Status Examination

Orientation to person, place, and time Immediate recall Attention Delayed verbal recall Naming Repetition Three-stage command

Reading Writing Copying

Direct questioning should convey a nonjudgmental attitude, and practitioners should provide empathy when asking e of alcohol, misuse of prescription medications, and use of illicit substances. Women should be questioned directly to assess for suicidal ideations. If suicide is being contemplated, crisis intervention is warranted. Sometimes hospitalization becomes necessary if the woman is unable to contract for safety.

TREATMENTS

Treatment options include therapy, groups, medication management, and social services intervention when warranted. Many older women enjoy groups that address developmental changes, such as widowhood, loss of independent living, or living with physical illnesses, such as arthritis, cancer, and other physical conditions. Treatment is aimed at promoting independence and well-being and minimizing symptoms. Medication management should be used to reduce symptomology while minimizing side effects and drug interactions because these are common in this population. Lower dosages may be warranted as a result of decreased body mass and alterations in excretion levels. Older women with substance abuse issues should be referred for substance abuse treatments. The need to consider outpatient or residential treatment is assessed on a case-by-case basis through a personalized treatment plan. Hospitalization is sometimes warranted for women with a dual diagnosis or who have suicidal thoughts and ideations.

SUMMARY

Aging is a normal process for women that, for some, results in the development of mental health disorders. While some women progress through perimenopause and menopause without difficulty, others develop depression and mental illness symptomology. As women age, late-onset depression can occur. The incidence of Dementia also rises significantly in the elderly population. Substance-abuse disorders are becoming more common in the elderly and require assessment and intervention when identified. A psychological assessment that includes evaluating the risk for suicide is also warranted for older women. Close assessment and screening is needed to detect subtle changes in elderly women. Interventions should be aimed at controlling symptoms while minimizing drug interactions and potential side effects.

Case Study

Ethel Myers is an 83-year-old Caucasian widow who presents to her primary care provider for refills on her medications today. She is being treated for hypertension and osteoporosis. Ethel lived independently in the family home where she raised her children and resided for the past 56 years along with her husband who died 3 years ago. After a hip fracture 14 months ago, her children decided she should sell the family home and move into an assisted-care facility against Ethel’s desires. Since that time, Ethel, who was once active in many community activities, has gradually stopped attending social functions. She stays in bed most of the day only getting up for meals and medication istration. She is tearful when her daughter leaves and often tells the staff she misses her house and her “old life.” What interventions would you recommend for Ethel? What medical interventions are likely to be prescribed?

Questions to Consider

How can culture impact a woman’s perception of menopause? What is the etiology of the various types of Dementia? What are the risk factors associated with late-onset depression?

REFERENCES

Ayers, B., Forshaw, M., & Hunter, M. S. (2010). The impact of attitudes towards the menopause on women’s symptom experience: A systematic review. Maturitas, 65(1), 28–36. Blazer, D. G., & Wu, L. T. (2009). The epidemiology of at-risk and binge drinking among middle-aged and elderly community adults: National survey on drug use and health. American Journal of Psychiatry, 166, 1162–1169. DOI: 10.1176/appi.ajp.2009.09010016 Boyd, M. A. (2008). Psychiatric nursing: Contemporary practice, 4th ed. Philadelphia: Lippincott, Williams, & Wilkins. Clayton, A. H., & Ninan, P. T. (2010). Depression or menopause: Presentation and management of major depressive disorder in perimenopausal and menopausal women. Primary Care Companion, Journal Clinical Psychiatry, 12(1), PCC.08r00747. Depression and Bipolar Alliance. (2010). Statistics on depression. Retrieved from http://www.dbsalliance.org/site/PageServer? pagename=about_statistics_depression Diem, S. J. (2008). Depression, antidepressants, and bone loss. Primary Psychiatry, 15(4), 27–29. Frey, B. N., Hall, G. B., Attard, S., Yucel, K., Skeltin, I., Steiner, M., & Soares, C. N. (2010). Shift in the brain network of emotional regulation in midlife women. Menopause, 17(4), 840–845. Halverson, J. L., & Walaszek, A. (2010). Late-onset depression. Retrieved from http://emedicine.medscape.com/article/1356106-overview Huang, C. Q., Wang, Z. R., Li, Y. H., Xie, Y. Z., & Liu, Q. X. (2010). Cognitive function and risk for depression in old age: A meta-analysis of published

literature. International Psychogeriatrics, 12, 1–10. Im, E. O., Lee, S. H., & Chee, W. (2010). Black women in menopausal transition. Journal of Obstetric, Gynecological, & Neonatal Nursing, 39(4), 435– 443. Kornstein, S. G., Jiang, Q., Reddy, S., Musgnung, J. J., & Guico-Pabia, C. J. (2010). Short-term efficacy and safety of desvenlafaxine in a randomized, placebo-controlled study of perimenopausal and postmenopausal women with major depressive disorder. Journal of Clinical Psychiatry, 71(8), 1088–1096. Kornstein, S. G., Young, E. A., Harvey, A. T., Wisniewski, S. R., Barkin, J. L., Thase, M. E., Trivedi, M. H., Nierenberg, A. A., & Rush, A. J. (2010). The influence of menopause status and postmenopausal use of hormone therapy on presentation of major depression in women. Menopause, 17(4), 828–839. Lenze, E. J., Mantella, R. C., Shi, P., Goate, A. M., Nowotny, P., Butters, M. A., Andreescu, C., Thompson, P. A., & Rollman, B. L. (2010). Elevated cortisol in older adults with generalized anxiety disorder is reduced by treatment: A placebo-controlled evaluation of escitalopram. American Journal of Geriatric Psychiatry, 2010 Aug 11. Maki, P. M., Freeman, E. W., Greendale, G. A., Henderson, V. W., Newhouse, P. A., Schmidt, P. J., Scott, N. F., Shively, C. A., & Soares, C. N. (2010) Summary of the NIA-sponsored conference on depressive symptoms and cognitive complaints in the http://www.health.com/health/library/mdp/0,,stm159386,00.html, menopausal transition. Menopause, 17, 815–822. Mayo Clinic. (2010). Alzheimer’s disease. Retrieved from http://www.bing.com/health/article/mayo-125403/Alzheimers-disease? q=alzheimer’s+disease&qpvt=alzheimer’s+disease+ Mills, D. (2010). Perimenopause and menopause. Retrieved from http://www.womentowomen.com/menopause/menopauseacrosscultures.aspx Naegle, M. (2008). Nursing standard of practice protocol: Substance abuse in older adults. Retrieved from http://consultgerirn.org/ National Co-Morbidity Survey. (2005). Lifetime prevalence rates. Retrieved

from http://www.h.med.harvard.edu/ncs/ftpdir/NCSR_Lifetime_Prevalence_Estimates.pdf National Institute of Mental Health. (2010). Depression. Retrieved from http://www.nimh.nih.gov/health/publications/depression/complete-index.shtml National Institute of Mental Health. (2011). Suicide in the U.S.: Statistics and prevention. National Institute of Neurological Disorders and Stroke. (2010). Multi-infarct dementia. Retrieved from http://www.ninds.nih.gov/disorders/multi_infarct_dementia/multi_infarct_dementia.htm Nosek, M., Kennedy, H. P., Beyene, Y., Taylor, D., Gilliss, C., & Lee, K. (2010). The effects of perceived stress and attitudes toward menopause and aging on symptoms of menopause. Journal of Midwifery & Women’s Health, 55(4), 328– 334. Rubin, A., & Rubin, H. (2011). Prescription drugs and the elderly. Retrieved from http://www.therubins.com/geninfo/eldpresc.htm Seritan, A. L., Iosif, A. M., Park, J. H., Deatherage-Hand, D., Sweet, R. L., Gold, E. B. (2010) Self-reported anxiety, depressive, and vasomotor symptoms: a study of perimenopausal women presenting to a specialized midlife assessment center. Menopause, 17(2), 410–415. Smith, J. M. (2010). Clinical implications of treating depressed older adults with SSRIs: Possible risk of hyponatremia. Journal of Gerontological Nursing, 36(4), 22–27. quiz 28-9. DOI: 10.3928/00989134-20100202-04 Torpy, J. M., Lynm, C., & Glass, R. M. (2008). Dementia. JAMA, 300(19), 2330. DOI:10.1001/jama.300.19.2330) Unsal, A., Tozun, M., & Ayranci, U. (2010). Prevalence of depression among postmenopausal women and related characteristics. Climacteric, 2010 Oct 21. U.S. Census Bureau. (2008). 2006–2008 American Community Survey 3-year estimates. Retrieved from http://factfinder.census.gov/servlet/ACSSAFFFacts? _submenuId=factsheet_1&_sse=on

Ward, E. C., & Heidrich, S. M. (2009). African American women’s beliefs about mental illness, stigma, and preferred coping behaviors. Research in Nursing and Health, 32(5), 480–492. DOI: 10.1002/nur.20344 Wetherell, J. L., Stoddard, J. A., White, K. S., Kornblith, S., Nguyen, H., Andreescu, C., Zisook, S., & Lenze, E. J. (2010). Augmenting antidepressant medication with modular CBT for geriatric generalized anxiety disorder: A pilot study. International Journal of Geriatric Psychiatry, 2010 Sep 27. Williams, C. M. (2002). Using medications appropriately in older adults. American Family Physician, 66(10), 1917–1925. Xu, Q., Anderson, D., & Courtney, M. (2010). A longitudinal study of the relationship between lifestyle and mental health among midlife and older women in Australia: Findings from the healthy aging of women study. Health Care Women International, 31(12), 1082–1096.

7

Physical Disabilities and Mental Health

In the United States, it is estimated that one in five women have some type of disability ( National Women’s Health Information Center, 2011 ). It is estimated that 35.6 million adults, 16% of the population, have a physical disability ( U.S. Department of Health and Human Services, 2009 ). A disability is defined as “a chronic physical or mental health problem or impairment that restricts an individual’s ability to perform one or more major activities” ( Davidson, London, & Ladewig, 2012 , p. 158). Of these 35.6 million adults with disabilities, 27 million are women with older women making up the largest percentage of this population. Of these women, 15.4% are unable to perform the basic activities of daily living ( Centers for Disease Control and Prevention, 2011 ). The most common causes of disability in women are arthritis and rheumatism (Centers for Disease Control and Prevention, 2011). Women with disabilities typically are less likely to receive medical services and screenings. They underutilize medical services, often because of lack of health insurance; are underinsured; have difficulty with transportation issues; lack access to needed health services; and experience feelings of discomfort with health care providers. In addition, many health care settings, including clinics and private offices, may not be accessible to women in wheelchairs or those with visual impairments. Women with physical disabilities are at an increased risk for mental health issues, including depression and anxiety, and are more likely to become victims of violence (Research and Training Center on Disability in Rural Communities, 2007; Bahm & Forchuk, 2008). Disability in and of itself is a risk factor for psychological stressors. Women who become physically disabled after a significant injury are one and one-half times more likely to develop a psychological comorbidity (Mohanan & Maselko, 2010).

DEPRESSION AND PHYSICAL DISABILITIES

It is estimated that 30% of women with disabilities have problems completing daily activities as a result of feelings of sadness and depression compared to only 8% of women without physical disabilities (U.S. Department of Health and Human Services, 2000). Women who need assistance with daily living activities are more likely to experience depression and suicidal ideations (Gadalla, 2008a). Women with disabilities often have lower levels of education, lower socioeconomic status, fewer resources, and an increased need to rely on family or caregivers to complete the basic tasks involved in everyday functioning (Research and Training Center in Rural Communities, 2007). Physically disabled women who lack a sense of control over their own lives and who do not enjoy their activities are at greater risk for developing depression (Lippold & Burns, 2009). Women in rural areas are even more likely to experience depression and often find they are lacking the resources needed for mental health treatment both because of their disabilities and their geographical location (Research and Training Center on Disability in Rural Communities, 2007). They often have lower levels of education and fewer opportunities to gain employment than their urban counterparts (Research and Training Center on Disability in Rural Communities, 2007). They also have fewer options for public transportation, which increases their dependence on others, reduces opportunities, and makes seeking treatment more difficult.

ANXIETY AND PHYSICAL DISABILITIES

Women with physical disabilities experience greater stressors and have more educational, financial, relationship, and social issues than women who are not disabled, making them more prone to anxiety disorders (Brenes, Penninx, Judd, Rockwell, Sewell, & Wetherell, 2008). In Canadian women, the risk of an anxiety disorder is significantly increased with physical disabilities. Women requiring assistance with the activities of daily living are also more likely to experience suicidal ideations when an anxiety disorder is present (Gadalla, 2008b). Anxiety disorders and the severity of symptoms seem to be directly related to advancing age, the level of disability, and the need for assistance with the activities of daily living in women as they age (Brenes et al., 2008; Brenes, Guralnik, Williamson, Fried, Simpson, Simonsick et al., 2005).

VIOLENCE AFFECTING WOMEN WITH PHYSICAL DISABILITIES

Women with physical disabilities are four to 10 times more likely to be victims of crime than women who do not have a disability. Intellectually disabled women have a 50% greater incidence of sexual assault than women of normal intelligence (Davidson et al., 2012). Women with physical disabilities are perceived as being more vulnerable and “easy targets” and are frequently victimized because of their perceived inability to fight off attackers, summon assistance, or report family or caregivers as abs for fear of retaliation or abandonment. Disabled mothers often stay with abusive spouses for fear of losing custody of their children (Davidson et al., 2012). Similar to women without disability, women who are subjected to violence or abuse have lower levels of self-esteem.

Clinical Pearl

Disabled women may benefit from assertiveness training, self-defense training, and educational endeavors

FALSE PERCEPTIONS ABOUT DISABLED WOMEN

Women with physical disabilities are often plagued by false perceptions that others may have about them, which leads to an increase in external stressors. Women with both a mental health and a physical disability face more discrimination and stigma than those with only a mental health diagnosis (Bahm & Forchuk, 2008). Many individuals, including health care professionals, assume that women with physical disabilities lack interest in sexual activity, are not interested in pursuing intimate relationships, and lack a desire to become mothers based solely on their physical disability (Center for Research on Women with Disabilities, 1999). Health care services that promote healthy sexuality are often not offered to disabled women because of these false perceptions. While women with disabilities do statistically engage in sexual activity less often, it is because of lack of a partner rather than lack of desire or disinterest in sexual activity. When sexual issues are present, women with disabilities often find themselves without resources or health care professionals with whom they can discuss their concerns. Taking a sexual history provides the woman with an opportunity to voice concerns and ask the nurse questions about sexuality issues and challenges the woman may face. There are approximately 1 million women of childbearing age who are physically disabled in the USA. The number of disabled women who are choosing to have families is increasing as societal values begin to shift (Davidson et al., 2012), however, are few obstetrical providers who have experience caring for women with disabilities. Women with more severe physical disabilities may be encouraged not to have children at all or to undergo unnecessary sterilization. This type of advice can lead to feelings of inadequacy, insecurity, sadness, and depression. Women with certain physical disabilities may be at an increased risk for some physical disorders as well as mood disorders during pregnancy (Signore, Spong, Krotoski, Shinowara, & Blackwell, 2011).

Clinical Pearl

All physically disabled women considering pregnancy should be screened for depression prior to, during, a

Health care professionals may wrongly assume that women with physical disabilities have low self-esteem when, in fact, research has shown that 78% of physically disabled women rated themselves as having high or moderately high self-esteem although they did have lower self-esteem scores when compared to women without physical disabilities (Center for Research on Women with Disabilities, 1999). Factors that include positive family perceptions of their ability to marry and develop an occupation, actual work outside the home, satisfaction with activities, and involvement within a relationship were all positively correlated with high self-esteem (Nosek, Howland, Rintala, Young, & Chanpong, 1997). Encouraging family to view their disabled family member as a valued, productive member of society contributes to a woman’s sense of self and self-esteem. Disabled women who are from ethnic minorities or are lesbians face even more discrimination than disabled Caucasian heterosexual women. These women face multiple factors that may result in discrimination, and they may be less financially stable. Women from certain cultures are often ostracized as a result of a physical disability. In some cultures, disabled girls are not given opportunities for education and may be denied assistive equipment such as crutches or wheelchairs. Family and community may view their disability as a source of shame or disgrace. In some countries, a young girl with a disability may be perceived as having had a curse placed on her that resulted in a physical deformity. Many of these girls suffer for years and are mistreated as a result of their physical disability.

INTELLECTUAL DISABILITIES AND MENTAL HEALTH

Intellectual disabilities (IDs) occur when an individual does not have fully developed intelligence and has issues with learning and understanding. Women with IDs often have alterations in social skills, cognition, language, and motor skills. Some women with more severe IDs may need additional and living assistance throughout their lives. The etiology of ID can be genetic, infection related, or can occur as a result of oxygen deprivation during pregnancy or at the time of birth (Davidson, Ladewig, & London, 2012). Sometimes women with mental illnesses are mislabeled by others as having IDs but IDs are not caused by psychological factors. Mental illness and ID are not the same. Women with IDs are, however, at higher risk for the development of mental illness (Chaplin, 2004). It is estimated that approximately 31% of individuals with an ID have comorbidity with mental illness. Although people with Down syndrome for the highest rates of ID, they have the lowest levels of mental illness in the ID population (Morgan, Leonard, Bourke, & Jablensky, 2008). The most commonly occurring mental illness in ID individuals is Pervasive Developmental Disorder (PDD) followed by Schizophrenia (Morgan et al., 2008). PDD is discussed in Chapter 5. In the United States, most women with comorbidities of mental illness and ID are treated in general psychiatric units. Other countries, such as Canada and Great Britain, have specialized units for women with ID impairment. Women placed in specialized units aimed at treating both ID and mental illness have better outcomes than general units (White, Lunsky, & Grieve, 2010). Women with IDs are at risk for abuse from other patients and need to be closely monitored to provide for their safety in the institutional environment. The specific plan of care for women with comorbid ID and mental illness is based on the woman’s psychiatric diagnosis and individual factors. Women with IDs often live independently although some live in assisted-living situations. Women with IDs are increasingly more active in the community, and many of these women obtain jobs, pursue ongoing educational programs, and marry.

Sexual activity is not uncommon, so appropriate contraception and avoidance of potentially teratogenic agents is imperative. As with any woman, a woman with a comorbidity of mental illness and an ID who wishes to become pregnant, preconception counseling with an obstetrical provider, geneticist, and mentalhealth provider is essential.

CHRONIC ILLNESS AND MENTAL HEALTH

The relationship between chronic illness and mental health symptomology is complex. While some chronic physical conditions may predispose a woman to a mental illness, likewise some mental illnesses may predispose a woman to a physical condition or chronic illness. There are also some pharmacological interventions used to treat illnesses that may precipitate some mental illness symptoms. For example, tamoxifen (Soltamox), an estrogen receptor antagonist, is commonly used to treat women who have had breast cancer, and it is known to decrease levels of serotonin and norepinephrine, which can be a triggering factor for depression. Chronic illnesses commonly associated with mental illness include cancer, neurological illnesses, cardiac disease, and rheumatoid arthritis (Katon & Sullivan, 1990). Some studies have shown that women with a chronic illness have a 41% increased risk of developing a comorbid psychiatric condition (Katon & Sullivan, 1990). Although chronic illness can lead to an increase in psychiatric morbidities, research has indicated that strong social can increase optimism and decrease the incidence of mental illness in women with high self-esteem levels. Women with higher self-esteem, in turn, experience fewer depressive symptoms than women with low self-esteem (Symister & Friend, 2003). Women with chronic illnesses may find that the health care staff is so focused on their chronic illness that their psychological symptomology is often overlooked. Often, psychological symptoms are attributed to the physical condition, and identification of a separate mental illness is missed. Nurses need to focus on identification of symptoms that can be contributing to chronic illnesses but that may be psychological in nature (Wagner, Austin, Davis, Hindmarsh, Schaefer, & Bonomi, 2001).

CHRONIC PAIN AND MENTAL HEALTH

Women living with chronic pain are more likely to experience depression, anxiety, and a lower quality of life. Studies show the presence of chronic pain can induce serious psychological consequences (Tarsuslu et al., 2010). Research has also shown that the less independence a woman has and the more dependence there is on caregivers or family , the higher the incidence of mental distress and illness (Tarsuslu et al., 2010).

DEPRESSION

Depression is widely associated with multiple chronic illnesses (Exhibit 7.1). Other depressive symptoms can cause an increase in certain medical conditions, making women with depression more prone to develop a chronic condition with depression serving as one of the risk factors.

Exhibit 7.1

Chronic Conditions Associated With Depression

Cardiac disease Myocardial infarction Cerebral vascular accident Cancer Chronic lung disease Diabetes mellitus Arthritis Alzheimer’s disease Hypertension

Rheumatism Back pain Migraines Dementia

Source: Adapted from Kilzieh, Rastam, Maziak, & Ward (2008); Patten, Williams, Lavorato, Modgill, Jetté, & Eliasziw (2008).

THE ROLE OF MEDICATION SIDE EFFECTS ON DEPRESSION

Some medications can increase depression or depression symptoms. Isotretinoin (Accutane), alcohol, anticonvulsants, disulfiram (Antabuse), barbiturates, benzodiazepines, beta blockers, bromocriptine, calcium channel blockers, corticosteroids, contraceptive implants, fluoroquinolone antibiotics, gonadotrophin-releasing hormones, histamine blockers, interferon, interleukin-2, mefloquine, narcotics, statins, and tamoxifen have all been reported as having properties that can either cause depressive symptoms or depression in women (Haines, 2005; Urbancic & Grob, 2009).

Clinical Pearl

Review a woman’s pharmacological history carefully to see if medications may have potential psychiatric

THE RELATIONSHIP BETWEEN DEPRESSION AND THE INCIDENCE OF CHRONIC DISEASE

Some diseases are precipitated by depression, meaning having depression actually puts a woman at risk for the development of certain chronic diseases. (Exhibit 7.2 lists diseases in which depression serves as a predisposing factor. Women with depression may report symptoms differently than women without depression. Women with diabetes tend to misreport their blood-sugar levels more frequently when depression is a comorbidity (Urbancic & Grob, 2009).

Exhibit 7.2

Chronic Diseases Precipitated by Depression

Myocardial infarction Stroke Diabetes mellitus Cancer Chronic pain

There are multiple etiologies for the connection between depression and chronic

illness, including environmental, psychological, behavioral, and physiological. There is some literature that s findings that women with depression are less likely to engage in physical activity, have less-healthy eating habits, and are more likely to be overweight or obese. All of these factors alone can predispose a woman to certain chronic diseases. Factors, including smoking, alcohol abuse/use, and substance abuse can also increase the risk of developing a chronic illness. Certain physiological factors that are present with depression can also lead to an increased risk of chronic disease, including decreased immunological functioning, increased platelet count, elevated cortisol levels, and elevated inflammatory markers (Urbancic & Grob, 2009).

HOLISTIC NURSING CARE FOR THE DISABLED WOMAN

Holistic nursing care includes encouraging a woman to seek routine preventivecare medical services on a regular basis. Ongoing psychiatric assessment can ensure that the woman who may be predisposed to depression, anxiety, or another mental illness is identified early. A review of medications and potential side effects should be conducted at each visit. A sexual history should be taken to provide the woman with ample opportunity to discuss concerns related to sexuality. Appropriate referral for gynecological services, including Pap smears, mammograms, preconception counseling, genetic counseling, and contraception, is essential. Women with disabilities should be counseled to eat a well-balanced, nutritious diet and aim for a healthy body mass index because extremes in weight can put a woman at risk for certain medical complications. Exercise programs that promote a woman’s abilities can assist in building self-esteem in addition to having multiple physical benefits. These women do face additional stressors that other woman do not experience on a daily basis. Use of stress-reduction activities and relaxation techniques can decrease the risk of anxiety and depression. Because this group is at an increased risk of violence and abuse, education in reducing the risk of victimization is essential. Self-defense classes, assertiveness training, and financial counseling are all ways that women with physical disabilities can protect themselves and should be discussed by the nurse.

SUMMARY

Women with physical disabilities face stigma and discrimination and often lack access to health care services. The risk of psychological disorders, especially anxiety and depression, is increased in women with disabilities. Women with disabilities are at a significant risk for physical violence, abuse, neglect, and sexual assault. The need for education to prevent abuse is warranted. False perceptions of physically disabled women contribute to stressors faced by this vulnerable population. Health care providers should include a mental health assessment when providing services to disabled women, especially because health care services are often underutilized within this population. Chronic illness can predispose a woman to depression, or depression can serve as a risk factor for chronic illness. Biological changes can put a woman at risk for chronic illnesses when mental health disorders are present. Certain medications can also induce depression, depressive symptoms, or anxiety. The presence of chronic pain can increase a woman’s risk of developing a mental disorder. Women with chronic illnesses warrant careful evaluation for the presence of depression, high-risk behaviors, and unhealthy lifestyle choices. A mental health history and an assessment for current symptoms are imperative in this population. Holistic care for women with chronic disease includes nutritional guidance, obtainment of healthy weight, exercise, stress reduction, elimination of unhealthy behaviors, and compliance with health care recommendations.

Case Study

Annette Francis is a 28-year-old American Indian woman who lives on an Indian reservation in central Texas. Annette was born with quadriplegia cerebral palsy

and is confined to a wheelchair. There were few resources for her growing up, but she did graduate from high school with the assistance of special education services. She has no intellectual impairments. Annette is on Social Security disability because she is unable to work. She lives with her mother and older brother. She has only met her father on a few occasions. Annette suffers from contractures as a result of her disability, osteoporosis, seizures, and depression. What interventions would you perform when Annette presents to the clinic for a medication refill?

Questions to Consider

Why is preconception counseling important for a disabled woman? What chronic illnesses increase the risk of developing a mental illness? What lifestyle modifications are recommended for women with physical disabilities?

REFERENCES

Bahm, A., & Forchuk, C. (2008). Interlocking oppressions: The effect of a comorbid physical disability on perceived stigma and discrimination among mental health consumers in Canada. Health & Social Care in the Community, 17(1), 63–70. DOI: 10.1111/j.1365-2524.2008.00799.x Brenes, G. A., Guralnik, J. M., Williamson, J. D., Fried, L. P., Simpson, C., Simonsick, E. M., et al. (2005). The influence of anxiety on the progression of disability. Journal of the American Geriatrics Society, 53, 15–22. Brenes, G. A., Penninx, B. W., Judd, P. H., Rockwell, E., Sewell, D. D., & Wetherell, J. L. (2008). Anxiety, depression and disability across the lifespan. Aging and Mental Health, 12(1), 158–163. Center for Research on Women with Disabilities. (1999). Abuse on women with disabilities. Retrieved from http://www.bcm.edu/crowd/abuse_women/abuse_women.html Centers for Disease Control and Prevention. (2011). Women with disabilities. Retrieved from http://www.cdc.gov/ncbddd/disabilityandhealth/women.html Chaplin, R. (2004). General psychiatric services for adults with intellectual disability and mental illness. Journal of Intellectual Disability Research, 48, 1– 10. DOI: 10.1111/j.1365-2788.2004.00580.x Davidson, M. R., London, M. L., & Ladewig, P. A. W. (2012). Olds’ maternalnewborn nursing and women’s health across the lifespan, (9th ed.), p. 158. Upper Saddle River, NJ: Pearson. Gadella, T. (2008a). Association of comorbid mood disorders and chronic illness with disability and quality of life in Ontario, Canada. Chronic Diseases Canada, 28(4), 148–154. Gadella, T. M. (2008b). Disability associated with comorbid anxiety disorders in

women with chronic physical illness in Ontario, Canada. Women & Health, 48(1), 1–20. Haines, C. (2005). Medications that can cause depression. MedicineNet.com. Retrieved from http://www.medicinenet.com/script/main/art.asp? articlekey=55169&page=2 Hershey, L. (2000). Women with disabilities: Health, reproduction, and sexuality. International Encyclopedia of Women: Global Women’s Issues and Knowledge, 4. Retrieved from http://www.cripcommentary.com/women.html Katon, W., & Sullivan, M. D. (1990). Depression and chronic medical illness. Journal of Clinical Psychiatry, 51(6, Suppl), 3–11. Kilzieh, N., Rastam, S., Maziak, W., & Ward, K. (2008). Co-morbidity of depression with chronic diseases: A population-based study in Aleppo, Syria. International Journal of Psychiatry in Medicine, 38(2), 169–184. Lippold, T., & Burns, J. (2009). Social and intellectual disabilities: A comparison between social networks of adults with intellectual disability and those with physical disability. Journal of Intellectual Disability Research, 53(5), 463–473. DOI: 10.1111/j.1365-2788.2009.01170.x Mohanan, M., & Maselko, J. (2010). Quasi-experimental evidence on the causal effects of physical health on mental health. International Journal of Epidemiology, 39(2), 487–493. Morgan, V. A., Leonard, H., Bourke, J., & Jablensky, A. (2008). Intellectual disability co-occurring with schizophrenia and other psychiatric illness: Population-based study. The British Journal of Psychiatry, 193, 364–372. DOI: 10.1192/bjp.bp.107.044461 National Women’s Health Information Center. (2011). Statistics. Retrieved from http://www.womenshealth.gov/statistics/ Nosek, M. A., Howland, C. A., Rintala, D. H., Young, M. E., & Chanpong, G. F. (1997). National study of women with physical disabilities: Final report. Houston: Center for Research on Women with Disabilities. Retrieved from http://www.bcm.edu/crowd/national_study/1NSWWPD.htm

Patten, S. B., Williams, J. V., Lavorato, D. H., Modgill, G., Jetté, N., & Eliasziw, M. (2008). Major depression as a risk factor for chronic disease incidence: Longitudinal analyses in a general population cohort. General Hospital Psychiatry, 30(5), 407–413. Research and Training Center on Disability in Rural Communities. (2007). Rural women with disabilities and depression, part one: Characteristics and treatment patterns. Retrieved from http://rtc.ruralinstitute.umt.edu/health/Depression.htm Signore, C., Spong, C., Krotoski, D., Shinowara, N., & Blackwell, S. (2011). Pregnancy in women with physical disabilities. Obstetrics & Gynecology, 117(4), 935–947. DOI: 10.1097/AOG.0b013e3182118d59 Symister, P., & Friend, R. (2003). The influence of social and problematic on optimism and depression in chronic illness: A prospective study evaluating self-esteem as a mediator. Health Psychology, 22(2), 123–129. DOI: 10.1037/0278-6133.22.2.123 Tarsuslu, T., Yümin, E. T., Oztürk, A., & Yümin, M. (2010). The relation between health-related quality of life and pain, depression, anxiety, and functional independence in persons with chronic physical disability. The Journal of the Turkish Society of Algology, 22(1), 30–36. Urbancic, J. C., & Grob, C. J. (2009). Women’s mental health: A clinical guide for primary care providers. Philadelphia: Lippincott, Williams, & Wilkins. U.S. Department of Health and Human Services. (2000). Healthy people 2010: Understanding and Improving health and objectives for health. 2nd ed. Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (2009). Summary health statistics for U.S. adults: National health interview survey, tables 11, 12, 18, 19. Retrieved from http://www.cdc.gov/nchs/data/series/sr_10/sr10_249.pdf Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001). Improving chronic illness care: Translating evidence into action. Health Affairs, 20(6), 64–78. DOI: 10.1377/hlthaff.20.6.64 White, S., Lunsky, Y., & Grieve, C. (2010). Profiles of patients with intellectual disability and mental illness in specialized and generic units in an Ontario

psychiatric hospital. Journal of Mental Health Research in Intellectual Disabilities, 3(3), 117–131. DOI: 10.1080/19315864.2010.487632

8

Lesbian and Transgender Women

It is estimated that approximately 9% of the population identifies themselves as being gay, lesbian, or bisexual or as having same-sex experiences as an adult ( Gates, 2010a ). In a recent study of women, 4.2% identified themselves as being lesbian. Women are twice as likely to be in a same-sex relationship or to identify themselves as being bisexual compared to men ( Gates, 2010a ). Younger people (ages 18–30 years old) are more likely to identify themselves as lesbian, gay, or bisexual (LGB). Almost half (45%) of lesbian and bisexual women do not reveal their sexual preference to their health care provider ( Gay and Lesbian Medical Association, 2010a ). Many of these women have risk factors that can impact their mental well-being, including fear of discrimination and stigma, underutilization of health care services, lack of health insurance, smoking, and substance abuse. Although some research has identified lesbians, gays, and transgendered individuals to be one and one-half to two times more likely to encounter a mental health disorder, additional research is needed to these findings (Brooks, 2011). These findings cite multiple causative factors for the increased incidence of mental illness in lesbians (Brooks, 2011):

■ Discrimination ■ Social pressures ■ Prejudicial practices ■ Anxiety ■ Violence

■ Stringent social attitudes ■ Cultural rejection of homosexuality

Previously to 1973, homosexuality was categorized as a mental health disorder. In 1973, homosexuality was removed from the DSM-II and identified as a normal healthy sexual orientation.

LESBIAN POPULATIONS

The number of lesbian women in same-sex relationships is also increasing. According to U.S. Census data, 581,300 couples identified themselves as samesex couples, up 3% from 2000 (Gates, 2010b). This number is likely to be extremely underrepresentative because of the large number of states that do not recognize same-sex marriages, unions, and other legal statuses that would put these women into a “married” category for data-collection purposes.

STRESSORS FACED BY LESBIAN, BISEXUAL, AND TRANSGENDERED WOMEN

Lesbian, bisexual, and transgendered women face a variety of daily stressors that are not endured by heterosexual women. Many young women explore their sexual orientation during their adolescent years, which can make their teen years a time of struggle and emotional stress and strain. Lesbian women often grapple with coming out and declaring their sexual orientation. Most lesbian women have faced discrimination at some point in their lives with many of them living with discrimination and social stigma on a regular basis. Some women may be fearful about telling family , friends, or coworkers about their sexual orientation and personal relationships. Many women fear harassment and verbal abuse and even become the victims of violence as a result of their sexual orientation. Society, in general, is geared toward heterosexual families, making lesbian families sometimes struggle to meet accepted norms. Lesbian women can face barriers in attempting pregnancy, obtaining housing for their same-sex family, and employment discrimination. In the U.S. military, before 2011, it was illegal and grounds for a dishonorable discharge to reveal a homosexual orientation. It was not until then that homosexual of the military could legally serve in the Armed Forces without fear of retribution. In some cultural and religious groups, homosexuality is viewed negatively or even seen as a sin. Women from diverse cultural groups may experience social stigma, family shame, parental rejection, and social rejection as a result of their sexuality. Eastern cultures typically have a more conservative perspective on homosexuality than Western cultures. Bisexual women are sometimes at odds with both the heterosexual and homosexual communities, being sandwiched in the middle and sometimes rejected by both groups.

BARRIERS TO HEALTH CARE SERVICES

In general, many lesbians feel uncomfortable about discussing their sexual orientation and, therefore, lesbian-specific health care issues with practitioners. Lesbian and bisexual women often feel as if health care providers are not open to their disclosure. Other lesbian women feel as if health care providers may not have adequate knowledge about lesbian issues and how they can impact a woman’s health status (Bjorkman & Malterud, 2009). Many lesbian and bisexual women avoid preventive care practices because of fear of stigma and negative stereotyping from health care professionals. Most health care facilities are heterosexual oriented. The majority of clinics and offices do not ask about sexual orientation and make the assumption that all women are indeed heterosexual. Other facilities may create barriers for women who wish to include their partners in health care services. Other forms of stigma may include the following (Committee on Lesbian, Gay, Bisexual, and Transgendered Health, 2011):

■ Verbal abuse ■ Refusal of treatment ■ Disrespectful behavior from care providers ■ Lack of respect for same-sex partner

Lack of health insurance is another common barrier to care because many lesbian and bisexual women do not have health insurance benefits (Committee on Lesbian, Gay, Bisexual, and Transgendered Health, 2011). Even though lesbians have higher incidences of hypertension, diabetes, obesity, and physical disabilities, they are less likely to receive medical care for these illnesses than

heterosexual women. Lesbians are less likely to undergo routine screenings for reproductive cancers putting them at higher risk for an undetected cancer (Committee on Lesbian, Gay, Bisexual and Transgendered Health, 2011).

TRANSGENDERED INDIVIDUALS

Transgender refers to individuals whose gender identity differs from that of their birth sex (American Psychological Association [APA], 2006). The incidence of transgender women is approximately 1 in 30,000. It is three times more common in men (APA, 2006). Biological females who wish to be identified and live as males are referred to as female-to-male transsexuals (FMT) or transsexual women. Men who wish to live as females are known as male-to-female transsexuals (MFT) or transsexual men. Cross-dressing is common in transgendered individuals. Women may wear masculine clothing, bind their breasts, or wear a penile prosthesis. Many of these individuals take steps to make their gender physicality consistent with their preferred gender through the process of hormone therapies or surgical intervention. Most of these therapies are not recommended until documented life experience has taken place for at least 3 months or has been prescribed by an evaluating mental health clinician (Harry Benjamin International Gender Dysphoria Association, 2006). For these individuals, sex reassignment surgery or gender reassignment is sometimes performed. These individuals typically have a distinct sexual orientation that does not change once reassignment surgery is completed.

GENDER IDENTITY DISORDER

Gender Identity Disorder (GID) exists when an individual experiences distress over his or her gender identity or it causes personal mental suffering; being transgendered is not, in itself, a mental health disorder. The etiology of GID is unknown; however, potential causes include the following (National Center for Biotechnology Information, 2010):

■ Genetic factors ■ Environmental triggers ■ Hormonal exposure in utero

In order to meet the diagnostic criteria, feelings of being “the wrong gender” must be present for a period of at least 2 years. A woman with GID may have many of her life choices affected by the disorder, including her self-concept and choice of sexual partners and the way she displays herself to the world. GID in children and adolescents is extremely complex and requires specialized care to address counseling needs. Symptoms of GID in children include disgust of their genitals, desire to be the opposite sex or belief they will grow up and become the other sex, social isolation from peers, anxiety, depression, and verbalization of not liking their sexual identity. Young women with GID may exhibit the following:

■ Loneliness ■ Depression

■ Anxiety ■ Desire for genitals of the opposite sex ■ Living as the opposite sex by using another name ■ Dressing like the opposite sex

For adults with GID, the treatment of choice includes therapy, group therapy, living as the identified gender, and sexual reassignment surgery (Harry Benjamin International Gender Dysphoria Association, 2001). Hormonal therapy is another option and should be managed by an experienced practitioner with expertise in treating individuals who desire hormonal manipulation. Hormonal therapy is usually more effective for individuals wanting male characteristics because undoing the effects of puberty are not possible. Women taking testosterone are at an increased risk for adverse cardiac complications because of these increased levels. Individuals with GID are at an increased risk for stress, isolation, anxiety, depression, poor self-esteem, and suicide. Prognosis is improved with early treatment and intervention. Sexual reassignment surgery notes beneficial outcomes for most women who pursue sexual reassignment surgery. Of the individuals who do undergo sexual reassignment surgery, 86% were assessed by their clinicians as having improved global functioning. In a Swedish study of 60 individuals who underwent sexual reassignment surgery, none of the participants regretted his or her decision to have the surgery, and 90% reported improvement in work, intimate-partner relationships, and sexual functioning following the sexual reassignment surgery (Johansson, Sundbom, Höjerback, & Bodlund, 2009). Adjustment issues may occur in the immediate postoperative phase. Most practitioners insist the individual live as the desired sex for a period of time prior to initiating surgical intervention to decrease the incidence of adjustment-related disorders.

DEPRESSION

Depression affects lesbian women at a higher rate than their heterosexual counterparts. Bisexual women report more sadness than lesbian or heterosexual women (Conron, Mimiaga, & Landers, 2010). Lesbians and bisexual women are one and one-half times more likely to become depressed compared to heterosexual women (King, Semlyen, Tai, Killaspy, Osborn, Popelyuk, & Nazareth, 2010). Rationales for these differences include facing discrimination, hiding their sexual orientation from others, strained family relationships regarding their sexual orientation, and challenges faced with living in a homophobic society (Gay and Lesbian Medical Association, 2010a). Risk factors for depression in lesbian and bisexual women include poor socioeconomic status, frequent mental distress, and poor general health (Fredriksen-Goldsen, Kim, Barkan, Balsam, & Mincer, 2010). Incidences of depression are higher in transgendered women who face discrimination from family and social rejection (Gay and Lesbian Medical Association, 2010b). Transgendered women tend to be underemployed, face job stress, and fear job loss more than those within the heterosexual population. Ethnic minorities face even greater discrimination than their White counterparts.

ANXIETY

Lesbian and bisexual women experience more daily anxiety, worry, and tension than their heterosexual counterparts (Conron, Mimiaga, & Landers 2010). Lesbian and bisexual women are one and one-half times more likely to experience an Anxiety Disorder than heterosexual women (King et al., 2010). Anxiety rates are higher for transgendered women who often worry about social interactions, job stress, and strained family relationships (Gay and Lesbian Medical Association, 2010b). Transgendered individuals often encounter harassment and social exclusion and are often exposed to violence. Increased levels of stress can predispose an individual to anxiety and depression.

SUBSTANCE ABUSE

Lesbian and bisexual women have higher rates of substance abuse than gay men and heterosexual individuals (Hughes, Szalacha, & McNair, 2010). Lesbian women smoke 200% more than heterosexual women (Gay and Lesbian Medical Association, 2010a) and are more likely than heterosexual women or gay men to develop alcoholism. The lifetime risk of alcoholism is 7% for lesbian women (King et al., 2010); it is theorized that some lesbian women consume alcohol as a coping mechanism for dealing with their stressors. Transgendered women have a high incidence of tobacco use, alcohol abuse, and substance abuse (Gay and Lesbian Medical Association, 2010b). Women who take testosterone have a higher incidence of myocardial infarction and stroke when related to substance abuse patterns. Lesbian women with substance abuse issues should be referred to a peer group specific to lesbians. Those with mental health and substance abuse issues should be referred to lesbian-specific dual diagnosis groups.

SELF-HARM PRACTICES

Resulting from many of the same etiologies as other mental health disorders, lesbian women are more at risk for self-harm practices than their heterosexual counterparts. Self-harm practices may include cutting, intentional poisoning, and intentional injury. Self-harm practices occur at the highest levels in lesbian women who encounter interpersonal trauma and sexual discrimination (House, van Horn, Coppeans, & Steppleman, 2011). Other studies that have examined self-harm practices have identified substance abuse, binge eating, binge drinking, depression, and cigarette smoking to be present more often in individuals who exhibit self-harm behaviors (Serras, Saules, Cranford, & Eisenberg, 2010). Because lesbians have a higher incidence of these risk factors, the need for careful history taking is imperative.

SUICIDE

Suicidal ideations are three times higher in lesbian women than in heterosexual women and men (House et al., 2011). The risk of suicide is two times higher in the lesbian and gay population (King et al., 2010). Suicide attempts and successful suicides occur more often in the gay and lesbian population than in heterosexual populations although gay men have higher success rates of suicide than lesbian women. In the U.S. data, transgendered women have a higher suicide rate both before and after gender reassignment surgery (Gay and Lesbian Medical Association, 2010b). These data are consistent with the heterosexual population in that males typically utilize more lethal modalities, making the success rates related to suicide higher in men than in women. Lesbians who experience intrapersonal trauma along with sexual discrimination encounters had a higher incidence of suicide (House et al., 2011). Although suicide rates are notably higher in the Caucasian population, the incidence in the gay and lesbian population is higher in Hispanic and African Americans (O’Donnell, Meyer, & Schwartz, 2011).

CREATING A CULTURE OF CARING FOR DIVERSE CLIENTS WITHIN THE HEALTH CARE SETTING

Nurses can play a key role in facilitating effective health care practices that will welcome and engage lesbian women.

■ Health care questionnaires that ask about sexual orientation and practices portray that the facility and providers are open to caring for lesbian women. ■ Frank and open discussions should focus on asking the woman about her personal preferences and her perceived health care needs. ■ Mental health care issues are often difficult subjects and should be approached with cultural sensitivity. ■ Portray respect and acceptance of the woman’s lifestyle, beliefs, and values. ■ Empower the woman and her partner (if desired) to become advocates for her own health care needs. ■ Develop advanced directives for mental health care services that include the desired facility, treatment provider, persons or partner involved in care decisions, and a legal power of attorney for health care decision making. ■ Education materials that include lesbian relationships and photos and information pertinent to the lesbian population. ■ Provide privacy, emotional , and involvement of partner and significant persons as desired by the woman. ■ Provide community-based resources in the lesbian community when available, such as dual diagnosis groups, Alcoholics Anonymous, Narcotics Anonymous,

etc. ■ Referral to therapists and psychiatrists who have experience in treating lesbian or bisexual women and caring for lesbian couples.

SUMMARY

Some lesbian, bisexual, and transgendered women may be at an increased risk for specific mental health disorders secondary to homophobia, social isolation, lack of knowledge of family about their sexual orientation, and risk of violence in the community. Practitioners need to provide culturally sensitive care to these women and screen this population carefully when providing primary health care services. Lesbians have a higher incidence of depression, anxiety, substance abuse, self-harm practices, and suicidal ideations. These warrant closer observation and assessment for these disorders within this population. Staff should receive training in providing appropriate nonjudgmental care to diverse client populations, including the lesbian community.

Case Study

Tasha Simon is a 20-year-old African American female who presents to the mental health clinic with symptoms of depression, anxiety, and generalized distress during her intake interview. Tasha confides she feels like she was born in the wrong body, and it “torments me daily.” She says that, from the age of 2, she has struggled with wanting to “be a boy.” Tasha reports that she only played boyoriented games and dressed in boys’ clothing since the age of 5. During her early school years, her mother fought with her to do more “girl things and wear dresses.” Tasha would sneak her brother’s clothing into her backpack and change at school. Over the years, her parents punished her repeatedly for expressing these behaviors and tried to overcompensate for her mannerisms by enrolling her in more feminine activities, such as Girl Scouts and dance. During the final phase of the interview, Tasha begins sobbing and states, “The strain of forcing me to act like a girl has driven me to my breaking point!” What interventions would be appropriate for Tasha? What is her probable mental health disorder?

Questions to Consider

What barriers do lesbians face when seeking health care services in the community? Why are lesbians and bisexual women at higher risk for certain mental illnesses? How can nurses create an environment that embraces women from all sexual orientations and puts them at ease in the health care setting? What stressors put lesbians at risk for adverse health outcomes?

REFERENCES

American Psychological Association. (2006). Answers to your questions about transgender individuals and gender identity. Washington, DC: Author. Bjorkman, M., & Malterud, K. (2009). Lesbian women’s experiences with health care: A qualitative study. Scandinavian Journal of Primary Care, 27(4), 238–243. Brooks, M. (2011). Mental health problems more common in gays, lesbians, bisexuals. Retrieved from http://www.medscape.com/viewarticle/736802 Committee on Lesbian, Gay, Bisexual, and Transgendered People. (2011). Building a foundation for a better understanding. Washington, DC: Institute of Medicine. Conron, K. J., Mimiaga, M. J., & Landers, S. J. (2010). A population-based study of sexual orientation, identity, and gender differences in adults. American Journal of Public Health, 100(10), 1953–1960. Fredriksen-Goldsen, K. I., Kim, H. J., Barkan, S. E., Balsam, K. F., & Mincer, S. L. (2010). Disparities in health-related quality of life: A comparison of lesbians and bisexual women. American Journal of Public Health, 100(11), 2255–2261. Gates, G. J. (2010a). Sexual minorities in the 2008 general social survey: Coming out and demographic characteristics. Los Angeles: Williams Institute. Gates, G. J. (2010b). New Census Bureau data show annual increases in samesex couples outpacing population growth: Same-sex couples affected by recession. Los Angeles: Williams Institute. Gay and Lesbian Medical Association. (2010a). Depression. Retrieved from http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageID=589 Gay and Lesbian Medical Association. (2010b). Ten things transgendered people should discuss with their health care provider. Retrieved from

http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageID=692 Harry Benjamin International Gender Dysphoria Association. (2001). Standards of care for gender identity disorders, 6th ed. Retrieved from http://wpath.org/Documents2/socv6.pdf House, A., van Horn, E., Coppeans, C., & Steppleman, L. (2011, Sep 13). Interpersonal trauma and discriminatory events as predictors of suicidal and nonsuicidal self-injury in gay, lesbian, bisexual, and transgender persons. Traumatology. DOI: 10.1177/1534765610395621 Hughes, T., Szalacha, L. A., & McNair, R. (2010). Substance abuse and mental health disparities: Comparisons across sexual identity groups in a national sample of young Australian women. Social Science Medicine, 71(4), 824–831. Johansson, A., Sundbom, T., Höjerback, E., & Bodlund, O. (2009). A five-year follow-up study of Swedish adults with gender identity disorder. Archives of Sexual Behavior 39(6), 1429–1437. DOI: 10.1007/s10508-009-9551-1 King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk, D., & Nazareth, I. (2010). A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry, 18(8), 70. National Center for Biotechnology Information. (2010). Gender identity disorder. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002495/ O’Donnell, S., Meyer, I. H., & Schwartz, S. (2011). Increased risk of suicide attempts among Black and Latino lesbians, gay men, and bisexuals. American Journal of Public Health, 1101(6), 1055–1059. DOI: 10.2105/AJPH.2010.300032 Serras, A., Saules, K. K., Cranford, J. A., & Eisenberg, D. (2010). Self-injury, substance use, and associated risk factors in a multi-campus probability sample of college students. Psychology of Addictive Behaviors, 24(1), 119–128. DOI: 10.1037/a0017210

9

Female Veterans

It is estimated that in 2010 in the United States there were approximately 1.8 million female veterans compared to 20 million male veterans. The number of female veterans has risen sharply as their job capacities in the military have expanded since 1994 when combat-related bans were lifted ( U.S. Department of Veterans Affairs, 2007 ). In 2008, 11% of individuals serving in Afghanistan and Iraq were female soldiers. The military is 15% women with women representing the fastest growing veterans group ( U.S. Department of Veterans Affairs, 2010 ). In this chapter, the generic term “soldier” will represent all women who are serving or have served in military operations. Types of female veterans vary from their male counterparts. Women veterans are younger (with a median age of 47 compared to men with a median age of 61) and frequently come from large geographical states (California, Texas, Florida, Virginia, New York, Pennsylvania, Ohio, and North Carolina), with the highest numbers originating from the southern region of the United States (U.S. Department of Veterans Affairs, 2007). Nearly 30% of female veterans identify themselves as being part of a minority group. Female veterans tend to enter military service with lower educational attainment although they typically come from a higher income level than their male counterparts (U.S. Department of Veterans Affairs, 2007). Female veterans face similar psychiatric morbidities as their male counterparts as a direct result of military service. The most commonly treated disorders in female veterans are Posttraumatic Stress Disorder (PTSD), hypertension, and depression. In 2006, there were 80,000 women with military-related disabilities, many of them psychiatric in nature (U.S. Department of Veterans Affairs, 2007). Risk factors for mental illness in the military include female gender, age less than 31 years, first deployment, African American or Hispanic race, enlisted

rank, and hip in a reserve or national guard unit (Batuman, BeanMayberry, Goldzweig, Huang, Miake-Lye, Washington, Yano, Zephyrin, & Shekelle, 2011). It is estimated that 18% of women and 14% of men who have served in the military have a mental health diagnosis (Batuman et al., 2011).

FEMALE-RELATED STRESSORS

Combat Operations

Although women are not specifically trained for combat operations, many female soldiers are exposed to combat situations on a daily basis. Women are often employed in combat- positions and stationed in areas where regular combat is a daily occurrence. They are exposed to gunfire, hostile fire, and bombings, and often see other soldiers wounded or killed. Many women develop subsequent psychiatric illness or symptoms as a direct result of these experiences. Female soldiers are more commonly removed from the field for psychological issues and experience more inpatient hospitalizations than male soldiers. Women exposed to combat operations also have higher incidences of severe weight loss and eating disorders, especially during their initial deployment (Batuman et al., 2011).

Separation From Family

Many female soldiers, because they are in the minority, feel isolated and alone while being estranged from their families. High soldier morale is linked to a feeling of cohesion, and some women may not feel included in a maledominated group (U.S. Department of Veterans Affairs, 2010). They may lack female counterparts who can provide and peer relationships during a time of intense stress. Just living in a predominantly male environment introduces varying norms and social culture and is often stressful. Because many women serve as caregivers to their children and elderly parents, their absence may put a strain on loved ones at home and serve as a constant source of stress. Separation from spouses, children, family, and friends can cause intense psychological reactions in these women. Many military deployments occur suddenly, and women may be away from home for periods of up to a year. Many have role disruptions in parenting their young children and sometimes have adjustment issues when returning home. It is difficult to relinquish caring for children to another adult and then attempt to return to that role suddenly when a deployment ends. Women soldiers often carry the weight of the battlefield along with the pressures of home with them and can become overloaded with these stressors.

MARITAL STRESSORS

Marriages under stress and distress are more likely to end in dissolution and divorce. Natural disasters, war and combat, and financial stressors all increase the risk for dissolution of marriages (Wadsworth & Riggs, 2011). The U.S. military has more married service than single soldiers. With the recent war efforts in Iraq and Afghanistan, female soldiers are deployed for longer periods of time and endure more frequent deployments. Active-duty soldiers experience the least amounts of marital stress compared to National Guardsmen and Reservists who may be less prepared to deal with a prolonged separation. Perhaps active-duty personnel are more prepared for the possibility of deployment based on their career choices. Women are more likely than their male counterparts to divorce or separate during or after a deployment (Wadsworth & Riggs, 2011). Of all married soldiers, women with children had a lower incidence of marital distress and lower divorce rates compared to soldiers without children (Wadsworth & Riggs, 2011). Some military marital distress occurs over the lack of communication that is mandated by military personnel during deployments. The power differential of having one spouse possess knowledge that cannot be shared with the other spouse creates a stressor between partners. Often, women cannot share their location, mission, or other intimate information with their partners, which leads to a lack of discourse between partners. There is also sometimes limited communication that further exerts strain and pressure on the couple (Durham, 2010).

Lesbian Families in the Military

Until fall of 2011, gay and lesbian soldiers were not permitted to openly disclose their sexual orientation during their military service. In 2011, the “Don’t Ask, Don’t Tell” laws were repealed, providing gay and lesbian service the ability to recognize previously hidden partners and families. The number of affected service is thought to range in the hundreds; however, experts expect these numbers to rise now that gay and lesbian service can now openly serve (Dao, 2011). These families continue to face stigma and discrimination and are not entitled to the same social, financial, housing, or health care services that are afforded other spouses. Under the federal legislation known as the Defense of Marriage Act, same-sex couples are excluded from receiving federally financed benefits otherwise afforded to opposite-sex couples (Dao, 2011). These lesbian soldiers face the stressors of war and combat while also dealing with issues of coming out in the military environment. Many of them are just now announcing and acknowledging the existence of girlfriends or wives and children. While many acknowledge a huge feeling of relief and a reduction in stress levels, others worry about open discrimination from their peers and the uphill battle to obtain military benefits for their spouses and partners.

Military Sexual Trauma

Military sexual trauma (MST) occurs when there is unwanted sexual attention that includes lewd sexual remarks being directed at women, unwanted sexual advances, and even sexual assault. Women who have experienced MST are at greater risk for isolation, anxiety, and depression (U.S. Department of Veterans Affairs, 2010). It is estimated that 50% of the women deployed to Afghanistan and Iraq encountered sexual harassment in the field (Dutra, Grubbs, Greene, Trego, McCartin, Kloezeman, & Moreland, 2011). Interestingly, women who experienced MST in the Gulf War more than 10 years ago have higher rates of physical ailments, including gastrointestinal, genitourinary, musculoskeletal, and neurological symptoms, than their counterparts who were not exposed to MST, thus indicating that MST has both physical and psychological adverse effects to military women (Smith, Shepard, Schuster, Vogt, King, & King, 2011).

MILITARY-RELATED PTSD

The incidence of PTSD in female veterans varies with each war. In Vietnam, the PTSD rate in female soldiers was 27%, whereas in Iraq and Afghanistan veterans, it is estimated to be 10% to 20% (U.S. Department of Veterans Affairs, 2010; Dutra et al., 2011). It is likely that statistics on previous conflicts were not tracked. Women with military-related PTSD tend to benefit from high levels of social and family . Having emotional from an individual who understands the emotional rigors of war seems to be of greatest benefit (U.S. Department of Veterans Affairs, 2010). groups for female soldiers who have returned from combat areas can offer these soldiers a safe place to share their feelings and experiences where they will feel ed and respected. Peers are more likely to understand the unique needs of the returning soldier— more so than well-meaning family and other ers. Some studies have shown that exposure to combat and MST result in a higher risk for the development of PTSD (Dutra et al., 2011; Batuman et al., 2011). Other studies have shown that women who have a history of intimate-partner violence, substance abuse, and preexisting psychiatric problems are more prone to military-related PTSD than other female soldiers (Dobie, Kivlahan, Maynard, Bush, Davis, & Bradley, 2004). These women are also more likely to experience physiological disorders, such as obesity, smoking, fibromyalgia, chronic pelvic pain, polycystic ovarian syndrome, asthma, cervical cancer, and stroke, thus making the need for comprehensive medical care imperative (Dobie et al., 2004). While female veterans tend to utilize Veterans istration (VA) medical services for physical ailments, they are less likely to seek care at a VA facility for psychiatric issues resulting from the sensitive nature of mental health conditions (Hoff & Rosenheck, 1998). Screening for psychiatric symptomology should therefore be assessed at every VA encounter to identify women veterans who may be suffering from mental illness. A complete discussion of PTSD is presented in Chapter 15.

Alcohol Use

The use and abuse of alcohol is higher in female veterans when compared to women who have not served in the military. When other psychological factors are present—such as MST and PTSD—the use of alcohol consumption increases. Although alcohol use is elevated compared to other women, it is lower when compared to male soldiers and veterans. Although female military personnel drink less than their male counterparts, they have more loss of productivity as a result and higher rates of dependence (Brown, Bray, & Hartzell, 2010). Nearly half of all women with military-related PTSD also have a high consumption of alcohol (Batuman et al., 2011). Although alcohol use rates were highest in the 1980s, the military has strongly discouraged alcohol abuse, and the numbers of affected women has declined in recent years (Wallace, Sheehan, & Young-Xu, 2009). Recent studies that have assessed the use of alcohol in Operation Iraqi Freedom found that 11% of troops misused alcohol while in combat (Felker, Hawkins, Dobie, Gutierrez, & McFall, 2008). Other studies that have evaluated alcohol abuse at 3 to 4 months post-deployment found rates of 27% (National Institute of Mental Health, 2011).

Substance Abuse

High stress levels perceived by military women increase the risk of illicit substance abuse. Military women are more likely than men to use illicit substances, and military men were more likely to engage in alcohol use (Bray, Fairbank, & Marsden, 1999). Although illicit drug abuse has decreased since 2002, the incidence of prescription drug abuse has doubled since 2002 and tripled between 2005 and 2008, making drug abuse a major issue in the military (National Institute of Mental Health, 2011).

EATING DISORDERS

Like other women, female soldiers are at higher risk for eating disorders than their male counterparts. Environmental stressors may play a role in the development of an eating disorder in female soldiers. In one study that examined female soldiers, 9% had Bulimia Nervosa, 3% were identified as having Anorexia Nervosa, 15% had a binge eating disorder, and an additional 33% had an Unspecified Eating Disorder (Eating Disorders Review, 2000). Because military women are obligated to maintain certain weight ratios as a component of military service, situational stressors, such as weigh-ins and fitness requirements, lead to adverse eating patterns, excessive exercise, binge eating behaviors, dissatisfaction with their bodies, and a drive to achieve thinness. The authors believe this drive for thinness to be similar to that of professional female athletes (Eating Disorders Review, 2000).

DEPRESSION

Depression rates are highest in women who are deployed and in those exposed to combat operations. It is estimated that 9% to 35% of women returning from the battlefield will experience depressive symptomology (Dutra et al., 2011; Smith et al., 2011). As in the general population, more women in the military experience depression than men. Men in the military are more likely to experience substance abuse than women soldiers. Women who were deployed in noncombat operations had lower levels of depression compared to women exposed to combat conditions (Batuman et al., 2011).

SUICIDE

In the general population, the ratio of male-to-female suicide rates is 4:1 compared to 3:1 in the military and post-military setting. Female veterans are more likely to commit suicide than their nonveteran female peers. Of particular interest, the number of female veterans utilizing firearms to commit suicide is also rising. Firearm-assisted suicide carries higher fatality rates than other methods commonly used by women. Women who served in the military have a 1.6 greater chance of utilizing a firearm than a nonveteran female. Veterans have a 66% higher suicide rate than nonveterans. Younger veterans are more likely to commit suicide than older veterans (Batuman et al., 2011). In military personal, 30% of suicides and 45% of suicide attempts are related to alcohol or drug use (National Institute of Mental Health, 2011).

SUMMARY

Our female veterans have made the ultimate sacrifice in serving our county in both combat and noncombat operations. As the number of female soldiers continues to rise, they make up the fastest-growing group of veterans in the United States. Women veterans are commonly exposed to combat operations and MST, both of which can predispose a woman to developing psychological disorders, such as depression, PTSD, and alcoholism. Women veterans are more likely to commit suicide than nonveteran women and are less likely to receive psychiatric services in the outpatient VA setting. Careful screening of female veterans at each medical encounter is imperative to identify female veterans who may have psychiatric morbidities.

Case Study

Emily Vasquez is a 23-year-old Hispanic soldier who just returned home from a 12-month tour in Iraq. During her time in Iraq, Emily tells her sister she was constantly “harassed” by her male counterparts and felt unsafe in her barracks because of the constant remarks and comments they made. She witnessed a significant amount of violence during her recent tour, and since her return, she has had trouble sleeping, sadness, recurrent thoughts of the battlefield, and flashbacks to a particular event in which her friend was severely injured and two other soldiers were killed. Emily feels responsible for their deaths and feels she should have done more during the incident although, realistically, this was not possible. What do Emily’s symptoms suggest her probable diagnosis to be? What interventions may be appropriate for Emily?

Questions to Consider

How can deployed married soldiers reduce the degree of marital distress on their relationship during a deployment? What barriers can be reduced through political policy making to assist lesbian families in obtaining family benefits through the military? Why are female soldiers more likely than their civilian peers to attempt and complete suicide? How can nurses provide to female veterans while identifying those at risk for developing military-related PTSD?

REFERENCES

Batuman, F., Bean-Mayberry, B., Goldzweig, C. L., Huang, C., Miake-Lye, I. M., Washington, D. L., Yano, E. M., Zephyrin, L. C., & Shekelle, P. G. (2011). Health effects of military service on women veterans. VA-ESP Project # 05-226. Bray, R. M., Fairbank, J. A., & Marsden, M. E. (1999). Stress and substance use among military women and men. American Journal of Drug and Alcohol Use, 25(2), 239–256. Brown, J. M., Bray, R. M., & Hartzell, M. C. (2010). A comparison of alcohol use and related problems among women and men in the military. Military Medicine, 175(2), 101–107(7). Dao, J. (16 July, 2011). Same-sex marriage faces military limits. The New York Times. Retrieved from http://www.nytimes.com/2011/07/17/us/17military.html? pagewanted=all Dobie, D. J., Kivlahan, D. R., Maynard, C., Bush, K. R., Davis, T. M., & Bradley, K. A. (2004). Posttraumatic stress disorder in female veterans: Association with self-reported health problems and functional impairment. Archives of Internal Medicine, 164(4), 394–400. Durham, S. W. (2010). In their own words: Staying connected in a combat environment. Military Medicine, 175(8), 554–559(6). Dutra, L., Grubbs, K., Greene, C., Trego, L. L., McCartin, T. L., Kloezeman, K., & Moreland, L. (2011). Women at war: Implications for mental health. Journal of Trauma & Dissociation, 12(1), 25–37. DOI: 10.1080/15299732.2010.496141 Eating Disorders Review. (2000). Eating disorders high among military women. Retrieved from http://www.bulimia.com/client/client_pages/newsletter6.cfm Felker, B., Hawkins, E., Dobie, D., Gutierrez, J., & McFall, M. (2008). Characteristics of deployed Operation Iraqi Freedom military personnel who

seek mental health care. Military Medicine, 173(2), 155–158(4). Hoff, R. A., & Rosenheck, R. A. (1998). Female veterans’ use of Department of Veterans Affairs Health Care Services. Medical Care, 36(7), 1114–1119. National Institute of Mental Health. (2011). Substance abuse among the military, veterans, and their families. Retrieved from http://www.nida.nih.gov/tib/vet.html Smith, B. N., Shepard, J. C., Schuster, J. L., Vogt, D. S., King, L. A., & King, D. W. (2011). Posttraumatic stress symptomatology as a mediator of the association between military sexual trauma and post-deployment physical health in women. Journal of Trauma & Dissociation, 12(3), 275–289. DOI: 10.1080/15299732.2011.551508 U.S. Department of Veterans Affairs. (2007). Women veterans: Past, present, and future. Retrieved from http://www.va.gov/womenvet/docs/womenvet_history.pdf U.S. Department of Veterans Affairs. (2010). Traumatic stress in female veterans. Retrieved from http://www.ptsd.va.gov/professional/pages/traumatic_stress_in_female_veterans.asp Wadsworth, S. M., & Riggs, D. (2011). Risk and resilience in U.S. military families. New York: Springer. Wallace, A. E., Sheehan, E. P., & Young-Xu, Y. (2009). Women, alcohol, and the military: Cultural changes and reductions in later alcohol problems among female veterans. Journal of Women’s Health, 18(9), 1347–1353. DOI:10.1089/jwh.2008.0861

10

Women and Forensic Mental Health Issues

The majority of women in the United States who are incarcerated for crimes meet the criteria of having a mental illness. Women with mental illnesses are more likely to be involved in the criminal justice system than women without a psychiatric morbidity. As the number of psychiatric inpatient facilities has declined, the number of women with mental illnesses entering the correctional environment has steadily climbed. Incarcerated women are far more likely to be mentally ill than their male counterparts at a ratio of 1:4 (American Radioworks, 2011). The majority of mentally ill inmates are white females. Minorities represent a lower number of incarcerated women with mental illness (American Radioworks, 2011). These women are more likely to have been homeless prior to their incarceration and more likely to have committed a violent crime in the past. In addition, 75% have at least one prior offense, and 50% have a history of three or more past offenses (America Radioworks, 2011). Women with mental health issues in the correctional system are more likely than men to have a dual diagnosis, i.e., a mental health issue that coexists with substance abuse or alcoholism (Foreman, 2011). It is estimated that 40% of mentally ill patients have been in jail at some time within their lives (Torray, Kennard, Eslinger, Lamb, & Pavle, 2010). Substance-abuse disorders represent a large portion of the mental illnesses that occur within the correctional setting. It is estimated that 60% of the correctional system population has a substance abuse issue (Rutherford & Duggan, 2007). The most commonly used substances by women in the criminal justice system are methamphetamines. Women who engage in substance abuse are more likely to participate in sexually risky behaviors as evidenced by increases in sexually transmitted infections including HIV, hepatitis B and C, chlamydia, and gonorrhea. Women who are substance abs in the criminal justice system are

more likely to be chronic substance abs and victims of violence. Since 1973, the number of women in correctional settings with substance abuse issues has increased by 737% (Correctional Association of New York, 2008).

STATISTICS

There are approximately 148,000 women in the United States confined to jail or prison (Amnesty International, 2011). Of women in jail or prison, 80% meet the criterion for one or more lifetime psychiatric disorders, and 70% of these women were symptomatic within the past 6 months prior to the study; other literature estimates are higher, stating that mental illness affects 90% of all female prisoners (Rutherford & Duggan, 2007). The most common diagnoses affecting women within the correctional setting include the following:

■ Substance abuse ■ Alcoholism ■ Posttraumatic Stress Disorder (PTSD) ■ Major Depressive Disorder

Major Depressive Disorder is the most common major mental illness found in incarcerated women within the United States. Most female forensic mental illness patients are charged with nonviolent crimes (Teplin, Abram, & McClelland, 1996). Although women detainees have a constitutional right to receive treatment while in jail or prison, it is estimated that only 23.5% of female inmates receive such services (Teplin, Abram, & McClelland, 1997). Lack of services is most commonly associated with overcrowding of facilities and lack of qualified professionals to conduct comprehensive screening (Stean, Osher, Robbins, Case, & Samuals, 2009). Most detainee programs do not offer counseling services for women with mental health or substance abuse disorders. It is estimated that 48% to 88% of these women have been previously exposed to

domestic violence, intimate partner violence, or sexual or physical abuse, or suffer from PTSD (Amnesty International, 2011). It is estimated that as many as 64% of all detainees (male and female) may have a mental health problem (James & Glaze, 2006). Of the prison population, it is estimated that 200,000– 300,000 have a serious mental health disorder, such as schizophrenia, bipolar disorder, or major depression (Fellner, 2006). New York’s Riker’s Island and the Los Angeles, County Jail currently have more mentally ill detainees than the largest mental health hospital in the United States, making the U.S. jails and prison systems the largest provider of mental health care in the United States (Forensic Mental Health Association of California, 2011; Fellner, 2006), with three times as many individuals in jail or prison suffering from a mental health disorder than there are in mental hospitals in the United States (Fellner, 2006). Women detainees are three times more likely to have a mental illness than their male counterparts (Stean, Osher, Robbins, Case, & Samuals, 2009).

DEFINING FORENSIC MENTAL HEALTH

Forensic mental health issues are defined as mental health issues that are intertwined with the legal system. Forensic is defined as pertaining to the law. Typically, when an individual who is mentally ill commits a crime, and the crime is a direct result of that individual having a mental illness, by definition it is considered a forensic mental health issue. The woman with forensic mental health issues is in need of a professional who specializes in the complexities of her medical psychiatric needs and the complex legal issues that are involved.

MENTAL ILLNESS WITHIN THE CORRECTIONAL SETTING

The jail and prison system has two to four times higher numbers of mentally ill patients than the general population and virtually no programming for the treatment of these mentally ill patients. The number of mentally ill detainees appears to be rising. This may be attributed to better mental health screening and an increase in those with mental illness being sent to prison (Fellner, 2006). There are a number of theories that reflect a rationale for rising numbers of these detainees, including a poorly run mental health system in the United States, lack of adequate funding for the treatment of the mentally ill, and more aggressive anti-crime and anti-drug laws. Some experts argue that if there were adequate treatment facilities and services available, the number of mentally ill prisoners would decline. Currently, in the general population, most women do not have access to comprehensive inpatient services unless they meet certain criteria, such as being psychotic or being a danger to self or others. Even women with private insurance may be turned away for comprehensive inpatient psychiatric services because they do not meet certain criteria. Women who fail to meet this criteria often are not given access to acute-care facilities because of overcrowding and lack of funding (Fellner, 2006). In 1955, there was one psychiatric bed for every 300 individuals. In 2010, there was one bed for every 3,000 individuals, and many of those are allotted to forensic patients, which means they are not readily available for the general public (Torrey et al., 2010). The current conditions in the United States are similar to situations circa 1842 when the mentally ill were jailed rather than being cared for in a health care setting. The creation of state mental facilities during the time of Dorothea Dix was the chief reform used to change this trend. Since the decentralization of mental health hospitals in the 1950s, the number of mentally ill patients in jail has continued to rise (Torrey et al., 2010). In most correctional facilities, there are no differential treatment programs for detainees who have a mental illness. Most of the codes and procedures in the correctional setting include treatment parameters that are counterproductive to the treatment of mental illness (Exhibit 10.1). It is not unusual for mentally ill

detainees to have difficulty adapting to the correctional setting, and as such, they are more likely to break rules and policies, ending up with more infractions. Despite the high number of mental health detainees, the correctional staffs often have little or no training in the treatment of mentally ill prisoners. As with other infractions, mental health detainees are treated with punishment regardless of their mental illness. Many infractions may be a symptom of their actual mental illness. Some women in the jail or prison setting may fail to understand they have broken rules or why punishment is being executed. Furthermore, many guards and prison officials actually believe individuals with mental illness are faking their illness to avoid strict punishment or as an excuse not to follow prison or jail rules and protocols (Fellner, 2006).

Exhibit 10.1

Correctional Procedures and Factors That Are Unfavorable for the Well-Being of Female Mentally Ill Detainees

Overcrowding Violence Victimization by other prisoners Mistreatment by correctional staff Lack of privacy Lack of stimulating activities Mistreatment by guards Isolation from family and friends

Uncertainty about life after prison/jail Inadequate health care services No availability of counseling services Lack of pharmacological treatment or lack of appropriate monitoring of medications Lack of access to psychiatrist, psychotherapist, or mental health nurse practitioner Tension between guards and detainees because of mental health diagnosis Sexual discrimination or sexual harassment by guards or jail personnel Lack of power Priorities on safety, security, and procedural rules and not mental health Possible segregation, including isolation, from other prisoners

Source: Adapted from Fellner (2006); Human Rights Watch (2003).

COMPETENCY TO STAND TRIAL

When a forensic mental illness detainee is identified, the first task is to determine if the woman is competent to stand trial. The premise of competency to stand trial is based on the Dusky Standard, which states that an individual must be able to assist his or her attorney with a reasonable degree of understanding and understanding of the proceedings against him or her (Roesch, Zapf, Golding, & Skeem, 2004). There are an estimated 25,000 to 39,000 competency hearings in the United States annually. This represents 2% to 8% of all felony defendants being referred for competency hearings on an annual basis (Roesch et al., 2004). In the past, measures of competency varied widely by jurisdiction until the introduction of forensic assessment instruments that have begun to establish validity and reliability and more systematic proof for evaluating defendants.

DIMINISHED CAPACITY

Diminished capacity is sometimes utilized as a means of reducing an individual’s sentence when mental illness is present. Nearly all of the states have adapted a statute or case decision that provides for this under the law. Legally, it represents an excuse as to why the criminal act is committed. It is based on the premise that one’s mental capacity was diminished at the time the crime occurred, which should be taken into consideration in the legal arena. It is not the same as the “not guilty by reason of insanity” (NGRI) defense. The outcome of the defense varies and may include a defendant being found not guilty, exculpation to a degree that results in a lesser charge being considered, or a mitigated sentence.

NOT GUILTY BY REASON OF INSANITY AND GUILTY BUT MENTALLY ILL

The NGRI or “guilty but mentally ill” (GBMI) sentences are sometimes used when an individual its to committing a criminal act but lacks the mental capability to have carried it out. The Insanity Defense Reform Act of 1984 clarifies that in Federal Courts the stated incompetence has to be the result of a “present mental disease or defect” (Novak, 2006). While individual states have varied legal definitions, most require that a mental illness exists and that the individual did not know right from wrong at the time of the criminal act or was unable to appreciate her actions. In some states, the presence of an irresistible impulse may also be considered as a factor for the defense. The defense must be ed by forensic mental health professionals who agree the petitioner meets the requirements. In more than 86% of cases, when forensic experts have determined a woman meets the criteria for NGRI, the prosecution does not object (Novak, 2006). It is commonly perceived by the general public that many mentally ill patients receive less stringent sentences or are sent to mental health care facilities for treatment, thus escaping jail sentences. In reality, the vast majority of mentally ill detainees do not get a NGRI sentence. Most states have no limit to how long an individual found NGRI will spend in a mental health facility. The NGRI defense is rare and is utilized in approximately 1% of all criminal cases with a 26% success rate, meaning .26% of all defendants are found NGRI (Schmalleger, 2001). Because media coverage of NGRI cases is common—for example, the Andrea Yates case, in which a woman in Texas with a postpartum mood disorder drowned her five children—the public often believes the defense is used more commonly in our legal system than it actually is. Once found NGRI, individuals who obtain this status are sent to a state mental health facility until they are deemed safe to return to the community. Unlike defendants found guilty in a criminal courtroom, there is no specific sentence or time period applied to these women. Many individuals spend more time in a state mental hospital than they would in jail or prison if found guilty under

traditional law and sentenced to jail time. NGRI female acquittees are much less common than males, although statistical data are difficult to obtain. Women who commit NGRI offenses are less likely to be substance abs than their male counterparts (Zonana, Bartel, Wells, Buchanan et al., 1990). Female acquittees are typically older than their male counterparts, have committed a single criminal act, and are more likely to be diagnosed with a Mood Disorder or Borderline Personality Disorder. While NGRI women tend to commit more serious crimes, their hospitalizations tend to be shorter than their male counterparts (Seig, Ball, & Menninger, 1995). Research has shown that aggressive and comprehensive outpatient, post-release, community-based programs can be effectively utilized to manage NGRI clients upon release into the community (Vitacco, Van Rybroek, Erickson, Rogstad, Tripp, Harris, & Miller, 2008).

Clinical Pearl

Most women who commit NGRI crimes spend more time in a mental hospital than they would serving a ja

PREVENTION AND TREATMENT

Many experts contend that a great number of women would be rescued from the correctional setting if adequate mental health care programs were in place. The lack of availability of inpatient psychiatric beds is one factor that contributes to the high numbers of incarcerated women (Torrey et al., 2010). Lack of available community-based mental resources is another limitation in our system. Women who lack health insurance may be unable to seek out services from mental health professionals while others who do receive needed services may be unable to afford their medications or the cost of ongoing therapies (Human Rights Watch, 2003). Stigma plays another role in women not seeking mental health care services. Women may fear stigma, loss of custody of their children, loss of their job, and disapproval from family and friends if they are labeled as mentally ill. Identification of risk factors, prompt identification of intimate-partner or family violence, substance and alcohol abuse treatment programs, and early diagnosis of mental illness can all play roles in reducing the number of female forensic mental health patients. Prompt ongoing treatment from properly trained personnel is essential to understanding and preventing recidivism in women with mental illness.

BARRIERS TO PROVIDING MENTAL HEALTH CARE

Most forensic mental health care facilities are state run and lack adequate staff and services. Forensic mental hospitals are tasked with maintaining safety first and providing care as a secondary task. Many facilities have difficulties finding willing or properly trained caregivers. These barriers can result in inadequate or sub-adequate care services for mentally ill women in the forensic setting. Many facilities have an extremely limited psychiatric staff that may have difficulty providing services to all of the clients who warrant care. Some regional correctional facilities have a single provider who sees patients on a part-time basis and whose role is limited to medication istration.

BARRIERS TO CONDUCTING RESEARCH

Forensic mental health research requires a vigorous approval process, which often leads to a reduction in the number of studies that are performed using women who meet the criteria for being classified as forensically mentally ill. Many qualified graduate and doctoral students are often discouraged from conducting research with mentally ill or incarcerated women because of the vast difficulties in obtaining approval to investigate these high-risk populations. State facilities may be reluctant to allow investigators to interview and conduct research with the forensic mentally ill population. There are few studies that examine women who are found NGRI, found incompetent to stand trial, or have a diminished capacity to assist in their defenses. Because these women are also involved in the legal system, their attorneys may object to participation in studies and research.

SUMMARY

Women with a forensic mental illness face multiple challenges in finding competent professionals to provide comprehensive health care and legal services. Trends in the care of the mentally ill have led to a rising number of female detainees in correctional settings in recent years. Unlike male detainees, women who are in a correctional setting are more likely to suffer from a mental illness. In the United States, the prison and jail system has more detainees with a mental health problem than all the U.S. mental hospitals combined. These women should be carefully evaluated for their competency to stand trial and to detect if diminished capacity exists. While thought to be commonplace, the NGRI or GBMI plea is uncommon and rarely successful in defending the mentally ill. Major reform is needed in the mental health care and correctional settings to change these demographics and improve outcomes for forensic mentally ill women.

Case Study

Jeanette Jennings is a 21-year-old Caucasian female whose mother died when she was 14 years old. Upon her mother’s death, Jeanette lived with her maternal grandmother in a somewhat chaotic household with her four siblings. Jeanette began abusing marijuana and alcohol shortly after her mother’s death and began “getting into trouble” with her peers during her adolescent years. At the age of 19, Jeanette was diagnosed with Bipolar Disorder but has been unable to afford her medications, so she has not been compliant with the medication regimen or therapies that were prescribed. On October 8, during a manic period, Jeanette began throwing baby powder around her grandmother’s home, broke a kitchen cabinet door, and threw her CD player through the window. Her grandmother called 911 with hopes they would take her for emergency psychiatric care. The

county prosecutor was called by the police and charged her with felony destruction of property. Jeannette was found NGRI and transferred to a state psychiatric hospital where she has resided for 20 months. What criteria are needed to establish a credible NGRI defense? Do you think she meets the criteria for NGRI? Please explain your answer and rationale.

Questions to Consider

What is the difference between competency to stand trial and not guilty by reason of insanity? What criteria are used to determine if a woman meets the standards for NGRI or GBMI? Why are women in the correctional system more likely to be mentally ill than their male counterparts? Provide possible explanations as to why there is a rise in mentally ill detainees in the criminal justice system in recent years?

REFERENCES

America Radioworks. (2011). Jailing the mentally ill. Retrieved from http://americanradioworks.publicradio.org/features/mentally_ill/poll/stats.html Amnesty International. (2011). Women in prison: A fact sheet. Retrieved from http://www.prisonpolicy.org/scans/women_prison.pdf Correctional Association of New York. (2008). Women in prison and substance abuse fact sheet. Retrieved from http://www.correctionalassociation.org/publications//wipp/factsheets/Women_ and_Substance_Abuse_Fact_Sheet_2008.pdf Fellner, J. (2006). A corrections quandary: Mental illness and prison rules. Harvard Civil Rights-Civil Liberties Law Review, 41. Retrieved from http://www.law.harvard.edu/students/orgs/crcl/vol41_2/fellner.pdf Foreman, C. (2011, March 13). PA professors fail mentally ill women. The Real Cost of Prison. Retrieved from http://realcostofprisons.org/blog/archives/2011/03/pa_professors_p.html Forensic Mental Health Association of California. (2011). FMHAC provides and education to professionals in the forensic mental health field. Retrieved from http://www.fmhac.net/ Human Rights Watch. (2003). United States: Mentally ill mistreated in prison. Retrieved from http://www.hrw.org/en/news/2003/10/21/united-states-mentallyill-mistreated-prison James, D. J., & Glaze, L. E. (2006). Mental health problems of prison and jail inmates. Pubication no. NCJ213600. Washington, DC, Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2006. Novak, B. (2006). Criminal forensic psychology. Retrieved from

Psychiatrywww.stanford.edu/.../Criminal%20Forensic%20Psychiatry%20Outlin Roesch, R., Zapf, P. A., Golding, S. L., & Skeem, J. L. (2004). Defining and assessing competency to stand trial. Retrieved from http://www.unl.edu/apls/student/CST%20assess.pdf Rutherford, M., & Duggan, S. (2007). Forensic mental health services: Facts and figures on current provision. Retrieved from http://www.centreformentalhealth.org.uk/pdfs/scmh_forensic_factfile_2007.pdf Schmalleger, F. (2001). Criminal justice: A brief introduction. Upper Saddle River, NJ: Prentice Hall. Seig, A., Ball, E., & Menninger, J. A. (1995). A comparison of female versus male insanity acquittees in Colorado. The Bulletin of the American Academy of Psychiatry and the Law, 23(4), 523–532. Stean, H. J., Osher, F. C., Robbins, P. C., Case, B., & Samuals, S. (2009). Prevalence of serious mental illness among jail inmates. Psychiatric Services, 60(6), 761–765. Teplin, L. A., Abram, K. M., & McClelland, G. M. (1996). Prevalence of psychiatric disorders among incarcerated women. I. Pretrial jail detainees. Archives of General Psychiatry, 53(6), 505–512. Teplin, L. A., Abram, K. M., & McClelland, G. M. (1997). Mentally disordered women in jail: Who receives services? American Journal of Public Health, 87(4), 604–609. Torrey, E. F., Kennard, A. D., Eslinger, D., Lamb, R., & Pavle, J. (2010). More mentally ill persons are in jails and prisons than hospitals: A survey of the States. National Sheriff’s Association. Retrieved from http://www.sheriffs.org/files/file/FinalJailsvHospitalsStudy.pdf Vitacco, M. J., Van Rybroek, G. J., Erickson, S. K., Rogstad, J. E., Tripp, A., Harris, L., & Miller, R. (2008). Developing services for insanity acquittees conditionally released into the community: Maximizing success and minimizing recidivism. Psychological Services, 5(2), 118–125. Zonana, H. V., Bartel, R. L., Wells, J. A., Buchanan, J. A., et al. (1990). Sex

differences in persons found not guilty by reason of insanity: Analysis of data from the Connecticut NGRI Registry: II. Bulletin of the American Academy of Psychiatry & the Law, 18(2), 129–142.

III

Childbearing and Women’s Health Issues

11

Menstrual-Related Issues

The reproductive years of a woman’s life are a time of great emotional stress, hormonal fluctuations, and life-changing events. During the reproductive years, women typically separate from their parents’ home, obtain a job or career, establish long-term relationships, and develop a sense of purpose for their lives. During early adulthood, many mental health issues may become evident or symptomatic. (Specific mental health disorders will be discussed in Part IV of this book). Some mental health conditions may be directly related to a woman’s hormonal cycle. As many as 75% of women experience physical or emotional changes routinely in the premenstrual period that results in mood changes (Massachusetts Center for Women’s Mental Health, 2011). The most common disorders related to the menstrual cycle are premenstrual syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD).

PREMENSTRUAL SYNDROME

The term PMS was first introduced in the 1950s to describe a collection of emotional, physical, and behavioral symptoms that occur one to two weeks before menses and cease within one to two days of the onset of menses. While PMS includes emotional symptoms, it is not categorized as a mental health disorder but is included within this text because of its common nature. The incidence of PMS is stated to be between 30% and 80% with a higher incidence in the third decade and in unmarried women (Tshchudin, Bertea, & Zemp, 2010). Women in their 40s and 50s commonly have symptoms of PMS with varying severity (Frank, Arkava, & McManus, 2011). Women with PMS typically have a higher incidence of psychological distress and poor physical health compared to women without PMS (Tshchudin et al., 2010).

Etiology

PMS occurs when the follicle is released from the ovary during the luteal phase of the menstrual cycle. This phase typically lasts from cycle day (CD) 14–28 in a normal 28-day cycle. (CD 1 is marked with the first day of menses. During this phase, progesterone levels are elevated and estrogen levels drop as the lining of the uterus thickens awaiting potential fertilization (Davidson, Ladewig, & London, 2012). The shift from a high-estrogen to a low-estrogen environment is thought to be the causative factor for symptomology (Frank et al., 2011). Other causal theories include lower endorphins in the luteal phase; overload of fluid in the kidneys; alterations in insulin, blood sugar, and vitamins A, B6, and E; cycling levels of serotonin; and alterations in prostaglandins (Chocano-Bedoya et al., 2011; Frank et al., 2011).

Signs and Symptoms

The signs and symptoms of PMS vary from woman to woman but include emotional, physical, and behavioral symptoms (Table 11.1). There are up to 150 symptoms that have been associated with PMS. According to the American College of Obstetricians and Gynecologists (2000), the following criteria establish the diagnosis of PMS:

■ At least one emotional symptom and one physical symptom must be present in the five days prior to menses for the last three menstrual cycles. ■ The symptoms must end four days after the onset of menses. ■ Recurrences of symptoms should not appear prior to CD 13. ■ The symptoms occur without the ingestion of alcohol, drugs, or therapeutic hormones. ■ The symptoms occur during two cycles of a reportable period in which symptoms are being tracked. ■ The woman suffers from social or economic performance issues.

Table 11.1 ■ Symptoms of PMS

Emotional Symptoms Anxiety, nervousness, mood swings, irritability, depression, forgetfulness, confusion, insomnia, hostility

Source: Adapted from Frank et al., 2011; Davidson et al., 2012.

Assessment and Screening

A diagnosis of PMS is typically based on a comprehensive history from the woman. A mood and symptom log may be helpful in identifying and specifying symptomology throughout the menstrual cycle. These instruments typically include a calendar, a place to identify the time of menses, and a coding system to record symptoms. Emotional, physical, and behavioral symptoms should be assessed and recorded. The practitioner can then identify where in the cycle the symptoms are occurring in order to make an accurate diagnosis. The number and severity of symptoms vary from woman to woman, but typically, women with PMS do not have an inability to function normally. Women with symptoms severe enough to interfere with normal functioning should be further screened for PMDD, to be discussed shortly. Some women may suffer from both PMS and PMDD (Davidson et al., 2012).

Treatments

Treatment is aimed at reducing the unpleasantness of symptoms. Women should be counseled to eat a well-balanced diet, limiting varying sugar levels, moderating alcohol use, limiting salt and caffeine (Frank et al., 2011). Exercise is a useful means of reducing stress and tension and reaps positive health benefits. Bio, relaxation techniques, and muscle tension/relaxation exercises may also prove beneficial. Nutritional supplements have been used with varying success to treat PMS. Supplements traditionally used in the treatment of PMS include vitamin E (200–1,000 IU/day), calcium (1–2 g/day), and magnesium (280–400 mg/day) (Chocano-Bedoya et al., 2011). Food sources of thiamine and riboflavin have been associated with a 35% reduction in PMS diagnosis (Chocano-Bedoya et al., 2011). Combined hormonal contraceptives, such as birth control pills, the patch, or the vaginal ring, can also be used to suppress ovulation and improve symptoms. Some research has shown that continuous istration without a withdrawal bleed can further improve symptoms in women with PMS (American College of Obstetricians and Gynecologists, 2010). Emotional symptoms can be treated with antidepressants or antianxiety medication as needed.

Essential Tip

Women should be encouraged to track PMS symptoms, attempted treatments, exercise, diet, and lifestyle ch

PREMENSTRUAL DYSPHORIC DISORDER

PMDD, like PMS, occurs in the luteal phase of the menstrual cycle and stems from hormonal changes associated with a woman’s menstrual cycle. PMDD is, however, classified as a mental health disorder and interferes with a woman’s daily functioning and involves more severe symptoms. It is commonly present for 7 to 14 days prior to the onset of menses and results in worsening symptoms. It is estimated that 2% to 8% of women suffer from PMDD during their reproductive years (Tshchudin et al., 2010).

Etiology

The etiology of PMDD is the same as PMS. Risk factors for PMDD include a history of depression, postpartum depression, anxiety, and seasonal affective disorder. Risk factors include alcohol abuse, obesity, family history of PMDD, lack of exercise, and high caffeine intake (National Center for Biotechnology Information, 2010).

Signs and Symptoms

Signs and symptoms of PMDD are listed in Exhibit 11.1. In order for a woman to be diagnosed with PMDD, at least five symptoms must be present during the week prior to the onset of menses in the majority of menstrual cycles within the last 12 months (Frank et al., 2011).

Exhibit 11.1

Symptoms of PMDD

Depression Anxiety Severe mood swings Marked anger Irritability Decreased interest in usual activities Difficulty concentrating Reduction in energy Increased appetite and cravings

Insomnia Hypersomnia Feeling overwhelmed or out of control Bloating Breast tenderness Headaches

Source: Adapted from Frank et al., 2011; Davidson et al., 2012.

These symptoms can occur in any woman during the years she is menstruating and can persist after a hysterectomy as long as at least one ovary is left in place. The illness typically ends when the woman enters menopause, and hormones no longer fluctuate each month. Differential diagnosis includes Major Depressive Disorder, anxiety, and personality disorders, which could also coexist with PMS or PMDD (Frank et al., 2011).

Assessment and Screening

Each woman should be evaluated for PMDD as part of her mental health and well-woman examination. A complete history and symptom log should be kept for one to two menstrual cycles to pinpoint symptoms. The Premenstrual Symptoms Screening Tool (PSST) can also be used to establish a diagnosis for the disorder. The PSST is a screening tool that includes 19 items: 14 premenstrual symptoms and five functional items that are derived from the DSM-IV diagnostic criteria for PMDD (Steiner, Peer, Palova, Freeman, Macdougall, & Soares, 2011). Recently, an updated revision of the tool, the PSST-A, was trialed to identify adolescents with PMDD (Steiner et al., 2011). In addition, a complete history and physical should be obtained to rule out other physiological causes, such as thyroid disorder, hormonal imbalance, electrolyte imbalances, and anemia. Women who meet the above discussed criteria are diagnosed with PMDD and should be advised of appropriate treatment. A psychiatric assessment is warranted to identify the existence of other possible disorders and to confirm the diagnosis.

Treatment

Treatment options should include behavioral, herbal, pharmacological, ive, and nutritional management. Treatment is aimed at reducing symptoms. Because women’s symptoms vary, treatment should be customized to reduce a woman’s particular symptoms. Women who are not trying to actively conceive may consider combined hormonal contraceptives, such as pills, patches, or vaginal rings. Combined hormonal contraceptives suppress ovulation and remove the fluctuation of hormones during the menstrual cycle. Yasmin or Yaz, combined oral contraceptives (COCs) that contain the progestin drospirenone, possess diuretic properties although, in comparison studies, they did not reduce PMS any more than the trialed vaginal ring (American College of Obstetricians and Gynecologists, 2010). Some studies have shown that continuous istration of COCs that eliminate a monthly withdraw bleed has been effective in managing PMS symptomology (American College of Obstetricians and Gynecologists, 2010). Other hormonal treatment options that suppress ovulation are available, including gonadotropin-releasing hormone (GnRH) agonists, such as Danazol and Depo Lupron; however, these are typically not first-line treatments because of the severity of side effects associated with their use. Other regimens include antidepressants or antianxiety medications for emotional symptoms. Anti-inflammatories can reduce bloating, cramping, breast tenderness, and headaches (Frank et al., 2011). Diuretics are sometimes used cautiously to decrease bloating and water retention (Davidson et al., 2012). The use of antidepressants and/or antianxiety medications is common in women with PMDD. There are three drugs that are FDA-approved to treat PMDD although many other antidepressants are commonly used. Fluoxetine (Sarafem), paroxetine (Paxil CR), and sertraline hydrochloride (Zoloft ) are also approved (see Table 11.2). Antidepressants should not be used concurrently with St. John’s wort because it also works on serotonin receptors and can lead to serotonin syndrome (Wilson, Shannon, & Shields, 2011). There are no FDA-approved

antianxiety drugs for the treatment of PMDD, but benzodiazepines are sometimes used.

Table 11.2 ■ FDA-Approved Antidepressants to Treat PMDD

Drug Name Fluoxetine (Sarafem) Paroxetine (Paxil CR) Sertraline hydrochloride (Zoloft)

Recommended Dosage 10–20 mg/day up to 60 mg/day; may also take cyclically 14 days prior to the onset of m 12.5 mg once daily; can increase dosage to 25 mg/day; may also be given cyclically 14 50 mg/day first cycle with titration up to 150 mg/day

Source: Data from Wilson et al., 2011; Nursing 2012 Drug Handbook, 2012.

groups are helpful for some women who may experience embarrassment, shame, or stigma as a result of their diagnosis. Peer allows a woman to express her feelings in a ive, nurturing environment. Cognitive behavioral therapy may provide the woman with a sense of control and allow her to develop coping strategies when symptoms do occur. Women with PMDD should be questioned about thoughts of self-harm because as many as 10% of women with PMDD experience suicidal thoughts, and most of these thoughts occur during the luteal phase of the menstrual cycle (National Center for Biotechnology Information, 2010). Suicidal thoughts warrant emergency treatment if a plan is in place to complete the act or if the woman cannot contract with the mental health professional to maintain her safety. Other regimens that decrease stress and anxiety may prove helpful, such as yoga, relaxation techniques, controlled breathing, muscle tension–relaxation exercises, and bio.

SUMMARY

The luteal phase of the menstrual cycle is a time of great hormonal change that can lead to symptomology in some women. As many as 80% of women experience PMS symptoms each month and up to 8% suffer from the mental health disorder PMDD. Clinicians should screen carefully for these disorders during each client encounter and be knowledgeable about screening and treatment options. A holistic approach is best used to treat women who suffer from PMS and PMDD. A psychiatric evaluation is warranted for women with worsening symptoms or those with symptoms that impair daily functioning on an ongoing basis each month. Many women experience elimination or a significant reduction in symptoms when holistic treatment is provided.

Case Study

Amanda Fairfield is a 38-year-old White woman, unmarried and not sexually active, who reports a worsening of PMS symptoms over the last 7 months. Amanda takes no medications and has no history of mental illness in her personal or family history. She has never been pregnant and states she does not plan on having children. She states she is heterosexual and has had boyfriends in the past. Her symptoms include moodiness, irritability, and bloating in her abdomen along with a sense of fullness in her lower quadrant that changes monthly from one side to the other. She asks the nurse if there is any treatment for her symptoms. What interventions would you discuss with her?

Questions to Consider

What preventive interventions can the nurse suggest to decrease the incidence of PMS? What pharmacologic interventions can be used to treat PMDD? How can the nurse explain the differences between PMS and PMDD to a woman with premenstrual symptomology?

REFERENCES

American College of Obstetricians and Gynecologists. (2000). Premenstrual syndrome. ACOG Practice Bulletin No. 15. Washington, DC: ACOG. American College of Obstetricians and Gynecologists. (2010). Noncontraceptive uses of hormonal contraceptives. ACOG Practice Bulletin No. 110. Washington, DC: Author. Chocano-Bedoya, P. O., Manson, J. E., Hankinson, S. E., Willett, W. C., Johnson, S. R., Chasan-Taber, L., Ronnenberg, A. G., Bigelow, C., & BertoneJohnson, E. R. (2011). Dietary B vitamin intake and incident premenstrual syndrome. American Journal of Clinical Nutrition, 93(5), 1080–1086. DOI: 10.3945/ajcn.110.009530 Davidson, M. R., London, M. L. & Ladewig, P. A. W., (2012). Olds’ maternalnewborn nursing and women’s health across the lifespan, (9th ed.). Upper Saddle River, NJ: Pearson. Frank, J., Arkava, T. E., & McManus, J. G. (2011). Premenstrual syndrome (PMS). E-medicine. Retrieved from http://www.emedicinehealth.com/premenstrual_syndrome_pms/article_em.htm Massachusetts Center for Women’s Mental Health. (2011). Retrieved from http://www.womensmentalhealth.org/blog/ National Center for Biotechnology Information. (2010). PMDD; Severe PMS. Pub-Med Health. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004461/ Nursing 2012 Drug Handbook (2012). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. Steiner, M., Peer, M., Palova, E., Freeman, E., Macdougall, M., & Soares, C. N. (2011). The premenstrual symptoms screening tool revised for adolescents

(PSST-A): Prevalence of severe PMS and premenstrual dysphoric disorder in adolescents. Archives of Women’s Mental Health, 14, 77–81. DOI: 10.1007/s00737-010-0202-2 Tshchudin, S., Bertea, P. C., & Zemp, E. (2010). Prevalence and predictors of premenstrual syndrome and premenstrual dysphoric disorder in a populationbased sample. Archives of Women’s Mental Health, 13(6), 485–494. DOI: 10.1007/s00737-010-0165-3 Wilson, B. A., Shannon, M. T., & Shields, K. M. (2011). Pearson nurse’s drug guide: 2011. Upper Saddle River, NJ: Pearson Education.

12

Infertility and Psychological Implications

It is estimated that 10% to 15% of couples experience infertility issues. Infertility is defined as the inability to conceive after 12 months of attempting pregnancy ( Davidson, London, & Ladewig, 2012 ). Infertility crosses all cultural, economic, and social barriers. Increases in infertility have evolved as a result of societal trends, such as delayed childbearing, infection with sexually transmitted infections (STIs), and exposure to certain medications. It is estimated that one-third of infertility is female-factor related, one-third is male-factor related, and the remaining one-third results from unknown factors ( Davidson et al., 2012 ). The two types of infertility are primary infertility , meaning the couple is unable to achieve pregnancy at all or to maintain a pregnancy, such as in cases of repeated spontaneous abortions. Secondary infertility occurs in couples who have had a previous pregnancy but are then unable to conceive again. Infertility, in the past, was a diagnosis that carried no hope for treatment and left many couples facing childlessness. In modern society, two-thirds of couples will experience success with fertility treatments. Today more than ever, couples seek out specialists to achieve pregnancy in hopes of building a family that includes children. Infertility services can be limited, however, by financial constraints, lack of insurance coverage, lack of health care specialists in rural areas, religious beliefs, and cultural norms. In addition to heterosexual couples, more single women, lesbian women, and homosexual couples are seeking infertility treatments. A woman undergoing infertility assessment and treatment should be evaluated for common psychological disorders that may impact a future pregnancy. Infertile women with preexisting mental health disorders need careful management to ensure any medications being istered are safe for a

pregnant woman. Ideally, medication manipulation should occur prior to the beginning of infertility therapy, so dosages can be stabilized and changed as needed prior to conception. A therapeutic relationship with both a therapist and a psychiatrist is recommended prior to the beginning of therapy. Because many infertility treatments manipulate hormones, the need for medication changes may occur. Women with a history of premenstrual dysphoric disorder (PMDD), postpartum depression (PPD), or postpartum psychosis (PPP) are particularly vulnerable to these hormonal changes.

CULTURAL AND RELIGIOUS REACTIONS TO INFERTILITY

In some cultures, the inability to bear children is grounds for divorce and estrangement from one’s family. A woman can be shunned for her inability to conceive. In some Muslim cultures, the inability to conceive may be thought to be related to the presence of evil spirits, witchcraft, and punishment from God (Fido & Zahid, 2004). In other cultures, such as African American, Asian, and Hispanic cultures, the man is seen as the dominant partner, and an inability to conceive may negatively impact his perceived masculinity. Some men may refuse infertility testing because of this reason for fear of embarrassment and stigma. In Western cultures where delayed childbearing is often associated with reaching educational and career goals, a woman may be perceived by others as putting her career aspirations ahead of her family. In some religions, the creation of children is considered a duty and couples unable to fulfill this duty may be stigmatized. In many religions, infertility is seen as a test of faith. In the Jewish faith, the creation of children is extremely important and is thought to be an obligation and a responsibility. In the Islamic and Catholic faiths, religion has a strong effect on high parity in women (Lutz, 1987). The Catholic Church has strict standards regarding the conception of children via intercourse and does not endorse many types of infertility treatments. Catholic couples who utilize treatments outside of the Church’s acceptable standards may feel conflicted and guilty, torn between following a church doctrine, achieving their desired goal of parenthood, and being faithful to their beliefs.

PSYCHOLOGICAL REACTIONS TO INFERTILITY

Women who desire children and are unable to conceive experience a variety of emotions. Some women with female factor–related infertility may experience guilt or shame. Some women are used to being in control of their lives and careers and have always been able to set and meet goals. The sudden inability to reach the desired goal of pregnancy can be devastating. Some women with infertility issues may develop resentment, anger, or jealousy toward their peers or family who can seemingly conceive effortlessly while they struggle with the task. Attending certain events, such as baby showers or baptisms, may be a source of psychological distress for women, with some women developing avoidance behaviors that result in social isolation. Women faced with infertility are at risk for certain mental health diagnoses including depression, anxiety, Sleep Disorders, marital dysfunction, and Sexual Dysfunction. Risk factors for mental health diagnoses secondary to infertility treatment include female gender, age greater than 30 years, lower educational obtainment, lack of career or work involvement, male-factor infertility, and infertility lasting 3 to 6 years (Massachusetts General Hospital Center for Women’s Mental Health, 2011). Infertile women with depression and anxiety achieve pregnancy less frequently, even with major technical intervention, such as in vitro fertilization (IVF) (Gürhan, Akyüz, Atici, & Kisa, 2009).

STRESS

Couples undergoing infertility evaluation or treatment experience a great deal of stress. Women are often facing the grief of not being able to conceive on their own. For these women, the onset of monthly menses represents a time of great loss as pregnancy has failed to occur. Couples facing an infertility evaluation are exposed to a variety of intensive testing procedures, which in and of themselves can be stressful. For many women, the fear that they are the causative partner creates anxiety, fear, guilt, sadness, and grief. When a diagnosis is confirmed, the couple may begin the grieving process and must deal with the psychological issues related to grief. Financial strain is another common obstacle for women facing infertility. Some women may not have health insurance coverage for infertility assessments and diagnostic testing. Other women may have limited benefits that do not cover certain recommended procedures. Some couples go to great financial lengths to finance infertility treatments with no guarantee of success. Some women find discussing the infertility process embarrassing or stigmatizing. Others feel their peers may not understand their situation. Lack of a system can increase stress levels and make women more vulnerable during an already difficult time period.

DEPRESSION

The incidence of depression is higher in women seeking infertility treatments than in their fertile peers. Studies have shown the ranges of depression in this group to be from 15% to 54%, which is comparable to women diagnosed with serious heart disease or cancer (Deka & Sharma, 2010). Interestingly, depression can play a key role in some women deciding not to pursue infertility treatment (Eisenberg, Smith, Millstein, Nachtigall, Adler, Pasch, & Katz, 2010). Women who decided not to pursue infertility treatments after a medical diagnosis are also more likely to have self-reported depression or other psychological disorders (Herbert, Lucke, & Dobson, 2010). In general, women with infertility, although they had higher levels of depression than the general population of women, had fewer psychiatric hospitalizations. Women who failed to ever conceive, however, had higher hospitalization rates with adjustment disorder being the most common diagnosis (Yli-Kuha, Gissler, Kemitti, Luoto, Kiovisto, & Hemminki, 2011). Conception and delivery were associated with better mental health outcomes (Schmidt, 2010).

ANXIETY

The incidence of anxiety in infertile women is higher than in the general population. It is estimated that 14.7% to 28% of women undergoing infertility treatment suffer from anxiety (Chiaffarino, Baldini, Scarduelli, Bommarito, Ambrosio, D’Orsi, Torretta, Bonizzoni, & Ragni, 2011; Massachusetts General Hospital Center for Women’s Mental Health, 2011). Younger women who had an equally anxious partner and who had a longer history of infertility were more likely than other infertile women within the same study to experience anxiety (Chiaffarino et al., 2011).

SIGNS AND SYMPTOMS

The signs and symptoms associated with stress, depression, and anxiety are presented in Table 12.1.

Table 12.1 ■ Signs and Symptoms of Stress, Depression, and Anxiety in Infertile Women

Stress Memory loss Lack of concentration Alterations in judgment Negative thinking Repetitive, racing thoughts Worrying Moodiness Anger/agitation Feeling overwhelmed Social isolation Depression/sadness Physical pain Gastrointestinal changes Nausea Dizziness Chest pain Loss of sex drive Decrease in immune system response Changes in appetite Changes in sleep habits Failure to meet responsibilities Use of tobacco, alcohol, illegal substances Nervous habits

Depression Depressed mood Sadness Decreased pleasure in activities Restlessness Appetite changes Weight changes Changes in sleeping patterns Agitation Slowing down of thoughts Fatigue, loss of energy Guilty feelings Feelings of worthlessness Difficulty concentrating Preoccupation with death Suicidal thoughts

Anxiety Feeling apprehensive Feelings of dread Irritability Feeling tense, jumpy Palpitations Diaphoresis Dizziness Gastrointestinal distress Shortness of breath Tremors, twitches Headaches Fatigue Insomnia

ASSESSMENT AND SCREENING

Ideally, all women undergoing an infertility evaluation should be screened with a psychological examination to identify preexisting and new-onset psychiatric disorders. Women with a current psychiatric condition should be comanaged with a therapist and psychiatrist in addition to the reproductive endocrinologist. The practitioner should evaluate the woman and her partner for signs of stress, depression, and anxiety. A brief interview can assess for symptoms. A review of marital distress, sleeping irregularities, and sexual dysfunction should also be obtained. Assessment for depression and anxiety should utilize the same screening tools used to diagnose the disorder in healthy women. For specific instruments used for diagnostic criteria, see various chapters in Section IV related to stress, depression, and anxiety.

TREATMENT

Treatment for anxiety and depression during infertility treatment must take into the potential for teratogenic effects on the fetus. Most reproductive endocrinologists attempt to avoid medications during the infertility treatment process when possible. Recent studies have shown that some antidepressants that were commonly prescribed for depression and anxiety during pregnancy were related to increases in certain birth defects, such as cardiac anomalies and neural tube defects (Malm, Artama, Gissler, & Ritvanen, 2011). Faramarzi et al. (2008) examined differences in multiple treatment modalities for infertile women experiencing depression and anxiety, which included cognitive behavioral therapy (CBT) or antidepressant istration. The group that underwent CBT had a 79% reduction in depression and anxiety symptoms; the antidepressant group stated a 50% reduction. Treatment modalities such as acceptance and commitment therapy, a behavioral therapy technique, have been used with success in treating infertile women and couples suffering from depressive symptomology (Peterson & Eifert, 2010). The therapy has been successful both in couples pursuing active infertility treatment and those who have experienced failed IVF attempts (Peterson & Eifert, 2010). Other studies have shown that couples who undergo psychological therapy during IVF have higher pregnancy rates than couples who do not undergo therapy (Hämmerli, Znoj, & Barth, 2009). Many couples and women may feel more comfortable revealing their feelings in a ive environment. Some fertility centers may offer groups for this purpose. RESOLVE is a network that was formed in 1974 to provide to women and couples dealing with infertility. The group also aims to increase awareness of infertility to the public (RESOLVE, 2011). Couples or individuals struggling with infertility can an established group or network within their community. There are also many online resources for infertility, including online discussion and networks. Many women undergoing fertility evaluation and receiving an infertility diagnosis will experience sadness and grief. For others, significant grief can

occur if the woman remains unable to conceive. Chapter 18 discusses issues related to grief and loss.

SUMMARY

Women undergoing fertility treatment encounter a great deal of stress that can lead to anxiety and depression. The need for ongoing assessment and is imperative for these couples during the course of treatment. Knowledgable practitioners who specialize in these complex issues can provide psychological and may make recommendations for pharmacological interventions as needed although it is desirable to utilize nonpharmacological interventions as a primary source of treatment due to the possibility of pregnancy. Nurses should provide ongoing for these couples.

Case Study

Jennifer Winters is a 42-year-old G2P1 (i.e., a woman who had two pregnancies and one birth) and gave birth to a fetus at 22 gestational weeks with Potter’s syndrome after 7 years of infertility. Her son, William, died at birth. For the past 5 years, Jennifer has undergone extensive infertility evaluations and has had several unsuccessful IVF procedures. Jennifer presents to the infertility group in her local community tearful, angry, and resentful because she has just learned her sister-in-law of 8 months is now pregnant. Jennifer reports feelings of worthlessness, hopelessness, sadness, and intermittent anger. She states she no longer enjoys hobbies she once engaged in and spends much of her time in bed although she has difficulties with insomnia. What is the most probable diagnosis for this woman? What interventions might be effective for her to improve her coping skills related to infertility and the pregnancy of her sister-in-law?

Questions to Consider

How can nurses decrease anxiety for the woman going through an infertility evaluation? Should infertility-related anxiety be treated with pharmacologic interventions? How can the nurse differentiate between stress, depression, and anxiety in a woman undergoing infertility treatments?

REFERENCES

Chiaffarino, F., Baldini, M. P., Scarduelli, C., Bommarito, F., Ambrosio, S., D’Orsi, C., Torretta, R., Bonizzoni, M., & Ragni, G. (2011). Prevalence and incidence of depressive and anxious symptoms in couples undergoing assisted reproductive treatment in an Italian infertility department. European Journal of Obstetrics & Gynecology and Reproductive Biology, 158(2), 235(7). DOI:10.1016/j.ejogrb.2011.04.032 Davidson, M. R., London, M. L., & Ladewig, P. A. W. (2012). Olds’ maternalnewborn nursing and women’s health across the lifespan, (9th ed). Upper Saddle River, NJ: Pearson. Deka, P. K., & Sharma, S. (2010). Psychological aspects of infertility. British Journal of Medical Practitioners, 3(3), 336. Eisenberg, M. L., Smith, J. F., Millstein, S. G., Nachtigall, R. D., Adler, N. E., Pasch, L. A., & Katz, P. P. (2010). Predictors of not pursuing infertility treatment after an infertility diagnosis: Examination of a prospective U.S. cohort. Fertility and Sterility, 94(6), 2369–2371. DOI: 10.1016/j.fertnstert.2010.03.068 Faramarzi, M., Kheirkhah, F., Esmaelzadeh, S., Alipour, A., Hjiahmadi, M., & Rahnama, J. (2008). Is psychotherapy a reliable alternative to pharmacotherapy to promote the mental health of infertile women? A randomized clinical trial. European Journal of Obstetrics & Gynecological Reproductive Biology, 141(1), 49–53. Fido, A., & Zahid, M. A. (2004). Coping with infertility among Kuwaiti women: Cultural perspectives. International Journal of Social Psychiatry, 50(4), 294–300. DOI: 10.1177/0020764004050334 Gürhan, N., Akyüz, A., Atici, D., & Kisa, S. (2009). Association of depression and anxiety with oocyte and sperm numbers and pregnancy outcomes during in vitro fertilization treatment. Psychological Reproduction, 104(3), 796–806.

Hämmerli, K., Znoj, H., & Barth, J. (2009). The efficacy of psychological interventions for infertile patients: A meta-analysis examining mental health and pregnancy rate. Human Reproductive Update, 15(3), 279–295. Herbert, D. L., Lucke, J. C., & Dobson, A. J. (2010). Depression: An emotional obstacle to seeking medical advice for infertility. Fertility and Sterility, 94(5), 1817–1821. Lutz, W. (1987). Culture, religion, and fertility: A global view. Genus, 43(3–4), 15–35. Malm, H., Artama, M., Gissler, M., & Ritvanen, A. (2011). Selective serotonin reuptake inhibitors and risk for major congenital anomalies. Obstetrics & Gynecology, 118(1), 111–120. Massachusetts General Hospital Center for Women’s Mental Health. (2011). Depression and anxiety: Do they impact infertility treatments? Retrieved from http://www.womensmentalhealth.org/posts/depression-and-anxiety-do-theyimpact-infertility-treatment/ Peterson, B. D., & Eifert, G. H. (2010). Using acceptance and commitment therapy to treat infertility stress. Cognitive and Behavioral Practice. DOI:10.1016/j.cbpra.2010.03.004. RESOLVE. (2011). groups. Retrieved from http://www.resolve.org/-and-services Schmidt, L. (2010). Psychological consequences of infertility and treatment. Reproductive Endocrinology and Infertility, Part 1, 93–100. DOI: 10.1007/9781-4419-1436-1_7 Yli-Kuha, A. N., Gissler, M., Kemitti, R., Luoto, R., Kiovisto, E., & Hemminki, E. (2011). Psychiatric disorders leading to hospitalization before and after infertility treatments. Human Reproduction, 25(8), 2018–2023. DOI: 10.1093/humrep/deq164

13

Antepartum and Intrapartum Psychological Issues

Pregnancy is a time of great physical and psychological change for a woman and her family. Whether the woman is giving birth for the first time or having her fifth child, pregnancy is a time of rapid hormonal, physical, social, and psychological change. While some women experience pregnancy without difficulty, others experience physical and psychological complications. Some women may enter pregnancy with a preexisting mental illness that warrants management throughout the pregnancy, labor, birth, and postpartum period. It is estimated that 500,000 pregnant women annually have an existing psychiatric disorder, and one-third of those will require pharmacological intervention with psychiatric medication during pregnancy ( American Congress of Obstetricians and Gynecologists, 2008 ). As many as 20% of pregnant women suffer from a mental illness during their pregnancy ( Davidson, London, & Ladewig, 2012 ). This chapter focuses on psychological issues impacting pregnancy, labor, and birth. Chapter 14 focuses on postpartum and lactation issues.

MATERNAL STRESS DURING PREGNANCY

Pregnancy is a time of great change and great personal and social stressors. Often, the woman is encountering a role change and significant life changes, either newly entering into motherhood or expanding her role as a mother. These changes can impact relationships with her partner, family, friends, and others. Prenatal stress can have an impact on the developing fetus as well as the woman. There is some evidence suggesting that extreme stress during the prenatal period can increase the risk of certain conditions in the offspring. Women experiencing severe stress have an 80% higher incidence of stillbirth and pregnancy loss compared to women with low to normal stress levels (Wisborg, Barklin, Hedegaard, & Henriksen, 2008). Attention Deficit/Hyperactivity Disorder (ADHD), anxiety, language delays, neurological dysfunction, developmental delays, cognitive deficits, and behavioral disturbances have been identified as having increased occurrences in the children of women with severe stressors during their pregnancy (Stone & Menken, 2008). Van den Bergh et al. (2007) examined adolescent children and found children whose mothers experienced severe stress during the antepartum period were more likely to develop childhood and adolescent depression. Other studies have examined cortisol levels during pregnancy and have found an association between high cortisol levels and lower childhood intelligence scores (LeWinn, Stroud, Molnar, Ware, Koenen, & Buka, 2009). Children whose parents suffer relationship stressors and those whose mothers experienced intimate-partner violence during pregnancy also have higher rates of altered neuropsychological development in childhood (Kohen, 2010). Other studies have shown increases in levels of depression and anxiety (Stone & Menken, 2008). Malaspina et al. (2008) examined women who had been exposed to significant acute stress during pregnancy during the short-lived ArabIsraeli War in 1967. The female offspring of these women who experienced the stress of the war during the third trimester of pregnancy had a higher incidence of Schizophrenia, indicating that sex-specificity and a short gestational time period of acute stress could play a role in the development of Schizophrenia.

ANXIETY DURING PREGNANCY

It is estimated that anxiety and Anxiety Disorders are the most common psychiatric disorders, affecting more women than men (Armstrong, 2008). It is estimated that as many as 30% of women experience an Anxiety Disorder at some time in their lives (Karsnitz & Ward, 2011). There is a growing body of evidence showing that Anxiety Disorders develop and worsen during pregnancy and the postpartum period (Vythilingum, 2008). There are a number of Anxiety Disorders that can impact a pregnancy. Table 13.1 presents common Anxiety Disorders and their impact during pregnancy.

Table 13.1 ■ Common Anxiety Disorders and Pregnancy Impact

Type of Anxiety Disorder Generalized Anxiety Disorder (GAD) Obsessive-Compulsive Disorder (OCD) Panic Disorder (PD) Posttraumatic Stress Disorder (PTSD) Social Anxiety Disorder/Social Phobia

Incidence in Pregnancy 9.5% 0.2% to 3.5% 1.3% to 2.0% 2.3% to 7.7% 6.8%

Symptoms Associated With Pregnancy Excessive worrying about the baby or self during pre Persistent unwelcome thoughts or images—often pre Intense overwhelming fear that occurs without warni Frightening thoughts and memories of a traumatic ev Persistent, intense, and chronic fear of or in social sit

Source: National Institute of Mental Health (2012).

Anxiety during pregnancy is associated with adverse perinatal outcomes, including spontaneous abortion, preterm birth, precipitous labor, prolonged labor, higher incidence of forceps deliveries, and non-reassuring fetal status during labor (American Congress of Obstetricians and Gynecologists, 2008). Newborns born to mothers with Anxiety Disorders have decreased developmental scores and inadaptability. In addition, at the age of 2 years, these infants continue to have slowed mental development (American Congress of Obstetricians and Gynecologists, 2008). Posttraumatic Stress Disorder (PTSD) is an Anxiety Disorder that results from severe physical or psychological trauma and often has implications during pregnancy, labor, and birth. PTSD typically affects more women than men. It is estimated that the prevalence of PTSD in women is approximately 9.7% to 10.4% at some point in their lives (U.S. Department of Veterans Affairs, 2011). Women exposed to emotional, physical, or sexual abuse may encounter symptoms during pregnancy and during the labor and birth process (Davidson et al., 2012). Some women develop PTSD as a result of a traumatic birth experience or medical procedure and may have a resulting psychological impact from that experience in subsequent pregnancies. Because PTSD can have negative effects on the fetus and mother and could potentially impair bonding and attachment in the postpartum period, the need for identification in early pregnancy is an important component to prenatal care. Women with PTSD may present for prenatal care with comorbidities and other risk factors, including the following (Rogal, Poschman, Belanger, Howell, Smith, Medina, & Yonkers, 2007):

■ Substance abuse ■ Panic Disorder ■ Depression

■ Prior preterm delivery

Treatment

Anxiety is commonly treated with benzodiazepines; however, the use of benzodiazepines is generally contraindicated during pregnancy as these drugs are category D or X (Armstrong, 2008). While some practitioners may give benzodiazepines occasionally during pregnancy for severe symptoms, the majority do not (Armstrong, 2008). While the risk of birth defects is relatively low, with only a slightly increased risk of cleft palate, there are other risks that more commonly occur if the medication is taken closer to the time of delivery. Infants whose mothers have taken benzodiazepines have increased incidences of floppy baby syndrome and withdrawal symptoms in the newborn (Armstrong, 2008). Other drug therapies that utilize non-benzodiazepine anxiolytics and hypnotics can be used with relative safety. Chloral hydrate, eszopiclone (Lunesta), and zolpidem (Ambien) have all been classified as category C drugs and can be used in pregnancy as indicated to control anxiety symptoms and assist with sleep. Buspirone (Buspar) is a category B drug and is considered safe in pregnancy although its effectiveness can be somewhat limited. The use of selective serotonin reuptake inhibitors (SSRIs) for the management of anxiety symptoms may be helpful in treating women with anxiety during pregnancy. Although there is some literature that states there is a slight risk of cardiac defects in the children of women treated with fluoxetine (Prozac), it remains a first-line therapy for pregnant women (Malm, Artama, Gissler, & Ritvanen, 2011). Bupropion (Wellbutrin), a category B SSRI, is an ideal firstline treatment because it is the safest drug choice for pregnant women. Other SSRIs have been used with effectiveness in the treatment of Anxiety Disorders as well. The use of cognitive behavioral therapy (CBT) has been an effective tool for the treatment of Anxiety Disorders during pregnancy. Many women are highly motivated during pregnancy to pursue non-pharmacological interventions because of concerns with pharmacological agents and their effects on the developing fetus.

MATERNAL DEPRESSION DURING PREGNANCY

Depression often occurs during the childbearing years with the prenatal period presenting an increase in vulnerability to depression because of biological and psychosocial factors (Davidson et al., 2012; Stone & Menken, 2008). It is estimated that 8.3% to 16% of pregnant women suffer from depression during pregnancy with an additional 70% reporting depressive symptoms during pregnancy (Grote, Bridge, Gavin, Melville, Iyengar, & Katon, 2010; American Congress of Obstetricians and Gynecologists, 2008). Women from minority groups, those living in urban areas, and those in lower socioeconomic groups are more likely to experience depression during pregnancy (Grote et al., 2010). Women with a family history of a first-degree relative with a psychiatric illness are one and one-half to three times more likely to develop depression than the general population (Beck, 1996; Stone & Menken, 2008). Women with a past history of postpartum depression (PPD) or postpartum blues have a 50% risk of relapse in subsequent pregnancies (Stone & Menken, 2008). Psychosocial risk factors associated with perinatal depression include the following:

■ Lack of a partner ■ Unplanned pregnancy ■ Undesired pregnancy ■ Stressful life events ■ Lack of a system ■ Poor family ■ Past history of sexual abuse (Stone & Menken, 2008; Beck, 1996; Davidson et al., 2012)

Women who experience depression during pregnancy are more likely to have adverse pregnancy outcomes, such as low infant birth weight and preterm birth (Grote et al., 2010). As with anxiety and stress, maternal depression in pregnancy can result in behavioral problems for the child although to a lesser degree than stress and anxiety (O’Connor, Heron, Golding, & Glover, 2002). Infants of mothers with depression show alterations in psychologic, cognitive, neurologic, and motor development (Gjerdingen & Yawn, 2007). When women with depression are successfully treated, their children’s mental and behavioral health improves as well, thus making the need for aggressive treatment imperative (Weissman, Pilowsky, Wickramaratne, Talati, Wisniewski, Fava et al., 2006).

Treatment

Treatment of depression during pregnancy may include psychotherapy, electroconvulsive therapy (ECT), or pharmacological intervention. The use of antidepressant therapy as a means of treatment for perinatal depression has been more widely used in recent years. The use of tricyclic antidepressants is the longest established treatment and appears to be safe in pregnancy, although some practitioners feel SSRIs are more effective in managing symptoms and have fewer side effects. The decision to continue with or pursue antidepressant therapy is based on a risk-benefit ratio. Women with mild depression symptoms may be able to taper off medications, and women with moderate but wellcontrolled symptoms may need to continue a medication regimen. Women with severe depression symptoms should continue their medication regimen to prevent relapses in symptoms (American Congress of Obstetricians and Gynecologists, 2008). Certain medications, such as the monoamine oxidase inhibitors (MAOIs) should not be taken while pregnant. Table 13.2 presents an overview of commonly used tricyclic antidepressant medications used to treat depression in the perinatal period and their pregnancy drug category. Exhibit 13.1 includes SSRIs commonly used to treat depression. All of the SSRIs are category C drugs with the exception of paroxetine (Paxil), which is a category D drug. Other antidepressants used to treat perinatal depression include bupropion (Wellbutrin), duloxetine (Cymbalta), mirtazapine (Remeron), nefazodone (Serzone), trazodone (Desyrel), and venlafaxine (Effexor).

Table 13.2 ■ Tricyclic Antidepressants Used for Perinatal Depression

Drug Name Amitriptyline (Elavil) Amoxapine (Asendin) Clomipramine (Anafranil)

Pregnancy Drug Category C C C

Desipramine (Norpramin) Doxepin (Sinequan, Adapin) Imipramine (Tofranil) Maprotiline (Ludiomil) Nortriptyline (Pamelor, Aventyl) Protriptyline (Vivactil)

C C C B C C

Exhibit 13.1

SSRIs Used in the Treatment of Depression

Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluvoxamine (Luvox) Sertraline hydrochloride (Zoloft)

Recent studies have identified a slightly increased risk of cardiac defects and neural-tube defects in the children of women who take SSRIs during pregnancy. In 2006, the American Congress of Obstetricians and Gynecologists issued a statement reporting that paroxetine (Paxil) was associated with right-ventricular outflow tract defects in infants whose mothers took Paxil during pregnancy. The drug was then changed from a category C to a category D classification, meaning it is known to cause birth defects in humans (Davidson et al., 2012). Recent evidence shows that fluoxetine (Prozac), the most commonly prescribed SSRI in pregnancy, is associated with a small elevated risk of isolated ventricular defects although additional studies are needed to confirm these findings. Citalopram (Celexa) is associated with an elevation of neural tube defects (Malm et al., 2011). Discontinuation of SSRIs is not always the best treatment for all women. Women who discontinue (SSRIs) are at risk for rebound symptoms upon conception.

Women who discontinue their medication regimen during pregnancy are less likely to receive prenatal care; are more likely to smoke, use alcohol, have poor or inadequate nutrition, use herbal antidepressant treatments or alternative medications; and experience more disruption in their family life (American Congress of Obstetricians and Gynecologists, 2008). In addition, women with depression are more likely to have alterations in bonding and maternal attachment issues in the postpartum period (American Congress of Obstetricians and Gynecologists, 2008; Davidson et al., 2012). Women with uncontrolled depression during the antepartum period are at an increased risk for a Mood Disorder in the postpartum period as well (Davidson et al., 2012). Infants born to mothers with depression are more likely to have prolonged crying periods and to be itted to the neonatal intensive care unit at the time of birth (American Congress of Obstetricians and Gynecologists, 2008). groups and perinatal classes may offer the pregnant woman an opportunity for peer (Davidson et al., 2012). If pharmacological intervention is needed, it is recommended that the woman take a single medication rather than a combination of medications. To reduce the amount of exposure to the fetus, it is better to have a higher dosage of one medication than multiple medications. Most SSRIs are categorized as category C medications with the exception of paroxetine (Paxil), which is a category D (contraindicated), and bupropion (Wellbutrin), which is a category B. Given that bupropion (Wellbutrin) is the only current category B medication, it may be reasonable to attempt treatment with that as a first-line choice.

BIPOLAR DISORDER DURING PREGNANCY

Bipolar Disorder (BPD) affects 0.5% to 1.5% of the general population and is equally distributed between men and women. BPD has an onset in late adolescence or the early 20s when pregnancy is most common (Yonkers, Wisner, Stowe, Leibenluft, Cohen, Miller et al., 2004). Studies on BPD show that symptoms can occur more commonly during pregnancy although the onset of a new case of BPD is relatively rare during pregnancy (National Alliance on Mental Illness, 2011). Pregnant women with BPD have a seven times higher risk of hospitalization than nonpregnant women with BPD. Women with BPD are more likely to experience depressive episodes, rapid cycling, and mixed episodes (American Congress of Obstetricians and Gynecologists, 2008). Of the women who discontinue their medication regimen 6 months prior to pregnancy or during early pregnancy, 40% experience bipolar symptomology compared to 8% of women who continue their medication during the antepartum period. Risk factors for symptomology during pregnancy include a young age of onset of the disease, BPD II, a history of mixed episodes and rapid cycling, a shorter duration of stability, use of multiple drugs to treat BPD, and treatment with mood stabilizers other than lithium (Viguera, Whitfield, Baldessarini, Newport, Stowe, Reminick, Zurick, & Cohen, 2007).

Treatment

Optimally, a woman with BPD should be counseled prior to conception regarding the necessary precautions and risks. Certain mood stabilizers are human teratogens and should be avoided during pregnancy. These include valproic acid (Depakote) and carbamazepine (Tegretol). Lamotrigine (Lamictal), also a mood stabilizer, is a category C drug and should be considered for women planning pregnancy or those who become pregnant. Lithium carbonate (Lithium) has been a major first-line treatment agent in the care of women with BPD. Clinicians should note Lithium is a category D drug and is not the first line of therapy although its use may be considered in pregnancy when other modalities fail and the mother cannot be managed on other regimens after the first trimester. Some women may continue to use Lithium after the first trimester; however, Lithium is associated with an increased risk of cardiac defects, including 10 times the risk of Ebstein anomaly (Rosene-Montella, Barbour, & Lee, 2008). Because of this risk, an ultrasound should be obtained between 16 and 18 weeks gestation to assess for any cardiac anomalies in the fetus. If Lithium is used, the dosage needs to be carefully monitored during the pregnancy with a reduction around the time of delivery to decrease neonatal effects, such as floppy baby syndrome, hypotonicity, and cyanosis. Other rare side effects of Lithium include diabetes insipidus, hypothyroidism, and polyhydramnios (Rosene-Montella et al., 2008). The use of antiepileptic medications is also a common treatment modality for women with BPD. Most of these agents are category D medications that carry risk of fetal birth defects and should not be the first line of therapy for pregnant women. If used, a single agent is recommended over multiple medications at the lowest dosage possible. Because antipsychotics carry fewer risks, they may be effectively used at a lower risk to the fetus and should be considered. Some women may respond well to the use of antipsychotics during pregnancy.

Most antipsychotics are category C drugs with the exception of clozapine (Clozaril), which is a category B drug (American Congress of Obstetricians and Gynecologists, 2008). Some women may choose to utilize a first-generation antipsychotic drug regimen throughout pregnancy or during the first trimester. It is also useful for women who have discontinued their medications if they become symptomatic during the pregnancy. ECT can also be used with good results during pregnancy without causing harm to the developing fetus (National Alliance on Mental Illness, 2011).

THOUGHT DISORDERS DURING PREGNANCY

Thought disorders during pregnancy represent risks for both the mother and her unborn child. A thought disorder occurs when there is disorganized speaking, which typically represents disorganized thinking. The most common thought disorder is Schizophrenia. The onset of Schizophrenia most commonly occurs in women between 25 and 35 years of age, the childbearing years. The incidence of schizophrenia is 0.04 to 0.58 per 1000 (Rosene-Montella et al., 2008). In the past, most women with Schizophrenia were managed with first-generation antipsychotics, which commonly elevated prolactin levels, offering some contraceptive benefit (Rosene-Montella et al., 2008). With the use of atypical antipsychotics, elevations in prolactin levels do not occur, and as a result, pregnancy rates in women with thought disorders has risen (Rosene-Montella et al., 2008). Women with Schizophrenia are more likely to have the following:

■ Unplanned pregnancies ■ Poor prenatal care ■ Higher incidence of sexual assault ■ Smoking ■ No partner or parent figure for their child

Perinatal outcomes among offspring of women with Schizophrenia include the following:

■ Premature birth ■ Low birth weight ■ Small for gestational age ■ Stillbirth ■ Infant death

Women diagnosed with Schizophrenia have a three-fold increase in placental abruption and an increased risk of non-reassuring fetal status. Women who are symptomatic during pregnancy had the highest risk of adverse fetal and infant outcomes (Nilsson, Lichtenstein, Cnattingius, Murray, & Hultman, 2002; Cunningham, Leveno, Bloom, Hauth, Rouse, & Spong, 2010). Although Schizophrenia in and of itself is an indicator for poorer outcomes, lack of prenatal care plays a key role in symptomatic women (Lin, Chen, & Lee, 2009). Still, other studies have examined the offspring of both mothers and fathers with Schizophrenia and found that these infants had twice the risk of infant mortality than infants born to unaffected parents, suggesting that parenting may play a role in infant demise in the first year of life (Nilsson, Hultman, Cnattingius, Olausson, Björk, & Lichtenstein, 2008).

Treatment

Schizophrenia is one of the most debilitating mental illnesses. The most commonly used pharmacological therapies include antipsychotics. Because many women with thought disorders present with unplanned pregnancies, the mental health care provider should ensure prompt referral to an obstetrical care provider with experience in treating women with mental illness. Typically, the mental health provider prescribes the psychiatric medications in consultation with the obstetrical care provider. Medications that reduce the risk of adverse side effects to the fetus should be selected. While first-generation antipsychotics have been used for a longer duration of time, some second-generation antipsychotics may also be helpful when treating a pregnant woman with significant thought disorders. There does not appear to be an increased risk of birth defects in fetuses whose mothers have taken first-generation antipsychotics during pregnancy, although large randomized studies have not been performed (Einarson & Boskovic, 2009). The antipsychotics are categorized as category C with the exception of clozapine (Clozaril), which is a category B drug. For this reason, Clozaril may be a firstline treatment for the management of thought disorders during pregnancy. As with other disorders, polydrug therapy should be avoided when possible because single therapeutic regimens should be the preferred treatment. These women may benefit from groups and educational classes aimed at teaching them about antepartum, intrapartum, and postpartum changes and infant care and needs after delivery. services should be in place that provide assistance with care for both the mother and her infant. Care should be taken when prescribing medications for a woman during pregnancy and if the woman intends to breast feed.

EATING DISORDERS DURING PREGNANCY

The incidence of Eating Disorders among American women is estimated to be 5% to 6% (Harris, 2010). The presence of Bulimia Nervosa, subclinical Anorexia Nervosa, or a Nonspecified Eating Disorder, such as binge-eating disorder, during pregnancy can be dangerous for both the mother and the developing fetus. Nutritional deficits in both the mother and fetus can occur. It is not uncommon for women with Eating Disorders to have an additional psychiatric comorbidity, such as depression or anxiety. Women with histories of physical and sexual abuse have a higher incidence of Eating Disorders as well (Meltzer-Brody, Zerwas, Leserman, Von Holle, Regis, & Bulik, 2011). Additional risk factors for Binge Eating Disorder (BED) include the following (Berg, Torgersen, Von Holle, Hamer, Bulik, & Reichborn-Kjennerud, 2010):

■ Smoking ■ Alcohol use ■ Poor self-esteem ■ Unhappiness with life satisfaction and partner ■ Lack of social

Because the diagnosis of Anorexia Nervosa includes amenorrhea for 3 months, pregnant women do not meet the criteria; however, it is possible to have a subclinical case of Anorexia during pregnancy (Harris, 2010). Women with subclinical Anorexia are at risk for spontaneous abortion and low birth-weight infants because of small body mass (Cunningham et al., 2010). It is estimated that 45% of women are self-referred for Eating Disorders, making the need for a careful review of eating patterns, weight gain and loss history, and unusual

behaviors related to eating and food to be examined at the initial prenatal visit (Harris, 2010). It is estimated that 70% of women with an Eating Disorder will improve during the antepartum period. Bulimia is the most common Eating Disorder that occurs during pregnancy. Women with Bulimia may do the following:

■ Induce vomiting ■ Misuse laxatives ■ Binge eat during pregnancy and then purge to get rid of the excess calories

Women with Bulimia are more likely to have excessive weight gain with pregnancy, putting them at risk for pregnancy complications, such as the following (Davidson et al., 2012):

■ Spontaneous abortion ■ Gestational diabetes ■ Preeclampsia ■ Difficult and prolonged labor ■ Cesarean birth ■ Postpartum depression

Diabulimia, named in 2007 and seen in as many as 30% of diabetic women, is an Eating Disorder not yet identified by the American Psychological Association but is associated with type I diabetes mellitus, in which women skip insulin dosages to purge glucose as a means of weight control (Harris, 2007). Women

with unstable blood glucose levels during pregnancy are at risk for adverse maternal and fetal effects including the following (Harris, 2010):

■ Birth defects early in pregnancy ■ Macrosomia ■ Preeclampsia ■ Stillbirth ■ Neonatal morbidity

Mothers with uncontrolled gestational diabetes or type I diabetes are more likely to develop preeclampsia and other complications (Davidson et al., 2012). Infants born to mothers with Eating Disorders are more likely to have complications, including the following (Davidson et al., 2012):

■ Premature birth ■ Low birth weight ■ Delayed fetal growth ■ Respiratory complications ■ Stillbirth

Treatment

A woman with an Eating Disorder should be comanaged by both obstetrical and mental-health practitioner. Initial weight, weight assessment at each visit, a graph of weight-gain patterns, an assessment of eating patterns or a food diary, and urine dips for the presence of glucose and ketones should be performed at each prenatal visit. Referral to a nutritionist can provide nutritional education and reinforce the importance of sound nutritional practices for the growing fetus. These women also benefit from behavioral and psychotherapy as a means for dealing with their Eating Disorder. Because most women improve their eating patterns during pregnancy to focus on the health of their baby, special attention during the postpartum period is warranted because many women return to unhealthy eating behaviors in the postpartum period (Crow, Agras, Crosby, Halmi, & Mitchell, 2007). groups may be effective in providing to pregnant women. CBT may also be used and has shown to be beneficial.

SUMMARY

Pregnancy represents a time of great hormonal changes in a woman’s body that can lead to instability in women with current psychiatric conditions. As many as 20% of women enter pregnancy with a mental illness (Davidson et al., 2012). Prolonged stressors as well as many psychiatric illnesses can have adverse effects on both perinatal and psychiatric outcomes. The need for collaborative care between an obstetrical and mental health care provider is essential. Ideally, a woman with a preexisting mental illness should seek preconception counseling on how best to manage her illness during pregnancy. Screening for mental illness should be performed at the initial prenatal visit. Women on certain medications may need to change their medication regimens during their pregnancy and if breast feeding is planned. Stabilization prior to conception is ideal but not always possible. Many women conceive without adequate consultation and will need pharmacological guidance during the first trimester of pregnancy. Women on potentially teratogenic medications need careful screening, which should include a second trimester sonogram to screen for cardiac defects and quadruple screen or alpha-fetoprotein (AFP) testing for neural tube defects (Davidson et al., 2012). Women who have continued to take certain medications during pregnancy without a full understanding of the risks should be counseled that while there are documented increased risks, these risks are still small, and the likelihood of an anomaly remains relatively low. If an anomaly is discovered, referral to a perinatologist and other specialists is warranted. Many women may be more open to CBT or other psychotherapy at this time in their lives to reduce the influence of pharmacological agents on the developing fetus. Practitioners should familiarize themselves with available community resources and area groups for pregnant women dealing with mental health issues. With careful management, intervention, and professional and family , many women with psychiatric illnesses can have a safe and satisfying pregnancy and birth experience.

Case Study

Tran Kim is a 28-year-old G3P2 (three pregnancies; 2 births) who presents to the certified nurse midwife (CNM) at 23 gestational weeks for a routine prenatal visit. Tran is usually quiet but lately has been withdrawn and tearful and feeling very overwhelmed with her two children at home who are 3 years and 16 months old. She tells the midwife she cries all the time and can’t seem to feel happy or content anymore. Her husband works 16 to 18 hours a day in their family business, and she feels guilty for asking him for help when he is home. Her mother was supposed to come from Korea to help her after the baby is born, but Tran just learned her mother’s visa was denied. Tran has no other family in the area and states her friends are all busy with lives of their own. Tran describes similar feelings after the births of her first two children, which eventually went away, and is stoic in that she does not wish to discuss any types of treatment for her symptoms. The CNM suspects that Tran has depression and worries it will worsen upon delivery. The CNM feels Tran developed undiagnosed postpartum depression in the past. What treatment options or interventions could you discuss with Tran? What risk factors does this young woman have?

Questions to Consider

What interventions are available to women experiencing anxiety or depression during pregnancy? How can the nurse provide assistance to the pregnant woman with Schizophrenia? What pharmacologic interventions are most safe for a woman considering medication management for a mental illness in the antepartum period?

REFERENCES

American Congress of Obstetricians and Gynecologists. (2008). Use of psychiatric medications during pregnancy and lactation. ACOG Practice Bulletin No. 92. Washington, DC: Author. Armstrong, C. (2008). Practice guidelines. American Family Physician, 78(6), 772–778. Beck, C. T. (1996). A meta-analysis of predictors of postpartum depression. Nursing Research, 45(5), 297–303. Berg, C. K., Torgersen, L., Von Holle, A., Hamer, R. M., Bulik, C. M., & Reichborn-Kjennerud, T. (2010). Factors associated with binge eating disorder in pregnancy. International Journal of Eating Disorders, 44(2), 124–133. DOI: 10.1002/eat.20797 Crow, S. J., Agras, S. W., Crosby, R., Halmi, K., & Mitchell, J. E. (2007). Eating disorder symptoms in pregnancy: A prospective study. International Journal of Eating Disorders, 41(3), 277–279. DOI: 10.1002/eat.20496 Cunningham, F. G., Leveno, K. J., Bloom, S. L., Hauth, J. C., Rouse, D. J., & Spong, C. Y. (2010). William’s obstetrics, 23rd ed. New York: McGraw Medical. Davidson, M. R., London, M. L., & Ladewig, P. A. W. (2012). Olds’ maternalnewborn nursing and women’s health across the lifespan, (9th ed.) Upper Saddle River, NJ: Pearson Education. Einarson, A., & Boskovic, R. (2009). Use and safety of antipsychotic drugs during pregnancy. Journal of Psychiatric Practice, 15(3), 183–192. Gjerdingen, D. K., & Yawn, B. P. (2007). Postpartum depression screening: Importance, methods, barriers, and recommendations for practice. Journal of the American Board of Family Medicine, May–June;20(3), 280–288. DOI: 10.3122/jabfm.2007.03.060171

Grote, N. K., Bridge, J. A., Gavin, A. R., Melville, J. L., Iyengar, S., & Katon, W. J. (2010). A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Archives of General Psychiatry, 67(10), 1012–1024. DOI: 10.1001/archgenpsychiatry.2010.111 Harris, A. A. (2010). Practical advice for caring for women with eating disorders during the perinatal period. Journal of Midwifery & Women’s Health, 55, 579– 586. DOI: 10.1016/j.jmwh.2010.07.008 Karsnitz, D. B., & Ward, S. (2011). Spectrum of anxiety disorders: Diagnosis and pharmacologic treatment. Journal of Nurse Midwifery & Women’s Health, 56(3), 266–281. DOI: 10.1111/j.1542-2011.2011.00045.x Kohen, D. (2010). Oxford textbook of women and mental health. Oxford: Oxford University Press. LeWinn, L. Z., Stroud, L. R., Molnar, B. E., Ware, J. H., Koenen, K. C., & Buka, S. L. (2009). Elevated maternal cortisol levels during pregnancy are associated with reduced childhood IQ. International Journal of Epidemiology, 38(6), 1700– 1710. DOI: 10.1093/ije/dyp200 Lin, H. C., Chen, Y. C., & Lee, H. C. (2009). Prenatal care and adverse pregnancy outcomes among women with schizophrenia: A nationwide population-based study in Taiwan. Journal of Clinical Psychiatry, 70(9), 1297– 1303. Malaspina, D., Corcoran, C., Kleinhaus, K. R., Perrin, M. C., Fennig, S., Nahon, D., Friedlander, Y., & Harlap, S. (2008). Acute maternal stress in pregnancy and schizophrenia in offspring: A cohort prospective study. BMC Psychiatry, 8, 71. DOI: 10.1186/1471-244X-8-71 Malm, H., Artama, M., Gissler, M., & Ritvanen, A. (2011). Selective serotonin reuptake inhibitors and risk for major congenital anomalies. Obstetrics & Gynecology, 118(1), 111–120. Meltzer-Brody, S., Zerwas, S., Leserman, J., Von Holle, A., Regis, T., & Bulik, C. (2011). Eating disorders and trauma history in women with perinatal depression. Journal of Women’s Health, 20(6), 863–870. DOI: 10.1089/jwh.2010.2360

National Alliance on Mental Illness. (2011). Bipolar disorder and pregnancy. Retrieved from http://www.nami.org/Template.cfm? Section=bipolar_disorder&template=/ContentManagement/ContentDisplay.cfm&ContentID=8 National Institute of Mental Health. (2012). Anxiety disorders. Retrieved from http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml Nilsson, E., Lichtenstein, P., Cnattingius, S., Murray, R. M., & Hultman, C. M. (2002). Women with schizophrenia: Pregnancy outcome and infant death among their offspring. Schizophrenia Research 1, 58(2–3), 221–229. Nilsson, E., Hultman, C. M., Cnattingius, S., Olausson, P. O., Björk, C., & Lichtenstein, P. (2008). Schizophrenia and offspring’s risk for adverse pregnancy outcomes and infant death. British Journal of Psychiatry, 193(4), 311–315. O’Connor, T. G., Heron, J., Golding, J., & Glover, V. (2002). Antenatal anxiety predicts child behavioral/emotional problems independently of postnatal depression. Journal of the American Academy of Child & Adolescent Psychiatry, 41(2), 1470–1477. Rogal, S. S., Poschman, K., Belanger, K., Howell, H. B., Smith, M. V., Medina, J., & Yonkers, K. A. (2007). Effects of posttraumatic stress disorder on pregnancy outcomes. Journal of Affective Disorders, 102(1–3), 137–143. DOI: 10.1016/j.jad.2007.01.003 Rosene-Montella K., Keely E., Barbour L. A., Lee R. V., eds. (2008). Medical Care of the Pregnant Patient, 2nd ed. Philadelphia, PA: American College of Physicians, 3–7. Stone, S. D., & Menken, A. E. (2008). Perinatal and postpartum mood disorders: Perspectives and treatment guide for the health care practitioner. New York: Springer. U.S. Department of Veterans Affairs. (2011). Epdiemiology of PTSD. Retrieved from http://www.ptsd.va.gov/professional/pages/epidemiological-facts-ptsd.asp Van den Bergh, B. R., Van Calster, B., Smitts, T., Van Huffel, S., & Lagae, L. (2007). Antenatal maternal anxiety and stress and the neurobehavioral development of the fetus and child: Links and possible mechanisms. A review. Neuroscience Biobehavioral Review, 29(2), 237–258.

Viguera, A. C., Whitfield, T., Baldessarini, R. J., Newport, D. J., Stowe, Z., Reminick, A., Zurick A., & Cohen L. S. (2007). Risk of recurrence in women with bipolar disorder during pregnancy: Prospective study of mood stabilizer discontinuation. American Journal of Psychiatry, 164, 1817–1824. DOI: 10.1176/appi.ajp.2007.06101639 Vythilingum, B. (2008). Anxiety disorders in pregnancy. Curr Psychiatry Rep. Aug;10(4):331–335. Weissman, M. M., Pilowsky, D. J., Wickramaratne, P. J., Talati, A., Wisniewski, S. R., Fava, M., et al. (2006). Remissions in maternal depression and child psychopathology: A STAR*D-child report. STAR*D-Child Team. Journal of the American Medical Association, 295, 1389–1398. Wisborg, K., Barklin, A., Hedegaard, M., & Henriksen, T. B. (2008). Psychological stress during pregnancy and stillbirth: Prospective study. BJOG, 115(7), 882–885. DOI: 10.1111/j.1471-0528.2008.01734.x Yonkers, K. A., Wisner, K. L., Stowe, Z., Leibenluft, E., Cohen, L., Miller, L., et al. (2004). Management of bipolar disorder during pregnancy and the postpartum period. American Journal of Psychiatry, 161, 608–620.

14

Postpartum Mood Disorders and Lactation Issues

The postpartum period represents a crucial chapter in a woman’s life, whether she is a first-time mother or a seasoned mom expanding her role with the addition of a new family member. For most families, while this is a time of great joy, it presents many new stressors and changes within the family unit. For most women, the expectation is that motherhood or the birth of an additional child will bring a sense of joy and happiness. For women who experience postpartum mood disorders, however, there is often a sense of loss, grief, anger, and sadness because they are not feeling “the way they should.” Many women express great frustration, feeling this should be the happiest time of their lives but actually feeling symptoms of depression, anxiety, fear, or confusion. Nurses play a key role in helping the new mother deal with her feelings, encouraging her and reassuring her that these feelings are not uncommon and medical intervention can improve her mood. Some women may feel like a failure if they seek treatment or perhaps feel others will perceive them as inadequate mothers. Others are concerned about the stigma associated with mental illnesses. It is not uncommon for women with postpartum mood disorders to deny that they have problems to family and friends and/or fail to seek treatment. Therefore, it is imperative for medical screenings to be performed, so if women do have symptoms, they can feel it is acceptable and safe to report and discuss them. Prompt treatment is the optimal intervention because it can reduce stressors and positively impact maternal-newborn bonding and family interactions at home. Women are especially vulnerable to postpartum mental illness during this period of rapid hormonal fluctuation, role change, and environmental stressors, such as lack of sleep, adjustment of roles by other family , and the physical demands created by a newborn. The mother is also facing the physical demands

of recovering from the birth experience. Some women may experience discomfort and fatigue and have to deal with physical limitations. In the United States, one-third of all births are via Cesarean section, adding surgical recovery to the postpartum tasks and creating additional limitations (Davidson, Ladewig, & London, 2012). Ideally, women in the postpartum period are surrounded by close family and friends to provide both physical and emotional ; however, that is not always the case. Women without adequate social are at increased risk of developing postpartum illness. In some cultures, women have a lying-in state when they stay home for various periods of time, often 42 days, and are waited on and cared for by family and female friends. In American culture, this is not commonplace, and women are expected to maintain their typical routine while dealing with the increasing demands of caring for themselves and their newborns.

RISK FACTORS

Risk factors for postpartum mood disorders include a lack of social , birth-recovery factors, and past history of specific illnesses. Many women are faced with inadequate systems as a result of cultural norms, geographic barriers, family issues, or lack of a partner. Other risk factors include the following (Davidson et al., 2012; Stone & Menken, 2008):

■ Low socioeconomic status ■ Maternal chronic pain ■ Sleep interference ■ Inflammation as a result of birth ■ Past history of substance abuse, sleep disorders, and eating disorders ■ Breast feeding difficulties ■ Breast infections ■ Nutritional deficits ■ Attempts at rapid weight loss ■ Genetic predisposition ■ Maternal age ■ Environmental toxins ■ Medications

■ Marital or relationship conflicts ■ Feelings of isolation ■ Loss of personal freedom ■ Need to care for other children ■ Child-care conflicts ■ Need to change employment status ■ Family history of postpartum mood disorder in first-degree relative ■ Mood disorder during pregnancy ■ Premenstrual dysphoric disorder (PMDD) ■ Significant mood changes while on hormonal contraceptives

BABY BLUES

Baby blues are characterized by anxiety, tearfulness, mood fluctuations, shorttemperedness, and oversensitivity, which are all common characteristics of changes that typically occur for several days with an onset within the first two weeks after giving birth (Gentile, 2005). It is estimated that 50% to 80% of all new mothers develop baby blues in the postpartum period (Gentile, 2005). For many women, one minute they feel overjoyed, and the next they are crying for no known identified cause. The period of baby blues typically lasts a few days and resolves within 2 weeks after the birth. Social , education to stress the normalcy of the event, catching up on sleep, a reduction of stressors, and a reduction in activity can all help the mother cope with these mood swings and changes.

Clinical Pearl

Practitioners advise women that if their baby blues have extended until the 6-week postpartum checkup, po

POSTPARTUM DEPRESSION

Postpartum depression (PPD) occurs when symptoms of baby blues persist for longer than 2 weeks and major depression symptomology occurs. Many PPDs occur within 4 weeks of birth, but others can occur up to one year after delivery (Stone & Menken, 2008). The incidence occurs in 15% to 25% of all women (American College of Nurse Midwives, 2011). In the United States, it is thought to affect up to two million women annually (American College of Obstetricians and Gynecologists, 2010). The symptoms can begin during pregnancy, after the birth, or within one year of birth (Stone & Menken, 2008). PPD can also occur following a spontaneous or induced abortion or after a fetal demise. PPD is not just a woman’s issue. It is a community-based problem that requires ongoing screening and prompt intervention. Children and infants of women with PPD have a higher incidence of delayed psychological, cognitive, neurological, and motor development. They are also at risk for developing avoidance and stressed behavior characteristics (Gjerdingen & Yawn, 2007). PPD can also cause an alteration in mother-infant bonding, which can result in long-term adverse outcomes for the dyad, alterations in the family’s functioning, and marital/relationship issues between the woman and her partner (Gjerdingen & Yawn, 2007).

Etiology

Neuroendocrine dysfunction likely causes imbalances and sudden shifts that create the mechanisms that lead to PPD. Other research has examined cortisol levels and the role of the hypothalamic-pituitary-adrenal axis as a causative factor for the illness. Immediately following birth, there is a sudden drop in estrogen, progesterone, and thyroid hormones, which can trigger depressive symptomology in some women. Cortisol levels also fall dramatically in the immediate postpartum period (Stone & Menken, 2008). Physiological changes associated with blood loss, hemodynamics, immunology, and metabolism can all cause dramatic physical stressors that can lead to symptoms such as fatigue and mood swings. Ethnicity also plays a role in the incidence of PPD. Native American women have the highest incidence of PPD, followed by Caucasian women, then Black women. Hispanic women have the lowest rates of PPD (Wei, Greaver, Marson, Herndon, Rogers, & Robeson Healthcare Corporation, 2008). Familial patterns and genetics also predispose women to postpartum mood disorders. Psychosocial factors also play a significant role. Women who lack social and feel alone quickly can become overwhelmed and stressed. Sleep deprivation, common in most new mothers, exaggerates already stressed circumstances and can increase symptoms of depression. Other stressors within the past year or that occurred during pregnancy can also increase the incidence of PPD. Women with a history of a preexisting mood disorder have a significantly higher incidence of PPD.

Signs and Symptoms

Postpartum depression symptoms include the following (Stone & Menken, 2008, p. 93; Davidson et al., 2012):

■ Feelings of sadness, anger, or irritability ■ Insomnia ■ Disinterest in activities of daily living ■ Disinterest in one’s children ■ Feelings of guilt, hopelessness, helplessness, or worthlessness ■ Labile moods with or without crying episodes ■ Uncontrollable crying ■ Lack of pleasure in caring for the baby and interacting with family ■ Fatigue and exhaustion ■ Excessive worrying ■ Lack of concentration ■ Feelings of being a bad mother ■ Lack of sexual desire beyond 6 weeks postpartum

Assessment and Screening

Ideally, every woman should be screened for PPD at their 6-week postpartum checkup. The American College of Obstetricians and Gynecologists (ACOG), the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), and the American College of Nurse Midwives (ACNM) all recommend routine screening for women at their 6-week postpartum checkup (American College of Obstetricians and Gynecologists, 2010; Association of Women’s Health, Obstetric & Neonatal Nurses, 2008; American College of Nurse Midwives, 2011). Pediatric care providers who care for newborns and infants should also assess new mothers for disruptions in moods in the postpartum period (Gjerdingen & Yawn, 2007). Often, once women attend their 6-week postpartum checkup, there is no further with their obstetrical provider for another 12-month period. Women who develop PPD after the initial 6 weeks are more likely to have interactions with a health care provider during a well-child visit than with any other practitioner because women sometimes decline to seek out services for mental illnesses. There are multiple tools available for the assessment of PPD, including the Beck Depression Inventory (BDI) and BDI-II, the Bromley Postnatal Depression Scale (BPDS), the Center for Epidemiologic Studies Depression Scale (CES-D), the Clinical Interview Schedule (CIS), the Diagnostic Interview Schedule (DIS), the Edinburgh Postnatal Depression Scale (EPDS), the General Health Questionnaire (GHQ), the Inventory of Depressive Symptomatology (IDS), the Postpartum Depression Screening Scale (PDSS), and the Zung Self-Rating Depression Scale (Zung SDS) (Gjerdingen & Yawn, 2007). The EPDS is the best study and has been found to be psychometrically sound. The scale is a self-reported scale in which women answer questions about their current mood and depressive symptomology. Other practitioners may utilize generalized scales to detect for the presence of depressive symptoms. The PHQ is a nine-item depression module (PHQ-9) that assesses the actual criteria for

Major Depressive Disorder. Some clinicians in the primary care setting use the initial two questions as an initial screen and then ister the complete screen to women who answer the first two questions with a positive response indicating possible depression (Gjerdingen & Yawn, 2007). Women with suspected mood disorders need to undergo a physical examination as well to rule out physiological causes of symptoms that may be misdiagnosed as PPD. Thyroid studies should be performed because 5% to 9% of women have a postpartum thyroid disorder and often have symptoms that mimic PPD. Anemia from the birth or surgery can also result in fatigue, weakness, cognitive decline, chest pains, palpitations, and shortness of breath (Stone & Menken, 2008).

Pharmacological Treatment

Many women with PPD are reluctant to initiate pharmacological intervention because of concerns about breast feeding, including the potential transfer of medications into breast milk and possible adverse fetal effects. Women with depression are less likely to breast feed than those without depressive symptomology, perhaps because of concerns related to infant medication side effects even though breast feeding in and of itself is associated with lower levels of PPD (Field, 2008). For a complete discussion on the effects of medications commonly used to treat mood disorders in the postpartum period, see the discussion on lactation at the end of this chapter. Most women with PPD are treated with selective serotonin reuptake inhibitors (SSRIs). Paroxetine (Paxil) and sertraline hydrochloride (Zoloft) are the most common SSRIs used to treat PPD (Øystein-Berle & Spigset, 2011). Medications should be selected that have the lowest concentration that ends up in the breast milk. Transdermal estrogen therapy has also been used in the treatment of PPD although it is not commonly utilized as it is known to transfer into the breast milk (Sit & Wisner, 2010). Women who are not breast feeding can be trialed on low-dose birth control medications to see if the symptoms improve with the addition of estrogen (Payne, Palmer, & Joeffe, 2009).

Behavioral Therapies

Many women prefer to seek out non pharmacological interventions in the postpartum period, especially women who are breast feeding their infants.

■ Short-term treatment success rates are similar for women who utilize psychological approaches although long-term benefits fall short when compared to medication management (Cooper, Murray, Wilson, & Romaniuk, 2003). ■ Interpersonal psychotherapy has been used effectively in treating PPD (O’Hara, 2009). ■ Psychoeducation interventions have also proven effective in coping with PPD (Cuijpers, Muñoz, Clarke, & Lewinsohn, 2009). ■ Group therapy options allow the mother to engage with peers who are experiencing similar symptoms and are also dealing with feelings of grief and loss because they experienced complications in the postpartum period. ■ groups and new mothers groups are gaining in popularity and are based on the same concepts as group therapy. They differ in that women are engaged in socialization and peer without the burdens typically associated with mental illness as the focus of the group.

Other therapy options have included bright-light therapy, nutritional intervention, essential fatty acid supplementation, and aerobic physical activity. Alternative therapy, such as massage therapy, has also been used and is shown to be an effective adjunct therapy (Field, 2008).

Clinical Pearl

Most local hospitals now incorporate new mom groups into their community outreach programmin

POSTPARTUM PSYCHOSIS

Postpartum psychosis (PPP) occurs infrequently but represents a significant mental health emergency. The incidence is 0.1% to 0.2% of all post-delivery women (Stone & Menken, 2008; Gentile, 2005). Risk factors for the illness include preexisting Bipolar Disorder, Schizoaffective Disorder, or a previous history of PPP. Large-scale studies on women with PPP are rare because the incidence of the disorder is so low. Kendall (1987) examined 54,000 births and found that, of the women who developed PPP, 72% to 80% had preexisting Bipolar or Schizoaffective Disorder and an additional 12% had preexisting Schizophrenia. PPP can occur within the first 12 months postpartum but most commonly occurs within the immediate postpartum period. Typical onset occurs around postpartum day eight with the typical psychosis period lasting 40 days (Melanie Blocker Stokes Foundation, 2011). Women with depressive symptomology tend to develop the disorder later in the postpartum period and have a longer duration of illness (Bergink, Lambregtse-van den Berg, Koorengevel, Kupka, & Kushner, 2011).

Etiology

The causative factors related to PPP are directly related to sudden shifts in hormones in the postpartum period. Family history plays a significant role in the development of PPP. Women with a personal or family history are three times more likely to develop PPP than other women (Spinelli, 2009). Women with Bipolar Disorder have the greatest risk for the disorder.

Signs and Symptoms

The symptoms associated with PPP differ from non-childbirth-related psychosis in their presentation. Women with PPP often present with cognitive disorganization psychosis, which presents with symptoms such as the following (Spinelli, 2009):

■ Cognitive impairment ■ Bizarre behaviors ■ Lack of insight ■ Thought disorganization ■ Delusions of reference ■ Delusions of persecution ■ Homicidal ideations and behaviors ■ Visual hallucinations ■ Tactile hallucinations ■ Olfactory hallucinations ■ Delirium-like appearance ■ Delusions focused on harm of their infant ■ Intense mood swings ■ Acting out of control

■ Command hallucinations

Women with PPP are more likely to be suicidal than women without psychosis. The suicide rate is 5%. Infanticide occurs in 4% of all women with PPP (Engqvist, Ahlin, Ferszt, & Nillson, 2011). Thoughts of harming their infant can occur with PPD, Obsessive-Compulsive Disorder (OCD), and PPP. The thoughts of women with PPP differ in that these women’s delusional thoughts about harming their infants are “ego-syntonic, associated with psychotic beliefs and loss of reality testing, with a compulsion to act on them and without the ability to assess the consequences of their actions” (Spinelli, 2009, p. 407).

Assessment and Screening

Women with PPP need to undergo a thorough psychological evaluation to identify associated symptomology. There is no standardized screening instrument for PPP although the EPDS is commonly used. The Mood Disorder Screening Scale is also used to indicate if bipolar symptomology is present. Many women may have such severe symptoms that they will be unable to complete written surveys. Laboratory studies should also be performed to rule out metabolic etiologies. Suggested laboratory studies are included in Exhibit 14.1. While approximately 72% of obstetricians screen for PPD, only 30% screen for PPP. Many providers do not feel comfortable asking questions related to PPP, may be unfamiliar with the diagnostic criteria, lack training, or state that time constraints limit screening (Leddy, Hagga, Gray, & Schulkin, 2011).

Exhibit 14.1

Laboratory Studies for Women With Postpartum Psychosis

Complete blood count (CBC) Blood chemistry Thyroid functions Antithyroid antibody

Calcium Vitamin B12 Folate levels Toxicology screen

Pharmacological Treatment

Pharmacological management includes the use of antipsychotics, mood stabilizers, and benzodiazepines. Sleep agents should be given to allow the woman to rest and sleep. Some experts advise against the use of antidepressants because there is such a high incidence of underlying Bipolar Disorder. If Bipolar Disorder is coexisting, the use of antidepressants can actually trigger rapid cycling or mixed states (Spinelli, 2009). If the woman does not have preexisting Bipolar Disorder or a close family member with Bipolar Disorder, antidepressants may be prescribed. Most women with PPP are hospitalized and will require intensive pharmacological therapy. Second-generation or atypical antipsychotics are commonly prescribed to control psychotic symptoms. Some women have reacted favorably to the use of estrogen therapy to correct the extremes in hormonal shifting that occur in the immediate postpartum period. Breast feeding is typically discouraged to maintain infant safety and promote sleep for the woman. Because of the structured psychiatric hospital environment in the United States, the separation of the mother and infant is commonplace. Infants are encouraged to visit with another responsible adult to maintain the mother-infant bond if the mother is stable. There is considerable disagreement as to how women with a history of PPP should be treated if another pregnancy is desired. Many practitioners discourage the woman from conceiving again because of the high rate of recurrence in subsequent pregnancies. Many women are extremely fearful of the lack of control and symptoms that occurred during a PPP episode and may decide not to pursue future pregnancies. For the woman who desires a pregnancy after a PPP diagnosis, careful management is essential with both an experienced obstetrical provider and a mental health care practitioner familiar with PPP. Women should be advised to avoid sleep deprivation during pregnancy and in the immediate postpartum period. Some women may be started on mood stabilizers or antipsychotics prior to the birth. Lithium is now used in pregnancy after the initial 12 weeks and may be started prior to birth. Atypical antipsychotics, such

as aripiprazole (Abilify), which is a category C drug, may be used with relative safety because there have been no reported fetal defects in women who have taken them during pregnancy (Wilson, Shannon, & Shields, 2011).

Behavioral Therapies

Some women with PPP may not realize the severity of their illness and may warrant involuntary hospitalization. In the United States, individuals who are at risk to themselves or others can be held involuntarily for up to 72 hours until a complete assessment is performed. The status of the woman is then presented to the court and then a judge decides if continued hospitalization is in order. For the woman who harms her baby or someone else during a PPP illness, incarceration can occur. For a complete discussion of the incarceration of mentally ill women and the “not guilty by reason of insanity” defense, see Chapter 10. The major treatment approach for PPP is aggressive medication management; however, ive behavioral therapies have also been found to be effective. Cognitive behavioral therapy is sometimes used as a short-term approach to change thinking after the psychosis has resolved (Doucet, Dennis, Letourneau, & Robertson-Blackmore, 2009). ive psychotherapy is often used to assist the woman in addressing her concerns and dealing with the feelings associated with her symptoms that occurred during the acute psychotic state. One study involved psychiatrists who treated women with PPP and assessed their treatment needs. Engqvist et al. (2011) found the main treatment needs included the following:

■ Providing safety and protection from harm ■ Prompt treatment ■ Caring behaviors directed toward the woman ■ Assisting the woman with the emotional components of her illness

POSTPARTUM ANXIETY DISORDERS

Postpartum anxiety disorders (PPAD) are anxiety disorders that occur in the postpartum period and may be as common or more common than PPD although there are few studies describing its incidence (Brockington, 2004). Some authors think the incidence is as high as 20% (Austin, Hadzi-Pavlovic, Priest, Reilly, Wilhelm, Saint, & Parker, 2010). Anxiety disorders are most commonly diagnosed in adulthood during the childbearing years and are twice as common in women as in men. There are a variety of anxiety disorders that can develop during the postpartum period:

■ Panic Disorder (PD) occurs in 10% of all postpartum women and is characterized by chest pain, shortness of breath, chest constriction, chest heaviness, trembling, tingling, numbness in extremities, an inability to focus, and terror sensations (Stone & Menken, 2008). Women with suspected Panic Disorder should be screened for postpartum anemia secondary to birth/delivery because disorders can have similar symptoms. ■ Posttraumatic Stress Disorder (PTSD) is commonly associated with sexual assault, rape, and physical and emotional abuse. Women who have a traumatic birth experience, infant death, degrading labor and delivery treatment by staff or providers, or medical emergencies are at greatest risk. The incidence of PTSD related to childbirth is approximately 9%, although as many as 34% of women may have experienced a traumatic event during childbirth (Beck, 2008). Symptoms include intrusive thoughts, flashbacks, and nightmares. Women commonly experience anniversary grief reactions on the date of the traumatizing event and should be monitored closely during those time periods. Women with PTSD may experience difficulty with maternal-infant attachment or during subsequent pregnancies. ■ Postpartum Obsessive-Compulsive Disorder (PPOCD) typically occurs by 6 weeks postpartum and affects 2% to 5% of all new mothers. Women with PPOCD may experience both anxiety and depressive symptomology. Common

symptoms include repeated ritualistic behaviors, repeated intrusive thoughts, loss of appetite, and fears of eating. Sometimes women develop avoidance behaviors toward their infants, or an urge to repeatedly wash and remove germs from the infant. These women are at risk for alterations in maternal-infant bonding. Many times, the woman experiences guilt, fear, or shame as a result of their feelings, thoughts, or actions. Women are typically treated with SSRIs and behavioral therapies. Cognitive behavior therapy (CBT) has been shown to be an effective short-term therapeutic intervention that focuses on using exposure and ritual prevention (Christian & Storch, 2009).

Etiology

There is some research indicating that PPAD are caused by extreme chronic stressors during the antepartum period (Hillerer, Reber, Neumann, & Slattery, 2011; Britton, 2007). Other studies have found that women who experience baby blues are more at risk to develop a PPAD (Reck, Stehle, Reinig, & Mundt, 2009). Other risk factors include low educational attainment, a history of depressed moods, negative life experiences, and a history of a preexisting mental health disorder (Britton, 2007). PTSD is caused by a catastrophic event that occurs during labor and delivery or in the early postpartum period. One woman was abandoned by her obstetrician and was forced to wait more than 90 minutes in the face of severe fetal distress. Her child was subsequently diagnosed with severe cerebral palsy and the woman developed PTSD and PPD, and went on to develop PPP as a direct result of the physician’s actions.

Signs and Symptoms

Signs and symptoms of postpartum anxiety may actually develop in the antenatal period and continue or worsen after birth. Common symptoms include the following (Stone & Menken, 2008):

■ Nervousness ■ Hypervigilance toward the baby ■ Overly concerned about the baby ■ Extreme lability ■ Appetite changes ■ Sleep disruption ■ Difficulty concentrating ■ Distractibility ■ Memory loss

Assessment and Screening

Women with PPAD often have symptoms of PPD as well. Screening tools that evaluate the woman for postpartum mood disorders are effective for the identification of symptoms and for making a diagnosis. Some providers utilize the EPDS and include an interval question that assesses for PPADs as well as depressive symptoms because there are no tools that specifically assess postpartum anxiety alone (Austin et al., 2010; Rowe, Fisher, & Loh, 2008). Drawbacks of this approach include difficulty in pinpointing differences between PPD and PPAD based on the screening instrument alone. The General Health Questionnaire 12 items (GHQ-12) and Zung’s Self-Rated Anxiety Scale (Zung SAS) are also used to detect anxiety disorders. Generalized anxiety screening tools, such as the Beck Anxiety Inventory can also be used. There are multiple tools that can be used to screen for PTSD. These include the Trauma Screening Questionnaire (TSQ), the Primary Care PTSD Screen (PC-PTSD), and the Beck Anxiety Inventory for Primary Care (BAI-PC).

Pharmacological Treatment

PPAD are commonly treated with SSRIs. The use of benzodiazepines is not routinely recommended because of their addictive qualities, potential to increase depressive symptoms, and incompatibility with breast feeding (Longo & Johnson, 2000). Serotonin-norepinephrine reuptake inhibitors (SRNIs) are sometimes used to treat anxiety symptoms in non-pregnant and non-nursing mothers; however, they have higher rates of concentration in breast milk and are not considered a first choice for treatment.

Behavioral Therapies

Behavioral and therapeutic treatment options have been used to treat women with postpartum anxiety (Anxiety Disorders Association of America, 2011):

■ Cognitive behavioral therapy (CBT) is a short-term—typically 12 to 16 weeks —of therapeutic intervention that is designed to change the woman’s thinking and behavior patterns. CBT and medication intervention have been proven to be more effective than therapy alone in treating postpartum anxiety (Misri, Reebye, Corral, & Mills, 2004). ■ Exposure therapy is also used to decrease a woman’s anxiety about a specific item or situation. In this form of therapy, the woman is gradually exposed to the stressor to decrease her sensitivity over time. ■ Dialectical therapy can take place in a group-therapy and individual-therapy format in which the woman combines acceptance and change to learn mindfulness and increase her skills for coping and dealing with her emotions. ■ Acceptance and Commitment Therapy (ACT) stresses mindfulness and acceptance and teaches the woman to be present-minded instead of focusing on the past. Skills focus on changing behavior, accepting experiences, and developing clarity about one’s values. ■ Interpersonal therapy is a short-term ive therapy that addresses interpersonal issues and symptoms. The therapy initially focuses on the woman’s experience with her symptoms and then moves on to recovery. ■ Eye Movement Desensitization and Reprocessing (EMDR) is a technique that mimics dreaming or REM sleep. It is used to decrease the intensity of the perceived anxiety and help the brain process the same information in a less

threatening way.

LACTATION

Lactation seems to provide a protective benefit from postpartum mood disorders. Women who breast feed are less likely to develop PPD, indicating that some of the hormonal influences associated with lactation may offer protective mental health benefits. Many women, once diagnosed with a postpartum mood disorder, will have great concerns about breast feeding their infants for fear of reactions to drugs that could be ed to the infant through breast milk. Most drugs used to treat psychiatric postpartum disorders are safe in pregnancy and are commonly prescribed. Women should be knowledgeable about resources available to providers and patients that provide detailed information on the percentage of the drug that is ed to the infant through nursing. Suggested resources include the following:

■ Briggs, G., Freeman, R. K., & Yaffe, S. J. (2011). Drugs in pregnancy and lactation: A reference guide to fetal and neonatal risk, 9th ed. Philadelphia: Lippincott, Williams, & Wilkins. ■ Hale, T. W. (2005). A medication guide for breastfeeding moms. Amarillo, TX: Pharmasoft Publishing.

The literature about pharmacologic treatment of depression and anxiety disorders and breast feeding varies. Many authors state that the negative effects of depressive symptomology on the infant is worse than any side effects associated with medication istration when safe medications are selected. Still, drug manufacturers continue to discourage breast feeding because of medical-legal liability concerns. Most antidepressants are not contraindicated for nursing women, and infant exposure through the breast milk is low. In general, milk levels are considered low if less than 10% of the drug is ingested per day by

the infant. SSRIs and nortryptyline are considered the safest treatment options for nursing women. There is some controversy in treating childbearing-age women with paroxetine (Paxil) because of its potential teratogenic effects if conception should occur. Paxil is a category D drug that is known to cause specific heart defects in women whose mothers are treated with the agent during pregnancy. Medications with the lowest concentrations within breast milk are included in Exhibit 14.2.

Exhibit 14.2

Medications With the Lowest Concentrations in Breast Milk

Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline hydrochloride (Zoloft) Duloxetine (Cymbalta) Reboxetine (Edronax)

Recent research indicates that fluoxetine (Prozac), citalopram (Celexa), and venlafaxine (Effexor) should be used with caution because the concentration levels in breast milk exceed the recommended levels of 10% per day (ØysteinBearle & Spigset, 2011). Certain medications, such as tricyclic doxepin (Silenor) and atypical nefazodone (Serzone) should be avoided with breast feeding, especially because of the wide variety of alternatives available. Lithium, a mood

stabilizer common in the treatment of Bipolar Disorder, was once considered contraindicated but is now increasing in popularity because it has not been associated with any negative infant outcomes (Davanzo, Copertino, De Cunto, Minen, & Amaddeo, 2011). The most direct measure of drug levels in infants is a measure of infant serum levels although this is not a routine practice. Studies have shown that among the SSRIs, paroxetine, fluvoxamine, and sertraline hydrochloride are undetectable in infant serum. Duloxetine (Cymbalta) and bupropion (Wellbutrin) are also not detected in infant serum testing; however, escitalopram, reboxetine, and mirtazapine have been identified in very low concentrations (Øystein-Bearle & Spigset, 2011).

SUMMARY

The postpartum period is thought to be a time of great joy and happiness for a woman and her family. For the woman who develops a postpartum mood disorder, the experience can bring guilt, sorrow, shame, anger, and sadness. While any woman can develop a postpartum mood disorder, some women are at greater risk. Identification of at-risk women and careful monitoring in late pregnancy and the early postpartum period can aid the practitioner in prompt, effective treatment. Pharmacologic and behavioral interventions are available to women who do develop postpartum mood disorders. Many women are reluctant to initiate medication management because of concerns related to breast feeding and infant exposure to psychotropic medications. Knowledge of appropriate medications and non-pharmacological interventions can enable the nurse to provide accurate information to the woman and her family.

Case Study

Patricia Greaves is a 29-year-old G2P2 (two pregnancies and two births) who gave birth to her son 2 weeks ago. During the 5th to 8th postpartum day at home, she developed tearfulness, crying spells, feelings of being overwhelmed, and the feeling she couldn’t do anything right. Patricia’s mother felt she had the baby blues and came and stayed with Patricia and her family during that time. Patricia’s mother left 3 days ago, and in the past 2 days, Patricia has been acting confused, paranoid her baby will starve to death, having exaggerated mood swings, and stopped sleeping at night. She told her husband this morning that someone is trying to steal their 3-year-old, and voices are telling her to run away with her children. Her husband, Paul, has never seen Patricia act this way although she did have postpartum depression after the birth of their 3-year-old daughter. What is the probable diagnosis? What immediate actions should Paul

take? What medical intervention is most appropriate for Patricia at this time?

Questions to Consider

Why do many women affected by a postpartum mood disorder fail to seek treatment for their symptoms? What screening practices should be in place to ensure that women are screened for postpartum mood disorders in the postpartum period? What information can the nurse provide to women who have been advised to start pharmacological treatment and who are breast feeding and concerned about the infant receiving the medication via the breast milk?

REFERENCES

American College of Nurse Midwives. (2011). Depression in women. Position statement. Retrieved from http://www.midwife.org/siteFiles/position/Depression_in_Women_05.pdf American College of Obstetricians & Gynecologists. (2010). Ob-Gyns encouraged to screen women for depression during and after pregnancy. Retrieved from http://www.acog.org/from_home/publications/press_releases/nr01-21-10.cfm Anxiety Disorders Association of America. (2011). Therapy. Retrieved from http://www.adaa.org/finding-help/treatment/therapy Association of Women’s Health, Obstetric, and Neonatal Nurses. (2008). The role of the nurse in postpartum mood and anxiety disorders. AWHONN position statement. Retrieved from www.awhonn.org/awhonn/binary.content.do? name=Resources/... Austin, M.-P. V., Hadzi-Pavlovic, D., Priest, S. R., Reilly, N., Wilhelm, K., Saint, K., & Parker, G. (2010). Depressive and anxiety disorders in the postpartum period: how prevalent are they and can we improve their detection? Archives of Women’s Mental Health, 13(5), 395–401. Beck, C. T. (2008). Impact of birth trauma on breastfeeding. Nursing Research, 57(4), 228–236. Bergink, V., Lambregtse-van den Berg, M. P., Koorengevel, K. M., Kupka, R., & Kushner, S. A. (2011). First-onset psychosis occurring in the postpartum period: A prospective cohort study. Journal of Clinical Psychiatry, 2011 August 23. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21903022 Britton, J. R. (2007). Maternal anxiety: Course and antecedents during the early postpartum period. Depression and Anxiety, 25(9), 793–800. DOI:

10.1002/da.20325 Brockington, I. F. (2004). Diagnosis and management of post-partum disorders: A review. World Psychiatry, 3, 89–95. Christian, L. M., & Storch, E. A. (2009). Cognitive behavioral treatment of postpartum onset obsessive compulsive disorder with aggressive obsessions. Clinical Case Studies, 8(1), 72–83. DOI: 10.1177/1534650108326974 Cooper, P. J., Murray, L., Wilson, A., & Romaniuk, H. (2003). Controlled trial of the short- and long-term effect of psychological treatment of postpartum depression. Impact on maternal mood. British Journal of Psychiatry, 182, 412– 419. Cuijpers, P., Muñoz, R. M., Clarke, G. N., & Lewinsohn, P. M. (2009). Psychoeducational treatment and prevention of depression: The “coping with depression” course thirty years later. Clinical Psychology Review, 29(5), 449– 458. DOI:10.1016/j.r.2009.04.005 Davanzo, R., Copertino, M., De Cunto, A., Minen, F., & Amaddeo, A. (2011). Antidepressant drugs and breastfeeding: A review of the literature. Breastfeeding Medicine, 6(2), 89–98. DOI:10.1089/bfm.2010.0019 Davidson, M. R., London, M. L., & Ladewig, P. A. W. (2012). Olds’ maternalnewborn nursing and women’s health across the lifespan, (9th ed). Upper Saddle River, NJ: Pearson. Doucet, S., Dennis, C. L., Letourneau, N., & Robertson-Blackmore, E. (2009). Differentiation and clinical implications of postpartum depression and postpartum psychosis. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 38(3), 269–279. DOI: 10.1111/j.1552-6909.2009.01019.x Field, T. (2008). Breastfeeding and antidepressants. Infant Behavior and Development, 31(3), 481–487. DOI: 10.1016/j.infbeh.2007.12.004 Engqvist, I., Ahlin, A., Ferzst, G., & Nillson, K. (2011). The qualitative report, 16(1), 66–83. Retrieved from http://www.nova.edu/ssss/QR/QR161/engqvist.pdf Gentile, S. (December 2005). The role of estrogen therapy in postpartum

psychiatric disorders: An update. CNS Spectrums. Retrieved from http://mbls.com/1205CNS_Gentile.pdf Gjerdingen, D. K., & Yawn, B. P. (2007). Postpartum depression screening: Importance, methods, barriers, and recommendations for practice. Journal of the American Board of Family Medicine, 20(3), 280–288. DOI: 10.3122/jabfm.2007.03.060171 Hillerer, K. M., Reber, S. O., Neumann, I. D., & Slattery, D. A. (2011). Exposure to chronic pregnancy stress reverses peripartum-associated adaptations: Implications for postpartum anxiety and mood disorders. Endocrinology, 152(10), 3930–3940. DOI: 10.1210/en.2011-1091 Kendall, R. E. (1987). Epidemiology of puerperal psychoses. The British Journal of Psychiatry, 150:662–673. DOI: 10.1192/bjp.150.5.662 Leddy, M., Hagga, D., Gray, J., & Schulkin, J. (2011). Postpartum mental health screening and diagnosis by obstetrician-gynecologists. Journal of Psychosomatic Obstetrics & Gynecology, 32(1), 27–34. DOI:10.3109/0167482X.2010.547639 Longo, L. P., & Johnson, B. (April 2000). Addiction: Part I. Benzodiazepines— Side effects, abuse risk and alternatives. American Family Physician, 2121– 2132. Melanie Blocker Stokes Foundation. (2011). About postpartum psychosis. Retrieved from http://www.melaniesbattle.org/ Misri, S., Reebye, P., Corral, M., & Mills, L. (2004). The use of paroxetine and cognitive-behavioral therapy in postpartum depression and anxiety: A randomized controlled trial. Journal of Clinical Psychiatry, 65(9), 1236–1241. O’Hara, M. W. (2009). Postpartum depression: What we know. Journal of Clinical Psychology, 65(12), 1258–1269. DOI: 10.1002/jclp.20644 Øystein Berle, J., & Spigset, O. (2011). Antidepressant use during breastfeeding. Current Women’s Health Reviews, 7, 28–34. Payne, J. L., Palmer, J. T., & Joeffe, H. (2009). A reproductive subtype of depression: Conceptualizing models and moving toward etiology. Harvard Review of Psychiatry, 17(2), 72–86. DOI: 10.1080/10673220902899706

Reck, C., Stehle, E., Reinig, K., & Mundt, C. (2009). Maternity blues as a predictor of DSM-IV depression and anxiety disorders in the first three months postpartum. Journal of Affective Disorders, 113(1–2), 77–87. DOI: 10.1016/j.jad.2008.05.003 Rowe, H. J., Fisher, J. R. W., & Loh, W. M. (2008). The Edinburgh Postnatal Depression Scale detects but does not distinguish anxiety disorders from depression in mothers of infants. Archives of Women’s Mental Health, 11(2), 103–108. DOI: 10.1007/s00737-008-0003-z Sit, D. K., & Wisner, K. L. (2010). The identification of postpartum depression. Clinical Obstetrics & Gynecology, 52(3), 456–468. DOI: 10.1097/GRF.0b013e3181b5a57c Spinelli, M. G. (2009). Postpartum psychosis: Detection of risk and management. American Journal of Psychiatry, 166, 405–408. DOI: 10.1176/appi.ajp.2008.08121899 Stone, S. D., & Menken, A. E. (2008). Perinatal and postpartum mood disorders: Perspectives and treatment guide for the health care practitioner. New York: Springer. Wei, G., Greaver, L. B., Marson, S. M., Herndon, C. H., Rogers, J., & Robeson Healthcare Corporation. (2008). Postpartum depression: Racial differences and ethnic disparities: Results. Medscape. Retrieved from http://www.medscape.com/viewarticle/581579_3 Wilson, B. A., Shannon, M. T., & Shields, K. M. (2011). Pearson nurse’s drug guide: 2011. Upper Saddle River, NJ: Pearson.

IV

Psychiatric Issues Common to Women

15

Anxiety Disorders

Anxiety Disorders are the most commonly occurring mental illnesses. They affect twice as many women as men. Culturally, anxiety disorders exist in all cultures although their care and treatment can vary significantly. There are different types of Anxiety Disorders including the following:

■ Generalized Anxiety Disorder (GAD) ■ Obsessive-Compulsive Disorder (OCD) ■ Panic Disorder (PD) ■ Posttraumatic Stress Disorder (PTSD) ■ Social Phobia (or Social Anxiety Disorder) ■ Specific Phobias (previously known as simple phobia)

Women diagnosed with Anxiety Disorders are more likely to have comorbidities including Depressive Disorders and other Anxiety Disorders. Women with prolonged anxiety have 36% higher rates of adverse cardiac events (Roest, Martens, Denollet, & De Jonge, 2010). Women with Anxiety Disorders also have a higher incidence of medical disorders and chronic pain. They are more likely to have a family history of Depressive Disorders than their male counterparts. In contrast, men with Anxiety Disorders are more likely to have nicotine dependence, alcohol abuse, and substance abuse issues.

Women have greater degrees of disabilities as a result of Anxiety Disorders than men even though women are more likely to seek treatment (Vesga-López, Schneier, Wang, Heimberg, Liu, Hasin, & Blanco, 2008). Women are also likely to develop Anxiety Disorders at younger ages than men (Anxiety Disorders Association of America, 2011). Unlike women, men tend to have a reduction in the occurrence of Anxiety Disorders with advancing age, whereas women show continued symptomology (Byers, Yaffe, Covinsky, Friedman, & Bruce, 2010). Risk factors for anxiety disorders include being a shy child or one that was bullied as a child, lack of social relationships and friends, immigration to a new country, and experiencing traumatic events in one’s life. Many times when women present with a chief complaint of anxiety, there are other physical morbidities that are present, or medications, herbal preparations, or substance abuse are causing the symptoms. Physical etiologies and substanceinduced anxiety need to be excluded before a diagnosis of an Anxiety Disorder is assigned. Women with chronic anxiety are at greater risk for suicide than women without anxiety.

ETIOLOGY OF ALL ANXIETY DISORDERS

Biochemical factors play a role in the development of Anxiety Disorders. The amygdala are brain circuits that are responsible for the regulation of fear and anxiety. In patients with anxiety, the amygdala have a heightened response to anxiety (Yates, 2011). Women have prolonged fight-or-flight reactions compared to men because of the elevated levels of estrogen and progesterone that occur with a stress response. It is also theorized that women do not process serotonin as quickly as men, which is why there is a higher incidence of anxiety and depression disorders in women. Low levels of corticotropin-releasing factor (CRF) may lead to increases in anxiety because CRF is associated with stress responses (Anxiety Disorders Association of America, 2011). Genetic factors also can predispose a woman to the development of an Anxiety Disorder. Psychosocial issues also play a role in developing an Anxiety Disorder. Women who have experienced trauma, injury, the death of loved ones, unresolved stressors, current stressors, and withdrawal from substances can all develop Anxiety Disorders.

EXCLUDING PHYSIOLOGICAL DISORDERS

When a woman presents with an intense anxiety response and the associated symptomology, the first step is to rule out a physiological etiology. Many of the symptoms associated with Anxiety Disorders can mimic life-threatening illnesses and conditions, and assumptions that the cause is psychological in nature could lead to a lethal misdiagnosis. Exhibit 15.1 includes possible tests and procedures that are sometimes performed to rule out physiological etiologies (Yates, 2011). The reader is cautioned to understand that not all of these tests will be performed. The decision to initiate specific tests is based on physical presentation and ruling out other causes.

Exhibit 15.1

Common Tests Performed to Rule Out Physiological Etiologies When Anxiety Presents as the Primary Symptom of Illness

Complete blood cell count Chemistry profile Thyroid function Urinalysis Urine drug screen Electroencephalography (EEG)

Lumbar puncture (LP) Computed tomography (CT) scan of the brain Magnetic resonance imaging (MRI) HIV screen Arterial blood gases (ABGs) Fluid and electrolyte levels Chest x-ray

Source: Adapted from Yates (2011).

GENERALIZED ANXIETY DISORDER

GAD occurs in 4.1% to 6.6% of Americans, more than 4 million people, and is twice as common in women than men (Beesdo, Pine, Lieb, & Wittchen, 2010). It is one of the most common mental illnesses in elderly women. Its onset typically occurs in childhood or adolescence or sometimes in early adulthood, although the disorder is common throughout one’s life, especially if untreated. Comorbidies with depression and other Anxiety Disorders are common.

Etiology

The cause of GAD is thought to include biopsychosocial etiologies. Genetic predisposition to the disorder may occur because there is a familial tendency to develop GAD (U.S. Surgeon General’s Report on Mental Health, 2004).

Signs and Symptoms

Women with GAD often have pronounced worrying behaviors that are out of proportion to the actual situation and that occur most of the time for a period of 6 months. They tend to worry about everything and are unable to control the worrying. They often experience fear and dread. In order to be diagnosed, women must exhibit three of the following symptoms:

■ Restlessness, feeling on edge, keyed up ■ Easily fatigued ■ Difficulty concentrating ■ Irritability ■ Muscle tension ■ Sleep disturbances

In addition, the worrying is not related to an Axis I disorder. Women with GAD have alterations in their function and experience distress in social, occupational, or other functioning areas. The symptoms associated with GAD are not related to another physiological or mental health disorder. Other common symptoms may include frequent voiding, trembling, being startled, nausea, headaches, and sweating.

Assessment and Screening

Assessment is typically based on symptomology. Screening tools can also be used that may include the Beck Anxiety Inventory, the Generalized Anxiety Disorder 7-item Scale, the Patient Health Questionnaire, the Primary Care Evaluation of Mental Disorders, the Sheehan Patient Rated Anxiety Scale (SPRAS), Anxiety Sensitivity Index (ASI), and the Anxiety Disorders Interview Schedule-IV (ADIS-IV) have all been successfully used.

Pharmacological Treatment

Most Anxiety Disorders are treated with benzodiazepines, which are effective in controlling symptoms; however, there are issues with developing tolerance and addiction to these medications. Commonly used drugs include the following:

■ Alprazolam (Xanax) ■ Chlordiazepoxide (Librium) ■ Diazepam (Valium)

Antidepressants can also be used for long-term management of Anxiety Disorders. Women who start therapy with an antidepressant should be advised that the drug takes a few weeks to reach therapeutic levels and the effects may not be immediate. Commonly used selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) include the following:

■ Paroxetine (Paxil) ■ Venlafaxine (Effexor) ■ Fluoxetine (Prozac) ■ Escitalopram (Lexapro) ■ Sertraline hydrochloride (Zoloft)

Older antidepressants, such as tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) can also be helpful in treating GAD but are rarely used because of their side-effect profiles. They have largely been replaced by the SSRIs and SNRIs. Commonly used SSRIs and SNRIs are listed in Table 15.1.

Table 15.1 ■ Commonly Used SSRIs and SNRIs Used to Treat Anxiety Disorders

SSRI Paroxetine (Paxil) Escitalopram (Lexapro) Sertraline hydrochloride (Zoloft) Fluoxetine (Prozac) Fluvoxamine (Luvox) Citalopram (Celexa)

SRNI Venlafaxine (Effexor XR) Duloxetine (Cymbalta)

Behavioral Therapies

Cognitive behavioral therapy (CBT) is commonly used to change the woman’s thoughts and beliefs that lead to anxiety and feelings of anxiety. Other therapies that have been used include relaxation therapy, ive psychotherapy, mindfulness therapy, integrative therapy, and emotional intelligence training (Evans, Ferrando, Findler, Stowell, Smart, & Haglin, 2008; Newman, Castonguay, Borkovec, Fisher, & Nordberg, 2008). Alternative stress reduction activities have also been shown to be effective in treating Anxiety Disorders and may include bio, yoga, and exercise. Hospitalization is warranted if the woman is unable to care for herself, has suicidal or homicidal thoughts, or if she would benefit from social skills training.

Obsessive-Compulsive Disorder

OCD occurs equally between men and women and is marked by ongoing obsessions and compulsive behaviors that commonly dictate a woman’s life. “Obsessions are recurrent, intrusive thoughts, impulses, or images that are perceived as inappropriate, grotesque, or forbidden” (U.S. Surgeon General’s Report on Mental Health, 2004, p. 154). Compulsions are repetitive activities that are performed to prevent a dreaded event from occurring. Even when women attempt to control obsessive thoughts and compulsive behaviors, they are unable to do so. These thoughts provoke severe anxiety and create stress for the woman. OCD tends to be chronic in nature and causes significant disability. It has a 2.4% incidence rate and commonly develops during childhood or adolescence (U.S. Surgeon General’s Report on Mental Health, 2004).

Etiology

Genetic factors, infections, extreme stressors, the presence of certain neurological conditions, and strained marital relationships have all been considered possible causative factors for OCD (Soomro, Altman, Rajagopal, & Oakley-Browne, 2008). Biologically, women with OCD appear to have an abnormality with the processing of serotonin levels. In addition, abnormalities in dopaminergic transmission also occur. Imaging studies have shown changes in blood flow patterns within the brain; specifically, increases in blood flow and metabolic activity in the orbitofrontal cortex have been identified (Soomro et al., 2008). Other theorists have considered that the glutamate and GABA synapses in neurotransmitters may be altered in women with OCD. Other causes include brain injury, stimulant abuse, and carbon monoxide ingestion (Yates, 2011).

Signs and Symptoms

Women with OCD have obsessive intruding thoughts that recur and the need to repeat compulsive actions. Common themes of obsession include the need for safety, cleanliness, needing to do the right thing, a need for symmetry, and unwanted sexual thoughts. Examples of common compulsions include the need to clean, to place things in a line, counting, hoarding, list making, confessing, seeking reassurances, and checking items (Soomro et al., 2008).

Assessment and Screening

A thorough interview and assessment are warranted. A structured interview should focus on the existence of obsessive thoughts and compulsive behaviors. Diagnosis is highly suspected if repetitive obsessive and compulsive behaviors are present. The screening instrument commonly used is the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Because of the high prevalence of coexisting disorders, screening should also be done for Mood Disorders, substance-abuse disorders, Somatoform Disorders, Eating Disorders, Tourette’s syndrome, impulse control issues, Schizophrenia, and AttentionDeficit/Hyperactivity Disorder (ADHD) (Soomro et al., 2008). “Other mental disorders that may fall within the spectrum of Obsessive-Compulsive Disorder include trichotillomania (compulsive hair pulling), compulsive shoplifting, gambling, and sexual behavior disorders” (U.S. Surgeon General’s Report on Mental Health, 2004, p. 157).

Pharmacological Treatment

Unlike many psychological disorders, even when treated OCD symptoms typically only reduce by 30% to 50%, thus leaving ongoing symptomology that must be continually assessed by the care provider. The first-line treatment regimens include use of SSRIs. Alternatively, SNRIs are also used. The use of SSRIs and SNRIs concurrently seems to yield favorable outcomes. Practitioners should be aware that when the treating etiology is OCD, the response time for medication is much slower than when these same agents are used to treat other psychiatric illnesses. Improvement may be slow, and no clinical effectiveness may be seen until 3 months of therapy has been completed (Soomro et al., 2008). Clomipramine, a TCA, has U.S. Food and Drug istration (FDA) indication in the treatment of OCD. It is the only TCA that has been approved for the treatment of OCD (Soomro et al., 2008). Other therapeutic measures that have been used include typical or atypical antipsychotics, glutamatergic agents, buspirone (Buspar), and inositol supplementation (Yates, 2011). Commonly used antipsychotics are listed in Exhibit 15.2.

Exhibit 15.2

Antipsychotics Commonly Used to Treat Obsessive-Compulsive Disorder

Risperidone (Risperdal) Aripiprazole (Abilify) Quetiapine (Seroquel)

Haloperidol (Haldol) Molindone (Moban) Clozapine (Clozaril) Olanzapine (Zyprexa)

Behavioral Therapies

Cognitive behavioral therapy (CBT) is the treatment of choice for women with OCD combined with pharmacologic intervention. Exposure and response therapy that targets ritual prevention is commonly employed. In CBT, women are challenged to identify their cognitive distortions, decrease occurrences of allor-nothing thoughts, and balance their thoughts and environments. Sometimes OCD treatments fail, and the practitioner must then examine other modes of treatment. Underlying disorders and comorbidities should also be treated simultaneously because the presence of untreated comorbidities can increase the likelihood of treatment failure. For severe cases of OCD that are unresponsive to other therapies, surgical intervention is possible. The most common procedures are the insertion of a specific small lesion (e.g., cingulotomy) or deep brain stimulation (DBS) in which a small device is implanted. It should be noted the effectiveness rates are somewhat low (28%) and few centers offer these surgical techniques (Cassels, 2010).

PANIC DISORDER

PD often develops in late adolescence and has an incidence rate of 3.5% to 9% in children and teens and 2% to 4% in adults (U.S. Surgeon General’s Report on Mental Health, 2004). The disorder is twice as common in women and typically develops either in the teen years or in the 40- to 54-year-old age group. Postmenopausal onset is also common. Risk factors for PD include smoking marijuana, illness, injury, stressors within the environment, loss, use of stimulants (including caffeine), exposure to environments that create stress in an individual, and abrupt discontinuation of SSRIs (Yates, 2011). The disorder presents with acute symptomology that mimics serious medical illnesses and should be considered an emergency until a physiological etiology is ruled out. Agoraphobia is marked by fear of being in groups, fear of public places, or fear of closed-in areas. The incidence of Agoraphobia is approximately 5% (U.S. Surgeon General’s Report on Mental Health, 2004). Women with Agoraphobia fear having an anxiety or panic attack in a public place. Women with Agoraphobia do not typically leave their homes and experience intense anxiety symptomology when they do so. Agoraphobia occurs in 50% of women who have PD (U.S. Surgeon General’s Report on Mental Health, 2004). Typically, women develop PD first and then may go on to develop Agoraphobia. PD and Agoraphobia are both associated with higher rates of suicide than the other Anxiety Disorders although any woman with an Anxiety Disorder is at risk for suicide (U.S. Surgeon General’s Report on Mental Health, 2004). Women with PD are at an increased risk of developing postpartum depression (PPD) and should be counseled prior to birth. These women would benefit from closer monitoring in the postpartum period and should be screened at various intervals for PPD (Rambelli, Montagnani, Oppo, Banti, Borri et al., 2010).

Etiology

Panic attacks and PD can be associated with poor health conditions and chronic stressors. There are complex etiologies associated with PD, including chromosomal alterations, autonomic nervous system imbalances, neurotransmitter imbalances, genetic factors, and hypersensitivity of certain receptors in the brain (Rambelli et al., 2010). Children diagnosed with Separation Anxiety Disorder commonly go on to develop panic attacks or PD (U.S. Surgeon General’s Report on Mental Health, 2004).

Signs and Symptoms

The signs and symptoms vary with each individual but may include the following (Yates, 2011):

■ Chest pain ■ Palpitations ■ Sweating ■ Trembling ■ Shortness of breath or inability to catch breath ■ Choking sensation ■ Dizziness ■ Nausea or gastrointestinal upset ■ Fear of loss of control ■ Derealization or depersonalization ■ Numbness or tingling ■ Headache ■ Fatigue

In general, a woman presenting with four or more episodes in a 4-week period or

one attack followed by a month of fearing an additional attack meets the diagnostic criteria for the disorder (American Psychological Association, 2000).

Assessment and Screening

For the practitioner evaluating a woman with the symptoms associated with PD, a complete assessment is warranted to rule out physiological etiologies. During the initial attack, transfer to a local emergency department is needed to rule out psychological causes. An extensive workup is performed, as discussed earlier, and symptoms usually subside in 20–30 minutes if a calming, low stimuli environment is created. The nurse plays a key role in providing reassurance and to the woman who often fears death will occur. Illicit drug use, use of medications and herbal supplements, and caffeine ingestion all need to be evaluated because they can cause or worsen panic disorder. Physiological causes, such as myocardial infarction, angina, hypoglycemia, mitral valve prolapse, pulmonary embolism, cardiac dysrhythmias, hypoparathyroidism, epilepsy, transient ischemic attacks, and pheochromocytoma all need to be eliminated as possible etiologies (Yates, 2011). A psychological interview should then be conducted to determine if the symptoms are likely related to a psychological cause. Commonly used assessment tools for the diagnosis of PD include standardized examinations, such as the Primary Care Evaluation of Mental Disorders (PRIME-MD), the Mobility Inventory for Agoraphobia (MIA), the Agoraphobia Cognitions Questionnaire (ACQ), and the Body Sensations Questionnaire (BSQ) (Yates, 2011).

Pharmacological Treatment

SSRIs are the front-line therapy for PD. TCA agents can also be used as a secondary treatment intervention. Fluoxetine (Prozac) is used but can initially increase anxiety symptoms. Paroxetine (Paxil) has some sedating properties and is sometimes used for this reason, although there is some debate whether it should be given to women during the childbearing years because of potential teratogenic effects on a fetus should conception occur. If Paxil is selected, practitioners should ensure that adequate contraception is in place. Another agent with sedating properties that can be istered at night and will also help with Insomnia symptoms is mirtazapine (Remeron). Zoloft and Lexapro have also been used successfully in the treatment of PD. Citalopram (Celexa) can also be used although it is known to increase the QT interval and should not be istered to individuals with congenital long QT syndrome. If it is used, dosages should not exceed 40 mg/day (Wilson et al., 2012). While benzodiazepines are effective for the treatment of PD, they have the potential for abuse and are not commonly used for prolonged periods of time and long-term management. Lorazepam (Ativan) and clonazepam (Klonopin) have been used with good success, but the duration of treatment should not exceed 6 weeks. In addition, rebound anxiety symptoms can occur with discontinuation. Exhibit 15.3 includes commonly used benzodiazepines used in the treatment of anxiety disorders, specifically PD.

Exhibit 15.3

Commonly Used Benzodiazepines for the Treatment of Anxiety Disorders

Alprazolam (Xanax) Lorazepam (Ativan) Clonazepam (Klonopin) Diazepam (Valium) Chlordiazepoxide (Librium) Oxazepam (Serax)

Behavioral Therapies

The most widely used and successful treatment modality is CBT. Women who undergo CBT learn to control and identify cognitive distortions along with learning how thoughts and behaviors can trigger symptoms. Exposure therapy is another approach in which the woman is slowly exposed to stimuli known to cause panic symptoms. The basis for this therapy is that women will become desensitized to the stimulus that causes the panic symptoms. Treatment with a psychiatric provider is important for women with PD because monitoring the symptoms, frequency and duration of attacks, and severity of symptoms is needed (American Psychological Association, 2011).

POSTTRAUMATIC STRESS DISORDER

The incidence of PTSD is considerably higher in women than in men. Individuals who experience a traumatic event are more likely to develop PTSD. Acute Stress Disorder is the term used to describe the acute anxiety symptomology and behavioral disturbances that occur within the first month after the traumatic event is experienced and is characterized by dissociation, anxiety, hyperarousal, avoidance behaviors, flashbacks, intrusive thoughts, and recurrent thoughts or visual images of the traumatizing event (U.S. Surgeon General’s Report on Mental Health, 2004). If these symptoms persist for more than a month, the diagnosis is changed to PTSD. The incidence of PTSD in the general population is 8% (University of Maryland Medical Center, 2011). Some studies have shown a higher incidence of PTSD in minority populations; however, other professionals have pointed out that minority populations are more commonly victimized, which may represent the differences in statistical variances. As many as 48% of women with PTSD do not receive any psychiatric treatment of their symptoms (Sinclair, Christmas, Hood, Potokar, Robertson, & Issac, 2009). Victims of sexual assault, rape, war, kidnapping, and childbirth-related trauma are at risk for developing PTSD. Military-related PTSD is discussed in Chapter 9; childhood-onset PTSD is discussed in Chapter 5; childbirth related trauma– induced PTSD is discussed in Chapter 14.

Etiology

The etiology of PTSD is experiencing a traumatic or stressful event. While not every woman who experiences a traumatic event will develop PTSD, it is estimated that up to 30% will. In the month following the World Trade Center attacks on September 11, 2001, 7.5% of residents living in New York City reported PTSD symptomology. Certain risk factors put a woman at a higher risk for developing PTSD should a traumatizing event occur. These include the following (University of Maryland Medical Center, 2011):

■ Alcohol or substance abuse ■ Insomnia ■ Preexisting mental illness ■ Family history of anxiety disorders ■ Lack of social or social isolation ■ Low socioeconomic status ■ Early separation from parental figure ■ Past history of abuse or neglect

Signs and Symptoms

The signs and symptoms of PTSD include being exposed to a traumatizing event when death, serious injury, or threat to an individual occurs. The woman then experiences helplessness, horror, and fear as a result of witnessing the event. Women who have these triggers then relive the event through nightmares, daydreams, thoughts, hallucinations, delusions, and flashbacks. Women with PTSD demonstrate avoidance behaviors when they avoid circumstances and events that may trigger these experiences. In order to be diagnosed, they must have three of the following behaviors (Yates, 2011):

■ Avoiding talking about the event ■ Avoidance of thoughts and feelings associated with the event ■ Inability to recall certain aspects of the events ■ Diminished interest in activities ■ Flat affect ■ Detachment from others ■ Fear of shortened life

Women with PTSD also exhibit arousal symptomology. Women with PTSD have at least two arousal symptoms, which include hypervigilance, Insomnia, lack of concentration, irritability, anger episodes, and an exaggerated startle response. The symptomology must create some type of functional impairment in social or occupational areas or other areas of the woman’s life (American Psychological Association, 2000). Other common symptoms include a lowered self-esteem

following the event, loss of sustained beliefs about trusting people or society as a whole, hopelessness, a sense of being permanently damaged, and difficulties in relationships (U.S. Surgeon General’s Report on Mental Health, 2004). PTSD is divided into various categories based on the onset of symptomology:

■ Acute PTSD lasts less than 3 months ■ Chronic PTSD persists for more than 3 months ■ Delayed onset occurs more than 6 months after the traumatizing event

ASSESSMENT AND SCREENING

Women with suspected PTSD should undergo a complete assessment and psychological screening. A comprehensive assessment should be preformed to rule out co-morbidities that often exist with PTSD. Women with suspected PTSD should be screened for related symptoms. Various assessment tools exist that can be used to screen for PTSD and other traumas. Most are checklists that assess specific symptomology and generally take 3–10 minutes to ister 4– 7 questions. Commonly used tools include the Primary Care PTSD Screen, form of the PTSD checklist, screening scale for PTSD, SPAN, SPRINT, Trauma screening questionnaire, and the PTSD checklist (Department of Veterans Affairs, 2012).

Pharmacological Treatment

The most commonly used agents to treat PTSD are the SSRIs. Sertraline hydrochloride (Zoloft) and paroxetine (Paxil) are the only FDA-approved pharmacologic treatments; however, escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), and citalopram (Celexa) have all been used with success in the treatment of PTSD although effectiveness is sometimes not seen until 2 to 4 weeks. Propranolol (Inderal, Betachron E-R, Innopran XL) has been used for up to one week after a traumatizing event to decrease symptomology related to sudden trauma, such as rape or sexual assault (Yates, 2011). Antidepressant agents can be used to treat PTSD and associated comorbidities. Common comorbidities include depression, substance abuse, alcohol abuse, and anxiety.

Behavioral Therapies

Behavioral therapies can be extremely effective in treating and preventing PTSD. Women who are exposed to a traumatic event, such as a rape, who begin treatment immediately prior to the onset of PTSD symptoms have a lower incidence of developing the disorder and less disability associated with the illness. Commonly used behavioral therapies include the following (Yates, 2011):

■ CBT ■ Art therapy ■ Eye movement desensitization and reprocessing (EMDR) ■ Hypnosis ■ Group therapy ■ Individual therapy ■ Family therapy ■ Repetitive transcranial magnetic stimulation (rTMS) (Osuch, Benson, Luckenbaugh, Geraci, Post, & McCann, 2008)

Hospitalization is warranted for women with suicidal thoughts or homicidal thoughts and ideations. Sometimes women with PTSD are hospitalized or treated on an inpatient basis for comorbidities. Women’s groups that are composed of survivors of trauma or sexual assault are also helpful in providing women with a peer-ed environment to share their feelings and reactions

to the traumatic event. PTSD resolves in 6 months in approximately 50% of women with the diagnosis. For the other 50%, the disorder commonly persists for years or throughout the woman’s life, dominating her thoughts. The highest incidence occurs in women who have been raped, been victimized in a crime, been held in a concentration camp, or endured torture of some form (U.S. Surgeon General’s Report on Mental Health, 2004).

SOCIAL PHOBIA

Social Phobia, also known as Social Anxiety Disorder, affects 7% to 12% of all individuals in Western countries and is more common in women (University of Maryland Medical Center, 2011). It typically has its onset in the adolescent years with 80% of suffers developing the illness by the age of 20 (Yates, 2011). Women with a diagnosis of Social Phobia are more likely to have comorbidities, such as depression and alcohol abuse. Substance abuse disorder can also occur but is more common in men than in women.

Etiology

Social Phobia appears to have some genetic component associated with its etiology. Biopsychosocial factors seem to play a role in the development of the disorder. Some researchers have theorized that there is either serotonergic or dopaminergic dysfunction involved. Social rejection or poor social skills can also play a role in the development of the disorder. It is theorized that women with Social Phobia have an exaggerated fear of being ridiculed or experiencing embarrassment.

Signs and Symptoms

The signs and symptoms of Social Phobia include exaggerated or persistent fear about engaging in social situations. When the woman is engaged in a social situation, she typically experiences a great deal of anxiety. Her ability to function is often impaired. Women with social anxiety adamantly avoid social situations and public events. When a social outing is anticipated, intense fear, anxiety, and distress usually occur prior to the event (Yates, 2011). Even though the woman recognizes her fears are out of proportion to the circumstances, she is unable to control her responses. In order for a diagnosis to be made, other etiological physiological diseases and psychological disorders need to be excluded.

Assessment and Screening

Assessment is typically based on a psychological interview that determines if symptoms of social anxiety are present. Primary care settings often use a version of the Social Phobia Inventory (SPIN) called the Mini-SPIN, which consists of three questions that can be used as an assessment tool (Ebell, 2008). It should be noted that once a woman experiences Social Phobia, complete resolution of the disorder is rare, even when she receives treatment (U.S. Surgeon General’s Report on Mental Illness, 2004).

Pharmacological Treatment

Pharmacological treatment typically includes the use of SSRIs for symptom management. Both SSRIs and MAOIs have been shown to be effective, but MAOIs are not a first-choice therapy because of their side effects. They may include the agents phenelzine (Nardil), selegiline (Emsam), tranylcypromine (Parnate), and isocarboxazid (Marplan). Sometimes beta blockers, such as atenolol, nadolol, or propranolol may be useful for situational/performance anxiety on an as-needed basis; however, long-term daily use is typically ineffective. Benzodiazepines are often effective but because of their addictive qualities are often not used. Sometime practitioners may try to wean women off of all medications after 6–12 months of continuous effective therapy, whereas some will maintain pharmacological treatment on a long-term basis. If the woman is weaned off medications and symptoms recur, then longterm pharmacological therapy is warranted.

Behavioral Therapies

CBT is often used to change a woman’s thoughts and perceptions about specific emotions and to help her adapt new beliefs. Desensitization is often used to decrease the anxiety reaction experienced when social integration does occur. Exposure therapy is often helpful in treating women with social anxiety. Group therapy has also been an effective approach for treating women with Social Phobia. Relaxation techniques and breathing exercises may also be used.

SPECIFIC PHOBIAS

Specific Phobias, which were previously termed Simple Phobias, occur when a woman has a severe intense fear of a specific object or situation. The incidence is approximately 8%. “The most common Specific Phobias include the following feared stimuli or situations: animals (especially snakes, rodents, birds, and dogs); insects (especially spiders and bees or hornets); heights; elevators; flying; automobile driving; water; storms; and blood or injections” (U.S. Surgeon General’s Report on Mental Illness, 2004, p. 125). The woman knows the fear is irrational but still exhibits marked anxiety that interferes with an area of functioning in her life. Specific Phobias are one of the most commonly occurring mental health disorders and affect twice as many women as men.

Etiology

Specific Phobias commonly coexist with another psychiatric morbidity such as GAD or depression. Some women with a Specific Phobia can trace the beginning of their illness to exposure to a traumatic event. Some women may develop the same phobia as their parents or other relatives who had an intense fear in childhood that they are now mimicking. Other etiological factors include a genetic tendency. Most Specific Phobias start in childhood prior to the age of 5 and then peak again in adulthood. Some are outgrown with age, whereas others persist through adulthood. Other phobias are thought to be related to unresolved childhood experiences (Kahn & Adamec, 2008).

Assessment and Screening

There are various types of phobias; Exhibit 15.4 lists a number of them. Women are interviewed and evaluated for the presence of Specific Phobia symptomology. Screening tools can also be used that may include the Beck Anxiety Inventory, the Generalized Anxiety Disorder 7-item Scale, the Patient Health Questionnaire, the Primary Care Evaluation of Mental Disorders, the SPRAS, the ASI, and the ADIS-IV.

Exhibit 15.4

Different Types of Phobias

Aichmophobia: Fear of needles or pointed objects Algophobia: Fear of pain Androphobia: Fear of men Anthropophobia: Fear of people or society Arachnephobia or Arachnophobia: Fear of spiders Bacteriophobia: Fear of bacteria Chiraptophobia: Fear of being touched Erotophobia: Fear of sexual love or sexual questions

Genophobia: Fear of sex Hedonophobia: Fear of feeling pleasure Heterophobia: Fear of the opposite sex Insectophobia: Fear of insects Katsaridaphobia: Fear of cockroaches Kolpophobia: Fear of genitals, particularly female Lockiophobia: Fear of childbirth Menophobia: Fear of menstruation Nudophobia: Fear of nudity Philophobia: Fear of falling in love or being in love Rhypophobia: Fear of defecation Scotophobia: Fear of darkness Tocophobia: Fear of pregnancy or childbirth Urophobia: Fear of urine or urinating Virginitiphobia: Fear of rape

Signs and Symptoms

Women with Specific Phobias will have a marked ongoing fear that is unreasonable and that provokes an immediate anxiety response when they are exposed to the specific object or situation. Women with Specific Phobias generally avoid the object or situation at all costs to the point that the avoidance behaviors can interfere with the woman’s normal functioning. Women with suspected Specific Phobia need to be evaluated for other mental illnesses. Other causative factors should be excluded before a diagnosis is made.

Pharmacological Treatment

Pharmacologic treatment for Specific Phobias includes the istration of SSRIs. Short-term use of benzodiazepines and beta blockers can also be used.

Behavioral Therapies

Exposure therapy is sometimes used to desensitize the woman to the specific object or situation that is the source of the phobia. CBT is also commonly used to assist the woman to learn new ways to cope when she is exposed to the object or situation that is the source of her phobia. Women with phobias are encouraged to talk openly about their fears, be positive when facing these fears, and strive not to reinforce phobias. Women with phobias should be counseled that ongoing reactions can trigger phobias in their children, so the need for psychiatric help is essential.

SUMMARY

Anxiety Disorders are one of the most commonly occurring mental illnesses. There are multiple disorders associated with anxiety that can cause significant impairment for a woman and her family. Anxiety Disorders tend to be biopsychosocial in their etiologies. While benzodiazepines are an effective treatment intervention to control symptoms, their tolerance and dependency properties make them less attractive for long-term management. Most of the Anxiety Disorders are more common in women and can be successfully treated with SSRIs. Other pharmacological regimens have proven effective for specific Anxiety Disorders. The addition of behavioral therapies can lead to higher success with treatment. Because anxiety commonly coexists with other psychiatric comorbidities, complete psychological assessment with proper treatment is imperative. Anxiety can be reduced with proper treatment and follow-up although complete resolution is not always possible with all disorders.

Case Study

Samantha Keyes is a 27-year-old woman who has always been described as “shy and awkward” by her peers. During high school, Samantha did not belong to any school groups or participate in after-school activities. She did complete a 2-year college program in computers and works from home doing medical transcription work. She emails all of her reports to the office manager of the practice where she is employed and has little interaction with her coworkers or the office staff there. Samantha lives with her parents and notes she has few friends. In the rare circumstances that Samantha does have to report to work, she notes intense anxiety, palpitations, and fear. While she knows her fears are unfounded, she cannot help but develop these feelings. Samantha presents to the medical office today with her mother to refill her inhaler prescription for her asthma. She has

not been seen there for over a year and only came today because they would not continue to refill her prescription without being seen. When the Family Nurse Practitioner (FNP) enters the room, Samantha fails to make eye and says very little. Her mother volunteers that Samantha cannot tolerate social situations and fears going out of the house. What is the most likely diagnosis? What treatment interventions can be suggested to Samantha?

Questions to Consider

How do cultural variations impact a woman’s response to anxiety symptoms? What Anxiety Disorder has the least favorable prognosis and why? How can women with Anxiety Disorders increase their social skills in order to function more appropriately in the community?

REFERENCES

American Psychological Association. (2000). Quick reference to the diagnostic criteria from DSM-IV-TR. Washington, DC: Author. American Psychological Association. (2011). Practice guideline for the treatment of patients with panic disorder. No. 65. (2nd ed.). Washington, DC: Author. Retrieved from http://www.psychiatryonline.com/pracGuide/pracGuideChapToc_9.aspx Anxiety Disorders Association of America. (2011). Facts on anxiety. Retrieved from Anxiety Disorders Association of America, http://www.adaa.org/ Beesdo, K., Pine, D. S., Lieb, R., & Wittchen, H. (2010). Incidence and risk patterns of anxiety and depressive disorders and categorization of generalized anxiety disorder. Archives of General Psychiatry, 67(1), 47–57. Byers, A. L., Yaffe, K., Covinsky, K. E., Friedman, M. B., & Bruce, M. L. (2010). High occurrence of mood and anxiety disorders among older adults. Archives of General Psychiatry, 67(5), 489–496. Cassels, C. (2010). Bilateral deep brain stimulation appears safe, effective for highly refractory OCD. Medscape. Retrieved from http://www.medscape.com/viewarticle/729917 Department of Veterans Affairs. (2012). Retrieved from National Center for PTSD http://www.ptsd.va.gov/professional/pages/assessments/screens-forptsd.asp. Ebell, M. H. (2008). Diagnosis of anxiety disorders in primary care. American Family Physician 15, 78(4), 501–502. Evans, S., Ferrando, S., Findler, M., Stowell, C., Smart, C., & Haglin, D. (2008). Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 22(4), 716–721. DOI: 10.1016/j.janxdis.2007.07.005

Kahn, A. P., & Adamec, C. A. (2008). The encyclopedia of fears, phobias, and anxieties, 3rd ed. New York: Facts on File. Newman, M. G., Castonguay, L. G., Borkovec, T. D., Fisher, A. J., & Nordberg, S. S. (2008). An open trial of integrative therapy for generalized anxiety disorder. Psychotherapy: Theory, Research, Practice, Training, 45(2), 135–147. DOI: 10.1037/0033-3204.45.2.135 Osuch, E. A., Benson, B. E., Luckenbaugh, D. A., Geraci, M., Post, R. M., & McCann, U. (2008). Repetitive TMS combined with exposure therapy for PTSD: A preliminary study. Journal of Anxiety Disorders, 23(1), 54–59. DOI: 10.1016/j.janxdis.2008.03.015 Rambelli, C., Montagnani, M. S., Oppo, A., Banti, S., Borri, C., et al. (2010). Panic disorder as a risk factor for post-partum depression: Results from the Perinatal Depression-Research & Screening Unit (PND-ReScU) study. Journal of Affective Disorders, 122(1–2), 139–143. DOI: 10.1016/j.jad.2009.07.002 Roest, A. M., Martens, E. J., Denollet, J., & De Jonge, P. (2010). Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: A meta-analysis. Psychosomatic Medicine, 72(6), 563–569. Sinclair, L. I., Christmas, D. M., Hood, S. D., Potokar, J. P., Robertson, A., & Isaac, A. (2009). Antidepressant-induced jitteriness/anxiety syndrome: Systematic review. British Journal of Psychiatry, 194(6), 483–490. Soomro, G. M., Altman, D., Rajagopal, S., & Oakley-Browne, M. (2008). Selective serotonin reuptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). Cochrane Database Systemic Review, 23(1), CD001765. University of Maryland Medical Center. (2011). Anxiety disorders. Retrieved from http://www.umm.edu/patiented/articles/who_gets_anxiety_disorders_000028_3.htm U.S. Surgeon General’s Report on Mental Illness. (2004). Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html Vesga-López, O., Schneier, F. R., Wang, S., Heimberg, R. G., Liu, S. M., Hasin, D. S., & Blanco, C. (2008). Gender differences in generalized anxiety disorder:

Results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Journal of Clinical Psychiatry, 69(10), 1606–1616. Wilson, B. A., Shannon, M. A., & Stang, M. L. (2012). Nurse’s drug guide. Upper Saddle River, NJ: Pearson. Yates, W. R. (2011). Anxiety disorders. Medscape. Retrieved from http://emedicine.medscape.com/article/286227-medication#11

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Mood Disorders

Mood Disorders are some of the most commonly occurring major mental illnesses in women. They include the various types of depression and the different types of Bipolar Disorder. The nurse plays a key role in assisting a woman with a Mood Disorder to understand her illness and seek appropriate treatment. It is estimated that at least 20% of the population reports a depressive symptom each month with another 12% reporting at least two per year ( Mental Health America, 2011 ). Women from different cultures offer a challenge when identifying the presence of Mood Disorders because it may not be culturally appropriate to seek out services for these symptoms; instead, maintaining the problems internally is viewed as the desired approach within their value system ( Lehti, Hammarstrom, & Mattsson, 2009 ).

MAJOR DEPRESSIVE DISORDER

Major Depressive Disorder (MDD) is marked by sadness, hopelessness, depression, and lack of interest in previously enjoyed activities along with other symptoms. MDD occurs twice as frequently in women than in men and typically begins in adolescence, continues through at least the end of middle age, and crosses cultural boundaries (Harkness, Alavi, Monroe, Slavick, Gotlib, & Bagby, 2010). While depression can occur in childhood, MDD in childhood is rare.

Etiology

MDD is complex in nature and includes the interplay between genetic, biological, and environmental factors. Genetic factors include a family tendency toward depression. Inheritance of depression may be as high as 40% to 50% based on twin studies (Levinson, 2005). Children with a family history of depression have a 2–3 times increased risk of developing depression compared to the average individual with no family history of a depressive episode. In families with a history of more intense depression, the risk may increase to 4–5 times that of the average individual (Levinson & Nichols, 2011). Biological factors specific to women include hormonal fluctuations throughout the menstrual cycle, which are known to affect a women’s mood (Ryan, Carrière, Scali, Ritchie, & Ancelin, 2008). Women deal with alternating hormonal changes throughout their lifespan, including puberty, pregnancy, postpartum, lactation, perimenopause, and menopause. These hormonal fluctuations can impact a woman’s mood considerably. There is some theoretical belief that increased cortisol levels secondary to stress are higher in women than in men and create a biological tendency toward depression along with other estrogendependent binding proteins (Dodig-Curkovic, Kurbel, & Matic, 2009). Low levels of serotonin, norepinephrine, and dopamine are associated with depression, bringing rise to the chemical imbalance theory. New studies indicate that monoamine oxidase A (MAO-A), a chemical that breaks down these neurotransmitters, may be as much as 34% higher in individuals with depressive disorders. It is theorized that these increased levels of MAO-A may be breaking down too many of the neurotransmitters, thus further explaining the chemical imbalance theory. Environmental factors can for 50% to 60% of depressive episodes in women (Levinson, 2005). There is a body of evidence that suggests women are exposed to more stressful life events throughout their lifespan. Harkness et al. (2010) found that women ages 18–29 experienced significantly more stress than women over the age of 50. Women also reported more adverse life events and more severe life events than men did in the same study (Harkness et al., 2010).

In addition, women may possess more biological and psychological vulnerabilities than men. It is more common for depressed women to report an adverse stressful life event prior to the onset of a major depressive episode (Harkness et al., 2010; Kendler, Kessler, Walters, MacLean, Neale, Heath, & Eaves, 2010).

Signs and Symptoms

MDD is categorized by a 2-week or longer period of varying symptoms not related to a medical diagnosis, a grief process, or induced by drugs. Commonly occurring symptoms include the following:

■ Depressed mood ■ Disinterest in past enjoyable activities ■ Weight changes ■ Sleep changes ■ Fatigue or lethargy ■ Feelings of worthlessness ■ Difficulty with concentration ■ Psychomotor agitation ■ Thoughts of suicide ■ Thoughts of death

The symptoms impair an individual’s functioning in work and social situations. Women who have at least five of these symptoms with impairment of a 2-week or longer duration are diagnosed with depression (Beck & Alfred, 2009). It is important to note that women may present to their primary care office with varying physical symptoms and often do not report depressive symptoms as the

reason for their visit. Common physical symptoms include “t pain, limb pain, back pain, gastrointestinal problems, fatigue, psychomotor activity changes, and appetite changes” (Trivedi, 2004, p. 12). In an examination by the World Health Organization of somatic complaints in 14 countries, 69% of patients presented for primary care intervention with somatic complaints only and ended their visit with a diagnosis of depression (Simon, Von Korff, & Piccinelli, 1999). Other studies have revealed that when patients present with nine or more physical complaints, 60% were diagnosed with a Mood Disorder compared to only 2% with a complaint for one somatic symptom (Kroenke, Spitzer, & Williams, 1994).

Assessment and Screening

Screening for MDD is recommended for all adults in the primary care setting. There are numerous screening tools that have been introduced to assess for depression in both adults and children. Clinicians should use the assessment model that works best for their practice population, personal comfort level, and patient needs (U.S. Public Health Task Force, 2009). Depression scales, such as the Beck Screening Inventory, Beck Screening Inventory-IA, and Beck Screening Inventory-II, Center for Epidemiological Studies Depression Scale, and the Zung Depression Scale are all recommended for the primary care setting. The tools use a self-reporting question design to elicit responses. The tools vary in their question length but average around 20 questions. Many primary care providers note, however, that they do not have time to ister these lengthy tests in a primary care setting. Current recommendations from the U.S. Public Health Task Force (2009) recommend screening all adults in the primary care setting for depression. It advocates two straightforward questions:

1) “Over the past 2 weeks, have you felt down, depressed, or hopeless?” 2) “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”

A positive response to either question warrants a full assessment on depressive symptoms to evaluate for the presence of depression. In patients who meet the diagnostic criteria for MDD, appropriate treatment is warranted. Recurrent screening is indicated for women with a past history of depression or other risk factors.

Pharmacological Treatment

Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat MDD and work by “inhibiting central nervous system (CNS) presynaptic neuronal uptake of serotonin, which results in antidepressant activity” (Wilson, Shannon, & Shields, 2010, p. 342). Before beginning treatment, any woman who was previously treated with a monoamine oxidase inhibitor (MAOI) should have discontinued that drug for at least 2 weeks prior to starting an SSRI. When prescribing an SSRI, routinely monitor hepatic functions, complete blood count (CBC), and serum sodium in patients with renal and cardiac dysfunction and in older adults. Assess heart rate (HR) and blood pressure (BP) in patients with cardiac disorders. SSRIs should be used with caution in older adults and in adolescents; they have been associated with increased incidence of suicide in these groups (Wilson et al., 2010). SSRIs and norepinephrine reuptake inhibitors (SNRIs) are used to treat depression by increasing the availability of serotonin and norepinephrine. These drugs are sometimes not indicated in adolescence and in the elderly or in individuals taking nonsteroidal antiinflammatory medications (NSAIDs). In adolescents and the elderly, there is an increased risk for suicide in patients taking SSRIs. In the elderly, especially those on aspirin or NSAIDs, there is an increased risk of gastrointestinal bleeding. This risk may be reduced by the cotreatment of proton pump inhibitors (PPIs) such as Prilosec, Prevacid, or Protonix (Targownik, Bolton, Metge, Leung, & Sareen, 2009). Table 16.1 includes commonly used SSRIs for the treatment of depression.

SSRIs and SNRIs are the most commonly prescribed pharmacological agents used to treat depression by increasing serotonin levels. In addition, serotonergics and noradrenergics can result in a lessening of depressive symptoms, and also have properties similar to tricyclic antidepressants (TCAs) that combat neuropathic pain. SNRIs have fewer side effects than SSRIs. Commonly used SNRIs are included in Table 16.2.

Other classes of medications used to treat depression include TCAs and MAOIs. TCAs, in general, are no longer the first line of treatment because of the higher incidence of side effects associated with them. MAOIs were the first antidepressants introduced but are typically reserved as the last choice in treatment because of the potentially lethal side effects that can occur. Other commonly used drugs for treating depression are listed in Table 16.3. Second generation MAOIs do have fewer side effects and have been successful in treating atypical depression, i.e., depression that does not respond typically to traditional medical treatment.

Table 16.3 ■ Other Types of Drugs Used to Treat Depression

Class of Medication Tricyclic antidepressants (TCAs) Adapin

Monoamine oxidase inhibitors (MAOIs) Other antidepressants

Drug Names Anafranil

Side Effects Dry mouth; blurred vision; increased fatigu

Aventyl Elavil Norpramin Pamelor Pertofrane Sinequan Surmontil Tofranil Vivactil Parnate Nardil Marplan Matulane Desyrel Bupropion

Severe food interactions, including tyramin Drowsiness, hypotension, orthostatic hypote

Source: Adapted from Turkington & Harris (2009); Wilson et al. (2011).

Patients with atypical depression or those who present with psychosis or other unusual symptoms should be referred to a psychiatrist and therapist for immediate treatment. Depression with psychotic features is depression that is also associated with psychotic symptoms. It is a serious diagnosis that warrants immediate hospitalization and aggressive inpatient treatment. It can occur in up to 10% to 15% of patients with severe MDD (Cassels, 2009). It is much more common in the elderly. It is commonly treated with SSRIs or SRNIs and antipsychotics and requires an experienced practitioner to manage the process because recovery times and treatments are beyond the scope of the primary care professional. Drug-resistant cases may be treated with electroconvulsive therapy (ECT) (Cassels, 2009).

Behavioral Therapies

Counseling or therapy interventions are commonly used to treat depression and may be used alone or with pharmacological therapies. Practitioners should refer women who they feel would benefit from therapy interventions to a trusted professional within the community. Most counties in the United States have mental health community services based on income-related sliding scales where women can obtain both psychiatric and psychotherapy services at reduced fees if they qualify. Cognitive behavioral therapy (CBT), psychotherapy, interpersonal therapy (IPT), and individual counseling can all be used to treat depression. The primary care provider should note that it is increasingly common for mental health practitioners to use a self-pay model that would severely inhibit some women from obtaining needed services. Other women may have insurance benefits but may be reluctant to submit claims for mental health services. CBT is a technique in which patients challenge basic beliefs about themselves and work to change those dysfunctional beliefs to replace those dysfunctional behaviors with productive coping skills. It has been shown to be effective in treating depression and in relapse prevention (Mor & Haran, 2009). IPT is a short-term therapy based on the belief that building interpersonal skills can positively impact the interpersonal issues that contribute to mental illness (CritsChristoph, Gibbons, Temes, Elkin, & Gallop, 2010). IPT has been shown to be an effective means to treat women with depression (Cambron, Acitelli, & Pettit, 2010). Psychoanalytic therapy is used less commonly and is a long-term treatment modality. Studies have demonstrated greater effectiveness in using CBT, IPT, and individual counseling techniques than in long-term psychotherapy (Hermann, Munsch, Biedert, & Lang, 2010). Individual counseling is based on an individual’s needs and assists the individual in everyday living and creates a plan for ongoing optimal mental health.

ELECTROCONVULSIVE THERAPY (ECT)

ECT for the treatment of depression has been used since 1939 and is highly variable in the rates of use with 0.04 to 82 cases per 10,000 populations reported. It was more common in White women with few Americans today having ECT therapy at all. ECT is done in an inpatient setting and is more common in private hospitals than in the public sector. It can be used to treat severe depression that is unresponsive to other therapies, depression with psychotic features, or in extreme cases of suicide risk when other treatments have failed (Lisanby, 2007). It is used with the elderly when traditional therapy may be ineffective or medications cannot be tolerated (Lisanby, 2007). It has success rates of up to 75% but is typically not the first line of treatment for depression and is mostly used for patients who have had success with the treatment in the past. It has also been used in the treatment of severe depression in the antepartum period (Lisanby, 2007).

SEASONAL AFFECTIVE DISORDER

Seasonal Affective Disorder (SAD) is a cyclical disorder in which depressive symptoms occur every fall and winter and improve throughout the spring and summer months (National Center for Biotechnology Information, 2011). SAD, like depression, affects women at higher rates than men (3:2 ratio) and is thought to be related to hormonal fluctuations, ambient light, and body temperature. It is also more prominent in northern geographic areas and in women under the age of 40 (Booker & Hellekson, 1994). There is a rare form of SAD that exists in summer. Symptoms typically begin to occur in late fall and increase in severity over the winter months. They may include the following (National Center for Biotechnology Information, 2011):

■ Feeling sluggish ■ Unhappiness ■ Lethargy ■ Slowness in movements ■ Loss of interest in previously enjoyed activities ■ Increased appetite ■ Weight gain ■ Daytime sleeping ■ Excessive sleeping ■ A noted afternoon slump

■ Loss of energy

Diagnosis is typically made on the presence of symptoms during an examination with the practitioner. A woman with SAD can be treated with the traditional pharmacological medications used to treat depression and with psychotherapy (see treatments for MDD). In addition, exercise outdoors with exposure to the sun during peak sunlight hours is also recommended. Patients should be encouraged to remain socially active because isolation can worsen symptoms. In addition to the therapies used for MDD, light therapy with a very direct light source using a bright fluorescent light bulb (10,000 lux) has yielded positive outcomes. The woman should be exposed to the light source in the early morning for 30 minutes to mimic the sun. Side effects include headache and eye strain. The treatment should be used with caution in individuals on medications that may cause sensitivity to light, such as antibiotics or psoriasis drugs and certain antipsychotics (Rohan, Roecklein, Tierney-Lindsey, Johnson, Lippy, Lacy, & Barton, 2007). Symptoms typically begin to improve within a few weeks of beginning light therapy and vastly improve in spring and summer (Rohan et al., 2007).

DYSTHYMIC DISORDER

Dysthymic Disorder (DD) is a disorder characterized by low moods and milder symptoms of depression. It is more common in women and commonly seen in women with chromic medical problems or other psychiatric diagnoses. Symptoms can include difficulty with concentration, abnormal sleep patterns, low self-esteem, extremes in eating, and low energy levels or fatigue. Typically if two or more of these symptoms are present almost all of the time, the diagnosis is made (Stewart, 2007). DD occurs in 5% of the population and may coexist with alcoholism and substance abuse. Individuals with DD often perceive themselves negatively. It carries a 50% risk of having an episode of MDD at some time in their lives, so women with DD should be screened for MDD at every patient encounter (Stewart, 2007). Pharmacological treatment is the same as MDD. In addition, CBT, insight-oriented therapy, and groups may be effectively used (Stewart, 2007). For some women, symptoms and ongoing treatment can be a lifelong process.

BIPOLAR SPECTRUM DISORDERS

Bipolar Disorder (BPD) is characterized by elevations in mood, known as mania, that alternates with symptoms of depression. The cycling, or switch from one mood to the other, can be quite abrupt. BPD tends to run in families and has genetic influences. It is experienced equally in men and women although women with BPD present differently than men. The average age of onset is in the late teens and early 20s. There are two types of BPD. BPD I, which was previously called manic depression, occurs when at least one manic episode has occurred followed by a period of depression. BPD II involves a state known as hypomania, when mood elevations still occur but not to the extremes of a full manic episode. These episodes of hypomania also alternate with periods of depression. Women with BPD II are prone to more frequent episodes of cycling (Swartz, Frank, Frankel, Novick, & Houck, 2009). In these disorders, significant impairment in social, occupational, or another area of functioning is severely impaired. Cyclothymia is considered a mild form of BPD and is evidenced by less severe mood swings that do alternate with hypomania and depression symptoms although at a much milder level.

Etiology

The etiology of BPD is thought to include genetic, biological, and environmental factors. In twin studies, 80% of identical twins both exhibited the disorder when it was present in one twin compared to only 16% in fraternal twins (Read, 2011). Biological factors are thought to include alterations within the neurotransmitters although the exact etiological factor remains unclear. Environmental causes can also play a role in developing BPD. Sometimes BPD is triggered by a major event, such as childbirth, a loss, substance abuse, treatments with other psychiatric medications, or prolonged periods without sleep.

Signs and Symptoms

The main signs and symptoms of BPD are mood swings that alternate between mania (or hypomania) and depression. The signs and symptoms are presented in Table 16.4. Mania symptoms occur in BPD I in greater extremes and are less intense in BPD II.

Table 16.4 ■ Signs and Symptoms Associated with Bipolar Disorder

Mania Symptoms Agitation Little sleep with little need for sleep Inflated self-esteem with ideas of grandiosity Elevated mood (unlimited energy, hyperactivity, lacks self-control, racing thoughts) Loses temper easily Engages in risk-taking behaviors (overspending, gambling, binge drinking, sexual practice) Distractibility

Depression Symptoms Chronic low mood, sadness Difficulty with concentration Difficulty making decisions Eating changes Lethargy, fatigue Suicidal thoughts Thoughts of dying and preocc Sleep disturbances Guilt, feelings of worthlessne Loss of self-esteem Social withdrawal

Assessment and Screening

Individuals with a family history of BPD or those demonstrating symptoms causing suspicions of BPD should undergo a complete assessment. Because BPD can be precipitated by a stressful life event or substance abuse, the practitioner should obtain a complete history from the woman and her family, if consent is given. Questions focusing on behaviors, moods, and behavior extremes should be asked. Physical examination should be performed to rule out underlying disease, such as a thyroid disorder. While there are multiple screening tools available for identifying BPD, the screening assessment of depression-polarity (SAD-P) is a three-item scale with established validity and reliability used to determine if BPD may be present and is the most time-effective means to identify BPD in the primary care setting (Solomon, Leon, Maser, Truman, Coryell, Endicott, Teres, & Keller, 2006). The SAD-P scale contains three essential elements of BPD I and II and includes the following: presence of delusions during the current episode of depression (score 0 for zero episodes, score 1 for 1 episode, s2 episodes, etc.); number of earlier episodes of depression (score per event, 0 episodes = 0, etc.), and family history of major depression or mania (0 = no family history, and 1 equals positive history in a first-degree relative). A score greater than 2 is suggestive of BPD and warrants further screening (Solomon et al., 2006). Substance abuse and BPD frequently coexist in women who utilize alcohol and drugs as a means of self-medication. Screening for alcohol and substance abuse should be performed in any woman identified as having BPD because dual diagnosis is common. Dual diagnosis, the presence of a mental health disorder and a substance abuse disorder, decreases compliance and increases treatment resistance (Pacchiarotti, Marzo, Colom, Sanchez-Moreno, & Vieta, 2009). Women with a dual diagnosis should be referred to a dual diagnosis group verses a traditional Alcoholics Anonymous (AA) group or other model of care. Women dealing with comorbidities face greater challenges than those who possess a single mental

health disorder because their treatment plans must meet the needs of separate diagnoses. A dual-diagnosis care model is designed to deal with multiple, complex mental health issues. Some dual-diagnosis groups may specialize in the treatment of women.

Pharmacological Treatment

In general, if BPD is suspected by the primary care provider, the woman is typically referred for evaluation and medication management by a psychiatrist or other mental health care provider. Women with BPD need medication management and will typically need this management throughout their lives. Stressful life events, such as transition into adulthood, pregnancy, postpartum, lactation, perimenopause, and menopause, can bring on cycling episodes. Mood changes can be associated with the menstrual period (Yatham, Maj, Frey, Macritchie, Soares, & Steiner, 2010). The primary care clinician needs to assess women with a diagnosis of BPD at every patient encounter and screen for treatment compliance, symptoms, and need for medication changes related to newly identified medical conditions because depressive symptoms are more common in women with BPD (Yatham et al., 2009). The primary care provider is an important player in the multidisciplinary team that coordinates care for the woman with BPD. Women with BPD need preconception counseling and may need medication adjustments throughout a pregnancy if they do become pregnant. Lithium, although still labeled a category D drug, seems to be the most commonly used for managing this disorder in pregnant women. Nurses should be aware that Lithium is known to cause cardiac birth effects, especially if taken during the first trimester. Clinicians may wish to use other interventions during the first 12 gestational weeks and then switch to Lithium if other interventions prove unsuccessful. Other drugs can result in teratogenicity, intrauterine growth effect, neurobehavioral complications, neonatal toxicity, and withdrawal syndrome in the neonate (Yatham et al., 2009). Careful planning with a psychiatrist and perinatologist is warranted. Lithium seems to dramatically reduce relapse by as much as 50% during the antepartum period (Yatham et al., 2009). Treatment for BPD focuses on normalizing moods and avoiding cycling of mood extremes. The length between cycles varies and is highly individualized (Goodwin & Jamison, 2007). The average individual has 8–10 cycling episodes during her lifetime (Goodwin & Jamison, 2007). Women are three times as

likely to have rapid cycling. Theories for the increased frequency of cycling in women include the increased alterations in thyroid hormones, fluctuation of estrogen and progesterone throughout the menstrual cycle, and the increased levels of stress experienced by women compared to men. Rapid cycling is defined as more than four mood cycles per year with a duration of at least 2 months in between (Yatham & Kusumakar, 2009). It is estimated that 16.3% of individuals with BPD have rapid cycling features (Yatham & Kusumakar, 2009). Rapid cycling can be brought on by the introduction of SSRIs when women are misdiagnosed as having depression. If the patient is on a SSRI, it should be tapered off and substituted with a mood stabilizer instead. If stability is achieved after 4 months, the medication is continued. If cycling is still occurring, typically another mood stabilizer is added in addition to psychotherapy (Yatham & Kusumakar, 2009). The first line of therapy in BPD is typically mood stabilizers. Lithium, mentioned previously, was the first mood stabilizer introduced in the United States and remains the gold standard for treatment. However, it takes up to 2 weeks to reach a therapeutic serum level. Patients experiencing an acute depressive or manic episode may require inpatient psychiatric care until symptoms are controlled. Because Lithium can reach toxic levels, serum measurement of Lithium is required weekly for the first 4 weeks of introduction and then at consistent intervals. Valproic acid or divalproex sodium (Depakote) is another mood stabilizer that is often used in the treatment of BPD and is found to be equally effective (National Institute of Mental Health, 2011). Valproic acid has been associated with increased testosterone levels in young women under the age of 20. These increased testosterone levels have been associated with the development of polycystic ovarian syndrome and should not be used in women under the age of 20 (National Institute of Mental Health, 2011). In addition, anticonvulsant medications, such as gabapentin (Neurontin), topiramate (Topamax), oxcarbazepine (Trileptal), and lamotrigine (Lamictal), are also used with good success. Atypical antipsychotics are also sometimes used to treat BPD. Drugs in this group include olanzapine (Zyprexa), aripiprazole (Abilify), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon) (National Institute of Mental Health, 2011). While SSRIs, such as lamotrigine (Lamictal), are sometimes used to control the depressive symptoms of a BPD depressive episode, they are typically used in combination with mood stabilizers and rarely given alone (National Institute of Mental Health, 2011).

Drugs commonly used to treat BPD are included in Table 16.5. Benzodiazepines are sometimes used in combination with other therapies to decrease anxiety in women with BPD. There has been some use of ECT to treat the manic or depressive symptoms that do not respond to medication; however, it is rare.

Clinical Pearl

Neuroleptic malignant syndrome is a potentially fatal syndrome marked by “hyperpyrexia, altered mental s

Table 16.5 ■ Drugs Commonly Used to Treat Bipolar Disorder

Drug Name Lithium carbonate (Eskalith, Lithane, Lithobid, Lithonate, Lithotabs, Eskalith CR) Valproic acid or divalproex sodium (Depakote, Depacon, Depakene, Depakote ER, Epival, Stavzor) Carbamazepine (Tegretol, Apo-carbamazepine, Carbatrol, Epitol, Mazepine, Tegretol XR) Haloperidol or haloperidol decanoate (Haldol, Peridol, Haldol LA) Olanzapine (Zyprexa, Zydis). Topiramate (Topamax)

Adult Dosage Loading dosage: PO Mania: PO 750 mg/d PO 200 mg/b.i.d. PO: 0.2–5 mg b.i.d. o PO initial dosage 10– PO 25 mg b.i.d.

Source: Adapted from Wilson et al. (2011).

Behavioral Therapies

Combination therapy along with medication management has shown beneficial effects in women with BPD and is the preferred method of choice in treating women with BPD. CBT, iteractive drawing therapy (IDT), cognitive therapy, and social rhythm therapy, where you establish daily patterns of living, all have been shown to be effective modalities for BPD in women (National Institute of Mental Health, 2011). Therapy alone has been shown to be effective, but typically as a monotherapy option, it is not used alone; however, it may be considered for individuals who are noncompliant with medications or refuse medications completely (Swartz et al., 2009). In one study, the use of monotherapy alone resulted in improved stability in 82% of treated patients who remained in the study at 12 weeks; however, the study did have a drop-out rate of 41% (Swartz et al., 2009). Therapy can also establish lifestyle changes, which are important for women with BPD. Many women experience embarrassment as a result of circumstances that may have occurred during a manic episode. Women can utilize therapy as a means to work though these emotions. Early identification of symptoms with prompt intervention is also warranted and may be best diagnosed by attending regular therapy sessions. The need to establish a daily routine with adequate sleep, exercise, and proper nutrition are all important. Women should be counseled to avoid drugs and alcohol use because it can worsen the course of the illness.

SUICIDE RISKS ASSOCIATED WITH MOOD DISORDERS

Women with Mood Disorders are at an increased risk for suicide. Suicide is the fourth leading cause of death for women ages 18–44 (Ortega & Karch, 2010). One study has found that even women without Mood Disorders are more prone to suicide during the perimenopausal period (Usall, Pinto-Meza, Fernández, de Graaf, Demyttenaere, Alonso, de Girolamo, Lepine, Kovess, & Haro, 2009). According to Ortega & Karch (2010), who examined female suicides in the United States between 2003 and 2007, women who commit suicide frequently have underlying mental disease (60%), have previously been treated for a mental disorder (54%), have a depressed mood at the time of death (44%), and have had or are having problems with an intimate partner (36%) (p. 5). Of the women who committed suicide, 37% had a previous attempt and 28% had reported their plans to another individual who had time to intercede (Ortega & Karch, 2010). Suicide prevention strategies should focus on treating women with mental illness; identifying women at risk; educating families about risk factors; identification and utilization of systems; and understanding available treatment options, such as short-term inpatient hospitalization, medication management, psychotherapy options, and use of groups.

SUMMARY

Mood disorders represent the most commonly occurring mental illnesses that occur in women. Depressive disorders and bipolar disorder can create significant symptomology that can be debilitating. Suicidal behaviors can increase in women with depressive disorders and results in significant mortality. Both behavioral and pharmacological interventions can improve the course of major mood disorders.

Clinical Pearl

Women who have developed a suicide plan are more likely to commit suicide than those who only have th

Case Study

Andrea Kyleberger is a married, 43-year-old woman with two high school-age children who recently was laid off from her IT position after 12 years of working for the same company. Since being laid off, Andrea reports a loss of interest in previously enjoyed activities, constant worrying about her finances, sadness, hopelessness, and crying. She sleeps most of the day and then has difficulty sleeping at night. Andrea was previously engaged with a group of friends but has grown more and more socially isolated since her layoff. Initially, she was sending her resume out and attempting to find a new position, but now she finds the entire process overwhelming, depressing, and exhausting. Her daughter thinks she is depressed and has made a doctor’s appointment for her. What treatment options are available for Andrea? What medications might the primary-care provider consider?

Questions to Consider

Why are women more prone to Mood Disorders? What interventions can the nurse suggest for a woman dealing with SAD? What medication interventions can be used for a woman experiencing depression? Why are dual-diagnosis groups more effective in treating women with substance abuse and Mood Disorders than traditional modes of monotherapeutic treatments?

Why should the nurse provide immediate intervention for a woman who verbalizes a plan when discussing suicide?

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Pacchiarotti, I., Marzo, S., Colom, F., Sanchez-Moreno, J., & Vieta, E. (2009). Bipolar disorder preceded by substance abuse: A different phenotype with not so poor outcome? World Journal of Biological Psychiatry, 10(3), 209–216. DOI: 10.1080/15622970701558488 Read, K. (2011). What causes bipolar disorder? Retrieved from http://bipolar.about.com/cs/bpbasics/a/what_causes_bp.htm Rohan, K. J., Roecklein, K. A., Tierney-Lindsey, K., Johnson, L. G., Lippy, R. D., Lacy, T. J., & Barton, F. B. (2007). A randomized controlled trial of cognitive-behavioral therapy, light therapy, and their combination for seasonal affective disorder. Journal of Consultation in Clinical Psychology, 75, 489–500. Ryan, J., Carrière, I., Scali, J., Ritchie, K., & Ancelin, M. L. (2008). Lifetime hormonal factors may predict late-life depression in women. International Psychogeriatrics, 20(6), 1203–1218. Simon, G. E., Von Korff, M., & Piccinelli, M. (1999). An international study of the relation between somatic symptoms and depression. New England Journal of Medicine, 341, 658–659. Solomon, D. A., Leon, A. C., Maser, J. D., Truman, C. J., Coryell, W., Endicott, J., Teres, J. J., & Keller, M.B. (2006). Distinguishing bipolar major depression from unipolar major depression with the screening assessment of depressionpolarity (SAD-P). Journal of Clinical Psychiatry, 67(3), 434–442. Stewart, J. W. (2007). Treating depression with atypical features. Journal of Clinical Psychiatry, 68, 25–29. Swartz, H. A., Frank, E., Frankel, D. R., Novick, D., & Houck, P. (2009). Psychotherapy as monotherapy for the treatment of bipolar II depression: A proof of concept study. Bipolar Disorders, 11(1), 89–94. DOI: 10.1111/j.13995618.2008.00629.x Targownik, L. E., Bolton, J. M., Metge, C. J., Leung, S., & Sareen, J. (2009). Selective serotonin reuptake inhibitors are associated with a modest increase in the risk of upper gastrointestinal bleeding. American Journal of Gastroenterology, 104, 1475–1482. DOI: 10.1038/ajg.2009.128 Trivedi, M. H. (2004). The link between depression and physical symptoms.

Primary Care Companion: Journal of Clinical Psychiatry, 6[suppl 1], 12–16. Turkington, C., & Harris, J. R. (2009). The encyclopedia of the brain and brain disorders, 3rd ed. New York: Facts on File, Inc. Usall, J., Pinto-Meza, A., Fernándeza, A., de Graaf, R., Demyttenaere,K., Alonso, J., de Girolamo, D., Lepine, J., Kovess, V., & Haro, J. (2009). Suicide ideation across reproductive life cycle of women. Results from a European epidemiological study. Journal of Affective Disorders, 116(1–2), 144–147. U.S. Public Health Task Force. (2009). Screening for depression in adults. UTPHTF recommendation statement. Retrieved from http://www.uspreventiveservicestaskforce.org/uspstf09/adultdepression/addeprrs.htm Wilson, B. A., Shannon, M. T., & Shields, K. M. (2011). Pearson nurse’s drug guide: 2011. Upper Saddle River, NJ: Pearson. Yatham, L. N., & Kusumakar, V. (2009). Bipolar disorder: A clinician’s guide to treatment management. New York: Taylor & Francis Group. Yatham, L. N., Maj, M., Frey, B. N., Macritchie, K. A., Soares, C. N., & Steiner, M. (2010). Bipolar disorder in women, in bipolar disorder. Chichester, UK: John Wiley & Sons, Ltd. DOI: 10.1002/9780470661277.ch36

17

Eating Disorders

Each year in the United States, Anorexia Nervosa (AN) and Bulimia Nervosa (BN) affect 10 million women and 1 million men with young girls and young adult women having the highest incidence of disease. The rate of the disease in the general population is approximately 1% ( Townsend, 2011 ). Additionally, millions more are affected with binge eating disorders ( National Eating Disorders Association, 2005a ). Eating Disorders represent the most costly of mental disorders to treat and have the highest incidence of premature morbidity and mortality when compared to other mental illnesses ( National Eating Disorders Association, 2005b ). Eating Disorders commonly go untreated despite their devastating results. While approximately one-third of women with AN get treatment, less than 6% of women with BN ever get treatment in their lifetimes ( National Eating Disorders Association, 2005a ). The lack of treatment is somewhat related to the lack of insurance coverage for the intensive inpatient therapies that are often necessary for comprehensive effective treatment modalities ( National Eating Disorders Association, 2002 ). The drive to be thinner has been perpetuated since the 1930s when the rise of Eating Disorders began. Models and celebrities who are chronically underweight set unrealistic expectations and unhealthy weight “norms” that are played out in the media. The average model is thinner than 98% of American women. In one survey, 42% of girls as young as 6 years old desired to be thinner, and 81% of girls ages 8 to 10 years are fearful of becoming fat (National Eating Disorders Association, 2005a). As a result, yo-yo dieting syndrome and back-and-forth dieting practices are commonplace in Westernized societies, such as in the United States and Western Europe (Townsend, 2011).

ANOREXIA NERVOSA

AN is a life-threatening mental illness that typically develops in late adolescence or early adulthood in young women and has the highest fatality rate of any mental disorder. The incidence of the disease is 0.5% to 1%, and it affects mainly women; the incidence in men s for approximately 10% of cases. In young women who have the disease, there is often a refusal to maintain their body weight in a minimally normal weight range for their age and height; their body weight is usually less than 85% of what is expected.

Etiology

The etiologies of Eating Disorders appear to have biopsychosocial components. There is a hereditary predisposition to the disorder that carries a 60% risk factor of acquiring the disease with psychosocial risks resulting in the other 40% of disease development (Karwautz, Wagner, Waldherr, Nader, Fernandez-Aranda, Estivill, Holliday, Collier, & Treasure, 2010). Early studies have identified possible gene alterations on chromosomes 1, 2, and 13 in women with AN (Halmi, 2008). There is some speculation that the disease can be caused by other biological factors, such as impairment in the hypothalamic system that results in an impairment in dopamine regulation. Higher circulating levels of endogenous opioids have also been identified as a possible causative factor for AN (Townsend, 2011). There is some literature that states the causative factors of AN are psychological in nature and result from altered family processes in the early home environment. Alterations in early mother-infant attachment, conflict avoidance within the family, and overriding factors related to power and control have all been cause for speculation within the literature (Townsend, 2011). Life stressors may also play a role in the development of Eating Disorders. Multiple studies have shown that life stressors, including work and recreational stress, can precipitate symptoms in women who already have an Eating Disorder (Inoue, Iwasaki, Yamauchi, & Kiriike, 2010; Grilo, Pagano, & Stout, 2010). Eating Disorders were once thought to only affect middle-class Caucasian females, but studies have now shown that Eating Disorders affects all races and socioeconomic classes. African American, Native Indian, Caucasian, and Asian women have all reported dissatisfaction with their body image and are at risk for Eating Disorders (National Eating Disorders Association, 2005c). African American girls are more at risk for binge-eating disorders. Hispanic girls also report alteration in body image and dissatisfaction with their physical

appearance. Lesbian women were not more unlikely than heterosexual women to develop an Eating Disorder (National Eating Disorders Association, 2005c). Clearly, all women are at risk for an Eating Disorder with no one group being immune.

Signs and Symptoms

Most women with Eating Disorders will not present for an evaluation of the disorder but may present with vague symptoms such as “dizziness, fatigue, low energy, amenorrhea, weight loss or gain, constipation, bloating, abdominal discomfort, heartburn, sore throat, palpitations, polyuria, polydipsia, and insomnia” (Williams, Goodie, & Montsinger, 2008, p. 187). Women with AN are often resistant to maintaining proper weight-to-height proportions even when they are underweight or at a low average weight. There is an intense fear of becoming overweight or fat. There is also a disturbance in body image in which the young girl or woman is in denial that she is underweight at all. Physically, the woman ceases having menstrual periods as a result of inadequate body fat needed for estrogen production (National Eating Disorders Association, 2005a; Davidson, London, & Ladewig, 2012). Women affected with the illness typically have a marked reduction in food intake and may exercise excessively to burn more calories. It is not uncommon for women with severe AN to be more than 85% of their ideal weight (Townsend, 2011). Medical complications are commonly associated with the disease and include the following (National Eating Disorders Association, 2005c; Wilson et al., 2012):

■ Hypotension ■ Hypothermia ■ Heart failure ■ Osteoporosis ■ Muscle-wasting syndrome

■ Dehydration ■ Kidney failure ■ Arrhythmias ■ Conduction defects ■ Hypoglycemia ■ Hypercholesterolemia ■ Thyroid abnormalities ■ Pancreatitis ■ Anemia ■ Seizures ■ Cognitive impairment ■ Multiple metabolic changes

Assessment and Screening

Assessment is based on initial questioning of women who are underweight for symptoms associated with AN. An intensive psychiatric history should be obtained because comorbidity with anxiety, depression, personality disorders, and substance abuse disorders is common. Excessive concern with weight and shape is another hallmark feature of an Eating Disorder. Dietary restriction is a common feature, and questions aimed at typical eating patterns are essential. Women with AN may exhibit an abnormal body image and report dissatisfaction with their weight and appearance. They also commonly have associated mood disturbances, often presenting with a negative affect or depression. Most women with an Eating Disorder will not present for an evaluation of an Eating Disorder but may present with vague symptoms such as the following (Williams, Goodie, & Montsinger, 2008, p. 187):

■ Dizziness ■ Fatigue ■ Low energy ■ Amenorrhea ■ Weight loss or gain ■ Constipation ■ Bloating ■ Abdominal discomfort ■ Heartburn

■ Sore throat ■ Palpitations ■ Polyuria ■ Polydipsia

The primary care provider typically serves as the source for managing related medical complications and is a member of a multidisciplinary team. There are multiple screening tools, including the Eating Attitudes Test (EAT), Eating Disorder Examination (EDE), and the Interview for the Diagnosis of Eating Disorders–IV; however, most of these tools take some time to ister and are best suited for other of the multidisciplinary team. The SCOFF tool is a short tool designed to identify AN and BN in the primary care setting. It has good reliability and validity and offers an effective means for clinicians to assess for Eating Disorders in the primary care setting (Hill, Reid, Morgan, & Lacey, 2010; Exhibit 17.1).

Exhibit 17.1

SCOFF Eating Disorder Assessment Tool

■ Do you make yourself Sick because you feel uncomfortably full? ■ Do you worry you have lost Control over how much you eat? ■ Have you recently lost more than One stone (14 lb or 7.7 kg) in a 3-month period?

■ Do you believe yourself to be Fat when others say you are thin? ■ Would you say that Food dominates your life?

Source: Adapted from Cotton, Ball, & Robinson (2003); Hill, Reid, Morgan, & Lacey (2010).

Pharmacological Treatment

There are no specific pharmacological interventions for Eating Disorders, but medications are often used as an adjunct therapy for AN. Selective serotonin reuptake inhibitors (SSRIs) have been shown to treat depression symptoms and anxiety symptoms associated with Eating Disorders. There have been some beneficial outcomes with the atypical antipsychotic olanzapine (Zyprexa) in recent clinical trials in the treatment of AN. When an Eating Disorder is suspected in the primary care setting, the primary care provider must first examine the woman’s motivation to change. Some women will be unwilling to seek treatment and may only wish to have associated symptoms treated. In these circumstances, careful attention to documentation is warranted because refusing intensive treatment for the disease often leads to worsening health status for the woman. Emphasis should be placed on facilitating referral for treatment and assessing the physiological condition of the woman to detect life-threatening disorders. Exhibit 17.2 includes recommended laboratory testing that should be obtained for a woman with a suspected Eating Disorder.

Exhibit 17.2

Recommended Tests for Women With Eating Disorders

Standard

■ Complete blood count (CBC) with differential ■ Urinalysis ■ Complete metabolic profile: sodium, chloride, potassium, glucose, blood urea nitrogen, creatinine, total protein, albumin, globulin, calcium, carbon dioxide, AST, alkaline phosphates, total bilirubin ■ Serum magnesium ■ Thyroid screen (T3, T4, TSH) ■ Electrocardiogram (ECG)

Special Circumstances 15% or more below ideal body weight (IBW)

■ Chest x-ray ■ Complement 3 (C3) ■ 24 creatinine clearance ■ Uric acid

20% or more below IBW or any neurological sign

■ Brain scan

20% or more below IBW or sign of mitral valve prolapse

■ Echocardiogram

30% or more below IBW

■ Skin testing for immune functioning

Weight loss 15% or more below IBW lasting 6 months or longer at any time during course of Eating Disorder

■ Dual energy X-ray absorptiometry (DEXA) to assess bone mineral density ■ Estadiol level (or testosterone in males)

Source: National Eating Disorders Association (2002). Permission granted for duplication and reprinting for educational purposes.

Behavioral Therapies

Treatment of AN is aimed at obtaining and maintaining a proper body weight and proper eating patterns while treating the underlying psychological implications associated with the disease. The level of care needed is associated with the staging of the disease. While some women may be able to obtain treatment via outpatient sources, others will require intense inpatient services. The level of care required is based on specific factors that are found in Exhibit 17.3.

Exhibit 17.3

Criteria for Level of Care Needed for Women With Anorexia Nervosa

Inpatient Medically Unstable

■ Unstable or depressed vital signs ■ Laboratory findings presenting acute risk ■ Complications resulting from coexisting medical problems, such as diabetes

Psychologically Unstable

■ Symptoms worsening at a rapid rate ■ Suicidal and unable to contract for safety

Residential

■ Medically stable, so does not require intensive medical interventions

■ Psychiatrically impaired and unable to respond to partial hospital or outpatient treatment Partial Hospital Medically Stable

■ Eating Disorder may impair functioning but not causing immediate, acute risk ■ Needs daily assessment of physiological and mental status

Psychologically Stable

■ Unable to function in normal social, educational, or vocational situations ■ Daily bingeing, purging, severely restricted intake, or other pathogenic weight control techniques

Intensive Outpatient/Outpatient Medically Stable

■ No longer needs daily medical monitoring

Psychiatrically Stable

■ Symptoms in sufficient control to be able to function in normal social, educational, or vocational situations and continue to make progress in recovery

Source: National Easting Disorder Association (2002). Permission obtained and granted from National Eating Disorder Association.

Treatment for AN is multifaceted in nature and requires close nutritional monitoring. Calorie counts, laboratory assessment, and weight monitoring are all critical determinants of patient well-being. Dental care is important because women with Eating Disorders often have tooth erosion issues. Women should be advised to rinse with baking soda solutions and brush their teeth after vomiting episodes (Wilson et al., 2012). Multivitamins should be prescribed because nutritional deficiencies are common. Physical activity should be monitored because excessive exercise is common with the disease. Treatment goals include achieving a weight within the 80th percentile for the patient’s age and height. Cognitive behavioral therapy (CBT) with intense behavior modification is usually indicated. Often, individual therapy is also utilized. Family therapy is often an effective tool because Eating Disorders

impact a young woman’s entire family and can impact family relationships. Eating Disorders are often thought to be a family disease rather than that of just the individual (Townsend, 2011). The fatality rate of AN is 5% to 20% of affected women. Few women achieve full recovery. Death is commonly a result of renal failure, heart failure, or cardiac complications. For women afflicted with the disease, the mortality rate is 12 times higher than all other causes of death in young women 15–24 years of age (National Eating Disorders Association, 2005a).

BULIMIA NERVOSA

BN is a life-threatening Eating Disorder that is characterized by cycles of binge eating followed by cycles of compensatory behaviors aimed at eliminating the ingested calories. Women with BN are likely to be of average weight or slightly overweight but routinely demonstrate binge eating followed by compensatory behaviors. Binge eaters typically consume a large volume of food, a greater volume than most people would eat, within a specific period of time. The woman experiences a lack of control over her eating during the time period. Women with BN will then engage in compensation behaviors, such as vomiting, excessive laxative use, ingestion of diuretics, enemas, fasting, or over-engagement in exercise. These behaviors occur at least twice per week for a period of at least 3 months. The woman cannot provide an accurate self-evaluation of her symptoms and weight during this time. Women with a diagnosis of BN do not have symptoms that occur during an episode of AN (Rushing, Jones, & Carney, 2003).

Etiology

BN is thought to have a combination of biological, social, environmental, and genetic etiologies. Women with a family history of BN have higher incidences than those without a family history. Societal or family pressures to be thin can also contribute to the disorder. With BN, there is some thought that alterations in serotonin and norepinephrine may be etiological factors. Women with certain personality traits can also be at risk. Women who strive to be perfect may see themselves as imperfect when comparing themselves to society’s perception of the ideal female weight and figure. Alterations in family relationships are another possible cause for BN.

Signs and Symptoms

Women with BN, unlike with AN, take in large amounts of food and then commonly express remorse and feelings of guilt resulting from the amount of food eaten. Women typically have an overly intense concern with their shape and weight and later engage in compensatory behaviors. Women with bulimia may present with arrhythmias, edema, menstrual abnormalities, amenorrhea, gastrointestinal disturbances, electrolyte imbalances, cognitive disturbances, aspiration pneumonia, and kidney stones (Wilson et al., 2012).

Assessment and Screening

There are a variety of clinical assessment tools available to screen for BN. The SCOFF tool, which is commonly used in the primary care setting can also be used for BN as well as AN, and is preferred by many primary care clinicians and nurses because of its ease of use. The EAT, the Eating Disorder Screen for Primary Care, the Bulimic Inventory Test Edinburgh (BITE), and the Bulimia Test–Revised (BULIT-R) are also assessment tools specifically designed to identify women with BN. When selecting a tool, the amount of time available to ister the assessment, the practitioner’s comfort level with evaluating the outcomes, and the type of practice setting should all be considered.

Pharmacological Treatment

There are no specific pharmacological interventions for Eating Disorders, but medications are often used as an adjunct therapy for the disorders. SSRIs have been shown to treat BN symptoms and any underlying depression and anxiety associated with the Eating Disorders. Fluoxetine (Prozac) is the only medication approved by the U.S. Food and Drug istration for the treatment of Eating Disorders, specifically for BN (Wilson et al., 2012). Therapies aimed at solely pharmacological approaches are not recommended; rather, it should be used in combination with other treatment modalities (Wilson et al., 2012). Antidepressants have been used to treat underlying depressive symptoms in BN.

Behavioral Therapies

With BN, nutrition education focuses on maintaining an ideal body weight. Early treatment of BN has been associated with higher success rates of resolution of the disease (National Eating Disorders Association, 2005c). Most women with BN are treated on an outpatient basis. The need for intensive inpatient hospitalization is usually not necessary. Outpatient therapy commonly utilizes CBT as the primary behavioral therapy. CBT is aimed at stopping the vicious cycle of overeating and vomiting or purging and modifying abnormal attitudes toward food (Rushing et al., 2003). BN treatment rates are much more successful than outcomes for women with AN. The mortality rates are much lower for BN as well, with rates up to 3% (Rushing et al., 2003). Of the women who do receive treatment, 50% are free from all symptoms 5 years after treatment (Rushing et al., 2003).

BINGE EATING DISORDER (COMPULSIVE EATING DISORDER)

Binge Eating Disorder (BED) is associated with the ingestion of large quantities of food and accompanying feelings of guilt, shame, and disgust as a result. This Eating Disorder is included in the category of Eating Disorder Not Otherwise Specified (NOS) but is included here because of its common occurrence. Unlike BN, it does not result in the use of compensatory mechanisms. It is slightly more common in women than in men (60%) and has an incidence of 1% to 5% of the population. The woman with BED often feels out of control with her eating habits. Comorbidity with Major Depressive Disorder is common. BED can result in adverse health manifestations, including the following (National Eating Disorders Association, 2005d):

■ Hypertension ■ Hypercholesterolemia ■ Cardiac disease ■ Diabetes mellitus ■ Gallbladder disease ■ Obesity

It is typically diagnosed by weight, diet history, and verbalization of symptoms during a primary care visit. Nutritional therapy should be focused on decreasing obesity and striving to reach a healthy body weight. A reduction in calories and introduction of exercise are important interventions for the woman with BED. Therapy should include treating underlying depression and other psychiatric disorders and include referral for CBT to change unhealthy behaviors (Wilson et

al., 2012). Individual therapy has also been shown to improve outcomes. Multiple pharmacological therapies have been used successfully: “SSRIs (e.g., fluoxetine [Prozac], sertraline [Zoloft], citalopram [Celexa]); tricyclic antidepressants (e.g., imipramine [Tofranil]); antiepileptics (e.g., topiramate [Topamax]); and appetite suppressants (e.g., sibutramine [Meridia]) demonstrated moderate evidence of the effectiveness of medication” (Wilson et al., 2012, p. 192).

PREGNANCY AND EATING DISORDERS

For the woman who wishes to conceive, an underlying Eating Disorder can be a common cause of infertility. Lack of regular menses, anovulation, lack of body fat to make required levels of estrogen, and hormonal imbalances all contribute to a reduced ability to conceive. With the increased use of reproductive technologies, however, women with untreated Eating Disorders can achieve pregnancy with artificial agents inducing ovulation (Micali, 2010). Women with AN have more impairment of fertility than women with BN. Women with a past history of Eating Disorders who are now in low-to-normal weight ranges also get pregnant more easily than women with significant weight reductions. In women who do become pregnant and who have an active disease, symptomology of the Eating Disorder often declines during pregnancy (Micali, 2010). Although symptoms of the Eating Disorder may improve during pregnancy, body image distortion typically increases during the antepartum period. Women with both past and current disease typically have poorer outcomes than women who have never been affected by an Eating Disorder. Prematurity and low birth weight have been associated with both AN and BN (Micali, 2010). Spontaneous abortions, breech presentation, and fetal death are reported more often in women with BN, and women with BED have a higher incidence of macrosomic infants (Micali, 2010). Women with Eating Disorders have a higher incidence of smoking during pregnancy, which is associated with an increased risk of adverse events. Women with severe nutritional defects have a higher risk of fetal defects, including neural tube defects, which are associated with a deficiency in folic acid during the preconception and early pregnancy period (Anderson & Ryan, 2009). Women who give birth are at risk for more severe Eating Disorder symptomology in the postpartum period and have a 30% increased risk of postpartum depression (Micali, 2010).

SUMMARY

Eating Disorders occur in late adolescence and early adulthood at much greater frequencies in women than in men. They are often under-treated in the primarycare setting and, left untreated, carry the highest morbidity and mortality rates of all the psychiatric illnesses. Screening in the primary care setting with the SCOFF tool can provide a way for the clinician to identify women at risk for Eating Disorders. Multidisciplinary treatment is aimed at correcting nutritional deficits or excesses, providing effective therapy interventions, and monitoring for medical complications. Some women with certain Eating Disorders may have difficulty conceiving. Women contemplating pregnancy need to have effective treatment prior to conception to ensure adequate nutritional resources are in place for the developing fetus. Women with Eating Disorders have more adverse fetal outcomes than their peers with no history of an Eating Disorder.

Case Study

Allison Peters is a 25-year-old graduate student majoring in chemical engineering at an elite private university. Allison’s parents have four children, and Allison is the only girl. Allison has been raised to be the perfect girl with a 4.0 grade-point average, hip in key organizations, and success in sports throughout her high school and undergraduate years. Allison is very critical of herself and views herself as inadequate much of the time despite her high achievements. Allison began losing weight approximately 7 months ago and is now a staggering 99 pounds at 5’6”. Her parents come for a visit and are shocked at her weight loss and concerned for her health and well-being. Allison’s mother always warned Allison about gaining too much weight in college, but now even Mrs. Peters is concerned. Allison has fatigue, muscle pains, amenorrhea, and irregular bowel movements. When her parents question

her about her weight, Allison becomes defensive and states she still needs to lose a few pounds. What type of therapy would you recommend for Allison? How can her parents assist her in obtaining adequate treatment when she is in denial about her problems?

Questions to Consider

What are the symptoms associated with AN? What behaviors are prominent in women with BN? What therapies would you recommend as an initial treatment for women with Eating Disorders? Why is it important for pregnant women to receive treatment for an Eating Disorder prior to becoming pregnant?

REFERENCES

Anderson, A., & Ryan, G. L. (2009). Eating disorders in the obstetric and gynecologic patient population. Obstetrics & Gynecology, 114(6), 1353–1367. DOI: 10.1097/AOG.0b013e3181c070f9 Cotton, M. A., Ball, C., & Robinson, P. (2003). Four simple questions can help screen for eating disorders. Journal of General Internal Medicine, 18(1), 53–56. DOI: 10.1046/j.1525-1497.2003.20374.x Davidson, M. R., London, M. L., & Ladewig, P. A. W. (2012). Olds’ maternalnewborn nursing and women’s health across the lifespan, (9th ed.). Upper Saddle River, NJ: Pearson. Grilo, C., Pagano, M., & Stout, R. (2010). Do stressful life events predict eating disorder relapse? Six-year outcomes from the collaborative personality disorders study. European Psychiatry, 24(1), S746. Halmi, K. A. (2008). Eating disorders: Anorexia nervosa, bulimia nervosa, and obesity. In R. E. Hales, S. C. Yudofsky, & G. O. Gabbard (Eds.), Textbook of psychiatry, 5th ed. Washington, DC: APA. Hill, L. S., Reid, F., Morgan, J. F., & Lacey, J. H. (2010). SCOFF, the development of an eating disorder screening questionnaire. International Journal of Eating Disorders, 43, 344–351. DOI: 10.1002/eat.20679 Inoue, K., Iwasaki, S., Yamauchi, T., & Kiriike, N. (2010). Eating disorders in the workplace. Seishin Shinkeigaku Zasshi, 112(8), 758–763. Karwautz, A. F. K., Wagner, G., Waldherr, K., Nader, I. W., Fernandez-Aranda, F., Estivill, X., Holliday, J., Collier, D. A., & Treasure, J. L. (2010). Geneenvironment interaction in anorexia nervosa: Relevance of non-shared environment and the serotonin transporter gene. Molecular Psychiatry, 7. DOI: 10.1038/mp.2010.125

Micali, N. (2010). Management of eating disorders during pregnancy. Progress in Neurology and Psychiatry, 14, 24–26. DOI: 10.1002/pnp.158 National Eating Disorders Association. (2002). Navigating the System. Retrieved from http://www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/NavSystm.pdf

National Eating Disorders Association. (2005a). National Eating Disorders Association statistics: Eating disorders and their precursors. Retrieved from http://www.nationaleatingdisorders.org/s/file/Statistics%20Updated%20Feb%2010,%20 National Eating Disorders Association. (2005b). Fast facts for activists (or anyone). Retrieved from http://www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/FactsAct.pdf National Eating Disorders Association. (2005c). Bulimia Nervosa. Retrieved from http://www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/Bulimia.pdf National Eating Disorders Association. (2005d). Binge eating disorder. Retrieved from http://www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/BingeED.pdf Rushing, J. M., Jones, L. E., & Carney, C. P. (2003). Bulimia nervosa: A primary care review. Primary Care Companion Journal of Psychiatry, 5(5), 216–225. Townsend, M. C. (2011). Essentials of psychiatric mental health nursing: Concepts of care in evidence-based practice. Philadelphia: F.A. Davis. Williams, P. M., Goodie, J., & Montsinger, C. D. (2008). Treating eating disorders. American Family Physician, 15(77)2, 187–195. Wilson, B. A., Shannon, S., & Stang, S. (2012). Pearson’s drug guide. Upper Saddle River, NJ: Pearson.

18

Grief and Loss

Grief and loss are profound psychological issues that can have a tremendous impact on a woman and her family. Women may face multiple losses throughout her life, including loss of a partner, divorce, loss of a job, loss of a pregnancy, infertility, loss of a child, death of parents or friends, retirement, and others. Loss encomes any event that the woman perceives as negative and as a loss of something that is important to her. Women may also feel loss over a change in role or functioning, such as loss of their career if they choose to quit work and become a stay-at-home mother. Grief is the internal feeling associated with a loss. Bereavement is the state of experiencing a loss that often has psychological manifestations. Some women may develop psychiatric disorders that are triggered by a loss. While grief is a normal process, adaptations in grief can lead to Adjustment Disorders, depression, anxiety, or Posttraumatic Stress Disorder (PTSD). Many women will mourn losses throughout their lives. Mourning is the external expression of or reaction to a loss. Mourning typically has three phases: the urge to bring back the deceased person or change the event causing the grief, disorganization and sadness, and reorganization. This chapter will focus on the most common losses experienced by women. Obviously, an exhaustive list of losses is beyond the scope of this text; however, this text should familiarize the reader with the issues related to loss and grief. Loss occurs when something or someone of value is suddenly gone, and the person mourns the event. Loss carries with it a complexity of emotions, including sadness, shock, denial, anger, and even guilt. Everyone mourns losses although each woman will mourn a loss differently. One woman who is unable to conceive may be resentful of other women with children, and another may embrace and cherish the children of friends and family as a result of her grief. Other factors can also impact loss, including the reactions of others, familial

values, one’s personality, spirituality, religious beliefs, coping strategies, cultural norms, social norms, personal reflection on the loss, degree of loss, and past experiences with loss and grieving. In general, the more severe the loss, the more intense the grief reaction. Grief is a natural reaction to a loss or perceived loss. Reactions to grief are individualized and complex. Grief involves a series of stages although not all women will work through each stage. Women progress through the stages of loss at their own pace, and some may skip certain phases. The phases are fluid, meaning a woman can go back and forth between multiple stages, skip stages, or become fixed in a stage. The grief process can vary in length with some women grieving for months, others for years, and some never completely recovering from the event that caused the grief. Many women undergoing the loss of a child may never fully recover from the loss and continue to grieve. Multiple researchers have examined loss. Perhaps the most well-known grief theorist is Elisabeth Kubler-Ross, who developed the stages of grief in 1969. See Table 18.1 for a description of Kubler-Ross’s stages of grief.

Table 18.1 ■ Elisabeth Kubler-Ross’s Stages of Grief

Phase of Grief Denial Anger Bargaining Depression Acceptance

Common Signs and Symptoms Unbelievable feeling that the event can’t be happening or hasn’t happened May place blame on an individual for the event, such as blaming the doctor for a child’s cerebral palsy wh Making a bargain with God or others to change the event in exchange for a behavior or item to reverse wh Feelings of sadness, crying, loss of interest in usual activities, sleeping difficulties Accepting what has occurred, a feeling of peace about the loss

Source: Data from Kubler-Ross (1969).

Other experts have cited an extended grief cycle based on the works of KublerRoss that have included an initial state of shock or disbelief and a stage of guilt that occurs between anger and depression. The sense of shock that commonly occurs with a loss is often described as a sense of being numb, an unrealistic feeling, or lack of ability to comprehend the event. The guilt stage is categorized as a sense of guilt or regret often related to unresolved issues with the relationship in which the loss occurred. For example, a young lesbian woman whose father suddenly dies may feel guilt that she didn’t have a better understanding between her and her father and his lack of acceptance of her sexuality.

TASKS OF GRIEVING

Although not all women move through all stages of the grieving process, it is essential that certain tasks are met in order to successfully deal with grief. Women need to accept the reality of the loss. For example, if the loss is related to a job, the woman must realize her source of employment is gone and hope of returning to the job is not possible. Individuals who experience a loss must allow themselves to accept the reality of the loss and what that means to them. For the woman who loses her job, this represents lost income, loss of friends and coworkers, loss of her preexisting career position, and possible loss of her selfidentity for the time being. The woman must also be able to adjust to her new reality, such as a lower income, fewer daily interactions with coworkers who were friends, etc. The woman must finally engage in new relationships and new ventures. She must seek other employment, find an opportunity to meet new friends, and adjust to her changing income. In cases of losses involving death or more severe losses, the symptoms may be more intense and the process more complicated and dynamic. Inability to complete these tasks may result in a complicated grief reaction (to be discussed shortly).

ANTICIPATORY GRIEF

Anticipatory grief occurs when there is a perceived loss that will occur, such as a terminal illness, an amputation, a divorce, the marriage of a child, or death of parents. Anticipatory grief can allow an individual to plan for a loss by saying goodbye to her family member, making arrangements for funeral plans, seeing that the individual’s wishes are followed, etc. Even when women do know a death or life-altering event is occurring soon, the woman will still experience grief and go through the grief process although some of the initial grief work may be completed prior to the event actually occurring. Women with anticipatory grief encounter feelings of personal death anxiety (fear of their own death) and often experience a threat to their own sense of self. While there is a relationship between grief and fear of one’s own death, the feelings appear to be intertwined and complex. This is especially true if the anticipated death is that of a woman’s child because much of her self-identity is rooted with the child (Barr & Cacciatore, 2008).

COMPLICATED GRIEF

Complicated grief occurs when an individual has difficulty accepting a loss and moving forward with her own life and her own needs. Although it is not listed in the DSM-IV TR, some clinicians are advocating for its inclusion in the DSM-V. Complicated grief occurs when symptoms of grief continue and fail to fade. In women with a complicated grief reaction, the symptoms may worsen, become sharper, and linger. It is estimated that 10% of women who experience a significant loss will encounter a complicated grief reaction (Shear, 2009). Women with complicated grief present with a variety of emotions and symptomology. Common symptoms are included in Exhibit 18.1.

Exhibit 18.1

Commonly Observed Traits Typical of Complicated Grief

Primary focus on the loss Appear numb, detached, preoccupied, bitter Sadness or depression Anger Agitation or irritation Persistent longing and yearning for the person or event

Preoccupation with the person or event Avoiding ing or denying the person is gone or the event has occurred Self-blame Lack of enjoyment in any type of activity

These women may have an inability to carry on in their current life and exhibit a decrease in functioning, loss of interest in activities, inability to move forward, and preoccupation with the loss, and they are typically stuck in a heightened stage of mourning. Risk factors for complicated grief include childhood trauma, abuse, neglect, separation anxiety, violent or unexpected death, lack of an adequate system, poor coping mechanisms, being unprepared for the death or event. Complicated grief can lead to the development of specific psychiatric disorders including anxiety, depression, PTSD, Adjustment Disorder, alcohol and substance abuse, and suicide. Women with complicated grief have higher incidences of smoking, cancer, hypertension, and cardiac disease. The woman with complicated grief should be immediately referred for treatment. Studies show that women treated for complicated grief within the first 9 months of occurrence have better outcomes than women who delay seeking treatment (Shear, 2009).

GRIEF AS A RESULT OF INFERTILITY

Infertility affects approximately 10% of American couples and can become a source for persistent stress and distress (Davidson, London, & Ladewig, 2012). For the couple who is unsuccessful in achieving a desired goal, grief can be a common reaction. While up to 45% of infertile couples may achieve pregnancy, the other 55% either do not seek treatment for infertility or simply fail to conceive. For women who do not achieve a positive outcome, mourning can occur. Grief reactions vary and are dependent on several variables. Some women experience grief when they are confronted with needing medical assistance to become pregnant, others feel grief during infertility treatments, and others may begin the grieving process only when they are unable to conceive. Because of the high level of stress involved with fertility treatments, couples should be advised to seek counseling prior to initiating treatment (Luske & Nicholas, 1999). Women undergoing infertility evaluations should be assessed for anxiety, depression, and other symptoms associated with grief. Some women may benefit from groups or counseling. If depression or anxiety is detected, women undergoing infertility treatments or planning fertility treatments should only be placed on medications safe for pregnancy use.

PERINATAL GRIEF

Grief can occur at any time during a pregnancy but is common following a spontaneous abortion, identification of a fetal anomaly, or a stillbirth. When a woman becomes pregnant, she begins to bond with the child and has dreams and ambitions for that child. A fetal loss is not just the loss of the actual child but a loss of her hopes and dreams for that child. The presence of certain factors often influences how a woman will respond to a fetal loss. For example, planned pregnancies, a history of infertility treatments, a lack of other children, a strong desire for children, a lack of a medical explanation for the loss, her perceived maternal role, and her perceived lack of control over fertility are all associated with a greater degree of distress following a miscarriage (Shreffler, Greil, & McQuillan, 2011).

GRIEF AS A RESULT OF EARLY PREGNANCY LOSS AND STILLBIRTH

Maternal attachment begins to develop at the onset of pregnancy and is related to a variety of complex factors. In general, as gestational age increases, so do feelings of attachment (Yarcheski, Mahon, Yarcheski, Hanks, & Cannella, 2009). Attachment is increased when there is strong social for the pregnancy and when prenatal testing has yielded reassuring results. With the variety of first trimester screening that now occurs, mothers are receiving reassuring findings earlier and earlier, making maternal attachment occur earlier. Thus, a pregnancy loss, even early in gestation, can be a great source of distress and grief for the expectant woman and her partner. Unresolved grief associated with a miscarriage in a previous pregnancy can produce anxiety and a recurrence of grief reactions when another pregnancy occurs (Woods-Giscombé, Lobel, & Crandell, 2010). Research shows that when an early pregnancy loss occurs, the reactions of parents are similar to any other major loss and follows the stages of grieving. Most women experience a grief reaction although most report a lessening of symptomology related to grief by 6 months after the loss (Brier, 2008). The Perinatal Bereavement Scale was developed to measure a woman’s grief reaction to a pregnancy loss or stillbirth. This instrument can be used to identify women experiencing a grief reaction and the yearning involved post-loss, and to differentiate between grief and depression (Ritsher & Neugebauer, 2002). Each year, 3 million stillbirths occur globally (Scott, 2011). Stillbirths are categorized as a fetal loss that occurs after 20 gestational weeks (Davidson et al., 2012). Couples faced with a stillborn infant undergo significant distress and grief. Men and women experience grief differently and grieve in various ways. While men present themselves as stoic, thinking they are putting on a strong front for their partner, women sometimes view it as uncaring and perceive the man is unaffected by the loss (Murphy, 2011).

The event of a stillbirth begins a time of ambiguity and disenfranchisement for couples who have lost an infant (Lang, Fleiszer, Duhamel, Sword, Gilbert, & Corsini-Munt, 2011). Parents coping with loss go through various degrees of grief based on a variety of factors including viability of the pregnancy, the physical process of pregnancy loss, making arrangements for the remains, and sharing the news with others (Lang et al., 2011). A woman’s religious beliefs, cultural and societal norms, and personal experiences can all impact the course of grief. Women who experience a religious struggle or who disagree with religious views regarding death and dying and those with a continued attachment to the baby experience a more severe grief reaction (Cowchock, Lasker, Toedter, Skumanich, & Koenig, 2009). Certain cultures react differently to death and dying. In some cultures, such as in Taiwan, it is inappropriate to talk about death or participate in death-related events, such as funerals, or to express grief in public (Hsu, Tseng, Banks, & Kuo, 2004). In some cultures, a stillbirth is thought to be brought about by evil spirits or to justify an improper act committed by the mother. In the Pokot tribe in Kenya, for example, women who experience a stillbirth are isolated from other of their community until a blessing or a slaying of an animal or other cultural tradition can be carried out (Paringiro, 2010). Women with a previous unresolved grief reaction may be unable to process the grief of a stillbirth without professional . Women with a fear of their own death or fears rooted in death issues often experience a prolonged or complicated grief reaction (Barr & Cacciatore, 2008). Because women and men do grieve so differently over the loss of a baby, counseling is always recommended. groups that specifically deal with fetal loss can assist the parents during their grief work. RESOLVE is a group for parents who have suffered a loss. The group provides , education, and advocacy. Women facing stillbirth are commonly met with inappropriate comments from well-meaning friends and family . Women should be forewarned that these comments are not intended to be hurtful but instead represent ignorance and lack of knowledge about what well-meaning friends or family should say to the couple.

GRIEF AS A RESULT OF AN IDENTIFIED CONGENITAL ABNORMALITY

Grieving can also occur when a fetus is diagnosed with a congenital anomaly or genetic defect. Some women with a fetal anomaly or a fetus identified with a genetic anomaly may choose to terminate the pregnancy, and others may wish to continue the pregnancy. Some women, even in the face of a lethal, nonviable pregnancy, may wish to continue the pregnancy to term. Some women may face a birth defect that is nonlethal but life-threatening, and others may be faced with having a child with a birth defect that leaves them with a child with pronounced lifelong disabilities. Even women who are faced with a diagnosis of a mild anomaly, such as a cleft lip, may encounter a sense of loss and experience grief. Grieving among mothers of children with birth defects identified in utero need additional , honesty about the fetus’s condition, reassurance when appropriate, additional pregnancy monitoring, and a revised plan of care for labor and birth. Some women may feel a sense of responsibility and guilt. Others may feel anger, desperation, and sadness. The feelings encountered by women vary. Whenever possible, early psychological intervention should focus on a referral to counseling. Many women find consulting a network related to the child’s condition can help ease anxiety and fears and better prepare them for what to expect. For example, a woman who discovers she is carrying an infant with Down syndrome should be referred to the National Down Syndrome Society for , peer counseling, and information. Many disorders have groups and advocacy networks for new parents whose children may be affected. Mothers of children with milder birth defects seem to do better with coping and adjustment than those with children with more severe and impairing deficits (McCaskgill, 1997). Parents of children with birth defects typically experience higher levels of distress, lower levels of self-confidence, and more marital conflict (Speltz, Armsden, & Clarren, 1990). These findings underscore the importance of appropriate referrals and counseling for this population. Culture, religious beliefs, and social norms can also play a key role in maternal adaptation and grief (Black, Girotto, Chapman, & Oppenheimer, 2009).

GRIEF RELATED TO THE LOSS OF A CHILD

Grief associated with the loss of a child represents one of the most acute and distressful life events a woman may ever face. Research has indicated that women have more severe grief reactions with the loss of a child than men (Wijngaards-de Meij, Stroebe, Stroebe, Schut, Van den Bout, Van Der Heijden, & Dijkstra, 2008). Certain circumstances related to the loss of a child can also impact the woman’s grief reaction. Women who are able to say goodbye to a child and perform certain death rituals that are important to her, such as a viewing or funeral, tend to cope better than those with children who die unexpectedly, have violent deaths, or commit suicide (Wijingaards-de Meij et al., 2008; Sveen & Walby, 2008). In our society, most women accept the loss of parents or friends or even a spouse as an expected norm; however, the loss of a child typically represents an unnatural and unexpected loss. Parents expect children to grow and mature and become adults and expect to die before their children. The death commonly represents loss of the future, of hopes and dreams. Women grieve the child they lose, the adult that the child was to become, and the loss of future grandchildren. Parental grief is said to be the greatest grief that exists. For a woman with other children, she is confronted with need to move forward and her other children while being submerged in her own grief. The progression of grief work is variable although parents who can make sense of a child’s death tend to recover more adequately than parents who find no sense in the death of their child (Keesee, Currier, & Neimeyer, 2008). In one examination of 156 bereaved parents, the parents who could find a sense of meaning, such as a spiritual or religious reason or an ability to help others cope with loss or accept their grief were more likely to recover from a loss of a child (Lichtenthal, Currier, Neimeyer, & Keesee, 2010).

GRIEF RELATED TO THE DEATH OF A SPOUSE

Of the 2.5 million individuals who die annually in the United States, the majority are elderly, over the age of 65 (Zhang, El-Jawahri, & Prigerson, 2006). In the United States, more than half of women become widows by the age of 65. Widowed women have a 40% risk of developing an Anxiety Disorder during the first year following the death of a spouse (Zhang et al., 2006). Many women also experience grief triggers that aggravate symptoms, such as Father’s Day, their loved one’s birthday, etc. For women who have spent decades with their spouse, their whole life can become disoriented and unfamiliar. Women who have a dysfunctional attachment to their spouse are more likely to encounter alterations in the grief process and may be unable to deal with grief issues as well as women who have a secure attachment style (Barr & Cacciatore, 2008). It is estimated that approximately 6% of all deaths in the United States involve unnatural or unexpected deaths (Zhanget al., 2006). Unexpected or violent deaths typically can leave family with a variety of emotions and risks for depression and PTSD (Zhang et al., 2006). Women whose loved ones experience a traumatic or violent death often experience shock, sadness, disturbing thoughts and images, guilt, anger, and anxiety. Violent deaths can impact the individual, family, and community. Women who have lost family to suicide may develop a preoccupation regarding the reasons surrounding the death and cause of the death. Guilt, feelings of rejection, stigma, actual rejection, a need to conceal the cause of death, and self-blame are common (Sveen & Walby, 2008). Although these women have unique symptoms related to a suicide as the mode of death, they are not at a higher risk for PTSD, depression, anxiety, or suicidal behaviors (Sveen & Walby, 2008).

GRIEF RELATED TO SEPARATION OR DIVORCE

Grief related to separation or divorce is common even if the woman was the pursuer of the separation or divorce. Divorce represents the end of a marriage and, in many cases, the end of a family unit. Many women feel a sense of failure as the result of an unsuccessful relationship. When a woman marries, she fully expects the marriage will last and be successful. When a separation occurs, it represents a loss of one’s dreams, hopes, and future plans. Often one’s home, friends, social status, and even job can change or be lost as a direct result. If children are involved, there can be a great sense of guilt and fearful feelings. Women may be facing the reality of becoming a single parent. Grieving related to divorce can be difficult because there is no set of accepted societal norms. During divorces, anger and ill feelings are common, and the grief process may be unrecognized or overlooked. Women commonly experience a variety of feelings and emotions. Women are facing multiple issues that may appear to take priority over grieving, such as securing living arrangements, making child-care plans, discussing visitation and child , and the division of marital property. The need to grieve is important. from friends who have undergone similar experiences can be helpful. groups can offer advice, encouragement, advocacy, and provide resources. Counseling may be advisable for the woman struggling with emotional issues or symptoms of depression and anxiety. Family therapy is sometimes helpful in assisting children who are going through divorce or separation from a parent.

ASSESSMENT AND SCREENING

Many nurses and clinicians have difficulties differentiating between grief and depression because so many of the symptoms overlap. Because of the similarities, the DSM-IV TR states depression should not be diagnosed if a loved one’s death has occurred in the past 2 months. Grief does differ from depression in a variety of ways. Yearning is a typical emotional reaction seen in grief that is absent in women with depression. Bereaved women are also able to express positive emotions and evoke positive memories of the loved one (Shear, 2009). Grief commonly occurs intermittently, in waves, while depression symptoms are more commonly continuous in nature and severity. The grief process is typically assessed during a question-and-answer interview technique with a health care provider. A description of the loss; the circumstances related to the loss; and emotional, physical, religious, and social symptoms should be assessed. Some women may present with physical symptoms that are suggestive of physical ailments when in fact they are related to a grief reaction. Symptoms related to grief are listed in Table 18.2.

Table 18.2 ■ Grief-Related Symptomology

Emotional Symptoms Crying, sadness, hopelessness, fear, guilt, self-blame, inability to concentrate

Physical Symptoms Insomnia or hypersomnia, chest pain, shortn

There are multiple assessment tools used to assess grief, ongoing grief symptoms, and resolution of grief. Some practitioners may find these tools helpful in identifying women with grief reactions. The tools range from visual analog scales to multiple-choice questions to an interview measurement. In a study at Brown University, 24 different grief evaluation instruments were identified (Roach, 2000). Practitioners should familiarize themselves with the different inventories and scales available and determine are best suited for their practice and patient population. While grief is considered a normal psychological process, other psychological impairments can emerge when grief is severe, unresolved, prolonged, or complicated. Common psychiatric illnesses related to grief reactions include Generalized Anxiety Disorder, Agoraphobia, Obsessive-Compulsive Disorder, Hypochondriasis, depression, PTSD, and Adjustment Disorders (Barr & Cacciatore, 2008). In addition, women with dysfunctional personality characteristics or those with a history of mental illness are more at risk of developing psychopathology as a result of grief. The clinician should use appropriate screening tools to assess for the presence of specific disorders. There is growing controversy about whether or not grief or abnormal coping mechanisms related to grief will be included in the DSM-V that is scheduled to be published in 2013. Regardless of its inclusion or exclusion, it continues to be a viable and important source of impairment regardless of the source of the grief. Additional assessments should screen for common comorbidities, including alcohol and substance abuse.

PHARMACOLOGICAL TREATMENT

Some practitioners are unable to deal with grief and loss in their patients, many times based on their own feelings and fears of death and dying. Historical practice included the istration of sedatives and avoidance of the topic of loss. This approach is inappropriate and outdated. While some women may need a mild sedative to promote sleep and rest in the immediate period of mourning, ongoing sedation is not recommended (Giles, 2008). Women should be ed with sympathetic active listening. In most cases of fetal, neonatal, or child death, the mother should be counseled on the cause of death and reassured she did not cause the loss. Practitioners should try to address misconceptions and feelings of guilt, which are common. Most women feel they could have done more, when, in reality, this is not the case (Giles, 2008).

BEHAVIORAL THERAPIES

While some professionals recommend counseling, others maintain that allowing the woman to work through the grief process is the best mode of treatment unless complicated grief occurs. Most women grieve a loss with from family and friends and find that the loss becomes less prominent in their lives and that they are able to carry on normal daily activities. Normal grief is extremely painful, disruptive, and consuming; however, it is usually self-limited and does not impair a woman’s ability to function (Zisook & Shear, 2009). If the loss is so profound or symptoms fail to resolve after a few months or begin to worsen, counseling and mental health intervention is warranted. Individual psychotherapy has been affective for the treatment of normal grief. More aggressive programs aimed at treating women suffering from complicated grief have shown greater effectiveness than individual therapy (Shear, Frank, Houck, & Reynolds, 2005). Cognitive behavioral therapy and ive therapy have also been helpful for women experiencing grief (Boelen, de Keijser, van den Hout, & van den Bout, 2007). Practitioners treating women dealing with grief should simultaneously treat underlying mental illness along with addressing the grief. Women with untreated depression who experience a loss have an 80% chance of developing complicated grief compared to women without an underlying depressive disorder (Shear, 2009). Other ive therapies have been used with varying success. Journaling has been found to be a helpful tool in working through the grief process. groups are also an effective means to deal with grief and provide a peer group that can understand the complex emotions that accompany the grief process. There are groups aimed at specific grief issues, such as living with cancer; widow groups; groups for women who have suffered the loss of a pregnancy, infant, or child; women facing end-of-life issues; and those dealing with divorce. Women with comorbidities can be referred to those specific groups as well. In addition, the woman dealing with grief should be encouraged to take care of herself through a healthy diet, exercise, and proper sleep and rest

patterns.

SUMMARY

Grief and loss are complex issues that many women will face at some point in their lives. While most women will experience specific stages of grief, these stages are fluid and dynamic in nature. Proper assessment and screening may include the use of specific assessment tools or a face-to-face interview with an experienced clinician. While sadness and mourning are common, prolonged grief can develop into complicated grief, which requires intervention from a health care professional. Mental health providers should perform an assessment to detect the development or existence of other psychological disorders, such as anxiety, depression, alcoholism, substance abuse, and PTSD. Therapeutic counseling services may be indicated for women unable to cope with a loss. Other ive therapies are helpful for some women.

Case Study

Michele Mhee is a 38-year-old G4P4 who gave birth to her son 8 months ago by emergency Cesarean birth after her physician failed to respond to calls from the birthing unit for more than 90 minutes. The lack of timely medical intervention led to her son’s recent diagnosis of cerebral palsy. Since learning of her son’s diagnosis and grim prognosis, Michele has begun to experience sadness, hopelessness, and self-blame. Her husband commonly arrives home from work to find Michele crying in the rocking chair holding her infant son. She has become socially isolated from friends and family and has voiced that she experiences difficulty sleeping as a result of her overwhelming feelings of grief. What interventions would be appropriate for Michele? What type of grief reaction is most likely occurring?

Questions to Consider

What are the normal stages of grief? How can nurses provide to grieving women? What types of circumstances would place a woman at high risk of developing a complicated grief reaction? What activities may prove helpful for women experiencing grief?

REFERENCES

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19

Personality and Dissociative Disorders

For women with Personality and Dissociative Disorders, the symptoms may be readily apparent to others and unknown to the woman herself, or she may feel something is not quite right. Both sets of disorders can result in behaviors that are identified as being unusual and both offer complexities when it comes to treatment. It is estimated that 9% of the general United States population meet the criteria for a Personality Disorder ( Lenzenweger, Lane, Loranger, & Kessler, 2007 ). There are 10 different types of Personality Disorders. Borderline Personality Disorder is three times more common in women than in men and is the most common Personality Disorder affecting women ( Bienenfeld, 2010 ). Dissociative Disorders are much rarer, occurring in 0.2% to 5% of the population (National Alliance on Mental Illness, 2011). Dissociative Disorder occurs almost predominantly in women with only 10% of the affected patients being male (National Alliance on Mental Illness, 2011). Although Dissociative Disorders are often sensationalized in the film and media industries, the effects of these disorders can be quite devastating for women experiencing them.

PERSONALITY DISORDERS

Women with Personality Disorders have difficulty relating to others and to specific situations. Often their perception is impaired, which results in an alteration in their interpersonal relationships with others and in turn impairs work, school, and social situations. Many women with Personality Disorders exhibit unhealthy and rigid thinking throughout their lives, commonly being unaware of their diagnosis because their behavior seems acceptable to them. There are many types of Personality Disorders divided into three distinct clusters (to be discussed later).

Etiology

Causative factors include genetic tendencies and environmental factors. There is some discrepancy on the etiological factors, but maladaptive patterns are believed to form when there is a dysfunctional environment with continual exposure in early life that results in maladaptive thinking, behaviors, and thoughts (Bienenfeld, 2010). Risk factors include the following:

■ Low socioeconomic status ■ Family history of mental illness ■ Childhood neglect or abuse ■ Dysfunctional family upbringing ■ Loss of parental figure through death or traumatic divorce ■ History of a conduct disorder in childhood ■ Genetic influences ■ Poor parenting or lack of adequate role modeling

Signs and Symptoms

The signs and symptoms of Personality Disorders vary with the type of disorder and the cluster in which it falls. In general, women with a Personality Disorder commonly exhibit the following signs:

■ Mood swings ■ Social isolation ■ Poor impulse control ■ Anger issues ■ Difficulty in relationships ■ Substance abuse issues ■ Mistrust of others ■ Paranoid thinking ■ Need for instant gratification

Again, specific symptoms vary depending on what cluster the disorder is part of. Physical symptoms may include drug or alcohol dependence and physical scars from suicide attempts (Bienenfeld, 2010). The three clusters are included in Table 19.1. Table 19.2 contains symptoms specific to each disorder.

Table 19.1 ■ Types of Personality Disorder Clusters

Cluster A

Characterized by odd eccentric behavior and odd thinking. ■ Paranoid ■ Schizoid ■ Schizotyp

Table 19.2 ■ Signs and Symptoms Related to Specific Personality Disorders

Cluster A

Paranoid ■ Distrust of others ■ Constant suspicion ■ Belief that others want to harm you or lo Schizoid ■ Limited emotions ■ Absent or reduced emotional expression ■ Flat affect ■ Lack o Schizotypal ■ Eccentric dress ■ Discomfort with interpersonal relationships ■ Flat affect ■ In

A 2007 randomized study in the United States found that the Cluster C Personality Disorders were the most common followed by Cluster A disorders. Antisocial Personality Disorder, which is less common in women, is the most rare of the disorders although it is associated with the most severe symptoms. It is present in only 0.6% of the population (Lenzenweger et al., 2007).

Assessment and Screening

In general, each unique Personality Disorder has specific criteria that are assessed in order to determine the exact diagnosis. Women with Personality Disorders exhibit a specific pattern of behavior that varies markedly from the cultural norm. The pattern occurs in two of the following areas: cognitive, affective, interpersonal functioning, or impulse control. Women with Personality Disorders are inflexible in personal and social situations, which leads to distress or impairment in an area of functioning in their lives. Typically the pattern begins in adolescence or early adulthood and is not related to another mental illness, substance effect, or other physiological cause. Screening includes a physical examination and laboratory studies to rule out an underlying physiological condition, such as thyroid dysfunction or alcohol or substance abuse. Psychological testing is then used to determine thought patterns, behaviors, and relationship issues. The Minnesota Multiphasic Personality Inventory (MMPI), the Eysenck Personality Inventory, and the Personality Diagnostic Questionnaire are all standardized tools that are commonly used to identify Personality Disorders (Bienenfeld, 2010). Most women develop Personality Disorders in late adolescence or early adulthood. A childhood onset has been cited in the literature but is rare. Some women with a Personality Disorder may meet the criteria for more than one disorder, so a complete psychological assessment is needed (Widiger, 2003). With Personality Disorders, comorbidities are common, and an assessment should include common comorbidity symptomology. The most commonly occurring comorbidities include the following (Lenzenweger et al., 2007):

■ Mood Disorders ■ Anxiety Disorders ■ Substance Disorders

Because women with some Personality Disorders may exhibit poor impulse control and participate in high-risk sexual behaviors, a complete examination and laboratory testing for sexually transmitted infections is warranted.

Pharmacological Treatment

Pharmacological intervention cannot cure Personality Disorders. They may be used to comanage symptoms on a short-term basis but are not likely to impact functioning because the basis of Personality Disorders are maladaptive behaviors. A variety of medications are used, depending on the symptomology of the woman. Antidepressants are sometimes used to control symptoms such as the following:

■ Sadness ■ Depression ■ Anger ■ Impulsivity ■ Irritability

Women with hopelessness and feelings of worthlessness may also benefit from antidepressant therapy. Mood-stabilizing drugs and anticonvulsants are sometimes used to prevent the following:

■ Severe mood swings ■ Irritability ■ Aggressiveness

■ Impulsivity

Some women may benefit from antianxiety regimens, which can reduce anxiety, insomnia, and agitation. Women with Personality Disorders are at higher risk for substance dependence, so use of benzodiazepines should be avoided whenever possible (Bienenfeld, 2010). Some women with severe symptoms rooted in a Personality Disorder may experience psychosis, severe anger, and debilitating anxiety. These women may benefit from antipsychotic medications.

Clinical Pearl

Because overdose occurs more commonly with tricyclic antidepressants and monoamine oxidase inhibitors

Behavioral Therapies

The majority of Personality Disorders are primarily treated with therapy. The goal of therapy is for women to develop healthy ways of managing their feelings, thoughts, moods, and behaviors. Several different therapies have been effective in women with Personality Disorders. Table 19.3 contains different therapies that have been used in treatment and provides an overview of each therapy. Group therapies have also been utilized to allow women to see maladaptive behaviors in others and identify appropriate behaviors for themselves and group .

Hospitalization for Personality Disorders is only indicated if the woman presents as a risk to self or others. Women with Borderline Personality Disorder are at risk for dependence on staff triangulation and manipulation and should only be hospitalized for short-term periods for medication management, stabilization, and to implement short-term psychotherapeutic strategies (Bienenfeld, 2010). Rarely, for women with gross inabilities to care for themselves or inabilities to function in a less-restrictive environment, long-term hospitalization or alternative-living placements may be warranted. Because Personality Disorders do not improve with age, long-term treatment is usually required. Women with Cluster A and B disorders are likely to encounter a lessening of symptoms with age, and those with Cluster C disorders usually continue to worsen with age. Women with Cluster B Personality Disorders are at an increased risk for suicide, accidental injury, homicide, poor parenting, child neglect or abuse, and a shortened life span because of these behaviors. Therapeutic interventions that assess suicidal ideations, homicidal ideations, child abuse and neglect, and self-harm practices are warranted. Because highrisk behaviors are also more common, risk-reduction strategies should also be employed by nurses caring for these women.

DISSOCIATIVE DISORDERS

Dissociative Disorders are characterized by dissociation from reality or an interruption of consciousness in which an individual utilizes dissociation as a coping mechanism. “Dissociative Disorders are a group of psychiatric syndromes characterized by disruptions of aspects of consciousness, identity, memory, motor behavior, or environmental awareness” (Sharon, 2010, p. 1). The escape from reality associated with Dissociative Disorders is involuntary and is an intense psychological reaction that allows the woman to keep unpleasant memories distant and remote from their present consciousness.

Etiology

Typically, tremendous psychological trauma has occurred, and it is theorized that these memories are suppressed within the mind, and memory coding is altered (Sharon, 2010). Women experience Dissociative Disorders more frequently than men and have commonly experienced some type of abuse or a severe traumatic event. Sometimes dissociative symptoms occur as a result of ingestion of substances and medications; in these circumstances, they are not considered psychological and are considered manifestations of a medical condition. Globally, the Dissociative Disorders are much more common in North America, suggesting cultural values and norms may play a role in the diagnosis of the disorder within this population (Dryden-Edwards, 2011). There are four types of Dissociative Disorders along with an unspecified category. The unspecified category includes Dissociative Disorders and symptomology that does not meet the diagnostic criteria of the other established disorders.

Signs and Symptoms

The symptoms of a Dissociative Disorder are largely dependent on the type of disorder. Women typically have repressed memories that are blocked out and may have coexisting mental illnesses, such as depression, anxiety, Posttraumatic Stress Disorder (PTSD), and Obsessive-Compulsive Disorder (National Alliance on Mental Illness, 2011). Symptoms common to the cluster of disorders include the following:

■ Memory loss or amnesia of certain places, events, or people ■ Mental illness symptoms and presence of other disorders ■ Detachment from self ■ Distorted reality ■ Blurred sense of identity

Certain risk factors can also put women at risk. These include the following:

■ Extensive psychological abuse in childhood ■ Extreme physical abuse in childhood ■ Excessive sexual abuse in childhood ■ Experiencing a traumatic event as a child or adult ■ Involvement in a natural disaster

■ Sexual assault ■ Exposure to war ■ Military service involving battle ■ Kidnapping ■ Undergoing torture ■ Invasive medical procedures

Assessment and Screening

A careful psychological assessment and review of childhood and adult history is the most common diagnostic method. Women are assessed for symptoms of the specific Dissociative Disorder. Other screening tests for related symptoms are sometimes utilized, such as inventories for depression, anxiety, PTSD, and other mental health disorders. Some professionals may utilize medications to facilitate hypnosis to retrieve suppressed memories and uncover childhood events. The woman is then screened for a specific Dissociative Disorder.

Dissociative Amnesia

Dissociative Amnesia is marked by symptoms related to memory loss and an inability to recall events on at least one occasion; it occurs independently of other mental illnesses, including Dissociative Identity Disorder (DID), Dissociative Fugue, PTSD, Acute Stress Disorder, or Somatization Disorder (Sharon, 2010). This disorder was formerly known as psychogenic amnesia. It occurs in 2% to 7% of the general population and is directly proportional to the degree of trauma experienced (Dell & O’Neil, 2009). It is categorized as marked disturbances in recall beyond typical forgetfulness that is typically sudden and dramatic. The episode has a marked beginning and end, and typically the end point is as sudden as the onset. Women with the disorder may present in a confused state and may be found wandering and appear perplexed, or the disorder is discovered only after intense interviewing when it is apparent the woman cannot recall personal information and facts (Dell & O’Neil, 2009). The symptoms are not related to a medical condition or a medical trauma, such as a head injury. Most women with Dissociative Amnesia cannot recall certain people, traumatic events, or childhood traumas. It is considered a protective adaptation because the recall of certain information would result in severe stress and is traumatic in nature. Symptoms related to this disorder typically cause severe stress and impairment in social and occupational functioning (Sharon, 2010). Women with Dissociative Amnesia are also at risk for suicide because of their inability to psychologically process the traumatic event that happened to them. There are different types of memory loss associated with the condition:

■ Localized amnesia: Failure to specific time periods and events, such as a rape ■ Generalized amnesia: Cannot recall anything about their lives

■ Continuous amnesia: No memory of the past or present ■ Systematized amnesia: Occurs when patients have a loss of memory of certain categories of information, such as certain places or persons

Clinical Pearl

A sudden onset of amnesia, such as from a blow to the head, is extremely rare and uncommon.

Dissociative Identity Disorder

DID was formerly known as multiple personality disorder in the literature and was sensationalized in movies and in the lay literature. Marked switching of completely different personae is rare and presents in only 5% to 20% of women with DID. Instead, subtle presentations are more the norm (Sinason, 2011). DID is marked by women switching to a different identity as a means of coping with stress and stressful situations. The incidence is 1% to 3% in the general population (Sinason, 2011). With this disorder, women have two or more separate identities or personality states that demonstrate control at a single time. Women with the disorder commonly feel there is more than one person inside them and may hear multiple voices within their heads talking to them. Often these different identities have their own names, personal histories, mannerisms, and unique characteristics. They may exhibit different physical characteristics, varying voices, and manners of speech or accents and even have different physical needs, such as using a cane when a specific identity is present. Some women may encounter identities of the other gender or of a different sexual orientation. Some personalities may be vastly different, whereas others may possess many similarities. Some identities may know of the presence of others while others may have less familiarity or no knowledge of other identities. Most women with DID report Dissociative Amnesia as well and often lose track of time when other identities are present that cannot be attributed to normal forgetfulness. The symptoms must not be related to a medical condition or other disorders including the following:

■ Dissociative Disorders ■ Mood Disorders ■ Personality Disorders

■ Schizophrenia ■ Seizures ■ Eating Disorders ■ Factitious Disorder

Because women with Schizophrenia also hear voices, the difference between the types of voices they encounter needs to be distinguished. Women with DID hear voices within their own head, whereas women with Schizophrenia usually report the source of voices as coming from outside themselves (Sharon, 2010; Sinason, 2011). Most women presenting with DID have had severe childhood abuse or other types of overwhelming experiences with the development of PTSD prior to the age of 6 (Sinason, 2011). The onset of DID usually occurs in adulthood, although the intense childhood experiences are the triggering event. A careful history of childhood trauma, overwhelming childhood experiences, and irregular caregiving that interrupts the normal psychological process of identity formation can provide important clues to the differential diagnosis of DID. Children exposed to war and lifelong childhood medical procedures involving intense pain are also at risk. Many women with DID also have a comorbidity, such as depression, PTSD, or anxiety. It is not uncommon for them to be previously diagnosed with other incorrect diagnoses. Suicide attempts are common in women with DID with many women having a history of multiple attempts (Foote, Smolin, Neft, & Lipschitz, 2008).

Clinical Pearl

In recent years, DID has sometimes been used as a defense for individuals who have committed a crime an

Dissociative Fugue

Dissociative Fugue is when a woman creates a physical distance from her own identity, and physically leaves her familiar environment, suddenly going to an unknown or unfamiliar place. Women with this disorder commonly leave their current location and end up in an entirely different place and are unable to recall past events and experiences. They commonly establish a new identity in a different geographic location and are confused about their past and past identity. These women usually blend into their new environments without major adjustment issues but do become distressed when the fugue lifts, often becoming confused about where they are and why they are there. It is common for them to have little with people during the episode. The incidence is very rare, occurring in approximately 0.2% of the population (Sharon, 2010). The episodes can last anywhere from hours to months, although the longer durations are uncommon. The fugue typically ends suddenly without warning and leaves the woman without a memory of the events that occurred during the episode itself. It is common for women to have no recall of events that occurred and no recollection of how they arrived at the new location. Typically the disorder causes marked social, occupational, and personal distress for the woman. As with the other Dissociative Disorders, other medical and psychological etiologies along with Factitious Disorders must be excluded for proper diagnosis to occur.

Depersonalization Disorder

Depersonalization Disorder is characterized by the sudden, immediate onset of the perception of being outside of one’s self, out of control of one’s self, or viewing one’s actions as an outsider would. Women with this disorder may perceive objects in the environment as changing shape or structure or may feel those around her are inhuman and robotic in nature. Some women describe the encounters as being like watching a film of themselves doing something. Distortion of the current environment, including one’s self, is common. During an acute episode, which may recur throughout the woman’s life but lasting only a few moments, time may seem to slow down, and the world around them may seem unreal. Most women suffering from this disorder realize at some level that the experience is not real. The incidence of the disorder is 2.4% and typically has an onset during adolescence (Sharon, 2010). A diagnosis is generally made if the woman experiences depersonalization or derealization on at least one occasion. The disorder cannot be related to another medical or psychological disorder or medications or substances. The disorder commonly coexists with other mental illnesses, such as depression, Anxiety Disorders, and Psychotic Disorders (Sharon, 2010).

Pharmacological Treatment

In general, Dissociative Disorders are treated with atypical antipsychotics. The most commonly used include aripiprazole (Abilify), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). New-generation anticonvulsants, such as quetiapine has also been shown to be effective. In all types of Dissociative Disorders, underlying comorbidities, such as Mood and Anxiety Disorders should be treated with medication as indicated for the specific diagnosis. Dissociative Amnesia is sometimes treated with SSRIs, serotoninnorepinephrine reuptake inhibitors (SNRIs), antiepileptics, and atypical neuroleptics (Sharon, 2010). In Dissociative Fugue, symptoms can vary widely. For women with mania symptoms, mood stabilizers may be indicated, whereas others with depressive symptoms may require antidepressants. The aim of medication management is to address specific symptomology generated by the disorder. Depersonalization Disorder is considered difficult to treat. Some studies suggest treatment with SSRIs or benzodiazepines may be useful; others have found medication ineffective for this disorder. Medications are rarely used in the treatment of DID unless another coexisting mental illness is present.

Behavioral Therapy

Multiple therapies and treatment modalities have been used for women with Dissociative Disorders. With DID, initially, the goal of therapy was to reintegrate the personalities into a single entity; however, there is conflict among professionals about whether this remains an effective means of treatment. Those who oppose this treatment goal feel this type of therapy causes internal conflict within the woman, often leaving her with the feeling that the practitioner’s expectation is to eliminate a part of her. Other practitioners favor focusing on building a mutual relationship of coexistence and adaptation between the different identities (Dryden-Edwards, 2011). The following therapies have been utilized effectively to treat Dissociative Disorders:

■ Cognitive-behavioral therapy ■ Psychoanalytical ■ Psychotherapy ■ ive therapies ■ Psycho-education

The initial goal of treatment is to manage symptoms and provide women with skills needed to handle their illness and symptoms. Psycho-education for both the woman and her family is important. Many providers utilize hypnotherapy to explore the woman’s unpleasant childhood or experiential memories that initially triggered the coping mechanism that led to the illness itself.

Women are counseled to avoid stressful circumstances and events because these can trigger an episode. Adequate coping skills and stress-management techniques are important. Women should be encouraged to build meaningful relationships and be assisted with learning to develop trust in others. Women should be counseled to establish boundaries to keep episodes from recurring. Rational, well thought-out decision making can assist the woman in avoiding making ill-advised decisions. Because the woman may regress, an emergency plan should be formulated.

For some women, hospitalization becomes necessary during acute phases when symptoms may deem the woman a danger to

SUMMARY

Women with Personality Disorders have an alteration in their interactions with others and often have altered perceptions. Many women with Personality Disorders exhibit unhealthy and rigid thinking throughout their lives and commonly are unaware of their diagnosis. There are three clusters of Personality Disorders, each having different characteristics. Therapeutic behavioral interventions are the hallmark of treatment because there are no specific medications to treat these disorders. Dissociative Disorders are characterized by alterations from reality or an interruption of consciousness in which an individual utilizes dissociation as a coping mechanism. Women for 90% of all clients with these types of disorders, which are typically caused by exposure to extremely stressful or abusive experiences. Behavioral interventions are the main treatment modalities utilized for the care of women with these types of illnesses. Comorbidities with other psychiatric conditions are common.

Case Study

Amelia Ericson is a 45-year-old Caucasian woman who presents to the emergency department with self-inflicted cut marks on both wrists. Amelia states she is enraged with her boyfriend for leaving her and that she is tired of constantly being abandoned by the men in her life. Amelia reports a recent breakup with her boyfriend of 3 months, which drove her to attempt suicide. Amelia does state she has had numerous romantic relationships, which time and again result in men deserting her. She states she views herself as a kind woman who is constantly victimized by others. She notes four previous suicide attempts in the past. She its to having an impulsive personality as evidenced by 64 sex partners, three reckless driving charges, and an inability to contain personal

spending that has resulted in two bankruptcies in the past 12 years. Amelia has been taken to an exam room, but every time the nurse leaves the room, she tells the nurse she is having thoughts of harming herself in the room. She is extremely paranoid that the nurse will leave her and not come back. What is her likely diagnosis? What would your immediate interventions be for dealing with Amelia?

Questions to Consider

What is the most commonly occurring Personality Disorder in women? What interventions are most appropriate for treating women with Personality Disorders? What etiological factors can lead to the development of Dissociative Disorders?

REFERENCES

Bienenfeld, D. (2010). Personality disorders. E-medicine. Retrieved from http://emedicine.medscape.com/article/294307-followup#a2647 Dell, P. F., & O’Neil, J. A. (2009). Dissociation and dissociative disorders: DSM-V and beyond. New York: Taylor & Francis. Dryden-Edwards, R. (2011). Dissociative identity disorder. Medicine Net. Retrieved from http://www.medicinenet.com/dissociative_identity_disorder/article.htm Foote, B., Smolin, Y., Neft, D. I., & Lipschitz, D. (2008). Dissociative disorders and suicidality in psychiatric outpatients. Journal of Nervous & Mental Disease, 196(1), 29–36. DOI: 10.1097/NMD.0b013e31815fa4e7 Lenzenweger, M. F., Lane, M. C., Loranger, A. W., & Kessler, R. C. (2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62(6), 553–564. DOI: 10.1016/j.biopsych.2006.09.019

National Alliance on Mental Illness. (2011). Mental illness: Dissociative disorders. Retrieved from http://www.nami.org/Template.cfm? Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID Sharon, I. (2010). Dissociative disorders. E-medicine. Retrieved from http://emedicine.medscape.com/article/294508-overview#aw2aab6b2 Sinason, V. (2011). Attachment, trauma and multiplicity: Working with dissociative identity disorder. New York: Taylor & Francis. Widiger, T. A. (2003). Personality disorder diagnosis. World Psychiatry, 2(3), 131–135.

20

Schizophrenia

Schizophrenia is the name of a group of severe brain disorders in which women interpret reality abnormally and have marked difficulties in their tasks of daily living. Schizophrenia affects men and women differently although the incidence is equal, and it is found in all cultural and socioeconomic groups. Women typically have a later onset, as late as in their mid-20s to early 30s during their childbearing years. Estrogen is thought to have a protective effect and thought to be responsible for the delayed onset in women ( U.S. Public Health Service, 2009 ). Women typically have better treatment outcomes than men. Schizophrenia is considered a long-term disease and represents one of the most severe, debilitating, psychiatric disorders. Women with Schizophrenia have alterations in their thinking, social behavior, and emotions (Tormoehlen & Lessick, 2010). They have a higher incidence of unplanned and unrecognized pregnancies, sexual abuse in both childhood and adulthood, victimization, a higher incidence of sexually transmitted infections (including HIV), and higher rates of rape and sexual molestation (Tormoehlen & Lessick, 2010). Women affected with Schizophrenia are commonly in lower socioeconomic classes, experience homelessness more often, and are more frequently unemployed or underemployed. It affects approximately 1% of the population yet s for 50% of inpatient hospitalizations and 25% of psychiatric treatment beds annually (Weinberger & Harrison, 2011).

ETIOLOGY

The exact etiology of Schizophrenia is unknown, but it appears to be related to multiple factors, including those genetic and biochemical in nature. In family, twin, and adoption studies, there is a strong genetic component that indicates Schizophrenia has genetic links; however, a specific gene that causes the disease has not been identified. Individuals with an affected family member are 10 times more likely to be affected with Schizophrenia than someone with no family history of the disease (Weinberger & Harrison, 2011). Biochemical imbalances within the brain biochemistry may for some Schizophrenia. There is some suggestion that dopamine-dependent neuronal activity may for acute Schizophrenia because agents that block dopamine seem to decrease symptoms in affected individuals. Autopsy examinations have also demonstrated that individuals affected with Schizophrenia have two-thirds more dopamine receptors in the brain than unaffected individuals. There are multiple theories that suggest other neurotransmitters may be associated with a predisposition to Schizophrenia. These include norepinephrine, serotonin, acetylcholine, and gamma-aminobutyric acid along with neuroregulators, such as endorphins and prostaglandins (Weinberger & Harrison, 2011). Other biological influences could include pregnancy-related events, such as viral infection with the influenza virus, severe maternal malnutrition, alloimmunization, and older paternal age; central nervous system illnesses in early childhood; and anatomical anomalies, such as ventricular enlargement, sulci enlargement, and cerebellar atrophy (Tormoehlen & Lessick, 2010). Histological changes, such as a disordering of the pyramidal cells in the hippocampal cell, have been reported and may be related to the influenza viral infection occurring in the second trimester of pregnancy. Other studies have shown links with epilepsy, Huntington’s disease, Wilson disease, birth trauma, adult head injuries, alcohol abuse, cerebral tumor, strokes, lupus, myxedema, and parkinsonism (Weinberger & Harrison, 2011). Psychological factors and environmental influences can impact the predisposition to Schizophrenia.

SIGNS AND SYMPTOMS

Schizophrenia may result in multiple symptoms, including negative and positive symptoms. Negative symptoms are typically a decrease in normal or common activities, whereas positive symptoms are a distortion of normal functioning or exaggerated behaviors. Cognitive symptoms involve thought processes and routinely significantly impair an individual’s ability to care for him- or herself or make effective decisions. Affective symptoms are related to mood alterations and may cause the woman to be perceived as inappropriate or odd. Table 20.1 is a list of symptoms associated with Schizophrenia.

Table 20.1 ■ Symptoms Associated With Schizophrenia

Negative Symptoms ■ Affective blunting: Loss of interest in previously enjoyed or everyday activities ■ Reduced ability to complete planned ac

Source: Adapted from Townsend (2011); Mayo Clinic (2011).

There are different types of Schizophrenia disorders. The specific diagnosis is made upon clinical presentation, family history, and symptomology and should be performed by a psychiatrist or other mental health professional. The diagnosis of Schizophrenia is typically out of the realm of expertise for most nurse practitioners or primary care practitioners. Table 20.2 is a list of the different forms of Schizophrenia.

Table 20.2 ■ Different Types of Schizophrenia

Type of Schizophrenia Disorganized Catatonic Paranoid Undifferentiated Residual

Common Symptoms Regressive and primitive behaviors, flat affect, poor with reality; inappropriate behaviors Marked changes in motor behavior, stupor, catatonic excitement, psychomotor retardation, mutism Presence of delusions of persecution or grandeur, auditory hallucinations, suspiciousness, guarded Exhibits psychotic behavior but does not meet the criteria for one category exclusively, typically p History of at least one previous psychotic episode, but there are no ongoing symptoms of definitiv

Source: Adapted from Beck, Rector, Stohler, & Grant (2011); U.S. Public Health Service (2009).

In addition to the varying types of Schizophrenia, there are other Psychotic Disorders, which are discussed in Chapter 21.

PHARMACOLOGICAL TREATMENT

Since the discovery of antipsychotics in the 1950s, the success of treatment of Schizophrenia and other Psychotic Disorders has vastly improved. Antipsychotics are also known as neuroleptics or major tranquilizers. Examples of typical or first-generation antipsychotics include the following:

■ Chlorpromazine (Thorazine) ■ Fluphenazine (Prolixin) ■ Haloperidol (Haldol) ■ Loxapine (Loxitane) ■ Perphenazine (Trilafon) ■ Pimozide (Orap) ■ Thioridazine (Mellaril) ■ Thiothixene (Navane) ■ Trifluoperazine (Stelazine)

Typical antipsychotics block dopamine reception in the brain by interfering with the postsynaptic receptors on the basal ganglia, limbic system, brainstem, and the medulla. They also have some affect on cholinergic, alpha-1 adrenergic, and histamine receptors along with inhibiting the dopamine-mediated neural impulses (Weinberger & Harrison, 2011). Atypical antipsychotics, a newer class of drugs, offer fewer side effects, are

better tolerated, have better treatment success, and are now commonly used. Examples of atypical antipsychotics or second-generation drugs include the following:

■ Aripiprazole (Abilify) ■ Clozapine (Clozaril) ■ Olanzapine (Zyprexa) ■ Quetiapine (Seroquel) ■ Risperidone (Risperdal) ■ Ziprasidone (Geodon)

While antipsychotics have revolutionized the care of women with Psychotic Disorders, there are a variety of complications, including shortened life expectancy rates; extrapyramidal symptoms; prolactin elevation; anticholinergic side effects, such as dry mouth, constipation, and urinary retention; orthostatic hypertension; dizziness; tremors; weight gain; and excessive sedation (Weinberger & Harrison, 2011). Women frequently encounter amenorrhea during treatment; however, the lack of menses does not cause anovulation, so contraceptive care is important because women with Schizophrenia commonly have significant impairment issues with pregnancy (Tormoehlen & Lessick, 2010).

Pharmacological Considerations in Pregnancy and Lactation

Women who desire pregnancy should be managed with clozapine (Clozaril) because it is the only category B antipsychotic medication. Women with Schizophrenia require careful assessment and monitoring for psychiatric disturbances during pregnancy related to hormonal changes. In general, women with Schizophrenia and Schizophreniform Disorders are at an increased risk for congenital anomalies, diabetes, low birth weight, induction, and augmentation of labor (Hizkiyahu, Levy, & Sheiner, 2010). The incidence of unplanned and unwanted pregnancy is significantly higher in women with Schizophrenia and Schizophreniform Disorders (Hizkiyahu et al., 2010). The research on the use of antipsychotics in lactation is limited with haloperidol (Haldol) having the best outcomes and being deemed the safest by the American Congress of Obstetricians and Gynecologists (2007). The care of pregnant women with Schizophrenia is probably best managed by a multidisciplinary team that includes a psychiatrist, therapist, obstetrician, case manager, and perinatologist.

Physiological Effects of Antipsychotics

Antipsychotics can also cause significant cardiac changes, most notably a prolonged QT interval; therefore, certain antipsychotics should not be prescribed for women with arrhythmias. Routine electrocardiography (ECG) is warranted prior to starting therapy and periodically throughout treatment. In addition, women with known seizures may have a reduction in their seizure threshold and should be prescribed clozapine because it does not appear to decrease seizure threshold. Agranulocytosis, a potentially fatal blood disorder, can occur at any time but is most common in the first 3 months of therapy with typical antipsychotics along with Clozaril and warrants monitoring with a complete blood count (CBC) and observation of symptoms, such as malaise, sore throat, and fever (Beck et al., 2011). Primary care providers are very unlikely to be the main care provider for managing a woman with Schizophrenia or a Psychotic Disorder as they warrant continuous monitoring, medication istration precautions, therapy interventions, case management, and skills training. Primary care providers should be familiar with the drugs involved in caring for women with these disorders, as well as possible drug interactions and risk factors, because they may provide subsequent care for other conditions. Care must be taken when prescribing antihypertensives, central nervous system (CNS) depressants, and anticholinergic agents with certain inhibitor agents, such as CYP3A/CYP2D6/CYP3A4/CYP1A2 and with anticoagulants (Beck et al., 2011).

PSYCHOLOGICAL THERAPIES

Psychological therapies are important for the care of women with a Psychotic Disorder and work best with combined with antipsychotic medications. Realityoriented therapy has been shown to be an effective tool in treating these disorders. Establishing trust with a care provider is a difficult task, but once established, continuity of care is important. Therapy sessions are aimed at improving communication, education of the disease process, typical emotional responses, and frustration tolerance (Beck et al., 2011). Outpatient group therapy that offers a ive approach is another effective tool when treating a woman with Schizophrenia and provides opportunities to meet peers, effectively communicate, and work on reality testing in a safe environment. Cognitivebehavioral therapy (CBT) has been effective in providing education to understand the disease process, collaborate with a trusted source to create treatment goals, and teaching the affected woman to deal with her symptoms. The goal of CBT is to help the woman cope with her disorder and is time limited and purpose driven (Dickerson, 2004). In the United Kingdom, all patients with Schizophrenia undergo CBT, but in the United States, it is not as widely accepted (Kuller, Ott, Goisman, Wainwright, & Rabin, 2010). Social skills training is another important component of care for a woman with a Psychotic Disorder and is widely used to improve social functioning. The therapy aims at identifying interpersonal skills, which will more effectively allow the woman to communicate in the world around her. Skills often addressed include nonverbal behaviors, paralinguistic features, verbal content, interactive balance, and shaping specific behaviors (Weinberger & Harrison, 2011). Milieu therapy involves manipulating the environment, usually by peer pressure, for normalized adaptation. It stresses the consumer’s rights to goals, encourages freedom and less-formal relationships between the peers and staff, and encourages clear, effective communication (Sadock & Sadock, 2007). In addition, the woman should be referred to the local mental health agency in her jurisdiction for case-management services. Various case-management models exists that offer a collaborative team approach that incorporates medication

management and compliance, therapy attendance, groups, vocational training and job placement services, and social connection groups. Other services can include substance abuse counseling or groups, family therapy or family services, couples counseling, mobile crisis intervention teams, basic living-skills groups, and collaboration with the various agencies that often provide services. With treatment, it is estimated that one-third of women with Schizophrenia will improve and have long-term improvements and function fairly well and likely never experience an additional psychotic break. Another third will show some improvement but will suffer intermittent relapses, some disabilities, and job disturbances along with social isolation as a result of the disease. Sadly, the other one-third of women will likely have severe mental illness resulting in ongoing disability and are unlikely to respond to medication or therapy intervention. Although women respond better to pharmacological intervention than men, some women will need lifelong and may need assisted-living conditions and persistent-care management in order to sustain their daily lives.

SUMMARY

Schizophrenia is a life-long, chronic, significantly disabling mental illness that affects a woman’s thoughts and ability to function independently. Although women typically have a later onset, they tend to function differently than men with Schizophrenia. There are various forms of Schizophrenia and different categories of symptoms. Women with Schizophrenia may manifest themselves differently depending on the types of symptoms they encounter with their illness. Pharmacologic intervention is essential and is the cornerstone of treatment. Behavioral therapy can be an effective adjunct therapy. Typically, these women need a lifetime of care and may need assistance maintaining a living environment and assistance with social and life skills.

Case Study

Erin Mancini is a 26-year-old college graduate with an art degree from a prestigious art institute who began having alterations in her thinking over the past 4 months. Erin’s parents, who adopted Erin as a newborn, live 45 minutes from her apartment and recently noted that their daughter began to act strangely during telephone calls and recent visits. Erin’s mother notes that the biological mother had a medical history of “mental problems”; however, a specific diagnosis was not provided to them during the adoption procedure. On a recent visit, Erin was so distraught and using unrecognizable words that her parents immediately took her to the local emergency department (ED). Erin had stopped bathing, stopped cleaning her apartment, and had refused to let any of her friends in to check on her. The physician at the ED itted Erin to the psychiatric unit where she was diagnosed with Schizophrenia. Erin’s parents were devastated and asked the nurse how this happened. What is the most common etiology of Schizophrenia? What treatment is likely to be most effective for managing her

diagnosis?

Questions to Consider

What etiological factors are associated with Schizophrenia? What are the common symptoms associated with Schizophrenia? What medications are most commonly prescribed for women with Schizophrenia? What is the long-term prognosis for a woman diagnosed with Schizophrenia?

REFERENCES

American College of Obstetricians and Gynecologists. (2007). Practice Bulletin No. 87 Use of psychiatric medications during pregnancy and lactation. Obstetrics and Gynecology, 110(5), 1179–1198. Beck, A. T., Rector, N. A., Stolar, N., & Grant, P. (2011). Schizophrenia: Cognitive therapy, research, and theory. New York: Guilford Press. Dickerson, F. B. (2004). Update on cognitive behavioral psychotherapy for schizophrenia: Review of recent studies. Journal of Cognitive Psychotherapy: An International Quarterly, 18(3), 145–152. Hizkiyahu, R., Levy, A., & Sheiner, E. (2010). Pregnancy outcome of patients with schizophrenia. American Journal of Perinatology, 27(1), 019–023. DOI: 10.1055/s-0029-1225529 Kuller, A. M., Ott, B. T., Goisman, R. M., Wainwright, L. D., & Rabin, R. J. (2010). Cognitive behavioral therapy and schizophrenia: A survey of clinical practices and views on efficacy in the United States and United Kingdom. Community Mental Health Journal, 46, 2–9. DOI: 10.1007/s10597-009-9223-6 Mayo Clinic. (2011). Schizophrenia. Retrieved from http://www.mayoclinic.com/health/schizophrenia/DS00196 Sadock, B. J., & Sadock, V. A. (2007). Synopses of psychiatry: Behavioral science and clinical psychiatry, 10th ed. Philadelphia: Lippincott, Williams, & Wilkins. Tormoehlen, K., & Lessick, M. (2010). Schizophrenia in women. Nursing for Women’s Health, 14(6), 482–495. Townsend, M. C. (2011). Essentials in psychiatric mental health nursing: Concepts of care in evidence-based practice. Philadelphia: F. A. Davis Company.

U.S. Public Health Service. (2009). Mental health: A report of the surgeon general. Chapter 4: Schizophrenia (pp. 1–19). Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/toc.html#chapter4 Weinberger, D. R., & Harrison, P. J. (2011). Schizophrenia, 3rd ed. West Sussex, UK: John Wiley.

21

Psychotic Disorders

Psychotic Disorders occur in women when there is an alteration in thinking and perceptions. Schizophrenia is the most common of the Psychotic Disorders and is discussed in Chapter 20 . Postpartum psychosis is discussed in Chapter 14 . This chapter focuses on other types of Psychotic Disorders. Women with psychosis lose touch with reality and often cannot distinguish between reality and fantasy or unreal perceptions. The lifetime prevalence of any Psychotic Disorder is approximately 3% ( Perälä, Suvisaari, Saarni, Kuoppasalmi, Isometsä et al., 2007 ). The most significant changes in Psychotic Disorders have occurred with increases in substance abuse–induced psychosis (SAIP). Although the incidence is much more common in men, it has also increased in the female population as a result of an increased use of illegal substances ( Kirkbride, Croudace, Brewin, Donoghue, Mason et al., 2009 ). The prevalence rates of specific Psychotic Disorders are listed in Table 21.1 .

Table 21.1 ■ Types of Psychotic Disorders and Their Prevalence

Type of Disorder Schizophrenia Schizoaffective Disorder Schizophreniform Disorder Delusional Disorder Major Depression with Psychotic Features SAIP Disorders Psychotic Disorders Related to Medical Conditions

Lifetime Prevalence 0.87% 0.32% 0.07% 0.18% 0.35% 0.42% 0.21%

Source: Adapted from Perälä et al. (2007).

Ethnic minorities and Blacks are more commonly diagnosed with Psychotic Disorders than Caucasians (Kirkbride, Fearon, Morgan, Dazzan et al., 2006). Other studies have shown that individuals living in densely populated urban areas had a 68% to 77% increased risk of developing a Psychotic Disorder when compared to those living in rural or less densely populated geographic areas (Sundquist, Frank, & Sundquist, 2004). Women are typically older when they are diagnosed than their male counterparts (Bogren, Mattisson, Isberg, MunkJørgensen, & Nettelbladt, 2010). Women with Psychotic Disorders function differently than men with the same diagnosis. They generally have better premorbid functioning, less severity in symptoms, lower levels of post-morbid disability, and a better integration into the community during the recovery period than their male counterparts (Morgan, Castle, & Jablensky, 2008). These gender differences may be a result of personality attributes that are more common in women and women’s adaptive behaviors prior to illness (Morgan et al., 2008). The two most common symptoms in all types of Psychotic Disorders are delusions and hallucinations. Delusions represent alterations in thinking and false beliefs. Examples of delusions include the belief by the woman that someone is following her or talking to her through the wall or television. Hallucinations are false perceptions that occur without the presence of a stimulus that occur in a wakeful state, meaning the woman is fully conscious and not asleep. There are various types of hallucinations:

■ Auditory hallucinations involve the belief that someone who is not there is talking to you or the sensation of hearing voices. ■ Visual hallucinations involve the presence of something who is not there. ■ Olfactory hallucinations involve the sense of smell; for example, an individual smells a distinctive odor, such as that caused by a fire. ■ Gustatory hallucinations involve the taste of a substance.

■ Tactile hallucinations involve the sensation on the skin that there is a stimulus, like a spider crawling on the arm. ■ Thermoception hallucinations involve the sensation of an alteration in temperature. ■ Proprioception hallucinations involve the sensation of movement within one’s own body. ■ Equilibrioception hallucinations refers to the sensation of imbalance or disequilibrium. ■ Nociceptive hallucinations occur when the peripheral and central nervous systems react automatically to a noxious stimulus. In a hallucination, the body reacts without the presence of a stimulus. ■ Chronoceptive hallucinations involve the loss of perception of time or the perception of time being different than the actual time that has elapsed. A women with a chronoceptive hallucinations may believe that something happened over the course of a day when in fact it happened within a few minutes.

There are various types of Psychotic Disorders, which represent the rarest of the psychiatric conditions. A listing of Psychotic Disorders is included in Table 21.2.

Table 21.2 ■ Types of Psychotic Disorders and Their Associated Symptoms

Type of Psychotic Disorder Schizoaffective Disorder Brief Psychotic Disorder Schizophreniform Disorder Delusional Disorder Shared Psychotic Disorder Psychotic Disorder Secondary to Medical Condition

Symptoms Associated with Disorder Schizophrenic behaviors associated with symptoms of mood disorde Sudden onset of Psychotic Disorder for more than 1 day but less than Same as Schizophrenia except duration is 1–6 months. If symptoms The presence of one or more non-bizarre delusion for at least 1 mont A delusional system that develops with another person in a close rela Prominent hallucinations and delusions attributed to a medical disord

Substance-Induced Psychotic Disorder

Presence of hallucinations and delusions directly related to substance

Source: Adapted from Townsend (2011); U.S. Public Health Service (2009).

SCHIZOAFFECTIVE DISORDER

Schizoaffective Disorder occurs when there is a loss of with reality in addition to a Mood Disorder. It is marked by elevations and depressions of moods that alternate with or occur simultaneously with episodes of psychosis. It occurs more commonly in women than in men and is rare in childhood. Women have a later age onset than men (Brannon, 2012). The illness is typically diagnosed in late adolescence or in early adulthood. In younger women, bipolar subtypes are more common, whereas older women tend to experience more depressive symptomology (Brannon, 2012). It is less common than Schizophrenia but more common than some of the other Psychotic Disorders. The disorder is divided into either depressive or bipolar types. Further division of the bipolar types include manic, hypomanic, or mixed episode. Women with Schizoaffective Disorder often have psychiatric comorbidities, including anxiety and substance abuse. Women with Schizoaffective Disorder reportedly have a shortened life expectancy and are at risk for suicide and accidental medication overdosage deaths. They reportedly have 17.5 life years lost when compared with women without serious mental illness (Chang, Hayes, & Perera et al., 2011). Cultural and international rates are difficult to assess but are thought to be similar to the reported rates of approximately 0.32% (Brannon, 2012). Women with Schizoaffective Disorder have a reported 10% suicide rate. Suicide rates are highest in the Caucasian population and lower in African American populations. Immigrants have higher rates than people born in the country where they live. Although more women attempt suicide, men are more successful because they typically use more violent and lethal means (Brannon, 2012).

Etiology

Schizoaffective Disorder is thought to be caused by early environmental influences and genetic, biological, social, and chemical influences within the brain and neurotransmitters. Specific neurotransmitters, including dopamine, serotonin, and norepinephrine, are thought to be involved (Brannon, 2012). Individuals with both Schizophrenia and Schizoaffective Disorder are thought to have abnormalities in the metabolism of tetrahydrobiopterin (BH4), dopamine, and glutamate although the exact etiological process remains unclear. There is some clinical evidence that suggests advanced paternal age is a risk factor (Brown, Schaefer, & Wyatt, 2002). Investigations into uterine factors, such as malnutrition, viral infections, and birth trauma have been examined as possible etiological factors (Brannon, 2012).

Signs and Symptoms

The signs and symptoms of Schizoaffective Disorder may include the following:

■ Disorganized thinking or thoughts ■ Disorganized illogical speech ■ Delusions ■ Hallucinations ■ Paranoia ■ Appetite changes ■ Changes in energy ■ Sleep disturbances (hypersomnia, insomnia) ■ Lack of impulse control ■ Lack of logical reasoning ■ Lack of adequate grooming ■ Difficulty concentrating ■ Isolation ■ Depression ■ Sadness

■ Hopelessness ■ Rapid speech patterns ■ Mania ■ Psychosis occurs during periods without mood disturbances

Assessment and Screening

Assessment is based on conducting an intensive behavioral profile in which the woman reports symptoms attributable to the illness. The symptoms observed by family or others are also important. In order to meet the criteria for diagnosis, the woman must experience two of the following criteria for onemonth period: hallucinations, delusions, disorganized speech, grossly disorganized behavior, catatonic behavior, or negative symptoms. Negative symptoms are described in Table 21.3.

Table 21.3 ■ Negative Symptoms and Their Presentations

Negative Behavior Affective flattening Alogia Avolition Social anhedonia Anhedonia

Manifestation Lack of an emotional response in interactions Lack of or decline in speech Lack of or decline in motivation Social withdrawal Lack or decline in ability to experience pleasure

If the delusions are bizarre or if auditory hallucinations include one voice continually speaking or two voices speaking to each other, the additional criteria are not needed. Speech disorganization criteria are met only if it interferes with the woman’s ability to communicate with others. In addition, two of the following are also present:

■ Depression ■ Mania episode ■ Mixed episode

The woman must encounter the delusions or hallucinations for at least a period of 2 weeks without associated mood symptomology. In addition, the Mood Disorder symptomology must be present for both the active and residual time periods. Other physiological medical conditions, such as a seizure disorder, need to be excluded. The use of illegal substances, such as cocaine, amphetamines, phencyclidine (P), or steroid medications, should be excluded because they can also cause peculiar symptomology.

Pharmacological Treatment

Pharmacological interventions are typically the major mode of treatment. The only medication the U.S. Food and Drug istration (FDA) approved for the specific treatment of Schizoaffective Disorder is paliperidone (Invega). Secondgeneration antipsychotics, such as risperidone (Risperdal), are used to treat symptoms of psychosis. Lamotrigine (Lactimal) is sometimes used because it is an antidepressant with mood stabilization properties. Antidepressants are used to treat depressive symptoms. These may include selective serotonin reuptake inhibitors (SSRIs), such as sertraline hydrochloride (Zoloft) or fluoxetine (Prozac). Serotonin-norepinephrine reuptake inhibitors (SNRIs) and Wellbutrin are not suggested because they can lead to a mixed episode or induce psychosis. For women with Bipolar Disorder-type symptoms, mood stabilizers are typically istered. These may include the following:

■ Lithium (Eskalith, Lithobid) ■ Valproate (Depakote) ■ Carbamazepine (Tegretol)

Combining mood stabilization agents with neuroleptic agents generally has been more effective than monotherapy although they carry a risk of the development of extrapyramidal side effects or confusion in some women. Benzodiazepines should only be used for short-term intervention in manic women because longterm use can lead to dependence and addiction. Sleep agents can also be used for short-term intervention. The importance of long-term medication therapy is imperative.

Behavioral Therapies

Behavioral therapies generally focus on symptom management and identifying treatment strategies to reduce symptoms and treat the illness. Group therapies are often used to provide peer and reduce social isolation. Social skills training is effective for women who have difficulty with interactions with others. Although women with Schizoaffective Disorder have better posttreatment outcomes than Schizophrenia, the need for long-term care is frequently indicated. Women with Mood Disorders, such as depression or anxiety, have more favorable outcomes than women with Schizoaffective Disorder. Poorer prognosis occurs in women with the following (Brannon, 2012):

■ Poor pre-morbidity functioning ■ Rapid onset of symptoms without precipitating factors ■ Severe psychosis ■ Presence of negative symptoms ■ Family history of Schizophrenia ■ Young age at onset of symptoms ■ Persistent symptoms despite treatment intervention

BRIEF PSYCHOTIC DISORDER

A Brief Psychotic Disorder occurs when a psychosis develops and is less than 1 month in duration. The occurrence of symptoms can be as short as 1 day and has a sudden onset. There are three types of Brief Psychotic Disorders. The various types are listed in Table 21.4.

Table 21.4 ■ Types of Brief Psychotic Disorders

Type of Disorder Brief Psychotic Disorder with obvious stressor (brief reactive psychosis) Brief Psychotic Disorder without obvious stressor Brief Psychotic Disorder with postpartum onset

Description of Type of Brief Psychotic Disorde Occurs in response to a trauma or significant str Occurs without known cause or stressor Typically occurs within 4 weeks of childbirth

The diagnostic category is used more commonly in Scandinavia and Western Europe than in the United States although the actual incidence does not seem to vary between geographic regions (Memon, 2012). Brief Psychotic Disorder is 10 times more common in developing countries. Risk factors include low socioeconomic status, preexisting Personality Disorders, and immigrant populations (Memon, 2012). In developing countries, the disorder is twice as common in women as men (Memon, 2012). Risks of suicidal behaviors are more common in women with Brief Psychotic Disorder than those without a psychiatric disorder.

Etiology

The etiology of the disorder is unclear, and its occurrence is uncommon. It occurs more commonly in women than in men and the onset is typically in the 20s and 30s. Some women can experience a Brief Psychotic Disorder as a result of a traumatizing event whereas others have an episode that is unrelated to a stressor. When a stressor is the identified cause, it is perceived as completely overwhelming by the woman (Memon, 2012). Although rare, some women develop the disorder in the postpartum period. The illness is more common in women with a family history of Bipolar Disorder. Some researchers have suggested that poor coping skills after exposure to a significant stressor may trigger the event.

Signs and Symptoms

At least one of the following symptoms is present for 1 day to 1 month along with the presence of hallucinations and delusions, such as:

■ Disorganized thinking ■ Alterations in decision-making abilities ■ Disorientation ■ Memory lapses ■ Confusion ■ Changes in energy levels of sleep patterns ■ Incoherent speech

Other symptoms that may occur include bizarre dress, rapidly changing mood, impaired attention, catatonic behavior, screaming, muteness, and impaired memory of recent events.

Assessment and Screening

Assessment and screening is done via psychological interview. Diagnosis is based on a psychological evaluation that assesses the woman’s symptoms and the presence of at least one of the following: hallucinations, delusions, and other symptoms of the disorder. The symptoms last a short period of time. Differential diagnosis to rule out other Schizophrenia spectrum disorders is imperative for proper diagnosis. Urine and drug toxicology screens can rule out substanceinduced psychosis. There are no laboratory or other medical tests that can confirm diagnosis. Careful exclusion of other psychiatric conditions is warranted.

Pharmacological Treatment

Medication intervention is the cornerstone of therapy for women with Brief Psychotic Disorder. Traditional antipsychotics or atypical antipsychotics are used to control symptoms and treat the psychosis. Sleep agents or antianxiety medications are sometimes utilized to treat symptoms of anxiety and insomnia associated with psychosis. These medications should only be used short term because they have addictive qualities. The use of antipsychotics is brief, usually only during the symptomatic phase. Once psychosis resolves, they are no longer indicated. The use of intramuscular ziprasidone (Geodon) has been used with good results to treat acute agitation associated with the disorder (Memon, 2012). Agents commonly used to treat Brief Psychotic Disorder include the following:

■ Haloperidol (Haldol) ■ Thiothixene (Navane) ■ Risperidone (Risperdal) ■ Olanzapine (Zyprexa) ■ Quetiapine (Seroquel) ■ Paliperidone (Invega)

Behavioral Therapies

Psychotherapy is an effective tool to assist the woman in dealing with the stressors that initially caused the psychotic reaction if it was related to a specific stressor. A brief hospitalization is sometimes warranted to control symptoms and ensure the woman’s safety during the acute episode, especially if personal safety or the safety of others is in question. As with all treatments, the least restrictive care should be facilitated. Therapeutic interventions can also be used to aid the woman in dealing with her emotions concerning her illness. The disorder is usually short in duration and recurrence rates are low. Women who experience a Brief Psychotic Disorder typically return to premorbid functioning when symptoms resolve (Memon, 2012). Family therapy may be used to address issues and stressors and to help deal with self-esteem issues. Prognosis is favorable with 50% to 80% of women never developing another psychotic episode (Memon, 2012). Predictors of favorable outcomes include sudden, brief onset of symptoms, high premorbidity performance, and short period of symptoms.

SCHIZOPHRENIFORM DISORDER

Schizophreniform Disorder causes the same symptomology as Schizophrenia except its duration ranges from 1 to 6 months. If symptoms persist beyond a 6month period, the diagnosis of Schizophrenia is made. The shorter the episode, the better the prognosis, especially in the absence of blunted affect and if preillness social and work history is normal. The onset of Schizophreniform Disorder is later in women and peaks between the ages of 24 and 35 (Bhalla, 2009). There is typically a rapid onset of symptoms, unlike Schizophrenia, which may take years to develop. Approximately two-thirds of women suspected of having Schizophreniform Disorder will eventually be diagnosed with Schizophrenia (Bhalla, 2009). The other one-third are commonly diagnosed with affective disorders.

Etiology

The exact cause of Schizophreniform Disorder is unknown, but it carries vast similarities to Schizophrenia. Biological and genetic etiologies are suspected in many women diagnosed with the disorder.

Signs and Symptoms

The symptoms observed for Schizophreniform Disorder are the same as Schizophrenia and include hallucinations, delusions, negative symptoms, disorganized speech, unorganized behavior, and catatonic behaviors. Additional symptoms may include the following (Bhalla, 2009):

■ Blunted mood ■ Flat affect ■ Paranoia ■ Ideas of reference ■ Intact memory ■ Suicidal behaviors ■ Homicidal thoughts or behaviors ■ Decreased social functioning ■ Vocational impairment

Assessment and Screening

Diagnosis can be difficult because other disorders need to be excluded. A detailed history is imperative. Often family can provide details about the onset, severity, and characteristics of symptoms. A mental status exam is required. Careful documentation about the onset of symptoms, course of illness, premorbid functioning, stressors, physical health, use of medications and substances, family history, and previous episodes is gathered. Diagnosis is based on the presence of specific criteria that are present for more than 1 month but less than 6 months. The criteria that must be present include hallucinations, delusions, disorganized speech, grossly unorganized behavior, negative symptoms, or catatonic behavior. As with Schizophrenia, if bizarre delusions exist or if auditory hallucinations include a voice that exhibits running commentary or two voices talking with each other, the diagnosis is made. In addition, medical conditions and substances that could cause symptoms need to be excluded. If women are diagnosed with suspected Schizophreniform Disorder, the diagnosis is considered provisional until at least 6 months have elapsed. If the symptoms persist beyond 6 months, the woman is diagnosed with Schizophrenia.

Pharmacological Treatment

Pharmacological interventions are similar to the treatment of Schizophrenia. The atypical antipsychotics are the first line of therapy in modern practice. The most commonly used atypical antipsychotics include the following (Bhalla, 2009):

■ Risperidone (Risperdal) ■ Olanzapine (Zyprexa) ■ Quetiapine (Seroquel) ■ Ziprasidone (Geodon) ■ Aripiprazole (Abilify) ■ Paliperidone (Invega) ■ Iloperidone (Fanapt)

There is some concern that the atypical antipsychotics have side effects, such as weight gain and metabolic problems, and may not be clinically more effective than the first-generation antipsychotics, such as Haldol (Sikich, Frazier, McClellan, Findling, Vitiello et al., 2008). Antidepressants are also commonly used to treat depressive symptomology; however, the practitioner must be alert for worsening psychotic symptoms when antidepressants are used. Electroshock therapy has been utilized for severe cases of the disorder in which pharmacological intervention has not proven effective; however, its use is rare and is not a first line of treatment. The treatment is sometimes utilized when the symptoms of psychosis are severe and have been present for a lengthy period of

time or when affective symptoms are persistent and drug resistant (Kristensen, Bauer, Hageman, & Jørgensen, 2011).

Behavioral Therapy

Various modalities of behavioral therapy have been utilized to treat women with this disorder.

■ Psychotherapeutic interventions are aimed at developing effective coping skills, problem solving skills, and ive therapy. ■ Group psychotherapy is often effective, but care should be taken because clients can become fearful of the prolonged symptomology that is sometimes found in patients with Schizophrenia (Bhalla, 2009). ■ Family therapy can be effectively utilized to foster and provide educational information to family and persons. ■ Because women with Schizophreniform Disorder tend to function more effectively socially and may be able to maintain occupational endeavors, occupational and social s remain important cornerstones of therapeutic interventions. ■ Psycho-education can provide women and their families with critical information, such as reviewing the early symptoms of relapse and stressing the need to reduce stressors for the woman. ■ Use of effective and adequate coping skills are also important. Therapies that teach the woman to develop strong coping skills are needed for long-term success.

DELUSIONAL DISORDER

Delusional Disorder is a Psychotic Disorder characterized by non-bizarre delusions that occur without Mood Disorder symptomology or psychotic symptoms. The term “non-bizarre” indicates that the thoughts could represent things that could happen in real life. The disorder is considered to be on the spectrum of a Psychotic Disorder and overvalued ideas (Chopra, 2011). Women with Delusional Disorder do not have good insight into their pathological experiences. Even though women with Delusional Disorder experience significant delusions, the presence of other psychological symptoms is typically absent. The disorder itself is rare and occurs in 0.03% of all individuals. The mean age of onset is 40 with a wide age range of 18–90 years, and it occurs more commonly in women than in men.

Clinical Pearl

Overvalued ideas are commonly influenced by religion, culture, and an individual’s value system. Nurses s

Etiology

The etiological factors associated with Delusional Disorder include genetics, biochemical factors, and psychological factors. Women with Delusional Disorder are more likely to have a family history of Paranoid Personality Disorder and rarely have a family history of Schizophrenia (Chopra, 2011). Biochemical factors that have been isolated as a causative factor in Delusional Disorder include hypoperfusion of the temporal and frontal lobes, abnormalities of voluntary specific eye movements, hyperdopaminergic states, and a prevalence of polymorphism at the D2 receptor gene at amino acid 311 (Chopra, 2011). Psychological factors associated with Delusional Disorder include the making of probability decisions based on fewer data compared with normal controls, making decisions based on insufficient information, connecting negative events to external causations, and having difficulty interpreting others’ intentions, feelings, or motivations (Chopra, 2011). There is another theory that women who develop Delusional Disorder have fragile egos and subsequently utilize delusions as a protective mechanism, a defense mechanism related to poor selfesteem (Abdel-Hamid & Brüne, 2008).

Signs and Symptoms

The signs and symptoms include the presence of non-bizarre delusions. Women with Delusional Disorder may not exhibit other symptomology beyond delusions or they may appear confused and agitated and have perceptional disturbances, irritability, depression, aggressiveness, and self-reference (Chopra, 2011). They are typically well-dressed and groomed. Although speech, psychomotor activity, and eye can become impaired depending on the severity of delusions, they are often normal. Mood is consistent with the content of the delusion. If the delusion is something that would cause stress for the woman or depress the mood, depressive symptomology may be noted. The level of consciousness, memory, and cognitive functioning remains intact. Tactile and auditory hallucinations sometimes occur if they are related to the delusion itself. Lack of insight about the delusions and judgment impairment are common. Suicidal or homicidal ideation can also occur. There are distinct subtypes that are included in Table 21.5.

Assessment and Screening

Diagnosis is based on the presence of non-bizarre delusions without the presence of other psychiatric symptomology occurring for a period of at least 1 month. Criteria for Schizophrenia are not met although the presence of tactile and auditory hallucinations related to the delusional concepts may be present. The woman’s basic functioning is typically normal without noted impairment. If mood symptoms are present, they are brief and less than the delusional time period. Like other Psychotic Disorders, the use of substances or medications as a trigger or the presence of medical conditions need to be ruled out.

Pharmacological Treatment

The use of antipsychotics is commonly the main pharmacological approach to treatment. In one of the largest sample-size studies of women treated with pharmacological interventions, a complete resolution rate of 50% with an additional 90% having some symptom improvement was noted when pharmacological therapy was initiated using antipsychotic and antidepressant therapies along with cognitive behavioral therapies (Proctor, Mitford, & Paxton, 2004). Both typical and atypical antipsychotics were used and modifications of therapeutic agents were common. The most commonly prescribed atypical antipsychotics for Delusional Disorder are olanzapine and risperidone (Freudenmann & Lepping, 2008). Women with somatic delusions had the highest resolution rates, and women with persecutory delusions had the poorest outcomes (Proctor et al., 2004). Antidepressant therapy was most effective in women with somatic delusions (Freudenmann & Lepping, 2008).

Behavioral Therapies

Many women with Delusional Disorder do not actively seek treatment for the disorder but are frequently seen by general practitioners who recognize the presence of symptoms, or they are referred to counseling by the police or court officials for illegal or inappropriate behaviors that occur as a result of their illness. Treatment and goals should focus on improving functioning within the community. The treatment of other comorbidities should be initiated once therapy is initiated. The most commonly used psychological therapies include the following:

■ ive therapies ■ Psycho-education ■ Cognitive behavioral therapies ■ Social skills training ■ Insight-oriented therapy

MAJOR DEPRESSIVE DISORDER WITH PSYCHOTIC FEATURES

The incidence of Major Depressive Disorder (MDD) with psychotic features, also known as psychotic depression, is estimated to be 0.35% (Perälä et al., 2007). The disorder occurs in cases of severe depression when psychosis subsequently occurs. The disorder is more common in women and typically occurs between the ages of 20 and 40 years. The average number of psychotic episodes during the lifetime averages 4–9. Most women experience a marked period of time when psychosis occurs and ends. Most women experience acute episodes for less than 24 months, and although chronic illness can occur, the incidence is rare. Most women experience recovery within a year. Suicidal behaviors are significantly higher in women with depression with a psychotic component. The most significant predictor of suicidal behaviors is the amount of time spent in a severe depressive state (Holma, Melartin, Haukka, Holma, Petteri, Sokero et al., 2010). Women with depression with psychotic features tend to function well between psychotic episodes although their prognosis is worse than women who have MDD without psychotic features.

Etiology

There seems to be some genetic component in development of the disease. Women who develop MDD with psychosis typically have a family history of depression or psychosis. There is some evidence that hyperactivity within the hypothalamic-pituitary-adrenal (HPA) axis is a causative factor in the disease. Women who experience the disorder also tend to have elevated 24-hour free cortisol, higher dexamethasone non-suppression, and high post-dexamethasone cortisol levels (Schatzberg, 2003).

Signs and Symptoms

Women with MDD with psychosis meet the criteria for depression and develop hallucinations and delusions as well. The hallucinations experienced by women with MDD with psychotic features tend to be auditory, somatic, or visual. The delusions tend to be guilty, paranoid, or somatic in nature (Schatzberg, 2003). Women with the disorder often develop suicidal thoughts that typically require intensive inpatient therapeutic interventions. Additional symptoms may include the following:

■ Agitation ■ Anxiety ■ Hypersomnia ■ Insomnia ■ Intellectual impairment ■ Constipation ■ Weight gain ■ Social isolation ■ Physical immobility ■ Hypochondria ■ Psychomotor agitation ■ Response inhibition

■ Lack of concentration ■ Memory impairment

Assessment and Screening

Diagnosis is typically made after a psychological interview that includes assessing for the presence of symptoms of both depression and psychosis. The criteria for MDD (see Chapter 16 for diagnostic criteria) and the presence of hallucinations and delusions also need to be present. Severe social and occupational dysfunction also occurs. Women with this diagnosis may also have increased and intense daydreaming. The practitioner should specify if psychotic symptoms are mood-congruent or mood-incongruent (Sadock, 2007). Mood-congruent psychotic features are consistent with depressive themes, such as death, guilt, disease, deserved punishment, and personal inadequacy. In mood-incongruent psychotic features, symptoms are not consistent with depressive themes. Instead, thought insertion, thought broadcasting, and delusions of control may occur. As with other Psychotic Disorders, causations such as substance abuse or other medical conditions need to be excluded.

Pharmacological Treatment

The use of antipsychotic and antidepressant therapy is used in the treatment of women with depression with psychotic features. Monotherapy that includes SSRIs or atypical antipsychotics have been effective in the treatment of the disorder; however, success rates are significantly higher when combination therapy using both type of agents are used. Monotherapy with tricyclic antidepressants, with the exception of amoxapine, is generally ineffective (Schatzberg, 2003). Amoxapine has both antidepressant and antipsychotic properties and has been shown to be effective in treating the disorder when delusions are the predominant psychotic symptomology. The atypical antipsychotics are typically used for a short duration of treatment. These may include the following:

■ Risperidone (Risperdal) ■ Olanzapine (Zyprexa) ■ Quetiapine (Seroquel) ■ Ziprasidone (Geodon)

Success rates in treatment can be between 80% and 90% resolution of symptomology with concurrent treatment using both medications (Belanoff, Flores, Kalezhan, Sund, & Schatzberg, 2001). SSRIs are the most common antidepressants used although SNRIs have also been used with positive outcomes. Multiple therapies have been used including aripiprazole (Abilify) combined with escitalopram (Lexapro) in the acute treatment of MDD with psychotic features with good success (Matthews, Siefert, Dording, Denninger, Park et al., 2009). Mifepristone has also been used in the past with positive outcomes and is thought to fix the disturbance that occurs in the HPA axis

(Belanoff et al., 2001). Electroconvulsive therapy has also been used with good clinical outcomes although this treatment is usually reserved for women who do not respond well to combination therapy. Despite the type of pharmacological therapy initiated, most women with the disorder require hospitalization to facilitate effective treatment.

Behavioral Therapy

Multiple behavioral interventions have been utilized as adjunct therapy for psychosis that occurs with MDD. Therapies include the following:

■ Cognitive behavioral therapy ■ ive therapy ■ Group therapy ■ Psycho-education ■ Family therapy

SUBSTANCE ABUSE INDUCED PSYCHOSIS (SAIP)

Psychotic symptoms that occur as a result of the ingestion of substances are the determining factor in identifying the woman with SAIP. While SAIP is more common in men because they have higher rates of substance abuse, it does occur in women, especially in those who have a history of substance abuse. Many women with SAIP do not receive treatment because symptoms often resolve when the drug or substance clears their system. Others avoid seeking medical treatment when the SAIP has been caused from illegal drug use for fear of prosecution or legal involvement from law enforcement.

Etiology

The causative factor is the ingestion of substances that produce symptoms. Causative agents may include alcohol, amphetamines (and related substances), cannabis (marijuana), cocaine, hallucinogens, inhalants, opioids, P and related substances, sedatives, hypnotics, anxiolytics, and other or unknown substances or toxins (Encyclopedia of Mental Disorders, 2011). “Some medications that may induce psychotic symptoms include anesthetics and analgesics, anticholinergic agents, anticonvulsants, antihistamines, antihypertensive and cardiovascular medications, antimicrobial medications, antiparkinsonian medications, chemotherapeutic agents, corticosteroids, gastrointestinal medications, muscle relaxants, nonsteroidal antiinflammatory medications, other over-the-counter medications, antidepressant medications, and disulfiram. Toxins that may induce psychotic symptoms include anticholinesterase, organophosphate insecticides, nerve gases, carbon monoxide, carbon dioxide, and volatile substances (such as fuel or paint)” (Encyclopedia of Mental Disorders, 2011). There is also an increased incidence in women with a family history of mental illness or Attention-Deficient/Hyperactivity Disorder (Salo, Nordahl, Leamon, Natsuaki, Moore, Waters, & Carter, 2008). Alcohol-induced psychotic illness occurs in 0.5% of the population and is more common in men. Risk factors include a history of the disorder in a family member, father’s mental health status, low socioeconomic status, and multiple hospitalizations with psychiatric symptomology (Perälä, Kuoppasalmi, Pirkola, Härkänen, Saarni et al., 2010). Alcohol-induced Psychotic Disorder typically occurs with chronic alcoholism. Individuals with this type of psychotic-induced disorder had a mortality rate of 38% within 8 years of the episode (Perälä et al., 2010). Most women who receive services for this disorder markedly improve within two years with intervention, including discontinuation of substances, antidepressant therapy, and addiction services (Drake, Caton, Xie, Gorroochurn, Samet et al., 2011).

Signs and Symptoms

The presence of hallucinations or delusions can occur with immediate use or may take several days or weeks of chronic use to develop. The symptoms can occur with either intoxication or withdrawal from the substance. The types of hallucinations or delusions experienced are related to the type of substance ingested. For example, women with alcohol-induced SAIP tend to have auditory, visual, and tactile hallucinations, whereas those who ingest cocaine are more likely to experience tactile hallucinations and persecutory delusions (Encyclopedia of Mental Disorders, 2011).

Assessment and Screening

The diagnosis is based on a history of using substances and experiencing prominent hallucinations or delusions during the time of use or within 1 month of use. Other medical conditions, psychotic disorders, and psychiatric disorders need to be excluded.

Pharmacological Treatment

The psychotic symptoms are typically treated with antipsychotic medications. Hospitalization is typically required. In general, symptoms typically resolve when the substance is discontinued or within 1 month of discontinuation. Additional interventions include toxicology screening, detoxification, and treatment of other comorbidities if present. Individuals with SAIP often recover to a higher functioning state within 2 years of a psychotic episode even with minimal pharmacological or behavioral therapies (Drake et al., 2011).

Behavioral Therapies

Behavioral therapies are aimed at treating the woman for a substance abuse disorder. Full discussion of a substance abuse disorder is included in Chapter 24. The following therapies are appropriate (Osher & Kofeld, 1989):

■ Case management ■ Group therapy ■ Psychotherapy ■ Family therapy ■ Self-help groups ■ Addiction-focused therapies

SHARED PSYCHOTIC DISORDER

A Shared Psychotic Disorder occurs when two or more people with close emotional ties share the delusions of the other individual. The disorder is slightly more common in women than in men. The disorder is also known as folie a deux (folly of two), shared imposed psychosis, infectious insanity, shared paranoid disorder, and symbiotic psychosis (Cervini, Newman, & Dorian, 2003). It can affect more than two people, even entire families, although the disorder is quite rare. Individuals with the disorder typically share close ties that are both cultural and geographic in nature. Most affected individuals share the same household (Sharon, 2011). In the disorder, delusions are typically derived from an individual with a Psychotic Disorder. A secondary person then begins experiencing the delusions although they usually disappear in the secondary source, typically when he or she is separated from the primary individual with psychosis. The disorder is common in married couples, sisters, mother-child, and twins.

Etiology

The etiology of the disorder is unknown; however, it is more common in closely tied individuals who are socially isolated from others and who have a great number of stressors or who are under a great deal of stress. Although it is common among family , it is unknown if there are genetic etiologies because of the rarity of the disorder.

Signs and Symptoms

Commonly, women with Shared Psychotic Disorder present sharing a delusion of an individual with a Psychotic Disorder. Besides sharing the delusion of another individual, they may experience anxiety, agitation, and insomnia. Women with a Shared Psychotic Disorder typically lack insight. There are four identified subtypes. Table 21.6 lists the subtypes.

Table 21.6 ■ Subtypes of Shared Psychotic Disorder

Folie Imposée Delusions of an individual with psychosis are transferred to a mentally sound individual.

Folie Simultanée Identical psychosis occurs in tw

Source: Adapted from Sharon (2011).

Assessment and Screening

The diagnosis is based on a careful and complete psychological examination that assesses for associated symptomology. Interaction between two affected individuals is necessary. An individual (primary source) with an established delusion is present and another individual (secondary source) develops the delusions of the same or similar content. The secondary source does not have a Psychotic Disorder or other disorder that is causing delusions. Because of the rarity of the disorder and the fact that affected individuals rarely seek treatment, it is often undetected.

Pharmacological Treatment

Pharmacological treatment is aimed at treating the delusions. Short-term use of antipsychotics is typically the cornerstone of treatment. Benzodiazepines or sleep agents may also be used initially to control symptoms and allow the woman to adequately rest and sleep. Initially it was thought that separation alone from the primary source would treat symptoms; however, current research reflects that antipsychotic therapy is also needed (Sharon, 2011). The treatment for shared psychotic disorders includes atypical newer neuroleptics and the newer-generation anticonvulsants. Aripiprazole (Abilify) and quetiapine (Seroquel) are often used effectively (Sharon, 2011).

Behavioral Therapies

When women are identified with this disorder, they are typically separated from the primary source or the individual with the Psychotic Disorder. Behavioral therapies are commonly used to help the woman deal with disruptions in relationships, occupational and social stressors, and separation from the affected individual. Psychotherapy can be utilized to assist the woman in understanding the delusions are not real and to assist in correcting underlying thinking. Family therapy is used to improve relationships within the family or relationship. Exposure to external events and reduction in social isolation between the two individuals experiencing shared delusions is important. Multiple-cont therapy is often used in modern medicine because it addresses symptoms related to dependency, guilt, anger, and distorted communication patterns (Sharon, 2011).

SUMMARY

Pyschotic disorders represent disturbances in thought and thinking. Although schizophrenia is the most commonly occurring psychotic disorders, other thought disorders do occur in women although they are uncommon. Substance abuse psychosis has increased in frequency in women as the number of women with substance abuse issues continues to grow. Women with psychotic disorders generally need intensive treatment and pharmacological management to adequately treat their illnesses. Clinicians should be aware of the various psychotic disorders that can affect women.

Case Study

Helen Zimmerman is a 29-year-old woman who has a history of severe worsening depression for the last 14 months after the death of her premature infant, Joseph. Helen was diagnosed with MDD and began intensive outpatient therapy with pharmacological intervention. Despite medication intervention, her symptoms have not improved and actually worsened with the anniversary of Joseph’s death. Two weeks ago, Helen began to experience delusions that other neonates would suffer a similar fate and began calling area hospitals warning them that premature infants were likely to die like her son. In addition, she noted hearing voices commanding her to warn all new mothers of the risk associated with preterm birth. The local authorities were ed by an area hospital. Helen was mandated to an area psychiatric hospital for court-ordered 24-hour evaluation and then voluntarily began in-hospital treatment of her psychotic symptoms. What is the medical diagnosis? What other treatment options are available to Helen?

Questions to Consider

How can nurses determine the different types of hallucinations being experienced by a symptomatic woman? Why does the diagnosis of a Psychotic Disorder have poorer outcomes than other mental illnesses? What role does family therapy have in treating women with various psychotic disorders?

REFERENCES

Abdel-Hamid, M., & Brüne, M. (2008). Neuropsychological aspects of delusional disorder. Current Psychiatry Report, 10(3), 229–234. Belanoff, J. K., Flores, B. H., Kalezhan, M., Sund, B., & Schatzberg, A. F. (2001). Rapid reversal of psychotic depression using mifepristone. Journal of Clinical Psychopharmacology, 21(5), 516–21. DOI: 10.1097/00004714200110000-00009 Bhalla, R. N. (2009). Schizophreniform Disorder. E-medicine. Retrieved from http://emedicine.medscape.com/article/292885-overview Bogren, M., Mattisson, C., Isberg, P. E., Munk-Jørgensen, P., & Nettelbladt, P. (2010). Incidence of psychotic disorders in the 50 year follow up of the Lundby population. Australian & New Zealand Journal of Psychiatry, 44(1), 31–39. Brannon, G. E. (2012). Schizoaffective disorder. emedicine. Retrieved from http://emedicine.medscape.com/article/294763-overview Brown, A. S., Schaefer, C. A., & Wyatt R. J. (2002). Paternal age and risk of schizophrenia in adult offspring. The American Journal of Psychiatry, 159(9), 1528–1533. DOI: 10.1176/appi.ajp.159.9.1528 Cervini, P., Newman, D., & Dorian P. (2003). Folie a deux: An old diagnosis with a new technology. Canadian Journal of Cardiology, 19(13), 1539–1540. Chang, C.-K., Hayes, R. D., Perera, G., Broadbent, M. T. M., Fernandes, A. C., et al. (2011). Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case in London. PLoS ONE, 6(5), e19590. DOI: 10.1371/journal.pone.0019590 Chopra, S. (2011). Delusional disorder. Medscape. Retrieved from http://emedicine.medscape.com/article/292991-overview#a11

Drake, R. E., Caton, C. L. N., Xie, H., Hsu, H., Gorroochurn, P., Samet, S., et al. (2011). A prospective 2-year study of emergency department patients with earlyphase primary psychosis or substance-induced psychosis. American Journal of Psychiatry, 168, 742–748. DOI: 10.1176/appi.ajp.2011.10071051 Encyclopedia of Mental Disorders. (2011). Substance abuse induced psychosis. Retrieved from http://www.minddisorders.com/Py-Z/Substance-inducedpsychotic-disorder.html Freudenmann, R. W., & Lepping, P. (2008). Second-generation antipsychotics in primary and secondary delusional parasitosis: Outcome and efficacy. Journal of Clinical Psychopharmacology, 28(5), 500–508. Holma, K. M., Melartin, T. K., Haukka, J., Holma, I. A. K., Petteri, T., Sokero, J., et al. (2010). Incidence and predictors of suicide attempts in DSM–IV major depressive disorder: A five-year prospective study. American Journal of Psychiatry, 167, 801–808. DOI: 10.1176/appi.ajp.2010.09050627 Kirkbride, J. B., Fearon, P., Morgan, C., Dazzan, P., Morgan, K., Tarrant, J., Lloyd, T., Holloway, J., Hutchinson, G., Leff, J. P., Mallett, R. M., Harrison, G. L., Murray, R. M., & Jones, P. B. (2006). Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes. Archives of General Psychiatry, 63, 250–258. Kirkbride, J. B., Croudace, T., Brewin, J., Donoghue, K., Mason, P., et al. (2009). Is the incidence of psychotic disorder in decline? Epidemiological evidence from two decades of research. International Journal of Epidemiology, 38(5), 1255–1264. DOI: 10.1093/ije/dyn168 Kristensen, D., Bauer, J., Hageman, I., & Jørgensen, M. (2011). Electroconvulsive therapy for treating schizophrenia: A chart review of patients from two catchment areas. European Archives of Psychiatry and Clinical Neuroscience, 261(6), 425–432. DOI: 10.1007/s00406-010-0173-3 Matthews, J. D., Siefert, C., Dording, C., Denninger, J. W., Park, L., et al. (2009). An open study of aripiprazole and escitalopram for psychotic major depressive disorder. Journal of Clinical Psychopharmacology, 29(1), 73–76. DOI: 10.1097/J.0b013e318193dfb4 Memon, M. A. (2012). Brief psychotic disorder. emedicine. Retrieved from

http://emedicine.medscape.com/article/294416-overview Morgan, V. A., Castle, D. J., & Jablensky, A. V. (2008). ‘Do women express and experience psychosis differently from men? Epidemiological evidence from the Australian National Study of Low Prevalence (psychotic) Disorders’. Australian and New Zealand Journal of Psychiatry, 42, 74-82. Osher, F. C., & Kofeld, L. I. (1989). Treatment of patients with psychiatric and psychoactive substance abuse disorders. Hospital Community Psychiatry, 40, 1025–1030. Perälä, J., Suvisaari, J., Saarni, S., Kuoppasalmi, K., Isometsä, E., et al. (2007). Lifetime Prevalence of psychotic and bipolar I disorders in a general population. Archives of General Psychiatry, 64(1), 19–28. Perälä, J., Kuoppasalmi, K., Pirkola, S., Härkänen, T., Saarni, S., et al. (2010). Alcohol-induced psychotic disorder and delirium in the general population. The British Journal of Psychiatry, 197, 200–206. DOI: 10.1192/bjp.bp.109.070797 Proctor, S. E., Mitford, E., & Paxton, R. (2004). First episode psychosis: A novel methodology reveals higher than expected incidence: A reality-based population profile in Northumberland, UK. Journal of Evaluative Clinical Practice, 10(4), 539–547. Sadock, B. J. (2007). Delusional and shared psychotic disorder. In B. J. Sadock & V. A. Sadock, Kaplan & Sadock’s Synopsis of Psychiatry, 9th ed., (511–520). Philadelphia: Lippincott, Williams, & Wilkins. Salo, R., Nordahl, T. E., Leamon, M. H., Natsuaki, Y., Moore, C. D., Waters, C., & Carter, C. S. (2008). Preliminary evidence of behavioral predictors of recurrent drug-induced psychosis in methamphetamine abuse. Psychiatry Research, 157(1–3), 273–277. Schatzberg, A. (2003). New approaches to managing psychotic depression. Journal of Clinical Psychiatry, 64(suppl. 1), 19–23. Sharon, I. (2011). Shared psychotic disorder. Medscape. Retrieved from http://emedicine.medscape.com/article/293107-overview#aw2aab6b2 Sikich, L., Frazier, J. A., McClellan, J., Findling, R. L., Vitiello, B., et al. (2008).

Double-blind comparison of first- and second-generation antipsychotics in earlyonset schizophrenia and schizoaffective disorder: Findings from the treatment of early-onset schizophrenia spectrum disorders (TEOSS) study. American Journal of Psychiatry, 165, 1420–1431. DOI: 10.1176/appi.ajp.2008.08050756) Sundquist, K., Frank, G., & Sundquist, J. (2004). Urbanisation and incidence of psychosis and depression: Follow-up study of 4.4 million women and men in Sweden. The British Journal of Psychiatry, 184, 293–298. DOI: 10.1192/bjp.184.4.293 Townsend, M. C. (2011). Essentials in psychiatric mental health nursing: Concepts of care in evidence-based practice. Philadelphia: F.A. Davis Company. U.S. Public Health Service. (2009). Mental health: A report of the surgeon general. Chapter 4: Schizophrenia (1–19). Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/toc.html#chapter4

22

Sexual Dysfunction

Sexual dysfunction is a common disorder found in women that can cause distress and self-esteem issues and can impair relationships. Sexual dysfunction or sexual malfunction occurs when a couple has difficulty in any of the stages of normal sexual activity. Sexual dysfunction disorders are generally classified as sexual and gender-identity disorders. Sexual dysfunction typically worsens with age and is progressive. It affects 20% to 50% of women at some time during their lives ( Basson, Berman, Burnett, Derogatis, Ferguson et al., 2000 ). Other sexual disorders include Paraphilias (sexual deviance disorders) and Gender Identity Disorder, which was discussed in Chapter 8. Paraphilia is rarer in women than in men. The different classifications of Paraphilias that occur in women include Pedophilia, Exhibitionism, Fetishism, Voyeurism, Sexual Masochism, Sexual Sadism, and Frottceurism. Definitions of each of the disorders are listed in Table 22.1. For additional information on Paraphilias, the reader is advised to consult (Aggrawal, 2009).

Table 22.1 ■ Different Types of Paraphilias

Pedophilia Exhibitionism Fetishism Voyeurism Sexual Masochism Sexual Sadism Frotteurism

A mental disorder in which a person has intense, sexually arousing fantasies, urges, or behaviors invol A mental disorder characterized by a compulsion to display one’s genitals to an unsuspecting stranger. A mental disorder characterized by sexual arousal received from a physical object or from a specific s A psychosexual disorder in which a person derives sexual pleasure and gratification from viewing gen A disorder characterized by sexual arousal that occurs as a result of feeling real, not imagined, pain, su A disorder that occurs when the woman achieves sexual arousal by giving physical or emotional pain A disorder characterized by rubbing, usually one’s pelvis, against a non-consenting person for sexual g

The lifetime prevalence of sexual dysfunction in women varies throughout the life span (Frank, Mistrella, & Will, 2008). While the presence of a single sexual disorder can occur, it is more common to develop multiple sexual disorders. For example, a woman with a sexual desire disorder may also have an orgasm disorder (Graham, 2009). Lesbian women can also have sexual dysfunction, but they appear to have a lower incidence than their heterosexual counterparts (Tartigalio & Riley, 2011). The sexual disorders category of the DSM-IV-TR is one of the most debated when it comes to proposed changes to the DSM-V. There is huge debate among practitioners and researchers to update the categories, change criteria, and expand diagnosis (Graham, 2009). Currently, there are four types of sexual dysfunction disorder classifications:

■ Sexual desire disorders ■ Arousal disorders ■ Orgasm disorders ■ Pain disorders

SEXUAL DESIRE DISORDERS

The category of sexual desire disorders includes disorders that occur when there is a lack of sexual desire or a reduction in libido. Women with sexual desire issues typically have an absence of sexual activity, lack of interest in sexual activity, and lack of sexual fantasy. The disorder can be either lack of interest in any sexual activity or lack of interest in a specific partner. Studies have shown vast discrepancies in the prevalence with ranges of 10% to 46% (Frank et al., 2008). Possible etiological factors in women include the following:

■ Low levels of estrogen or testosterone ■ Fatigue (especially related to child-rearing duties and occupational demands) ■ Pregnancy ■ Aging ■ Certain medications (such as SSRIs) ■ Depression ■ Anxiety

This disorder is common and occurs in more than one in four premenopausal women and one in two postmenopausal women (West, D’Aloisio, Agans, Kalsbeek, Borisov, & Thorp, 2008). Disorders specific to decreased desire diagnosis include Hypoactive Sexual Desire Disorder (HSDD) and sexual aversion. HSDD occurs in one-third of all women at some time during their lives. It is more common in the postmenopausal period. The highest incidence is in

younger women who undergo surgical menopause (West et al., 2008). Primary HSDD occurs when a woman has a lack of interest in sexual activity throughout her life span although this is uncommon and rare. Secondary HSDD occurs when a woman has a normal period of sexual desire, and then her desire decreases. Sexual aversion is a rare disorder that affects more women than men; the woman has a complete aversion to genital with a sexual partner that results in distress and interpersonal conflict. The absence of an Axis I disorder is necessary for the diagnosis to be given (Brotto, 2009). Suggested etiologies include relationship conflict and sexual abuse in the past. Common symptoms include disgust, anxiety, and fear. There are subtypes of the disorder. Women can have a lifelong type or one that is acquired. It can be generalized or situational and can be a result of psychological factors or combined etiologies (Brotto, 2009).

SEXUAL AROUSAL DISORDERS

Sexual arousal disorders, once known as frigidity, occur when a woman fails to become aroused during sexual activity or displays an inability to maintain arousal or an inadequate lubrication-swelling response that is needed for sexual activity. The incidence of Female Sexual Arousal Disorder (FSAD) varies in studies but is said to be between 6% and 21% (Frank et al., 2008). Other studies that have identified lubrication issues report occurrence of lubrication difficulties to be as high as 31% (Graham, 2009). Diagnosis is made when there is distress that also occurs as a result of these sexual issues, and there is not another etiological factor such as another comorbid psychiatric condition, substanceinduced etiology, or medical physiological cause. Commonly, there are physiological etiologies that include lack of lubrication or a reduction in blood flow. Psychological factors, such as conflict between partners, can also play a role in the disorder. Other possible etiological factors include the following:

■ Physiological disease (hormonal or vascular disease) ■ Pharmacological therapies ■ Psychological distress or illness ■ Relationship issues

Lack of estrogen is often a cause of reduced lubrication and vaginal atrophy. Past sexual abuse, sexual trauma, and negativity about sexuality during upbringing can also contribute to the disorder (Graham, 2009). Treatment modalities may include psychoeducation or the use of the Eros Clitoral Therapy Device, the only FDA-approved therapeutic intervention, which increases vascularity via stimulation to the clitoris and increases arousal (Frank et al., 2008). FSAD can be lifelong or acquired. Further subcategories include a generalized or situational

type that can be a result of psychological factors or combined factors. Most researchers agree that FSAD is rarely the primary disorder, and comorbidities with other sexual disorders are common (Graham, 2009).

ORGASM DISORDERS

Orgasm disorders occur when there is an absence or marked delay in female orgasm despite a normal excitement phase of activity. The etiological factors Female Orgasmic Disorder can be physical, psychological, or pharmacological in nature. SSRI antidepressants can delay or inhibit orgasm. The incidence ranges from 4% in the general population up to 41% in specific care settings (Frank et al., 2008). Treatment options include directed masturbation, cognitive behavioral therapy, and sensate focus. Sensate focus is a sexual therapy technique that has the couple start with nongenital touching and progress to genital touching (Frank et al., 2008).

SEXUAL PAIN DISORDERS

Sexual pain disorders that occur during sexual activity are almost exclusively encountered in women. Dyspareunia or painful intercourse and vaginismus, involuntary spasm of the muscles of the vaginal wall, are the most common. Vulvar vestibulitis can also be a source of pain. Etiological factors can include the following:

■ Infection ■ Psychological disorders ■ Relationship issues ■ Endometriosis ■ Vaginal atrophy caused by hormonal imbalances or perimenopause ■ Menopause ■ Lactation

Pain disorders are often associated with anxiety disorders in women. Physiotherapy is often used with pain disorders to treat the etiological and causative factors. Physiological therapies may include “hands-on techniques, bio, pelvic floor electrical stimulation, perineal ultrasonography, use of vaginal dilators” (Frank et al., 2008, p. 641). Vulvar vestibulitis is commonly treated with antidepressants, anticonvulsants, or sometimes with topical agents (Frank et al., 2008). As the DSM-V is currently being developed, some experts in the field of sexual health have advocated for the inclusion of an additional sexual pain

classification known as noncoital sexual pain disorder, which occurs when persistent or recurrent genital pain occurs with noncoital sexual stimulation (Basson et al., 2000).

ETIOLOGY

Sexual disorders can occur as a result of multiple and complex etiologies:

■ In women, physiological and hormonal changes associated with premenstrual syndrome, pregnancy, postpartum, and menopause can cause sexual changes and dysfunctions. ■ Relationship issues, lack of trust, guilt, marital distress, poor communication, and the presence of psychological disorders (depression, anxiety) can be causative factors. ■ Sexual abuse and trauma and severe sexual fears. ■ Stringent religious beliefs that sex is “bad,” viewing sex as a chore, negative perceptions of sex reinforced in childhood and adolescence, and other cultural factors can also play a contributing role. ■ Certain medications can also cause biological changes that interfere with normal sexual activity. These can include SSRIs, antipsychotics, tricyclic antidepressants, nicotine, stimulants, hormones, anticholinergics, antihypertensives, alcohol, antihistamines, amphetamines, and opioids (Phillips, 2000). ■ Physical injury and specific medical conditions, such as spinal cord injuries, cerebral palsy, multiple sclerosis, back injuries, arthritis, urinary incontinence, and spina bifida, can also impact sexual functioning. Liver and kidney failure, along with endocrine, vascular, and hormonal deficiencies, can impact sexual functioning. ■ Psychological factors may include immediate stressors, such as anxiety, relationship issues, and communication issues. Long-term causes may include

fear of intimacy, prior learning patterns, and intrapsychic conflict. ■ Gynecological surgeries, such as hysterectomies or for breast or ovarian cancer, may impact a woman’s view of her femininity (Phillips, 2000).

SIGNS AND SYMPTOMS

Specific symptoms are based on the type of disorder present. Sexual desire disorders involve a lack of sexual desire or an aversion to sexual activity. Some women may classify themselves as having a low sex drive. The symptoms associated with sexual arousal disorders include an inability to become physiologically aroused during sexual activity despite the desire to engage in sexual activity. Orgasm disorders are marked by the inability to experience an orgasm despite engagement in sexual . Pain disorders occur when there is pain associated with sexual or sexual intercourse.

Clinical Pearl

Cultural factors can dramatically impact the symptoms that women will report and if they will feel comfor

ASSESSMENT AND SCREENING

A complete sexual history is warranted. Many women feel uncomfortable talking about sexuality issues with their care provider. The need for an open therapeutic relationship is imperative. Many women feel more comfortable confiding in a nurse, a nurse practitioner, or other female care provider. The nurse may need to act as an advocate for the woman. Referral to a specialist who treats women with sexual dysfunction may be warranted. Most providers will perform a pelvic exam to rule out physiological etiologies. Physiological etiologies related to pelvic abnormalities are found in Exhibit 22.1. Hormonal studies can indicate if a hormonal imbalance may be responsible for the symptoms. If an infectious process is suspected, cervical cultures can be obtained (Davidson, London, & Ladewig, 2012). A careful review of a patient’s medical conditions and personal medical history can determine if other medical causes may be present. If no physiological abnormalities are identified on exam, the possibility of other etiologies needs to be explored through a psychological interview, including assessment for past abuse or sexual assault and the possibilities of relationship issues between the couple.

Exhibit 22.1

Physiological Etiologies Found on Pelvic Exam That Can Lead to Sexual Dysfunction

Vaginismus Atrophy

Vulva disorders Clitoral adhesions Herpes simplex virus (HSV), human papillomavirus (HPV) Bacterial vaginosis, vaginitis Sexually transmitted infections Vulvar vestibulitis Bartholin gland cyst Episiotomy scarring, laceration scarring from vaginal birth Cystocele, rectocele, uterine prolapse Urethritis, urinary tract infection, cystitis Peritonitis, pelvic infection Fibroids, endometriosis, ovarian cysts or tumors, follicular cysts

Source: Adapted from Davidson et al. (2012); Phillips (2000).

PHARMACOLOGIC TREATMENT

■ The most commonly used form of treatment for women with HSDD is testosterone therapy, which is thought to heighten sexual desire in women with declining or low testosterone levels because these levels in women decline with advancing age. This therapy is considered controversial because it carries unwanted side effects, such as aggression, facial hair growth, deepening of the voice, weight gain, acne, and loss of head hair (Carroll, 2007). ■ Estrogen therapy can be an effective treatment for women with low estrogen levels related to perimenopause or menopause. Estrogen can help decrease the effects of vaginal atrophy, increase blood flow to the pelvis, improve vaginal tone and elasticity, and enhance lubrication. ■ Arousal disorders can be treated with clitoral stimulation devices to increase blood flow to the genital area. The Eros Clitoral Therapy Device, which is the only FDA-approved therapeutic intervention, is available to women by prescription for arousal disorders. ■ Pain disorders with a physiological dysfunction in place, such as endometriosis, may opt for surgical intervention to decrease painful symptoms. ■ Smoking can be an etiology factor because it can restrict blood flow. Smoking cessation therapies such as Chantix and Zyban can prove beneficial. ■ Because of the lack of pharmacological therapies available, some women may try natural remedies for female sexual disorders. The most commonly used include DHEA, Ginkgo biloba, L-arginine, and damiana. Yohimbe is also sometimes used; however, because it has been found to have dangerous and severe side effects, it should always be discouraged (Wong, 2011). One largescale study examined the use of Angelica sinensis, Cimicifuga racemosa, Ferula hermonis, Ginkgo biloba, Humulus lupulus, Lepidium meyenii, Tribulus terrestris, Trifolium pratense, and Vitex agnus-castus and found no significant differences in effectively treating female sexual disorders (Mazaro-Costa,

Andersen, Hachul, & Tufik, 2010).

Clinical Pearl

Women may ask nurses about their use of Viagra. Although there have been some clinical trials in which V

BEHAVIORAL THERAPIES

Behavioral therapies that have been used in treating sexual disorders include sex therapy, marital therapy, cognitive-behavioral therapy, and psychological counseling to explore past issues and sexual abuse or sexual assault. Mindfulness therapy has been used to increase a woman’s awareness and promote living in the present. Group therapy has been used with positive results although some women may feel uncomfortable discussing such personal issues within a group environment. Behavioral sex therapists commonly use techniques developed by Masters and Johnson and sensate focus exercises. Common specific techniques are included in Exhibit 22.2.

Exhibit 22.2

Common Behavioral Interventions for Women With Sexual Dysfunction

Open, frank, honest communication between partners Making a date for sexual activity Use of stimulating devices, such as vibrators or clitoral suction devices Encouraging use of fantasy Encouraging nongenital , such as massage, foot rubs, caressing other body parts Encourage therapeutic, directed dialogue during sexual activity

Self-masturbation or directed stimulation by partner Pelvic exercises Oral stimulation to both genital and nongenital areas Bio, relaxation exercises For pain disorders, a warm bath prior to intercourse, lidocaine gel and NSAIDs for dyspareunia, woman-dominant positioning without deep thrusting

In the Masters and Johnson approach, both partners are evaluated during a 2week time period by a practitioner of their same sex. An extensive physical and psychological examination is conducted, and then both the practitioners and the couple meet as a group to discuss treatment goals. Long-term psychotherapy is not a component of this approach. Sensate exercises focus the couple on engaging in pleasurable activities while avoiding intercourse. This provides the couple with a means to offer other sources of enjoyment outside of sexual intercourse. Psychoeducation is imperative, so the woman (and her partner if she wishes to include him or her) can understand the etiological factors, treatment options, and other available therapies. Women who are chronic or regular heavy alcohol s should be counseled on the adverse effects alcohol has on the sexual response cycle. Other substances can also interfere with sexual responses, and urging the woman to discontinue their use is sometimes helpful if that is a causative factor. Bio and hypnosis is sometimes utilized. Other alternative therapies that have proven beneficial for women with sexual dysfunction include yoga, acupressure, and acupuncture.

SUMMARY

Female sexual disorders may affect approximately 40% of American women (Basson et al., 2000). There are various types of sexual disorders, including Paraphilias (sexual deviance disorders that are rare in women), Gender Identity Disorder, and Sexual Dysfunction Disorders. The Female Sexual Dysfunction Disorders are categorized into four distinct categories, which include sexual desire disorders, arousal disorders, orgasm disorders, and pain disorders. The disorders occur in different phases of the sexual response cycle and can be based on physical, psychological, pharmacological, or relationship-related factors. Nurses play a key role in the development of a therapeutic, frank, honest relationship in which the woman can feel comfortable discussing her sexuality. Diagnosis includes a multidimensional approach that includes a physical examination, psychological interview, assessment of relationship status, cultural and family assessment for views on sexuality, and an exploration of history of sexual abuse or sexual assault. Laboratory testing is often utilized to diagnosis hormonal factors. A complete medical history is obtained to identify any physiological factors. Treatment may include pharmacological intervention; however, behavioral interventions are more common.

Case Study

Renee Schmeltz is a 37-year-old woman who has been married for the past 15 years to her college sweetheart. She has two children, both born via vaginal delivery without complications with the exception of postpartum depression that occurred after her second birth. Her children are 18 months and 3 years old. She has been successfully treated with Zoloft, 50 mg per day, with complete resolution of depression symptoms. She continues on Zoloft at the advice of her primary care provider. Renee works full time as a marketing representative and

travels approximately 30% of the time for her job. She is also the primary caretaker for her children because her husband commutes a long distance to work on a daily basis. She presents for her annual gynecological examination and reports increasing frustration from her husband resulting from her lack of interest in lovemaking. She notes a general disinterest in sexual activity and feelings of guilt and sadness because of her decreasing libido. She notes she had a sexually satisfying relationship in the past with her husband that has steadily declined in frequency and intensity since the birth of her second child. Renee’s menses remains irregular because she discontinued breast feeding 5 months ago. She previously thought her lack of interest in sexual activity was related to her breast feeding; however, since discontinuation of nursing, her level of desire has not changed. Renee feels the reduction in desire is a result of fatigue and her increasingly demanding daily schedule. What possible etiological factors can be contributing to Renee’s current sexual dysfunction? What is the medical diagnosis? What treatment interventions may be effective for Renee and her husband?

Questions to Consider

What considerations need to be made for lesbian and culturally diverse women seeking care for sexual dysfunctions? How can the nurse promote open discussions between partners to address issues related to sexuality? How would you describe the assessment process to a shy young woman who is reluctant to speak to her male obstetrician about her lack of interest in sexual activity?

REFERENCES

Aggrawal, A. (2009). Forensic and medico-legal aspects of sexual crimes and unusual sexual practices. Boca Raton, FL: Taylor & Francis. Basson, R., Berman, J., Burnett, A., Derogatis, L., Ferguson, D., et al. (2000). Report of the international consensus development conference on female sexual dysfunction: Definitions and classifications. Journal of Urology, 163, 888–893. Brotto, L. A. (2009). The DSM criteria for sexual aversion disorder. Archives of Sexual Behavior. DOI: 10.1007/s10508-009-9534-2 Carroll, J. L. (2007). Sexuality now: Embracing diversity, 3rd ed. Belmont, CA: Cengage Learning. Davidson, M. R., London, M. L., & Ladewig, P. A. W. (2012). Olds’ maternalnewborn nursing and women’s health across the lifespan, (9th ed.). Upper Saddle River, NJ: Pearson. Encyclopedia of Mental Disorders. (2012). Retrieved from http://www.mind disorders.com/ Frank, J. E., Mistrella, P., & Will, J. (2008). Diagnosis and treatment of female sexual dysfunction. American Family Physician, 77(5), 635–642. Graham, C. A. (2009). The DSM diagnostic criteria for female sexual arousal disorder. Archives of Sexual Behavior. DOI: 10.1007/s10508-009-9535-1 Krueger, R. B. (2009). The DSM diagnostic criteria for sexual sadism. Archives of Sexual Behavior. DOI: 10.1007/s10508-009-9586-3 Mazaro-Costa, R., Andersen, M. L., Hachul, H., & Tufik, S. (2010). Medicinal plants as alternative treatments for female sexual dysfunction: Utopian vision or possible treatment in climacteric women? Journal of Sexual Medicine, 7(11), 3695–3714. DOI: 10.1111/j.1743-6109.2010.01987.x

Phillips, N. A. (2000). Female sexual dysfunction: Evaluation and treatment. American Family Physician. Retrieved from http://www.aafp.org/afp/20000701/127.html Sex and Society, 2nd ed. (2010). London: Marshall Cavendish. Tartigalio, M., & Riley, K. (2011). Lesbians and female sexual dysfunction: What physicians learn from lesbian sex. Retrieved from http://www.cecity.com/aoa/women_well/feb_11/print5.pdf West, S. L., D’Aloisio, A. A., Agans, R. P., Kalsbeek, W. D., Borisov, N. N., & Thorp, J. M. (2008). Prevalence of low sexual desire and hypoactive sexual desire disorder in a nationally representative sample of US women. Archive of Internal Medicine, 168(13), 1441–1449. Wong, C. (2011). Natural remedies for sexual dysfunction in women. Retrieved from http://altmedicine.about.com/od/sexualhealth/a/TreatFemaleSexu.htm

23

Sleep Disorders

Sleep Disorders are disturbances of sleep that interfere with an individual’s functioning and lead to distress. Sleep Disorders affect women more often than men. It is estimated that 30% of women develop a Sleep Disorder ( Hertz & Cataletto, 2011 ). There is an estimated 40 million Americans affected by chronic Sleep Disorders and another 20 million with occasional Sleep Disorders ( National Institute of Neurological Disorders and Stroke, 2011a ). Younger women have fewer sleep problems than women over the age of 40. Many women develop Sleep Disorders during the reproductive years in response to hormonal influences that cause less sound and lighter sleep. During the premenstrual phase of the menstrual cycle, as many as 80% of women experience difficulties with sleep ( Hertz & Cataletto, 2011 ). Reduction of estrogen levels during the menopausal years leads to hot flashes and night sweats, making nighttime awakening common in approximately two-thirds of all menopausal women ( Hertz & Cataletto, 2011 ). The awakening patterns that begin during the menopausal years seem to worsen during subsequent years making Sleep Disorders even more common in the postmenopausal years. Sleep Disorders are included in the DSM-IV-TR and are also classified using the International Classification of Diseases. There are more than 75 different classifications of Sleep Disorders. The most commonly occurring disorders will be included in this book. Sleep Disorders fall into various categories. Dyssomnias are disorders that are characterized by difficulty falling asleep, staying asleep, or disorders that include excessive sleepiness. These include intrinsic, extrinsic, and circadian-rhythm Sleep Disorders. The most common cause of excessive daytime sleepiness is sleep deprivation resulting from poor sleep habits and poor sleep hygiene. Parasomnias are Sleep Disorders that do not include extreme sleepiness as a symptom. These include arousal disorders, sleepwake transition disorders, and parasomnias associated with REM sleep or with

other parasomnia disorders. Examples of parasomnias include nightmares, sleepwalking, sleep terrors, sleep-related enuresis, and sleep-related hallucinations. The third category includes Sleep Disorders that are related to medical or psychiatric illness. This category includes psychiatric illness, neurological disorders, and other medical disorders. In general, Sleep Disorders are more common in women than in men. Specific Sleep Disorders include the following:

■ Insomnia ■ Sleep-disordered breathing ■ Restless legs syndrome (RLS) ■ Narcolepsy

INSOMNIA

Insomnia is an intrinsic Sleep Disorder that is the most common of all the Sleep Disorders and more common in women than in men. It affects 60% of adults at least one night per week. Insomnia can be episodic or chronic in nature. Shortterm Insomnia lasts less than 3 weeks; chronic Insomnia occurs in the presence of symptoms that last for at least a month or more. Insomnia can significantly impair a woman’s quality of life and is a common comorbidity with other psychiatric disorders. Women with existing psychiatric illness who also suffer from Insomnia have poorer clinical outcomes when Insomnia is present (National Center on Sleep Disorders Research, 2011). Psychiatric morbidity is the leading cause of Insomnia (National Center on Sleep Disorders Research, 2011). Women with Insomnia utilize health care services more frequently than those without Insomnia. It is estimated that the United States spends in excess of $16 billion annually on medical expenses related to Sleep Disorders. This does not take into functional costs and time lost from work (National Institute on Neurological Disorders and Stroke, 2011a).

Etiology

Sleep Disorders can be caused by a variety of issues, including hormonal variations, stress, medical problems, psychological disorders, lifestyle, and environmental factors. Learned insomnia occurs when a woman is so preoccupied with getting adequate sleep that Insomnia follows. The following risk factors can contribute to Insomnia:

■ Psychological stress ■ Pregnancy: Sleeping difficulties are common in the first trimester of pregnancy as a result of urinary frequency, an increased need for sleep, general discomfort, and nausea. During the third trimester, urinary frequency returns and heartburn, leg cramps, fetal movement, an inability to find a comfortable position, Braxton-Hicks contractions, and low back pain can interfere with the sleep cycle. Preeclampsia and hypertension disorders in pregnancy can also cause sleep issues (Davidson, London, & Ladewig, 2012). ■ Lifestyle factors, such as working long hours, working rotating shifts, jet lag, and constant changes in time-zone areas, can impact sleep schedules. ■ Ingestion of nicotine and caffeine or other stimulating agents (substance abuse–related Insomnia). ■ Psychiatric conditions, such as Mood Disorders, Anxiety Disorders, panic attacks, Posttraumatic Stress Disorder (PTSD), psychosis, and alcoholism. ■ Grief: Women experiencing grief may have difficulty falling asleep or awaken during the night. ■ Pain: Acute pain resulting from an injury, medical condition, or surgery may also cause difficulty with sleep. Women with chronic pain may also experience sleep issues.

Signs and Symptoms

The most common symptoms of an intrinsic Sleep Disorder, including Insomnia, include difficulty falling asleep, difficulty staying asleep, early morning waking, fatigue, and extreme tiredness throughout the day. Daytime sleepiness is a common symptom in women with Insomnia. Women who continually lack adequate sleep are at risk for auto accidents as a result. They also make more errors at work and other focused activities. In addition, women with poor sleep patterns have lowered immunity and are more at risk for infections. Common somatic complaints include tension headaches, gastrointestinal complaints, depression, and anxiety. Women with Insomnia may also become irritable and have difficulties with concentration.

Assessment and Screening

For the woman with sleep-related symptomology, a complete medical examination with laboratory testing is needed. Once gross physical abnormalities are eliminated, psychological variables should be examined. An examination should also include history of sleep patterns, menstrual history, and pregnancy history. Family patterns and work demands should be considered. Women who travel for work and cross into multiple time zones and then must continually change their sleep patterns should be identified. Specific questions related to alcohol use, smoking, and use of any pharmacological agents need to be examined. A frank discussion about the woman’s stressors should also occur. Many women report loss of sleep as a result of having young children who awaken them at night. Once other factors are considered, sleep studies are typically used to diagnose specific disorders. Sleep logs are sometimes used to track circadian-rhythm disorders and irregular sleep patterns. A polysomnograph is a test performed overnight while a woman is sleeping that monitors brain activity, heart rate, muscle-tone changes, respirations, leg movements, and eye movements. Multiple sleep latency testing (MSLT) may be performed following a sleep study to monitor daytime sleepiness.

Pharmacological Treatment

Pharmacological treatment is sometimes used when lifestyle modification has been ineffective. Some practitioners advocate for using antihistamines as a pharmacological intervention initially because they do not carry the side effects and addictive qualities of some of the other treatments. Antihistamines can cause some memory loss in some women, especially older women, so they should be used with caution in that age group. Short-term treatment includes the use of sedatives or hypnotics. Benzodiazepine and nonbenzodiazepine drugs are the most commonly used medications in the treatment of Sleep Disorders. The main concern with the continual use of these agents is that drug dependence typically occurs. Withdrawal symptoms can also occur with sudden discontinuation of the medication. The drugs most commonly used include the following:

■ Lorazepam (Ativan) ■ Triazolam (Halcion) ■ Temazepam (Restoril) ■ Zolpidem (Ambien) ■ Zaleplon (Sonata)

Ramelteon (Rozerem) is also sometimes used to treat Insomnia in women. Rozerem acts to stimulate melatonin receptors and is thought to normalize circadian-rhythm disorders. Other pharmacological interventions are sometimes used. Many women respond well to hormone replacement therapy although the risks and benefits need to be weighed carefully. Other women may benefit from antidepressants such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). Antidepressants are often

effective for women with long-term sleep disorders with no history of depressive symptomology. They are also effective in women with hormonal fluctuations and do not cause dependency. Examples of antidepressants used to control Insomnia include the following:

■ Sertraline hydrochloride (Zoloft) ■ Fluoxetine (Sarafem, Prozac) ■ Mirtazapine (Remeron)

Behavioral Therapies

Women with Sleep Disorders should be counseled on promoting healthy sleep habits prior to the use of medication intervention whenever possible. Cognitive behavioral therapy and psycho-education can be used to encourage the woman to maintain a usual sleep routine, such as going to bed and arising at consistent times; decreasing environmental stimuli; promoting a calm relaxing environment for sleep with decreased noise and light; avoiding daytime napping; exercising early in the day and avoiding exercise just prior to sleeping; eliminating tobacco, alcohol, and caffeine use at night; and avoiding stimuli, such as television viewing and loud music. Late eating and excessive fluid intake in the evening should also be avoided.

BREATHING-RELATED SLEEP DISORDERS

Breathing-Related Sleep Disorders are categorized as an alteration that occurs in the breathing during the sleep cycle. Breathing-Related Sleep Disorders affect approximately 20 million Americans. It is the second most common Sleep Disorder. Sleep apnea is the most common of the Breathing-Related Sleep Disorders. (National Center on Sleep Disorders Research, 2011). The disorder is treated more commonly in men; women with the disorder traditionally do not seek treatment for it possibly because of a perceived embarrassment about snoring. Breathing-Related Sleep Disorders involve more than just snoring with excessive daytime sleepiness. It can increase the risk of the following:

■ Myocardial infarction ■ Stroke ■ Hypertension ■ Arrhythmias

Sudden death from respiratory depression can also occur. Women with diagnosed sleep apnea are 10 times more likely to be involved in a motor vehicle accident because of daytime sleepiness (National Institute of Neurological Disorders and Stroke, 2011).

Etiology

Women with sleep apnea experience an abrupt cessation of breathing while sleeping. Physiologically, there is a build-up of carbon monoxide in the blood stream that causes the woman to awaken gasping for air. While some women may be conscious of these symptoms, others may be unaware it is occurring. Some women experience long apnea periods that result in cyanosis and a reduction in oxygen-saturation levels. Alcohol ingestion is known to exacerbate sleep apnea and therefore should be avoided in women with the disorder, especially just prior to sleeping (National Center on Sleep Disorders Research, 2011). Women who are overweight or obese are more likely to experience sleep apnea. There also seems to be a familial component to sleep apnea and Breathing-Related Sleep Disorders.

Signs and Symptoms

One of the main signs of sleep apnea is loud snoring. Women with sleep apnea suffer episodes of apnea that can last a few seconds to more than a minute. Severe cases can lead to a reduced oxygen-saturation rate and cyanosis. Partners may notice that the woman awakens and is gasping for air. Because the normal sleep cycle is continually disrupted by these episodes, women do not get adequate rest and typically have daytime sleepiness. They may easily nod off or fall asleep at required activities, such as while working or driving. Women may also present as being irritable, depressed, and have personality changes related to chronic sleep deprivation. Disinterest in sex, morning headaches, and cognitive impairment can also occur (National Institute of Neurological Disorders and Stroke, 2011a).

Assessment and Screening

A careful, detailed interview should be performed to assess for associated symptoms. An examination by an ear, nose, and throat (ENT) specialist can evaluate the oral space to determine if a physiological etiology exists. Rarely, surgical intervention may be advised to remove abnormally large tonsils, adenoids, or to reduce the size of the posterior tongue. Women should also ask their sleep partner or family about observed symptoms. A polysomnograph is typically performed. MSLT may be performed following a sleep study to monitor daytime sleepiness. For women with sleep apnea who have been diagnosed during a sleep study, referral to a sleep specialist is usually warranted.

Pharmacological Treatment

There are no approved medication therapies for sleep apnea. Sometimes certain substances or medications can trigger or worsen sleep apneas. These include hypertension medications, alcohol, and sleep agents.

Behavioral Therapies

For overweight or obese women with sleep apnea, weight-loss intervention may reduce or eliminate nighttime snoring. These women may need to sleep with a continuous positive airway pressure (AP) machine to maintain adequate oxygenation. There has been some success with using oral appliances (primarily mandibular advancing devices) for sleep to reduce apnea episodes (National Center on Sleep Disorders Research, 2011). Although rare, some women may opt for an uvulopalatopharyngoplasty (UPPP), an operation that eliminates loud snoring by removing excess throat tissue.

RESTLESS LEGS SYNDROME

RLS is a neurological condition characterized by a marked desire to move the legs that may be perceived as throbbing, creeping, or other unpleasant sensations within the legs (National Institute of Neurological Disorders and Stroke, 2011b). Although the legs are most commonly affected, other body parts can also be affected. The syndrome can occur at any age but almost half of those affected develop symptoms prior to the age of 20. Women are twice as likely as men to develop RLS. The disorder affects 7% to 10% of individuals in North America (Gamaldo & Earley, 2006). It is estimated that 2% to 3% have moderate to severe RLS (National Institute of Neurological Disorders and Stroke, 2011b). RLS can be primary, which is typically idiopathic in nature, occurring before the ages of 40 to 45 with worsening as a woman ages. The disorder can completely disappear for months or years at a time. Secondary RLS begins after the age of 40 and is commonly associated with medical conditions or medications.

Etiology

There are a variety of causes of RLS. The disease is still being extensively researched, and developing theories continue to arise. Commonly accepted etiologies include the following:

■ Genetics: RLS is an autosomal dominant disorder, and genetics s for 60% of all cases of RLS. ■ Pregnancy is also associated with development or worsening of RLS. ■ Medical problems associated with Sleep Disorders, such as anemia, thyroid disorders, sleep apnea, obstructed airway, and difficulty breathing. ■ Iron-deficiency anemia, varicose veins or venous reflux, folate deficiency, magnesium deficiency, fibromyalgia, sleep apnea, uremia, diabetes, thyroid disease, peripheral neuropathy, Parkinson’s disease, diabetes, and certain autoimmune disorders, such as Sjögren’s syndrome, celiac disease, and rheumatoid arthritis, are all causative factors related to RLS (Pantaleo, Hening, Allen, & Earley, 2010). ■ Medications commonly implicated include antidepressants, antiemetics, antihistamines, antipsychotics, and anticonvulsants. The disorder is also known to worsen should a woman discontinue sleeping medications.

Signs and Symptoms

Women with RLS have unpleasant sensations within their legs accompanied by a need to continually move their legs to obtain more comfortable positioning. Symptoms tend to worsen at night and typically the movement is uncontrollable. When women attempt to lay down, it actually exacerbates the symptoms, making them worse. Women with RLS often become exhausted, irritable, have difficulty concentrating, and have disrupted occupational and social interactions as a result of intense symptomology. Approximately 80% of women with RLS also have periodic limb movement of sleep (PLMS), which is characterized by involuntary leg twitching or jerking movements during sleep. The movements occur every 15 to 40 seconds throughout the night, making it impossible to sleep. PLMS can occur as a separate Sleep Disorder from RLS in which RLS symptoms do not occur. As a separate disorder, it is more common in women with Attention-Deficit/Hyperactivity Disorder (ADHD).

Assessment and Screening

The diagnostic criteria include presence of leg complaints with a strong and often overwhelming need or urge to move, often associated with paresthesias or dysesthesias. Sensory symptoms that become more severe during rest and relaxation, with a need to move the legs that worsens at night. These symptoms are relieved with movement but recur when movement ceases (National Institute of Neurological Disorders and Stroke, 2011b). A careful interview is performed to assess for symptoms, family history, and underlying possible etiological factors. Laboratory testing is used to rule out causative factors such as anemia, vitamin deficiencies, and major medical causes. Sleep studies may be performed to confirm diagnosis and assess sleep patterns.

Pharmacological Treatments

Dopamine agonist preparations are the first line of treatment in RLS (Gamaldo & Earley, 2006). These medications have been shown to be effective in managing symptoms short term; however, long-term use has sometimes resulted in a worsening of symptoms. Commonly used agents include the following:

■ Carbidopa-levodopa (Sinemet) ■ Pergolide (Permax) ■ Ropinirole (Requip) ■ Pramipexole (Mirapex) ■ Gabapentin (Horizant)

Severe persistent RLS can be treated with opioids, such as codeine or methadone. Benzodiazepines, such as diazepam, are also sometimes used when first-line therapies are ineffective and can provide much-needed sleep. Painful episodes are sometimes treated with anticonvulsants, such as carbamazepine.

Behavioral Therapies

While movement of the legs stops the sensations, it is impossible to completely stop movement, especially when attempting to sleep. Warm tub baths, warm compresses, massage, and ice may reduce the painful sensations sometimes associated with RLS. Women should be counseled to eliminate certain agents, especially prior to sleeping, that include the following:

■ Caffeine ■ Alcohol ■ Tobacco products

Vitamin and mineral supplementation is sometimes helpful if it addresses the etiological factor. Iron therapy is only recommended for women with low blood counts (National Institute of Neurological Disorders and Stroke, 2011b). Moderate exercise is also recommended.

NARCOLEPSY

Narcolepsy is a neurological Sleep Disorder that involves intense sleepiness during the day. It is experienced by both men and women. Narcolepsy is considered one of the Hypersomnia disorders, which are marked by the inability to remain awake. The incidence is 1 in 3,000 American adults with cataplexy and is probably more common and undiagnosed when cataplexy is not present (National Institute of Neurological Disorders and Stroke, 2011c). The disorder typically begins in childhood or during the adolescent period, usually between the ages of 7 and 25, and is life-long in nature (National Institute of Neurological Disorders and Stroke, 2011c). Women have more episodes related to hormonal changes in their menstrual cycles and hormonal variations associated with adolescence, premenstrual syndrome (PMS), pregnancy, perimenopause, and menopause that may directly impact symptomology and frequency of sleep attacks. Menstrual-Related Hypersomnia, another disorder within this classification, occurs in the luteal phase and is marked by chronic sleepiness during this phase of the menstrual cycle (Davidson et al., 2012).

Etiology

Narcolepsy is found to have a genetic component and often runs in families; however, most women who develop Narcolepsy do not know of any other affected family . Only 10% of women with Narcolepsy report having a close family member with the illness. Risk factors include infection, immunesystem dysfunction, trauma, hormonal changes, and stress that present before the onset of symptoms (National Institute of Neurological Disorders and Stroke, 2011c). The disease appears to be autoimmune in nature. If cataplexy is present, a reduction or absence of the brain protein hypocretin is the etiology. Other alterations in neurotransmitters or in the neurons occur and the woman immediately enters REM sleep in which case the normal sleep cycle is severely interrupted and Narcolepsy is diagnosed.

Signs and Symptoms

Women with Narcolepsy experience abnormal REM sleep, such as sleep paralysis, hypnagogic hallucination, cataplexy (loss of muscle control), and interference with nocturnal sleep (National Center on Sleep Disorders Research, 2011). Although it is commonly perceived that those affected with Narcolepsy sleep all of the time, in fact they do not. They often experience interrupted sleep. Periods of drowsiness that occur every 3–4 hours and last 15 minutes in duration or longer occurs with women with Narcolepsy. The woman has a strong desire to sleep and then frequently experiences a sleep attack (short nap period) that is uncontrollable. Sleep attacks can appear during normal activities, such as driving, eating, talking to others, or other physically active events. The woman typically awakens quickly and feels refreshed after approximately 15 minutes. During the stage between sleep and waking, hallucinations can occur. Hallucinations and sleep paralysis are rarer symptoms but do occur in some women (National Institute of Neurological Disorders and Stroke, 2011c). Hypnagogic hallucinations occur during sleep onset, and hypnopompic hallucinations occur during periods of waking. Sleep paralysis is the inability to move or speak during the period of falling asleep or awakening. Only 10% to 15% of women exhibit all of these symptoms although 70% do experience cataplexy. Women with cataplexy often note specific triggers, such as sudden laughter or intense anger. The woman may fall to the floor with the associated paralysis continuing for several minutes. Narcolepsy worsens when there are changes in sleep habits and if the triggers that cause Insomnia occur. Because there is a dysfunction in the normal sleep cycle, women with Narcolepsy never feel refreshed upon wakening and are usually tired all of the time.

Assessment and Screening

Practitioners should conduct a careful interview to assess for sleep-related symptoms. The presence of other disorders should be excluded. Most women with Narcolepsy have peers or family who report their symptoms as well as the woman. The woman may be advised to keep a sleep journal to track her sleep patterns and the frequency of sleep attacks. Women with symptoms specific to Narcolepsy are referred for sleep studies. Other etiological factors, such as seizures; sleep apnea; various viral or bacterial infections; Mood Disorders, such as depression; and chronic illnesses, such as anemia, congestive heart failure, and rheumatoid arthritis, that disrupt normal sleep patterns need to be excluded (National Institute of Neurological Disorders and Stroke, 2011c). A polysomnograph and MSLT are commonly ordered. Genetic testing, including human leukocyte antigen typing, can also be performed to determine if a low level of hypocretin is the etiological factor. A definitive diagnosis of absence of or low hypocretin can be measured by obtaining cerebral spinal fluid from a lumbar puncture. Women with suspected symptomology should be referred to a neurologist for treatment. The presence of comorbidities, such as sleep apnea, should also be ruled out.

Pharmacological Treatment

There is no cure for Narcolepsy, so treatment is aimed at controlling symptoms. Usual treatment of the disorder involves the use of dopaminergic amphetamine– like stimulants, gammahydroxybutyrate and monoaminergic antidepressant therapy (National Center on Sleep Disorders Research, 2011). The stimulant modafinil (Provigil) and sodium oxybate (Xyrem) are both approved by the U.S. Food and Drug istration (FDA) for the treatment of narcolepsy. Xyrem is a strong sedative and can only be taken at night to regulate sleep patterns. Stimulants used in Narcolepsy treatment include dextroamphetamine (Dexedrine, Dextrostat) and methylphenidate (Ritalin), which enable the woman to stay awake during the daytime. Both SSRIs and SNRIs, including venlafaxine, fluoxetine, and atomoxetine, and tricyclic antidepressants (TCAs) (imipramine, desipramine, clomipramine, and protriptyline) are used to reduce hallucinations, cataplexy, and sleep paralysis (Dauvilliers, Arnulf, & Mignot, 2007). Amphetamines are not the first choice in therapy because of their side-effect profile and risk for dependence.

Behavioral Therapies

Lifestyle modification is essential for the woman with Narcolepsy. Dietary counseling is needed to advise the woman to eat light, low protein, small, frequent meals. Avoidance of heavy meals is important to prevent sleep attacks. A woman diagnosed with narcolepsy commonly experiences significant weight gain in the treatment period, so nutritional counseling that focuses on maintaining ideal body weight is necessary. Women often experience sleep attacks after eating heavy meals, so planned naps should be included in the treatment plan to decrease the incidence of unexpected sleep attacks. A short 15minute nap postprandial may help ward off sleep attacks. In addition to healthy eating, exercise sessions 4–5 hours prior to attempting sleep can also improve nighttime sleeping. Women with Narcolepsy may have issues with social isolation, social impairment, or school or occupational issues. Friends, persons, teachers, and employers should be made aware of their symptoms and possible reactions associated with sleep attacks. Some employed women may need to approach their human resources office and ask for accommodations based on the disability caused from Narcolepsy. Allotting time periods for naps may decrease unexpected sleep attacks and assist the woman in maintaining employment. Because comorbidities with other Sleep Disorders is common, they should also be managed effectively to reduce the symptoms associated with Narcolepsy. Nighttime sleep hygiene with preset rituals, such as a bath prior to retiring is imperative. Bedroom temperatures should be kept warm but not hot. Maintaining a regular bedtime, arising at the same time each day, and avoiding stimulants, alcohol, and tobacco prior to bed are all recommended measures for individuals with this diagnosis. Women with Narcolepsy should be counseled on safety issues in their own environment that can result in intense anxiety, fear, and perceived social stigma. Women are at risk for falls, motor vehicle accidents, and other injuries because of the nature of their illness. Women with uncontrolled Narcolepsy experience

10 times more automobile accidents than unaffected individuals. Individuals with uncontrolled Narcolepsy may be prohibited from driving or operating machinery until symptoms are considered under control and may have to appear before the Department of Motor Vehicles Medical Advisory Board before being approved to resume driving. For a woman lacking social and living in a geographically isolated, rural area, the suspension of a license can become an enormous stressor that can impact all facets of her life. Some women with Narcolepsy may experience such profound symptoms that they may not be able to maintain their current employment as a result of their symptoms. Vocational rehabilitation may be indicated. Others may be unable to work because of the severity of symptoms. While disability does not have Narcolepsy as a specific indicator for benefits, women may be included under the functional capacity classification for this condition (Ginsberg, 2011). Psychotherapy is often indicated because women with Narcolepsy may be wrongly labeled by peers as being lazy, unmotivated, intellectually impaired, or undisciplined. Social stigma is common, and because extremes in emotions can trigger symptoms, the need to deal effectively with one’s emotions is imperative. Social from family, friends, and coworkers is needed. Women may benefit from peer groups and having opportunities to share their experiences with others impacted by the disorder.

SUMMARY

Sleep Disorders affect a large number of women and for significant cost expenditures annually. Insomnia is the most commonly occurring Sleep Disorder and often exists with other psychiatric comorbidities. Breathing-Related Sleep Disorders are often undiagnosed in women and can have significant risk factors for morbidity if left untreated. RLS occurs twice as frequently in women than in men and can cause considerable symptomology, making adequate sleep impossible to obtain. Narcolepsy is a rare disorder marked by sudden sleep attacks in which the woman falls asleep unexpectedly. The disorder can be extremely limiting because symptoms can produce significant disability. Most sleep disorders are diagnosed using a polysomnograph and MSLT. Treatment can include pharmacological approaches, behavioral interventions, oral appliances, surgical approaches, or AP machines.

Case Study

Tashera Jamisson is a 32-year-old G0 (no pregnancies) with a history of PMS. Janice notes ongoing difficulties with falling asleep. She states she is chronically experiencing early wakening, falling asleep, and interrupted sleep. Tashera works full time as a flight attendant and often travels overseas on a regular basis. She consumes 6–8 cups of coffee per day and drinks alcohol socially. Janice had been taking Benadryl at night to assist with falling asleep, but it is no longer working. She presents to her primary care physician for a consultation for Insomnia. What behavioral interventions would you recommend for Tashera? What are the pros and cons of beginning pharmacological intervention?

Questions to Consider

If a perimenopausal woman presents with complaints of Insomnia, what would be the initial counseling provided to promote sleep hygiene? What pharmacological options are available for women with RLS? What barriers might a woman with Narcolepsy face when pursuing employment? What signs and symptoms would warrant an assessment for sleep apnea in a woman who presents to her primary care provider for a routine physical?

REFERENCES

Dauvilliers, Y., Arnulf, I., & Mignot, E. (2007). Narcolepsy with cataplexy. Lancet, 369(9560), 499–511. Davidson, M. R., London, M. L., & Ladewig, P. A. W. (2012). Olds’ maternalnewborn nursing and women’s health across the lifespan, (9th ed.). Upper Saddle River, NJ: Pearson. Gamaldo, C. E., & Earley, C. J. (2006). Restless legs syndrome: A clinical update. Chest, 130(5), 1596–1604. DOI: 10.1378/chest.130.5.1596 Ginsberg, J. (2006). Narcolepsy as a basis for social security disability? Social security disability blog. [Blog Entry]. Retrieved from http://www.ssdanswers.com/2006/08/19/narcolepsy-as-a-basis-for-socialsecurity-disability/ Hertz, G. & Cataletto, M. E. (2011). Sleep disorders in women. Emedicine. Retrieved from http://www.emedicinehealth.com/sleep_disorders_in_women/article_em.htm National Center on Sleep Disorders Research. (2011). Sleep disorders research plan agenda. Retrieved from http://www.nhlbi.nih.gov/health/prof/sleep/res_plan/section5/section5a.html National Institute of Neurological Disorders and Stroke. (2011a). Brain basics: Understanding sleep. Retrieved from http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm National Institute of Neurological Disorders and Stroke. (2011b). Restless legs syndrome fact sheet. Retrieved from http://www.ninds.nih.gov/disorders/restless_legs/detail_restless_legs.htm National Institute of Neurological Disorders and Stroke. (2011c). Narcolepsy fact sheet. http://www.ninds.nih.gov/disorders/narcolepsy/detail_narcolepsy.htm

Pantaleo, N. P., Hening, W. A., Allen, R. P., & Earley, C. J. (2010). Pregnancy s for most of the gender difference in prevalence of familial RLS. Sleep Medicine, 11(3), 310–313. DOI: 10.1016/j.sleep.2009.04.005

24

Substance Abuse Disorders

Substance abuse disorders encom a variety of psychiatric diagnoses that are chronic and relapsing in nature. Substance abuse disorders include substance use problems, substance abuse, and substance dependence. It is estimated that each year, 40 million people within the United States suffer an injury or serious illness as a result of substance use ( National Institute on Drug Abuse, 2011a ). It is estimated that in the United States, 9 million women have used drugs within the last 12 months and that, of those women, 4 million women are substance abs. The abuse of prescription drugs is estimated to include 3.7 million women. Illegal drug use is responsible for 70% of all cases of HIV infection in women. Sadly, 50% of women between the ages of 15 and 44 have experimented with drugs on at least one occasion (National Institute on Drug Abuse, 2011b). Women who use drugs typically engage in polydrug abuse, meaning they use more than one substance. Women who abuse drugs come from all cultural groups, races, and socioeconomic statuses. Common problems associated with drug use are included in Exhibit 24.1.

Exhibit 24.1

Common Problems Associated With Drug Use

Sexual abuse

Low self-esteem Low self-confidence Powerlessness Loneliness Social isolation Pregnancy complications Fetal drug addiction HIV infection Sexually transmitted infections Mental-health problems

Substance abuse predisposes women to more medical complications when compared to nons. Women substance abs have higher rates of hypertension, trauma, cardiac arrhythmias, gastrointestinal disease, neurocognitive deficits, and osteoporosis (Brady, Back, & Greenfield, 2009). They also have a higher incidence of accidents and accidental injury. Women process drugs and alcohol differently than men. Modern research has shown that there are variations in absorption factors associated with the menstrual cycle. During the follicular phase, stimulants are processed quicker, and absorption rates are higher than in the luteal phase (Brady et al., 2009). When women consume alcohol, they tend to metabolize it more quickly than men and are also more likely to develop liver disease at faster rates. Women with Bulimia are more likely to engage in alcohol abuse than other women, making Eating Disorders a risk factor for alcohol abuse. Women with depression commonly have issues with alcohol and women who drink alcohol also have higher suicide rates than women who do not (Saunders, Davis, & Williams, 1984).

Until recently, the identification and complexities of women with substance use/abuse disorders has largely been unexamined. In the medical community, practitioners are less likely to ask women about substance use in the primary care setting. In the obstetric population, assessment for substance abuse is routinely recommended; however, because of the social stigma associated with substance abuse in pregnancy, many women are not truthful with their health care provider (Davidson, London, & Ladewig, 2012). In addition, because of social stigma and fear of losing custody of their children, many women are fearful to come forward and seek treatment when substance abuse disorders are present. Women have multiple risk factors including higher incidences of abuse, sexual trauma, chronic stressors, and Posttraumatic Stress Disorder (PTSD) (Brady et al., 2009). Men are three to five times more likely to engage in substance abuse than women. In some cultures, substance abuse in women is even less common, but in the United States and Western countries, the incidence of women who engage in substance use is rising with alcohol, marijuana, and cocaine use (Degenhardt, Chiu, Sampson, Kessler, Anthony, et al., 2008). Certain cultural groups that are male-dominated actually offer a protective mechanism against the development of alcoholism in women because it is so socially unacceptable and carries grave consequences. While this social behavior is likely related to fear, socially embraced norms also play a role in the low incidence (Kubička & Csémy, 2008). Another theory as to the lower incidence of substance use in women is the identification of substance use/abuse being an externalizing behavioral pattern. Externalizing behavior patterns are traditionally more male-dominated and are said to occur when pain is turned outward. These behaviors include aggression and impulse control. Psychiatric conditions commonly believed to be externalizing include Attention-Deficit/Hyperactivity Disorder, Conduct Disorder, and Oppositional Defiant Disorder (Hecksher & Hesse, 2009). Internalizing behaviors are those in which pain is turned inward. These disorders are more common in women and include anxiety, depression, and Eating Disorders. It is more acceptable for women to internalize pain than to react with externalizing behaviors. Substance abuse is considered an externalizing behavior pattern (Zucker, 2008). Of the women who do use substances, they are more likely to engage in highrisk behaviors than women who do not use drugs or alcohol. They are more likely to be isolated from their peers because the behavior is usually considered unacceptable by the majority of women. Women with substance abuse issues are

viewed more negatively than their male counterparts and are more likely to experience guilt and shame than men, making seeking treatment more difficult (Hecksher & Hesse, 2009). Women who utilize substances are more likely to suffer from a comorbid psychiatric disorder. Those who suffer from a psychiatric disorder in addition to substance abuse are termed to have a dual diagnosis. These women are more likely to have been abused during childhood, and/or to have experienced a sexual trauma in their past (Zucker, 2008). Female drug s are more likely to have a partner that engages in drug use. When women do abuse substances, their disorders tend to be more severe with a more rapid onset than their male counterparts. Substance use is characterized by the use of alcohol or drugs on more than one occasion, yet the behavior is not a regular pattern nor has it impaired functioning. Typically, the women has experienced negative consequences from her use of the substance, such as injury, legal intervention, or difficulty with family . Substance abuse occurs when the woman repeatedly uses substances despite negative consequences. There is a lack of control or an inability to stop use, which results in any of the following: inability to meet obligations, such as those that are required in school, work, or in the family setting; recurrent use in hazardous situations, such as driving while under the influence; legal issues, such as stealing to gain financial access to drugs or alcohol; or persistent social and interpersonal problems that occur. Substance intoxication occurs when the woman ingests a substance and encounters symptoms that are reversible when the substance wears off. During the intoxication, behavioral and psychological changes occur as a result of the effects of the drug on the central nervous system. The behavioral and psychological changes are directly related to the use of the substance and not to another physiological or psychological condition. Substance dependence occurs when an individual has a desire and compulsion to take a drug, develops an inability or loss of control in their use of the substance, and has a negative emotional state associated with its use over a 12month period of time (Galanter & Kleber, 2008). Substance dependence may or

may not include physiological dependence. Individuals must have at least three of the following associated symptoms to meet the diagnostic criteria:

■ Tolerance ■ Withdrawal ■ Dosages increase in strength, duration longer than intended ■ A persistent desire to reduce or eliminate use of the substance ■ A large amount of time spent attempting to obtain or recover from the effects of the drug ■ Social/occupational/recreational activities are decreased as a result of drug use ■ Drug use persists even after the woman clearly recognizes she has a problem with drugs or alcohol

Substance withdrawal occurs when there is the development of a substancespecific syndrome related to the discontinuation of a specific substance that has been heavily used over a prolonged period of time resulting in significant impairment in an area of functioning. The withdrawal symptoms are not related to other physiological causes and are caused by the specific withdrawal from the identified substance.

CLASSIFICATION OF SUBSTANCE ABUSE DISORDERS

There are two broad classifications of these disorders. The first classification is substance use disorders and includes substance dependence and substance abuse. The second, larger category includes substance-induced disorders, which are included in Exhibit 24.2. The scope of substance-induced disorders is beyond the scope of this text; however, readers are encouraged to consult Ghodse, H., Herrman, H., Maj, M., & Sartorius, N. (2011).

Exhibit 24.2

Substance-Induced Disorders

Substance intoxication Substance withdrawal Substance-induced delirium Substance-induced persisting dementia Substance-induced persisting amnesiac disorder Substance-induced Psychotic Disorder Substance-induced Mood Disorder Substance-induced Anxiety Disorder

Substance-induced Sexual Dysfunction Substance-induced Sleep Disorder

The major drugs have their own classification categories within the DSM-IV-TR. Other or unknown substances have a separate category as Polysubstance Dependence. Substance abuse disorders are also defined by the following specifiers:

■ With/without psychological dependence ■ Early full remission/early partial remission/full remission/sustained partial remission ■ With onset during intoxication/with onset during withdrawal

Substances that have all been associated with substance abuse dependency are included in Exhibit 24.3.

Exhibit 24.3

Substances Associated With Drug Dependence

Alcohol Amphetamine-like substances

Cannabis Cocaine/crack Hallucinogens Inhalants Nicotine Opioids Phencyclidine Sedatives Hypnotics Caffeine

ETIOLOGY

Drug addiction clearly has multifaceted neurobiological etiologies. Many women with substance abuse disorders have impulsivity and compulsivity issues. Women with impulse-control issues experience arousal symptoms before committing an impulsive act and subsequently experience gratification and pleasure once the act has been committed. Regret and guilt typically follow the gratification state. Those with compulsivity issues will experience a buildup of stress and anxiety prior to the compulsive act and then experience relief when they actually commit the act. As drug use moves from an impulsive act to a compulsive one, it changes from positive reinforcement to negative reinforcement. In drug addiction, there is a three-stage process that moves from impulsivity to compulsivity during the following stages (Galanter & Kleber, 2008):

■ Binge/intoxication ■ Withdrawal/negative affect ■ Preoccupation/anticipation ■ Transition to addiction

SIGNS AND SYMPTOMS

The signs and symptoms of drug and alcohol use and abuse can vary significantly based on multiple factors, including the frequency of use, type of substance used, tolerance to the agent, and individual characteristics of the . In general, women who abuse drugs sometimes do the following:

■ Neglect responsibilities ■ Engage in high-risk or dangerous circumstances (irresponsible sexual behaviors, driving under the influence) ■ Engage in behaviors that cause legal issues ■ Have difficulties with interpersonal relationships ■ Develop financial problems ■ Engage in secretive or suspicious activities ■ Have sudden shift in friends or acquaintances

Women using drugs can also exhibit physical and psychological symptoms that warrant further assessment to determine if drug use could be a possible etiological factor. These may include the following:

■ Bloodshot eyes ■ Changes in sleep patterns

■ Changes in appetite ■ Loss of interest in grooming ■ Unusual smells on clothing and breath ■ Impaired coordination ■ Slurred speech ■ Tremors ■ Personality changes ■ Hyperactivity, giddiness ■ Anxiety without a cause ■ Mood swings ■ Sudden anger or tearfulness ■ Decreased motivation

ASSESSMENT AND SCREENING

Many women who use drugs and alcohol will not readily disclose this information to their practitioner. The Substance Abuse and Mental Health Services istration (SAMHSA, 2009) recommends that clients should be screened at each encounter and asked about their use of alcohol and illicit substances. Providers often worry that asking women about drug use will create a sense of negative judgment; however, utilizing a nonjudgmental approach and explaining that all women are asked these routine questions will usually alleviate uncomfortable feelings for the woman and the nurse. In women suspected of alcohol or drug use, a complete physical examination is warranted along with laboratory testing that includes blood-alcohol levels, a drug screen, HIV, hepatitis B and C, HPV, syphilis, chlamydia, gonorrhea, tuberculosis, and a Pap smear. Women who use drugs have higher incidences of infectious diseases and sexually transmitted infections.

PHARMACOLOGICAL TREATMENT

Women must first undergo medical detoxification from the substance. Some women may be given specific medications to ease the symptoms associated with withdrawal. Pharmacological treatment varies widely and is based on the type of substance involved. Alcohol dependence, for example, can be treated with a variety of agents, including anticonvulsants for acute alcohol withdrawal and benzodiazepines and barbiturates to reduce agitation symptoms related to withdrawal. Disulfiram (Antabuse) and opioid receptor antagonists, such as naltrexone (Vivitrol) are sometimes used to prevent relapses and aid in maintenance. Other drugs are selected based on the indication needed. Withdrawal from opiates is often treated with methadone, buprenorphine, and naltrexone. Medications commonly used for withdrawal from nicotine associated with tobacco use include nicotine-replacement agents, such as patches, gums, lozenges, and sprays. In addition, two other medications have also been FDAapproved for tobacco addiction: bupropion (Wellbutrin) and varenicline (Chantix) (National Institute on Drug Abuse, 2011c). As with other mental illnesses, comorbidities should also be treated. Women with a dual diagnosis are commonly maintained on other medications. For example, women with coexisting depression may be maintained on selective serotonin reuptake inhibitors (SSRIs) to treat depressive symptoms along with opioid receptor antagonists to aid in treatment of alcohol abuse. Women with a dual diagnosis should be cared for by practitioners who have experience in the treatment of dual diagnoses.

BEHAVIORAL THERAPIES

Women have distinct differences in their perceptions and preferences for treatment. Women prefer to be treated in a mental health facility rather than one specifically for substance-related issues. Women are more likely to identify stress or anxiety as the causative factor for their issues, whereas men are more likely to identify drug or alcohol use as their primary problem (Hecksher & Hesse, 2009). They are more concerned with harsh treatment and rules than men are when they seek treatment. Because women may have fewer financial resources than men, cost is often a factor when women wish to pursue treatment intervention. Men are more likely than women to seek help for substance abuse issues although when women do receive treatment, they have better treatment outcomes than men. The main modes of treatment for women with drug addiction involve both individual and group counseling sessions. Motivational interviewing is a technique that is sometimes used with women to assess if they are mentally prepared to discontinue drug use and to identify motivating factors needed to change. Cognitive behavioral therapy has been effective in helping women identify, avoid, and cope with situations that may make them crave drugs. Multidimensional family therapy is frequently used with adolescents to address drug abuse issues and family functioning. Contingency management is a form of therapy that utilizes positive reinforcement to reward behaviors that embrace a drug-free lifestyle (National Institute on Drug Abuse, 2011c). Twelve-step programs have been used to treat women with substance abuse disorders. The premise of the program is that a set of guiding principles is used to outline a course for recovery. The program was initially introduced in the 1930s by the cofounders of Alcoholics Anonymous (AA) and has since been used by more than 200 other organizations. It is theorized that millions of people have successfully used the program for addictions, dependency, and behavioral problems. The program embraces a holistic approach in that participants base their recovery in all areas of health, including physical, mental, emotional, and spiritual recovery.

One study examined the belief in a higher power that is reinforced in a 12-step program and found that in Europe some practitioners have voiced concerns that the program may interfere with religious beliefs. These findings were not found in U.S. based providers. (Vederhus, Laudet, Kristensen, & Clausen, 2010). Because of this criticism, it is advisable that nurses familiarize themselves with the program prior to referring clients to this model of care. Some clients with an atheist view and others with feminist views that feel programs are rooted in shame and stigma may not be proper candidates for referrals to these programs (Vederhus, Laudet, Kristensen, & Clausen, 2010; Saunders, 2011).

RESIDENTIAL TREATMENT

Residential treatment regimens have also been commonly used. The successes of residential treatment programs have multiple variables that determine their success. Women make up approximately one-third of the clients in residential treatment centers (Brady & Ashley, 2005). Women who have a past history of childhood abuse or intimate partner violence have poorer outcomes than women without a trauma history (Sacks, McKendrick, & Banks, 2007). Women can be treated in either women-only programs or mixed-sex programs. Women in female-only programs tend to have more significant drug issues, be homeless, pregnant, or on probation. Women who entered female-only programs were more likely to spend more time in treatment and had higher success rates than women who enrolled in mixed-sex programs (Grella, 2010). The women-only facilities are more likely to offer adjunct services that are important for women, such as child care services, prenatal care, transportation, and financial assistance (Brady & Ashley, 2005).

BARRIERS TO TREATMENT SPECIFIC TO WOMEN

Women who wish to pursue substance abuse treatment face barriers that are unique to women. Many women do not have the financial resources to afford treatment programs or the financial resources available to afford child care to attend treatment meetings. Nationally, an estimated 13% of substance abuse treatment programs offer child care services (Brady & Ashley, 2005). Because most women are the primary caregivers of their children, they may have difficulties even attending AA or Narcotics Anonymous (NA) meetings because of lack of child care. Many women become highly motivated to discontinue drug use during pregnancy; however, less than 12% of residential treatment centers offer prenatal care services (Brady & Ashley, 2005). Women also may lack transportation to obtain services. Lack of public transportation or the high cost of transportation can also be a barrier. More female substance abs are unemployed or underemployed compared to their male counterparts, making financial resources scarce (Brady & Ashley, 2005).

SUMMARY

Although men have significantly higher rates of substance abuse than women, the number of women suffering from substance abuse issues continues to rise. Women substance abs face higher rates of medical complications than women who do not use drugs and alcohol. Women face greater barriers in accessing treatment and benefit from programs specifically gaged to treat women. The need for prompt intervention and treatment is imperative for women and their families.

Case Study

LaSheryl is a 29 year old single mother of an adopted daughter who began using alcohol and cocaine when her husband left her. Since beginning her drug use 14 months ago, LaSheryl has lost her job and has been evicted from her apartment. Her children are staying with her sister, however, her sister is unwilling to let LaSheryl stay with her because of her misuse of drugs.

Questions to Consider

Why do women have lower rates of substance use than men? What barriers do women face when attempting to receive treatment for substance abuse issues?

What dual diagnoses commonly coexist with substance abuse in women?

REFERENCES

Brady, T. M., & Ashley, O. S. (Eds.). (2005). Women in substance abuse treatment: Results from the Alcohol and Drug Services Study (ADSS) (DHHS Publication No. SMA 04-3968, Analytic Series A-26). Rockville, MD: Substance Abuse and Mental Health Services istration, Office of Applied Studies. Brady, K., Back, S. A., & Greenfield, S. F. (2009). Women and addiction: A comprehensive view. New York: Guilford Press. Davidson, M. R., London, M. L., & Ladewig, P. A. W. (2012). Olds’ maternalnewborn nursing and women’s health across the lifespan, (9th ed.). Upper Saddle River, NJ: Pearson. Degenhardt, L., Chiu, W. T., Sampson, N., Kessler, R. C., Anthony, J. C., et al. (2008). Toward a global view of alcohol, tobacco, cannabis, and cocaine use: Findings from the WHO World Mental Health Surveys. PLoS Medicine, 5, 141. Galanter, M., & Kleber, H. D. (2008). The American Psychiatric Publishing textbook of substance abuse treatment, 4th ed. Washington, DC: American Psychological Publishing. Ghodse, H., Herrman, H., Maj, M., & Sartorius, N. (2011). Substance abuse disorders: Evidence and experience. New York: Wiley & Blackwell. Grella, C. E. (2010). Women in residential drug treatment: Differences by program type and pregnancy. Journal of Health Care for the Poor and Underserved, 10(2), 1049–2089. Hecksher, D., & Hesse, M. (2009). Women and substance use disorders. Women’s Health, 7(1), 52–70. Kubička, L. and Csémy, L. (2008). Women’s gender role orientation predicts their drinking patterns: A follow-up study of Czech women. Addiction, 103,

929–937. DOI: 10.1111/j.1360-0443.2008.02186.X National Institute on Drug Abuse. (2011a). Drug abuse and addiction: One of America’s most challenging public health problems. Retrieved from http://archives.drugabuse.gov/about/welcome/aboutdrugabuse/ National Institute on Drug Abuse. (2011b). Women and drug abuse. Retrieved from http://archives.drugabuse.gov/womendrugs/Women-DrugAbuse.html National Institute on Drug Abuse. (2011c). Treatment approaches to drug abuse. Retrieved from http://www.nida.nih.gov/infofacts/treatmeth.html Sacks, J. Y., McKendrick, K., & Banks, S. (2007). The impact of early trauma and abuse on residential substance abuse treatment outcomes for women. Journal of Substance Abuse Treatment, 34(1), 90–100. DOI: 10.1016/j.jsat.2007.01.010 Saunders, J. B., Davis, M., & Williams, R. (1984). Do women develop alcoholic liver disease more readily than men? British Medical Journal, 282, 1140–1143. Saunders, J. M. (2011). Feminist perspectives on 12-step recovery: A comparative descriptive analysis of women in alcoholics anonymous and narcotics anonymous. Alcoholism Treatment Quarterly, 29(4), 357–378. DOI: 10.1080/07347324.2011.608595 Substance Abuse and Mental Health Services istration. (2009). Screening, Brief Intervention, and Referral to Treatment (SBIRT): New populations, effectiveness data. SAMHSA News, 17(6), 1–28. Vederhus, J. K., Laudet, A., Kristensen, O., & Clausen, T. (2010). Obstacles to 12-step group participation as seen by addiction professionals: Comparing Norway to the United States. Journal of Substance Abuse Treatment, 39(3), 210– 217. DOI: 10.1016/j.jsat.2010.06.001 Zucker, R. A. (2008). Anticipating problem alcohol use developmentally from childhood into middle adulthood: What have we learned? Addiction (Suppl. 1), 100–108.

Index

abandonment, 52 Abilify. See aripiprazole acceptance and commitment therapy (ACT) for PPAD, 185 acceptance, phase of grief, 248 acculturation, 27. See also culture acute stress, 14. See also stress acute stress disorder, 203 Adderall. See dextroamphetamine adjustment disorder in aging woman, 84 adolescence. See also childhood ADHD in, 68–71 anxiety in, 64–67 ASD in, 77, 79 BPD in, 73–74 conduct disorder in, 70–71 depression in, 72–73 disruptive disorders in, 68–71

eating disorders in, 77 GAD in, 64–65 mood disorders in, 71 OCD in, 65 ODD in, 70 onset of disorders in, 63–64 PD in, 65 PSD in, 65–66 separation anxiety disorder in, 66 social anxiety disorder in, 66 specific phobia in, 67 substance abuse in, 75–76 suicide and, 74–75 treatment of anxiety disorders in, 67–68 Adult Protective Services, 53 affective symptoms, Schizophrenia, 278, 279 African Americans mental health disorders, rates of, 6 poverty and mental health implications, 31–32 women during midlife, 84 aging woman, mental health for, 83–95

adjustment disorder, 84 African American women during midlife, 84 anxiety, 89–90 dementia, 90–92 depression, 87–89 menopause, 85–86 midlife crisis, 83–84 older women, 87 overview, 83 perimenopause, 84–85 screening, 93–94 substance abuse, 92–93 suicide, 89 treatments, 94 agoraphobia, 200 agoraphobia cognitions questionnaire (ACQ), 202 aichmophobia, 209 Alaska Natives mental health disorders, rates of, 6 alcohol use. See also substance abuse in adolescence, 76

in elderly population, 93 female veterans, 125 in lesbian, bisexual, and transgendered women, 116 RLS and, 331 sexual dysfunction and, 319 algophobia, 209 alprazolam for GAD, 196 alternative and complementary therapies for stress reduction, 24 Alzheimer’s disease (AD) dementia and, 90, 91 treatments, 91 Ambien. See zolpidem American Indians mental health disorders, rates of, 6 amitriptyline for ADHD, 70 amnesia, dissociative, 268–269 amygdala and anxiety disorders, 194 AN. See anorexia nervosa androphobia, 209 Angelica sinensis

for sexual dysfunction, 318 anger, phase of grief, 248 anorexia nervosa (AN), 77, 78. See also eating disorders assessment and screening, 235–236 behavioral therapies, 237–238 etiology, 234 level of care needed, 239 overview, 234 pharmacological treatment, 237 during pregnancy, 167 signs and symptoms, 235 antepartum psychological issues, 157–170 anthropophobia, 209 anticipatory grief, 249 antidepressants. See also specific entries for depression during pregnancy, 162, 163 for PMDD, 146 for PTSD, 205 antiepileptic medications for BPD during pregnancy, 165 antipsychotics

for BPD during pregnancy, 165 for Schizophrenia, 279–280 for Schizophrenia during pregnancy, 166–167 anxiety disorders, 193–210. See also specific disorders in childhood and adolescence, 64, 67 etiology, 194 global prevalence of, 7–8 incidence, 4 and infertility, 152 in lesbian, bisexual, and transgendered women, 115 men versus women, 193–194 OCD (see obsessive-compulsive disorder) in older adults, 89–90 overview, 193 PD (see panic disorder) and physical disabilities, 100 physiological disorders, excluding, 194–195 during pregnancy, 158–160, 158–161 PTSD (see posttraumatic stress disorder) social phobia (see social phobia/anxiety disorder) specific phobias (see specific phobias)

treatment during pregnancy, 160–161 treatment, in childhood and adolescence, 67–68 anxiety disorders interview schedule-IV (ADIS-IV), 196 Anxiety Sensitivity Index (ASI), 196 arachnephobia, 209 arachnophobia, 209 aripiprazole for Schizophreniform disorder, 297 arousal disorders, sexual, 313–314, 317 arrhythmias breathing-related sleep disorders and, 327 Asperger’s disorder, 77 assessment transcultural assessment model, 35–40 assimilation, 27. See also culture Ativan. See lorazepam atomoxetine for ADHD, 70 attention deficit/hyperactivity disorder (ADHD), 19 in childhood and adolescence, 68–70 symptoms, 68 treatment, 69–70

atypical antipsychotics for Schizophrenia, 281 auditory hallucinations, 288 autism incidence, 4 autism-spectrum disorders (ASD) in childhood and adolescence, 77, 79

baby blues, 175 bacteriophobia, 209 bargaining, phase of grief, 248 barriers cultural, to mental health care services, 32–33 to forensic mental health care facilities, 135 to forensic mental health research, 135–136 to health care services for lesbian, bisexual, and transgendered women, 112–113 Beck Anxiety Inventory, 196 behavioral therapies for AN, 237–238 for BN, 241 for BPD, 229 for breathing-related sleep disorders, 328–329

for brief psychotic disorder, 295 for delusional disorder, 301 for dissociative disorders, 272–273 for GAD, 197 for grief/loss, 257–258 for MDD, 220–221 for OCD, 199–200 for PD, 202–203 for personality disorders, 265–267 for postpartum depression, 178 for postpartum psychosis, 181–182 for PPAD, 184–185 for PTSD, 205–206 for RLS, 331 for SAIP, 305 for Schizoaffective disorder, 292–293 for Schizophreniform disorder, 297–298 for sexual dysfunction, 318–319 for shared psychotic disorder, 307 for social phobia/anxiety disorder, 207 benzodiazepines, 89, 105, 146

for anxiety during pregnancy, 160 for PD, 202, 203 for social phobia, 207 bereavement, 247 binge eating disorder (BED), 78, 241–242 health manifestations, 242 during pregnancy, 167 bio for sexual dysfunction, 319 biological factors, 4–5 bipolar disorder (BPD), 71 assessment and screening, 224–225 behavioral therapies, 229 in childhood and adolescence, 73–74 and disability, 7 dual diagnosis and, 225 etiology of, 223–224 incidence, 4 overview, 223 pharmacological treatment, 225–228 during pregnancy, 164–165

signs and symptoms, 224 types of, 74 birth defects paxil and, 163 bisexual women. See lesbian, bisexual, and transgendered women Blacks income levels, 19, 20 mental health disorders, rates of, 6 blood glucose levels during pregnancy, 168 body sensations questionnaire (BSQ), 202 body’s stress response, 14–15 borderline/dependent ab, 48 borderline personality disorder, 4 BPD type I, 73, 74 BPD type II, 73, 74 breathing-related sleep disorders, 327–329 assessment and screening, 328 behavioral therapies, 328–329 etiology, 327–328 pharmacological treatment, 328 risk associated, 327

signs and symptoms, 328 brief psychotic disorder, 289, 293–295 assessment and screening, 294 behavioral therapies, 295 etiology, 293–294 overview, 293 pharmacological treatment, 294–295 signs and symptoms, 294 bulimia nervosa (BN), 77, 78. See also eating disorders assessment and screening, 240–241 behavioral therapies, 241 etiology, 240 overview, 240 pharmacological treatment, 241 during pregnancy, 167–168 signs and symptoms, 240 bupropion for ADHD, 70, 73 for anxiety during pregnancy, 161 for depression, 70, 73 for perinatal depression, 162

for substance abuse disorders, 343 Buspar. See buspirone buspirone for anxiety during pregnancy, 160

caffeine and RLS, 331 carbamazepine avoid during pregnancy, 164 for Schizoaffective disorder, 292 carbidopa-levodopa for RLS, 330 caregivers, resources for, 23 caregiver stress, 21–22 interventions to decrease, 22 Caucasians income levels, 20 Celexa. See citalopram Chantix. See varenicline childhood. See also adolescence ADHD in, 68–71 anxiety in, 64–67 ASD in, 77, 79 BPD in, 73–74

conduct disorder in, 70–71 disruptive disorders in, 68–71 GAD in, 64–65 mood disorders in, 71 OCD in, 65 ODD in, 70 onset of disorders in, 63–64 PD in, 65 prevalence in ages 7 to 19 years, 64 PSD in, 65–66 selective mutism in, 66–67 separation anxiety disorder in, 66 social anxiety disorder in, 66 specific phobia in, 67 treatment of anxiety disorders in, 67–68 childhood disintegrative disorder, 77, 79 child, loss of grief related to, 254 chiraptophobia, 209 chloral hydrate for anxiety during pregnancy, 160 chlordiazepoxide for GAD, 196

chronic illness, 5–6 depression associated with, 104–106 and mental health, 103–104 chronic pain, and mental health, 104 chronic stress, 14. See also stress physical and psychological disorders associated with, 16 chronoceptive hallucinations, 288 Cimicifuga racemosa for sexual dysfunction, 318 citalopram, 68, 73 birth defects and, 163 for PD, 202 for perinatal depression, 163 clonazepam for PD, 202 clozapine during pregnancy, 165 for Schizophrenia during pregnancy, 167 Clozaril. See clozapine cognitive behavioral therapy (CBT), 67, 90 for anxiety, 161 for anxiety during pregnancy, 161

for GAD, 197 for OCD, 199–200 for PPAD, 184–185 for Schizophrenia, 282 cognitive symptoms, Schizophrenia, 278, 279 collaborative team approach for Schizophrenia, 283 combat operations stressor for female veterans, 122 combined oral contraceptives (COCs) for PMDD, 145–146 comorbidities in girls with depression, 73 mental illness and, 8 competence, cultural. See cultural competence competency, to stand trial, 133 complicated grief, 249–250 compulsive eating disorder. See binge eating disorder (BED) Concerta. See methylphenidate conduct disorder in childhood and adolescence, 70–71 congenital abnormality, identified grief as a result of, 253–254 continuous positive airway pressure (AP)

for breathing-related sleep disorders, 328 correctional setting. See also forensic mental health issues for female mentally ill detainees, 131–133 corticotropin-releasing factor (CRF) anxiety disorders and, 194 costs, of treatment, 8–9 cultural competence defined, 27–28 in mental health, 28 mental health care strategies, 33 treatment strategies, 35–40 cultural disparities, 6 culture. See also cultural competence barriers to mental health care services, 32–33 beliefs, 34 defined, 27 ethnicity and, 27 immigration and, 27 implications, race and, 31 inequality in mental health services, 28–31 misdiagnosis and, 33–35

physical disability and, 102 poverty and, 31 racism and discrimination, 32 reactions to infertility, 150 role of, 27–40 transcultural assessment model, 35–40 culture shock, defined, 27 cyclothymia, 223 cyclothymic disorder, 73, 74 Cymbalta. See duloxetine

death cause of, among American women, 8, 9 of spouse, grief related to, 254–255 Defense of Marriage Act, 123 delusional disorder, 289, 298–301 assessment and screening, 299 behavioral therapies, 301 disability and, 7 etiology, 298 overview, 298

pharmacological treatment, 299 signs and symptoms, 299 subtypes, 300 delusions, 288 dementia causes of, 90–91 multiinfarct, 92 older adults, 90–92 signs of, 90 treatments, 91 denial, phase of grief, 248 Depakote. See valproic acid depersonalization disorder, 271–272 depression in adolescence, 72–73 chronic conditions associated with, 104–106 comorbidities in girls, 73 disability and, 7 female veterans, 126 incidence, 4 and infertility, 151–152

in lesbian, bisexual, and transgendered women, 115 medications associated with, as a side effect, 88, 104–105 and older women, 87–89 phase of grief, 248 physical disabilities and, 100 during pregnancy, 161–164 symptoms, BPD, 224 symptoms, in girls and teens, 72 treatment, 73 Desyrel. See trazodone detainees, female. See also forensic mental health issues correctional setting for mentally ill, 131–133 statistics, 130–131 Dexedrine. See dextroamphetamine dexmethylphenidate for ADHD, 69 dextroamphetamine for ADHD, 69 for narcolepsy, 333 Dextrostat. See dextroamphetamine DHEA, for sexual dysfunction, 318 diabetes, during pregnancy, 168

diabulimia, 168. See also bulimia nervosa diagnosis, societal issues, 3 dialectical therapy for PPAD, 185 diazepam for GAD, 196 diminished capacity, 133 disability(ies). See also intellectual disabilities; physical disabilities causes, 99 children, stress and, 18–19 defined, 99 discrimination and, 33 federal programs, 7 from mental illness, 6–7 discrimination physical disability and, 102 racism and, 32 disparities, cultural and mental illness, 6 disruptive disorders. See also specific disorders childhood and adolescence, 68–71 risk factors, 71 treatment, 71

dissociative amnesia, 268–269 dissociative disorders, 267–274 assessment and screening, 268 behavioral therapy, 272–273 depersonalization disorder, 271–272 DID, 269–271 dissociative amnesia, 268–269 dissociative fugue, 271 etiology, 267 overview, 267 pharmacological treatment, 272 signs and symptoms, 268 dissociative fugue, 271 dissociative identity disorder (DID), 269–271 distress, defined, 13 disulfiram for substance abuse disorders, 343 divalproex sodium for BPD, 226 divorce/separation, grief related to, 255–256 domestic abuse. See intimate partner violence domestic violence. See intimate partner violence “Don’t Ask, Don’t Tell” laws, 123

Down syndrome and IDs, 103 drug abuse as risk factors, 13 DSMIV-TR criteria, 83, 93 dual diagnosis, 76, 339 BPD and, 225 duloxetine for perinatal depression, 162 Dusky Standard, 133 dyspareunia, 314 dyssomnias, 323 dysthymic disorder (DD), 222–223

eating disorders, 233–244 in adolescence, 77 classifications of, 78 female veterans, 125–126 incidence, 4 overview, 233 during pregnancy, 167–169, 242–243 recommended tests, 238 eating disorders not otherwise specified, 77 economic difficulties as risk factors, 13

Effexor. See venlafaxine Elavil. See amitriptyline elder abuse, 51–53 types of, 52 elderly. See aging woman, mental health for; older adults; older women electroconvulsive therapy (ECT) for depression during pregnancy, 162 for MDD, 221 emotional abuse, 52 empty nest syndrome, 18 Emsam. See selegiline Equal Pay Act of 1963, 19 equilibrioception hallucinations, 288 Eros clitoral therapy device for sexual dysfunction, 317 erotophobia, 209 escitalopram, 68, 90 for GAD, 197 Eskalith. See lithium estrogen therapy for sexual dysfunction, 317 eszopiclone for anxiety during pregnancy, 160 ethnic diversities related to mental health services, 28–30

ethnicity. See also culture; racism defined, 27 minorities, psychotic disorders and, 287 eustress, defined, 13 exhibitionism, 311, 312 expenditures, health care, 8–9 exposure therapy for PPAD, 185 for specific phobias, 209 eye movement desensitization and reprocessing (EMDR) behavioral therapies, 205 for PPAD, 185

Fanapt. See iloperidone female friends, 15–17 female-related stressors, female veterans, 122 female sexual arousal disorder (FSAD), 313–314 female-to-male transsexuals (FMT), 113 female veterans, 121–126 alcohol use, 125 combat operations, 122

depression, 126 eating disorders, 125–126 female-related stressors, 122 lesbian families, 123 marital stressors, 123–124 military-related PTSD, 124–125 military sexual trauma, 124 overview, 121–122 risk factors, 121–122 separation from family, 122 stressors, 122–124 substance abuse, 125 suicide, 126 types, 121 feminization of poverty, 31 Ferula hermonis for sexual dysfunction, 318 fetishism, 311, 312 fight-or-flight response, 14 financial abuse, 52–53 financial stressors, 19–20

first-generation antipsychotics for Schizophrenia, 280 fluoxetine, 68, 73, 89 for anxiety during pregnancy, 160 birth defects and, 163 for GAD, 197 for insomnia, 326 for PD, 202 for perinatal depression, 163 for PMDD, 146 fluvoxamine, 68, 89 anxiety disorders and, 197 breast milk and, 186 Focalin. See dexmethylphenidate folie a deux. See shared psychotic disorder Food and Drug istration (FDA), 68 forensic, defined, 131 forensic mental health issues. See also detainees, female barriers, to conducting research, 135–136 barriers, to health care services, 135 competency to stand trial, 133 within correctional setting, 131–133

defined, 131 diminished capacity, 133 NGRI/“guilty but mentally ill,” 133–134 prevention and treatment, 135 friendships as effective means to reduce depression, 16–17 female, 15–17 frigidity. See sexual arousal disorders frontotemporal Dementia (FTD), 90, 92 frottceurism, 311, 312

gabapentin for BPD, 226 for RLS, 330 gender identity disorder (GID), 114–115 causes, 114 characteristics, 114 gender inequality in women’s mental health, 4 generalized anxiety disorder (GAD), 159, 193, 195–197. See also anxiety disorders assessment and screening, 196

behavioral therapies, 197 in childhood and adolescence, 64–65 etiology, 195 overview, 195 pharmacological treatment, 196–197 signs and symptoms, 195–196 Generalized Anxiety Disorder 7-item Scale, 196 genophobia, 209 Geodon. See ziprasidone Ginkgo biloba for sexual dysfunction, 318 global prevalence, 7–8 gonadotropin-releasing hormone (GnRH) for PMDD, 146 grief and loss, 247–258 anticipatory grief, 249 assessment and screening, 256–257 behavioral therapies, 257–258 complicated grief, 249–250 death of a spouse, 254–255 defined, 247

early pregnancy loss and, 251–253 identified congenital abnormality, 253–254 infertility and, 250–251 loss of a child, 254 overview, 247–248 perinatal grief, 251 pharmacological treatment, 257 separation/divorce, 255–256 stages of, 248 stillbirth, 251–253 tasks of, 249 group therapy for Schizophrenia, 282 “guilty but mentally ill” (GBMI), 133–134 gustatory hallucinations, 288

Halcion. See triazolam Haldol. See haloperidol hallucinations, 288 auditory, 288 chronoceptive, 288 equilibrioception, 288

gustatory, 288 nociceptive, 288 olfactory, 288 proprioception, 288 tactile, 288 thermoception, 288 types, 288 visual, 288 haloperidol for brief psychotic disorder, 295 health care services barriers, for lesbian, bisexual, and transgendered women, 112–113 cultural barriers to, 32–33 culturally competent strategies, 33 effective, for lesbian, bisexual, and transgendered women, 117 ethnic diversities related to, 28–30 expenditures, 8–9 inequality in, 28–31 hedonophobia, 209 Heller’s syndrome. See childhood disintegrative disorder heterophobia, 209 Hispanics

income levels, 19, 20 mental health disorders, rates of, 6 HIV/AIDS, 8 holistic nursing care for disabled woman, 106–107 homelessness as risk factors, 13 homicide by male perpetrators, 44–45 Horizant. See gabapentin hormonal therapy for GID, 114 hormone replacement therapy (HRT), 86 hostile/controlling ab, 47–48 Humulus lupulus for sexual dysfunction, 318 hypertension and breathing-related sleep disorders, 327 hypnagogic hallucinations, 332 hypnopompic hallucinations, 332 hypnosis for sexual dysfunction, 319 hypoactive sexual desire disorder (HSDD), 313 hyponatremia, 89

iloperidone for Schizophreniform disorder, 297 immigration and culture, 27

incidence, of mental illness, 3–4 inequality(ies) in mental health services, 28–31 in women’s mental health, 4 (see also gender inequality) infectious insanity. See shared psychotic disorder infertility, 149–154 anxiety, 152 assessment and screening, 152–153 cultural and religious reactions, 150 defined, 149 depression, 151–152 grief as a result of, 250–251 overview, 149–150 primary, 149 psychological reactions, 150–151 secondary, 149 signs and symptoms, 152, 153 stress, 151 treatment, 153–154 Insanity Defense Reform Act of 1984, 133 insectophobia, 209

insomnia, 88, 324–327 assessment and screening, 325–326 behavioral therapies, 327 etiology, 324–325 pharmacological treatment, 326 signs and symptoms, 325 intellectual disabilities (IDs) and mental health, 102–103 International Classification of Sleep Disorders, 323 interpersonal therapy for PPAD, 185 intimate-partner violence (IPV) behavioral consequences of, 45–46 male-dominated cultures and, 49 mental illness and, 46 national organizations for screening, 53 neuropsychological development and, 158 patient safety checklist, 56 physical illness related to, 46–47 in United States, 43–44 intrapartum psychological issues, 157–170. See also pregnancy Invega. See paliperidone

isocarboxazid for social phobia, 207

katsaridaphobia, 209 Klonopin. See clonazepam kolpophobia, 209 Kubler-Ross, Elisabeth stages of grief, 248

lactation and postpartum mood disorders, 185–186 Lamictal. See lamotrigine lamotrigine avoid during pregnancy, 164 for BPD, 226 language issues as barrier to mental health services, 32 L-arginine for sexual dysfunction, 318 late-onset depression. See also depression defined, 87 Lepidium meyenii for sexual dysfunction, 318 lesbian, bisexual, and transgendered women, 111–117 anxiety, 115

barriers to health care services, 112–113 causative factors, 111 cultural barriers to mental health services, 32–33 depression, 115 effective health care practices for, 117 gender identity disorder, 114–115 in military, 123 overview, 111 risk factors, 111 self-harm practices, 116 sexual dysfunction, 311 stressors faced by, 112 substance abuse, 116 suicide, 116–117 Lewy body dementia, 90, 92 Lexapro. See escitalopram Librium. See chlordiazepoxide lithium for BPD, 226 for BPD during pregnancy, 164–165 for Schizoaffective disorder, 292

lithium carbonate, 164–165 Lithobid. See lithium lockiophobia, 209 lorazepam for insomnia, 326 for PD, 202 Lunesta. See eszopiclone Luvox. See fluvoxamine

major affective disorder as chronic mental illness, 5 major depressive disorder (MDD), 87, 213–221 assessment and screening, 215–216 behavioral therapies, 220–221 in childhood and adolescence, 71 and disability, 7 etiology, 213–214 in incarcerated women, 130 overview, 213 perimenopause and, 85 pharmacological treatment, 216–220

signs and symptoms, 214–215 major tranquilizers for Schizophrenia, 280 male-dominated cultures and IPV, 49 male perpetrators, homicide by, 44–45 male-to-female transsexuals (MFT), 113 mania symptoms, BPD, 224 MAOIs. See monoamine oxidase inhibitors marital stressors, female veterans, 123 Marplan. See isocarboxazid marriages, unhappy as a cause of stress, 16 maternal depression, during pregnancy, 161–164 treatment, 162–164 maternal stress. see also stress during pregnancy, 157–158 medications. See also specific drugs associated with depression as a side effect, 88, 104–105 menopause, 85–86 menophobia, 209 menstrual-related hypersomnia, 331 menstrual-related issues, 141–147

overview, 141 premenstrual dysphoric disorder, 144–147 premenstrual syndrome, 141–143 “Mental Health: A Report of the Surgeon General,” 28 mental health disability, 6–7 Metadate. See methylphenidate methamphetamines, 129 methylphenidate for ADHD, 69 for narcolepsy, 333 midlife African American women during, 84 crisis, 83–84 Milieu therapy for Schizophrenia, 283 military sexual trauma (MST), 124 mini-mental status examination, components of, 94 Mini-SPIN, 207 minorities income levels, 19, 20 mental health disorders, rates of, 6 Mirapex. See pramipexole

mirtazapine for insomnia, 326 for PD, 202 for perinatal depression, 162 misdiagnosis, cultural aspects leading to, 33–35 misogyny, 48 mixed episode BPD, 73, 74 mixed-sex programs for substance abuse disorders, 345 mobility inventory for agoraphobia (MIA), 202 modafinil for narcolepsy, 333 monoamine oxidase inhibitors (MAOIs), 73 for depression during pregnancy, 162 for GAD, 197 for perinatal depression, 163 for social phobia, 207 mood disorders, 213–230 BPD (see bipolar disorder) in childhood and adolescence, 71 DD, 222–223 MDD, 213–221 overview, 213

seasonal affective disorder (SAD), 221–222 suicide risks, 229–230 mood stabilizers. See also specific entries BPD and, 164, 226 during pregnancy, 164–165 mourning, 247 multiinfarct dementia, 92 multiple sleep latency testing (MSLT) for insomnia, 326 mutism, selective in childhood, 66–67 myocardial infarction breathing-related sleep disorders and, 327 incidence of, 8

naltrexone for substance abuse disorders, 343 narcolepsy, 331–334. See also sleep disorders assessment and screening, 332–333 behavioral therapies, 333–334 etiology, 331–332 pharmacological treatment, 333

signs and symptoms, 332 narcotics anonymous (NA) meetings substance abuse and, 345 Nardil. See phenelzine Navane. See thiothixene nefazodone for perinatal depression, 162 negative symptoms, Schizophrenia, 278, 279 neglect, 52 neuroleptics for Schizophrenia, 280 Neurontin. See gabapentin nociceptive hallucinations, 288 noncoital sexual pain disorder, 315 nonspecified eating disorder during pregnancy, 167 “not guilty by reason of insanity” (NGRI), 133–134 nudophobia, 209 nursing care holistic, for disabled woman, 106–107

obsessive-compulsive disorder (OCD), 159, 197–200. See also anxiety disorders assessment and screening, 198–199 behavioral therapies, 199–200

in childhood and adolescence, 65 etiology, 198 pharmacological treatment, 199 signs and symptoms, 198 olanzapine for brief psychotic disorder, 295 for MDD, 295 for Schizophreniform disorder, 297 older adults. See also aging woman, mental health for anxiety disorders in, 89–90 dementia, 90–92 older women, 87. See also aging woman, mental health for depression and, 87–89 substance abuse in, 92–93 suicide in, 89 olfactory hallucinations, 288 oppositional defiant disorder (ODD) in childhood and adolescence, 70 orgasm disorders, 314 SSRI and, 314 oxcarbazepine for BPD, 228

pain, chronic and mental health, 104 pain disorders, sexual, 314–315 paliperidone for brief psychotic disorder, 295 for Schizophreniform disorder, 297 panic disorder (PD), 159, 182. See also anxiety disorders assessment and screening, 201–202 behavioral therapies, 202–203 in childhood and adolescence, 65 etiology, 201 overview, 200 pharmacological treatment, 202 signs and symptoms, 201 paranoid personality disorder and disability, 7 paraphilias, types, 311, 312 parasomnias, 323–324 parenting stressors, 17–19 empty nest syndrome, 18 external, 18

internal, 18 Parnate. See tranylcypromine paroxetine, 68, 89 for GAD, 196 for PD, 202 for perinatal depression, 162, 163 for PMDD, 146 Patient Health Questionnaire, 196 Paxil. See paroxetine pedophilia, 311, 312 perceptions, false about disabled women, 101–102 “perfect woman,” pressures to be as stressor, 20–21 pergolide for RLS, 330 perimenopause, 84–85 perinatal depression, psychosocial risk factors, 161 perinatal grief, 251 Permax. See pergolide perpetrators categories, 47–48

characteristics of, 47–49 male, homicide by, 44–45 personality disorders, 261–267 assessment and screening, 264 behavioral therapies, 265–267 etiology, 262 overview, 261 pharmacological treatment, 264–265 signs and symptoms, 262–264 pervasive developmental disorder (PDD). See autism-spectrum disorders pharmacological treatment for AN, 237 for BN, 241 for breathing-related sleep disorders, 328 for brief psychotic disorder, 294–295 for delusional disorder, 299 for dissociative disorders, 272 for GAD, 196–197 for grief/loss, 257 for MDD, 216–220 for OCD, 199

for PD, 202 for personality disorders, 264–265 for postpartum depression, 177–178 for postpartum psychosis, 181 for PPAD, 184 for PTSD, 205 for RLS, 330 for SAIP, 305 for Schizoaffective disorder, 292 for Schizophrenia, 279–282 for sexual dysfunction, 317–318 for shared psychotic disorder, 307 for social phobia/anxiety disorder, 207 phenelzine for social phobia, 207 philophobia, 209 phobias specific (see specific phobias) types, 209 physical abuse, 52 physical disabilities, 99–107. See also intellectual disabilities anxiety and, 100

chronic illness (see chronic illness) defined, 99 depression and, 100 false perceptions, 101–102 holistic nursing care for, 106–107 overview, 99 violence affecting women with, 100–101 Pick’s disease. See frontotemporal dementia (FTD) polydrug abuse, 337 positive symptoms, Schizophrenia, 278, 279 postpartum anxiety disorders (PPAD), 182–185 assessment and screening, 184 behavioral therapies, 184–185 etiology, 183 overview, 182 PD, 182 pharmacological treatment, 184 PPOCD, 183 PTSD, 182–183 signs and symptoms, 183–184 postpartum blues, 161

postpartum depression (PPD), 161, 175–178 assessment and screening, 176–177 behavioral therapies, 178 etiology, 175–176 overview, 175 pharmacological treatment, 177–178 signs and symptoms, 176 postpartum mood disorders, 173–187 baby blues, 175 lactation and, 185–186 overview, 173–174 risk factors, 174 postpartum obsessive-compulsive disorder (PPOCD), 183 postpartum psychosis (PPP), 179–182 assessment and screening, 180 behavioral therapies, 181–182 etiology, 179 pharmacological treatment, 181 signs and symptoms, 179–180 posttraumatic stress disorder (PTSD), 158–160, 182–183, 203–206 acute, 205

assessment and screening, 205 behavioral therapies, 205–206 in childhood and adolescence, 65–66 chronic, 205 as chronic mental illness, 5–6 delayed, 205 etiology, 204 incidence, 4, 203 military-related, 125 overview, 203 pharmacological treatment, 205 during pregnancy, 158–160 signs and symptoms, 204–205 poverty and mental health implications, 31–32 pramipexole for RLS, 330 pregnancy anxiety during, 158–161 bipolar disorder during, 164–165 depression during, 161–164 eating disorders during, 167–169 stress during, 157–158

thought disorders during, 165–167 pregnancy loss, early grief as a result of, 251–253 premenstrual dysphoric disorder (PMDD), 74, 85, 144–147 assessment and screening, 144–145 etiology, 144 overview, 144 signs and symptoms, 144, 145 treatment, 145–147 Premenstrual Symptoms Screening Tool (PSST), 144 premenstrual syndrome (PMS), 74, 85, 141–143 assessment and screening, 143 etiology, 142 overview, 141 signs and symptoms, 142 treatments, 143 prevalence, global, 7–8 primary care evaluation of mental disorders (PRIME-MD), 196, 202 proprioception hallucinations, 288 Provigil. See modafinil Prozac. See fluoxetine

psychoeducation for sexual dysfunction, 318 psychological therapies for Schizophrenia, 282–283 psychotic disorders, 287–308 brief psychotic disorder, 293–295 delusional disorder, 298–301 MDD, 301–303 overview, 287 prevalence, 288 SAIP, 303–305 Schizoaffective disorder, 289–293 Schizophreniform disorder, 295–298 shared psychotic disorder, 305–307 types, 288–289 Puerto Ricans mental health disorders, rates of, 6

quetiapine for brief psychotic disorder, 295 for MDD, 295 for Schizophreniform disorder, 297

race and cultural implications, 31 lifetime rate of rape/attempted rape for women by, 50 racism. See also ethnicity and discrimination, 32 raising children and stress, 17–19 rape, 50–51. See also violence incidence of, 50 rapid cycling, 226 rapid-cycling BPD, 73, 74 reality-oriented therapy for Schizophrenia, 282 religion. See also culture reactions to infertility, 150 Remeron. See mirtazapine Requip. See ropinirole residential treatment for substance abuse disorders, 345 RESOLVE, 154 restless legs syndrome (RLS), 329–331. See also sleep disorders assessment and screening, 330 behavioral therapies, 331 etiology, 329

pharmacological treatments, 330–331 signs and symptoms, 330 Restoril. See temazepam Rett’s disorder, 77, 79 rhypophobia, 209 Risperdal. See risperidone risperidone for brief psychotic disorder, 295 for MDD, 295 for Schizophreniform disorder, 297 Ritalin. See methylphenidate RLS. See restless legs syndrome ropinirole for RLS, 330

sandwich-generation women exposed to stressors, 21 Sarafem. See fluoxetine Schizoaffective disorder, 289–293 assessment and screening, 291–292 behavioral therapies, 292–293 etiology, 290 pharmacological treatment, 292

signs and symptoms, 290–291 negative symptoms and their presentations, 291 Schizophrenia, 277–283 as chronic mental illness, 5 and disability, 7 etiology, 277–278 incidence, 4 overview, 277 perinatal outcomes, 166 pharmacological treatment, 279–282 during pregnancy, 165–167 psychological therapies, 282–283 signs and symptoms, 278–279 types of, 280 Schizophreniform disorder, 289, 295–298 assessment and screening, 296 behavioral therapy, 297–298 etiology, 296 overview, 295 pharmacological treatment, 297 signs and symptoms, 296

scotophobia, 209 screening assessment of depression-polarity (SAD-P) for BPD, 224–225 screening, in elderly population, 93–94 seasonal affective disorder (SAD), 221–222 second-generation drugs for Schizophrenia, 281 selective mutism in childhood, 66–67 selective serotonin reuptake inhibitors (SSRIs), 67–68, 73, 88–89, 90, 160–161. See also specific types for anxiety, 160–161 for anxiety during pregnancy, 160–161 for GAD, 196–197 for narcolepsy, 333 orgasm disorders and, 314 for perinatal depression, 162–164 for Schizoaffective disorder, 292 for social phobia, 207 for substance abuse disorders, 343 selegiline for social phobia, 207 self-esteem and physical disability, 102 self-harm practices, 116

self-neglect, 52 separation anxiety disorder in childhood and adolescence, 66 separation/divorce, grief related to, 255–256 separation from family, stressor for female veterans, 122 Seroquel. See quetiapine serotonin–norepinephrine reuptake inhibitors (SNRIs) for GAD, 196–197 for narcolepsy, 333 for Schizoaffective disorder, 292 sertraline hydrochloride, 67, 68 for depression, 73 dose, 67 for GAD, 197 for insomnia, 326 for PMDD, 146 for PTSD, 205 Serzone. See nefazodone sexual abuse, 52 sexual arousal disorders, 313–314 etiology, 314 sexual assault, 50–51. See also violence

incidence of, 50 sexual assault nurse examiner (SANE), 52 sexual aversion, 313 sexual desire disorders, 313 etiology, 313 sexual dysfunction, 311–320 arousal disorders, 313–314 assessment and screening, 316–317 behavioral therapies, 318–319 etiology, 315–316 orgasm disorders, 314 overview, 311 pain disorders, 314–315 pelvic abnormalities, etiologies related to, 317 pharmacologic treatment, 317–318 prevalence of, 311 sexual desire disorders, 313 sexuality and physical disability, 101 sexual masochism, 311, 312 sexual pain disorders, 314–315 etiology, 315

sexual reassignment surgery for GID, 115 sexual sadism, 311, 312 shared imposed psychosis. See shared psychotic disorder shared paranoid disorder. See shared psychotic disorder shared psychotic disorder, 289, 305–307 assessment and screening, 306–307 behavioral therapies, 307 etiology, 306 pharmacological treatment, 307 signs and symptoms, 306 subtypes, 306 Sheehan patient rated anxiety scale (SPRAS), 196 “silent strokes,” 92 simple phobias. See specific phobias Sinemet. See carbidopa-levodopa sleep apnea, 327. See also breathing-related sleep disorders sleep attack, 332 sleep disorders, 323–334 breathing-related sleep disorders, 327–329 (see also breathing-related sleep disorders) dyssomnias, 323

insomnia, 324–327 (see also insomnia) narcolepsy, 331–334 overview, 323 parasomnias, 323–324 RLS, 329–331 (see also restless legs syndrome (RLS)) sleep paralysis, 332 smoking and sexual dysfunction, 318 social anxiety disorder in childhood and adolescence, 66 socialization problems as risk factors, 13 social phobia/anxiety disorder, 159, 206–207. See also anxiety disorders assessment and screening, 207 behavioral therapies, 207 etiology, 206 pharmacological treatment, 207 signs and symptoms, 206 Social Phobia Inventory (SPIN), 207 Social Security Disability Insurance (SSDI), 7 social skills training for Schizophrenia, 283 sodium oxybate for narcolepsy, 333 soldiers, female. See female veterans Sonata. See zaleplon

specific phobias, 207–209. See also anxiety disorders assessment and screening, 208 childhood and adolescence, 67 etiology, 208 overview, 207–208 signs and symptoms, 208–209 spousal abuse. See intimate partner violence stalking, 44 statistics, 5–6 stay-at-home mothers, parenting stressors, 17 stillbirth grief as a result of, 251–253 stimulants in ADHD, 69 Strattera. See atomoxetine stress acute, 14 alternative and complementary therapies, 24 body’s response, 14–15 caregiver, 21–22 chronic, 14 distress, 13 effects of, 14–15

eustress, 13 and infertility, 151 interventions for coping with, 22–24 maternal, during pregnancy, 157–158 modernizing factors, 13 nontraditional student, returning to school as a, 20 during pregnancy, 157–158 raising children and, 17–19 relationship issues, 15–17 risk factors, 13–14 types of, 13 stressors, 13–24 faced by lesbian, bisexual, and transgendered women, 112 female veterans, 122–124 interventions, 22–24 parenting, 17–19 relationship issues, 15–17 sandwich-generation women, 21 striving to be the “perfect woman,” 20–21 work and financial, 19–20 stroke and breathing-related sleep disorders, 327

substance abuse, 337–345 in adolescence, 75–76 assessment and screening, 343 barriers to treatment, 345 behavioral therapies, 344 classification, 340–341 common problems associated with, 338 defined, 339 dual diagnosis, 339 etiology, 341–342 female veterans, 125 intimate partner violence and, 45 in lesbian, bisexual, and transgendered women, 116 in older women, 92–93 overview, 337 pharmacological treatment, 343 residential treatment, 345 signs and symptoms, 342 women in criminal justice system, 129–130 (see also forensic mental health issues) Substance Abuse and Mental Health Services istration (SAMHSA), 343

substance abuse induced psychosis (SAIP), 303–305 assessment and screening, 305 behavioral therapies, 305 etiology, 304 overview, 303–304 pharmacological treatment, 305 signs and symptoms, 304–305 substance dependence, 340 substance-induced disorders, 340, 341 substance intoxication, 339–340 substance use, 339 disorders, 340 substance withdrawal, 340 suicide and adolescence, 74–75 female veterans, 126 in lesbian, bisexual, and transgendered women, 116–117 mood disorders and, 229–230 in older women, 89 Supplemental Security Income (SSI), 7 symbiotic psychosis. See shared psychotic disorder

tactile hallucinations, 288 tamoxifen (Soltamox), 103–104 Tegretol. See carbamazepine temazepam for insomnia, 326 testosterone therapy for sexual dysfunction, 317 thermoception hallucinations, 288 thiothixene for brief psychotic disorder, 295 thought disorders during pregnancy, 165–167 treatment, 166–167 tobacco use. See also substance abuse in elderly population, 93 in lesbian, bisexual, and transgendered women, 116 RLS and, 331 tocophobia, 209 Topamax. See topiramate topiramate for BPD, 226 transcultural assessment model, 35–40 transgender, defined, 113 transgendered women. See lesbian, bisexual, and transgendered women tranylcypromine for social phobia, 207

trauma. See also violence caring for woman experiencing, 53–57 trazodone for perinatal depression, 162 triazolam for insomnia, 326 Tribulus terrestris for sexual dysfunction, 318 tricyclic antidepressants (TCAs), 70, 73, 88 for GAD, 197 for narcolepsy, 333 for perinatal depression, 162, 163 Trifolium pratense for sexual dysfunction, 318 Trileptal. See oxcarbazepine

United States, intimate partner violence in, 43–44 urophobia, 209 U.S. Department of Health and Human Services Healthy People 2020 program, 28 uvulopalatopharyngoplasty (UPPP) for breathing-related sleep disorders, 329

vaginismus, 314–315 Valium. See diazepam valproate for Schizoaffective disorder, 292 valproic acid avoid during pregnancy, 164 for BPD, 226 varenicline for substance abuse disorders, 343 venlafaxine for GAD, 196 for perinatal depression, 162 veterans, female. See female veterans Viagra for sexual dysfunction, 318 violence, 43–57 affecting women with physical disabilities, 100–101 caring for woman experiencing, 53–57 cycle of, 48 elder abuse, 51–53 homicide by male perpetrators, 44–45 intimate partner (see intimate partner violence (IPV)) New York State Department of Health Domestic Violence Assessment Survey, 54

overview, 43 perpetrators, characteristics of, 47–49 pertinent data, 55 sexual asault and rape, 50–51 stalking, 44 virginitiphobia, 209 visual hallucinations, 288 Vivitrol. See naltrexone voyeurism, 311, 312 vulvar vestibulitis and sexual pain, 314–315

war, stress of pregnancy and, 158 Wellbutrin. See bupropion White Americans mental health disorders, rates of, 6 Whites mental health disorders, rates of, 6 working mothers parenting stressors, 17–18 work and financial stressors, 19–20

work stressors, 19–20

Xanax. See alprazolam Xyrem. See sodium oxybate

Yale-Brown Obsessive Compulsive Scale (Y-BOCS), 198 Yasmin/Yaz, 145

zaleplon for insomnia, 326 ziprasidone for MDD, 295 for Schizophreniform disorder, 297 Zoloft. See sertraline hydrochloride zolpidem for anxiety during pregnancy, 160 for insomnia, 326 Zyprexa. See olanzapine