Caring for Women in Prison: Psychogenic Seizures

Brain StormCalled to a housing unit on a man-down emergency, a nurse finds a female inmate on the floor flailing about, arching her back, crying, and shaking her head side-to-side. She does not lose consciousness but is holding her eyes tightly shut. The housing officer says she is just throwing a tantrum and faking a seizure. What other diagnoses should be considered?

Seizure disorders are common in the inmate patient population.  In fact, incarcerated patients are four times more likely to have a seizure disorder than the general  population. Reasons for increase seizure activity in our patient population include frequent histories of head trauma, physical abuse, and drug or alcohol involvement. There are many causes of seizures, with the most common, epileptic seizures, being the result of spontaneous and uncontrolled electrical discharge of neurons in the brain that interrupts normal body functions.

However, what the nurse is witnessing in the case above does not appear to be an epileptic seizure as the patient seems to be in control of her actions – shaking her head and holding her eyes tightly shut. Maybe the housing officer is correct and this inmate is merely pretending to be seizing to gain attention?

Another possible diagnosis in this presentation could be Psychogenic Nonepileptic Seizure (PNS) activity; a psychiatric rather than physiologic condition. PNS results most often from severe childhood trauma and manifests during a psychologically stressful situation. Individuals with PNS are not ‘faking it’ and are not in control of when and how a seizure takes place. Instead, the seizure activity is a coping mechanism to an intense emotional event.

Three times more women are diagnosed with PNS than men.  Although the exact reason is still unknown, it is suggested that these seizures are an expression of rage, fear, and helplessness that manifests most frequently in women who have histories of abuse. More than half of patients with PNS also have concurrent psychiatric illness such as post-traumatic stress disorder, anxiety disorders, depression, or dissociation disorders.

In the case presentation above, the person needs to be treated with compassion. Observations should be carefully documented and medical treatment sought. In particular, the nurse should document the nature, timing, and context of seizure activity. Psychogenic seizures are diagnosed by their presentation and EEG-video monitoring. Once diagnosed, PNS is treated based on the underlying condition and mainly through psychiatric services. Patients may benefit from supportive psychotherapy and lifestyle changes to reduce the effect of situational stressors. Underlying anxiety or depressive disorders may respond to drug treatment. Some patients are helped through behavior modification therapy.

You can learn more about psychogenic seizures in the female inmate population by listening to this podcast interview with Gregory Famiglio, MD.

What are your experiences with inmate seizure activity? Share your thoughts in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 and shipping is free.

Photo Credit: © AlienCat – Fotolia.com

Caring for Women in Prison: Mental Illness and Self-Harm

The mindThe disturbing story of 19 year old Ashley Smith’s witnessed suicide in a Canadian prison highlights the complex issue of mental illness and self-harming behaviors among incarcerated women. Ashley Smith attempted self-harm over 150 times during a three year period as outlined in this report of her treatment and in-custody death. She was a very troubled young women, as so many of our patients are.

Women in the criminal justice system have higher rates of serious mental illness than male counterparts; including higher rates of depression, bipolar disorders, antisocial personality disorder, and post-traumatic stress disorder. This can be attributed to many factors including histories of childhood abuse, adult victimization, substance abuse, and traumatization.

Social problems add to emotional stress; intensifying mental and behavioral disorders. Financial hardship, parental stress, and inadequate relational support make dealing with mental illness more difficult. Higher rates of chronic illness among female inmates compound the burden of mental illness.

Deliberate Self-Harm

Some women turn their distress inward and engage in deliberate self-harm (DSH) also called self-injurious behavior (SIH). In fact, as many as 30-50% of incarcerated women may harm themselves intentionally; most often by cutting or scratching with an object. This behavior can be perplexing and frustrating for healthcare and custody staff, alike. Conflicting interpretations cloud objectivity. Healthcare staff are more likely to see self-injury as a condition in need of treatment while custody staff are more likely to see it as a behavior issue requiring control.  Although Ashley Smith received anger management interventions and participated in group activities early in her incarceration, increasingly frustrated custody staff resorted to isolation, restraint, and pepper spray to compel her to comply with security requirements.

Mental health professionals, however, see self-harm as a coping mechanism brought on by distress, like the stress of incarceration. Therefore, a therapeutic response involving a non-judgmental attitude and interventions to decrease injury events is advocated over punitive measures. Phased-in behavior management plans, for example, have been effective for self-injury reduction. In this program, individualized incentives are developed and awarded when self-injury is avoided for periods of time. Patients move into advanced phases of the program with positive behavior change or back into earlier, more restrictive, phases if self-injury returns.

Suicide

Deliberate self-harm when used as a coping mechanism rarely moves to suicide. Ashley Smith, however, began attempting suicide soon after she was transferred to an adult facility at age 18. Women inmates attempt suicide more frequently than men; although men have more completed suicides. Frequent, unsuccessful suicide attempts are viewed by staff as attention-seeking behavior and can soon be disregarded. It appears that Ashley Smith was allowed to kill herself while being watched by security officers. By that time she had been transferred 17 times through 9 different institutions. She entered the system as a youth on a 30 day sentence and accrued additional time for various charges resulting in a total of 2,239 days cumulative sentence.

As noted in the ombudsman report, there is no record of a psychiatric evaluation once Ms. Smith was transferred to the adult facilities; even after beginning a string of suicide attempts. Could a concerted program of therapy and behavioral management have avoided this fatal outcome? It is hoped that something positive will come from the death of Ashley Smith. The inquest jury has made 104 recommendations for improvements in mental health care and inmate treatment. The case highlights the challenges of working with mentally ill female offenders and the need for a coordinated program of care.

What has been your experience working with incarcerated women with mental illness? Share your thoughts in the comments section.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 and shipping is free.

Photo Credit: © Rob hyrons – Fotolia.com

Caring for Women in Prison: Sexual Assault and Family Groups

kids girlfriends sharing a secret isolated

Cheryl is a petite inmate in her twenties who just entered a federal prison to serve out her drug trafficking sentence. She is quiet and withdrawn during her intake screening and admits to the nurse that she was sexually abused by an uncle when she was 12. Her family and friends are over 200 miles away and will be rarely able to visit. Several weeks into her stay she is seen almost exclusively in the company of an older woman who orders her around and often shouts profanity at her. The nurse wonders if this is a sexually abusive relationship.

Sexual assault is a real concern for incarcerated women. Although all inmates are at risk for sexual assault, female inmates are twice as likely as their male counterparts to be coerced by a fellow inmate according to a recently published Bureau of Justice report. The authoritarian structure of the prison system also contributes to sexual victimization by staff. Like Cheryl, a high number of women in prison have sexual abuse histories, some as children.

All forms of sexual contact are prohibited by the Prison Rape Elimination Act (PREA) of 2003. This federal mandate requires jails and prisons to prevent, detect, and respond to indications of sexual victimization within their facilities. Correctional nurses need to be aware of the prevalence of abuse histories and vigilant for sexual assault in the female patient population.

Risk factors for sexual assault: The following classes of individuals are more vulnerable for sexual assault while incarcerated.

  • Mental, physical, or developmental disability
  • Age
  • Physical build
  • Gay, lesbian, bisexual, transgender, intersex, or gender nonconforming
  • Previously experienced sexual victimization

With her slight build, young age, and past abuse history, Cheryl has a potential for sexual victimization while in the prison system.

The smaller size of the female inmate population and the special needs of this group mean there are few female prisons in the federal and state systems. Therefore, many female inmates are sent to facilities far from home with little opportunity to have contact with family and friends. The relational nature of this gender and the desire for belonging and group identity leads to the emergence of family groups within female prisons. The pseudo-family distinction in female prisons parallels gangs in male prisons. This can blur the relationship boundaries and make it difficult to determine if an intimate relationship is consensual or coerced.

How do you think a correctional nurse should respond to Cheryl’s situation? Should this nurse intervene? Would you? Share your thoughts in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1209 the price is discounted by $15 and shipping is free.

Photo Credit: © Oksana Kuzmina – Fotolia.com

Caring for Women in Prison: Health Education and Parenting Skill

Adorable small scottish kitten in wicker basket

A Bureau of Justice Report indicates that the majority of female prison inmates have minor children (62% of state and 56% of federal). More than half of these women were the primary financial support for their children.  While incarcerated, mothers depend on others to care for their children – the majority are cared for by grandparents (42%) followed by fathers (37%) and other relatives (23%). The remaining 19% are in foster care or with a friend.  This can be an additional life stress while in custody.

Health teaching and promotion is a major part of correctional nursing practice. According to the Correctional Nursing Scope and Standards of Practice, health teaching and health promotion include:

  •  Proving health teaching that addresses health lifestyles and risk reducing behaviors, developmental needs and preventive self-care
  • Using the teaching methods that are appropriate to the situation
  • Providing educational material in a variety of formats

Correctional nurses can assist mothers to better care for their children through health education and parenting skills training while they are separated. This can be a motivational time for mothers. Health education can focus on family health that will benefit both the patient and her children after re-entry into the community. Here are a few ideas for healthy living and parenting topics from the CDC:

  •  Basic first aid and safety
  • Child development
  • Check-ups and vaccinations
  • Healthy eating
  • Regular exercise

Information can be provided in a variety of methods including simple handouts, posters, individual teaching or group sessions. Family health teaching can be incorporated into the regular operations of a health unit. Five minute informational sessions can take place during other scheduled visits such as sick call or chronic care clinic.

Teach back/Show back is one method for increasing retention in patient education situations. This process evaluates comprehension by asking the patient to explain the material presented or demonstrate back the new skill. The nurse can then clarify and tailor further explanation to the remaining needs of the patient.

Parenting skills need not be limited to women’s services. Some male prisons have started healthy parenting programs in efforts to improve dysfunctional family situations among the offender population. One popular program is Parenting Inside Out. This program is available in some state and federal prisons.

Does your correctional setting provide parenting skills or family health education? Share your experiences in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1209 the price is discounted by $15 and shipping is free.

Photo Credit: © Oksana Kuzmina – Fotolia.com

Caring for Women in Prison: Menopause and Osteoporosis

Old Lady's hands open - My mother at 90 years old

Hazel is a diminutive 56 year old state prisoner serving a life sentence for murder. She has been incarcerated for 18 years now and recently fell on the icy path while heading from her housing unit to breakfast early one morning. She sustained Colles fractures of both wrists. While being treated for the fractures she was also diagnosed with advanced osteoporosis.

Not all women in prison are dealing with pregnancy and reproductive health issues. The aging of the inmate population means that an increasing number of female inmates need assistance with menopause symptoms and protection from osteoporosis. Managing these conditions in the criminal justice system may require creativity and a bit of patient advocacy. Here are some key concerns with possible nursing interventions:

  • Nutrition: Hazel has been eating prison food for more than a decade. Unfortunately, most prison are challenged to provide a calcium-rich diet. Hazel needs counselling on the best options in both the cafeteria and commissary menus to increase her vitamin D and calcium intake. Supplementation may be necessary.
  • Exercise: Weight bearing exercise may not be convenient or even available. Hazel appears to be walking to various inmate activities; and that is a good start. She could benefit from support in developing an exercise program based on the prison gym and yard schedule. An in-cell exercise routine can also be established and encouraged.
  • Dry, Fragile Skin: Lack of estrogen dries out skin and eyes which can lead to discomfort, breakdown, and infection. Saline eye drops and therapeutic lotions may be needed and possibly provided through the healthcare unit or placed on the commissary list.
  • Body Temperature Fluctuations: Many prisons are not well ventilated in summer or heated in winter. Menopausal women may need layers of clothing for increased comfort.
  • Lack of Sleep: Sleep is a difficult commodity in many prisons and menopausal women with insomnia or hot flashes may have even more trouble obtaining rest. Correctional nurses can help patients establish good sleep hygiene habits and possibly provide natural sleeping aids such as melatonin through the commissary.

Do you have menopausal or osteoporotic inmates at your facility? How are you helping them to manage their condition while incarcerated? Share your tips in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1209 the price is discounted by $15 and shipping is free.

Photo Credit: © Fenton – Fotolia.com

Caring for Women in Prison: Reproductive Health

HomelessTwenty-five year old Joanie found out she was pregnant during routine screening on intake to the city jail. She had been picked up during a street sweep over the New Year’s holiday. A series of poor decisions and an addiction to cocaine that she couldn’t shake had landed her on the street, sleeping rough, and getting by sleeping at the local shelter, doing odd jobs, and some occasional prostitution. She hadn’t noticed any pregnancy symptoms but was starting to feel anxious and irritable since she had been drug-free while detained.

Joanie is not unlike many women in jails and prisons. She is young, sexually active, and not paying much attention to her reproductive health. Like Joanie, many women in prison have not had regular healthcare, are poorly nourished and are substance involved. The jail she entered is following the American College of Obstetricians and Gynecologists (ACOG) guidelines for care of incarcerated women in screening all females for pregnancy at intake. This practice assures adequate attention to prenatal care and accommodation of pregnancy in medical treatment decisions while detained.

Like most women entering the criminal justice system, Joanie is of childbearing age. She is in the early stages of an unplanned pregnancy and has not been regularly practicing any contraceptive method. Incarceration is an opportunity to increase her knowledge of contraception options and organize her future choices. One study in a northeastern US jail/prison system found that female inmates were more likely to initiate birth control methods if information and medication was started before release. This is an interesting finding and indicates that correctional nurses should establish practices of educated about contraception while women are incarcerated. Unfortunately, this is not a widespread practice. For example, when I interviewed Piper Kerman about her experiences with correctional healthcare during her federal prison experience chronicled in the popular book turned Netflix series “Orange is the New Black”, she said she was surprised that contraception was not discussed with her in preparation for release and she had to ask about it herself.

Joanie is also going to need counseling about her options for her newly discovered pregnancy. She has a lot to think about. If she chooses to keep the baby she is likely to have a high risk pregnancy. As discussed in a prior post, poor nutrition, lack of prior healthcare, and drug and alcohol abuse put many incarcerated women at risk for complications during pregnancy; as can the high prevalence of sexually transmitted infection. If she wants to terminate this pregnancy she may face roadblocks while incarcerated as many facilities do not easily accommodate this procedure.

Correctional nurses have an opportunity to improve the health of young women by attending to reproductive health needs while they are incarcerated.

What reproductive health services would Joanie have if she was entering your facility? Share your thoughts in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1209 the price is discounted by $15 and shipping is free.

Photo Credit: © fotosmile777 – Fotolia.com

Caring for Women in Prison: Pregnancy Management

Babybauch

With almost 80% of female inmates of child-bearing age, it is not surprising that an estimated  6-10% of incarcerated women are pregnant at any time in the criminal justice system. Correctional nurses who care for women need to know how to assess and manage pregnancy, labor, and precipitous delivery. This can be challenging in a secure environment not arranged to accommodate pregnancy and childbirth.

Risky Business

Poor prenatal care combined with poor nutrition, drug and alcohol abuse, smoking, and sexually transmitted infections contribute to the high risk nature of pregnancy while incarcerated. It is important to identify all pregnant women at intake screening in order to register them in the prenatal monitoring program and to determine housing needs. Routine perinatal visits should be arranged either with an outside obstetrical service or in-house with appropriately credentialed providers:

  • Every month to 28 weeks
  • Biweekly during 28-30 weeks
  • After 30 weeks: weekly until delivery

Substance Withdrawal

Drug charges are a primary reason for the incarceration of women and many pregnant inmates will also be abusing drugs and alcohol. Withdrawal from these substances can be difficult when considering the effect on both the mother and unborn child. Opioids like heroin, hydromoorphone and oxycodone are of greatest concern as detoxification can risk increases in miscarriage and premature labor. In all cases, withdrawal during pregnancy should be handled carefully with management by an obstetrical specialist.

Perinatal loss

Already often suffering from post-traumatic stress from past childhood and domestic trauma, incarcerated women are highly susceptible to intensified grief following pregnancy loss, whether intentional or unintentional. Therefore, correctional nurses need to be sensitive to the emotional needs of women experiencing perinatal loss and intervene with additional counseling or mental health services when appropriate.

Interventions for All

The American College of Obstetrics and Gynecology (ACOG) published excellent recommendations for the care of pregnant and post-partum incarcerated women. The committee report recommends that the following services are provided in correctional facilities housing pregnant women:

  • Pregnancy counseling and abortion services
  • If opiate-using, opioid-assistance therapy with methadone or buprenorphine while pregnant
  • HIV testing
  • Postpartum depression screening
  • Dietary supplementation
  • Postpartum contraception

Labor Disputes

Active labor can be difficult to determine in this patient population. Contractions that are strong and last from 45-60 seconds at a frequency of 3-5 minutes indicate the active labor stage. This is the time most women are admitted to the hospital. However, high risk pregnancies or women with histories of difficult or precipitous labors need to be closely monitored earlier. The high risk nature of the majority of pregnant inmates requires a high level of suspicion that labor may be progressing even if the woman is not in the final weeks of pregnancy.

Unshackled

Of particular concern is the shackling of laboring inmates. ACOG and advocacy groups such as the ACLU decry the practice of shackling laboring inmates. ACOG presents a compelling case for the detrimental health effects of this practice including increased risk of venous thrombosis and interference with the management of labor and delivery emergencies.

How do you manage pregnancy in your setting? Share your thoughts in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1209 the price is discounted by $15 off and shipping is free.

Photo Credit: © Light Impression – Fotolia.com