243 E2

Understanding death: birth - age 2

cannot understand death but can experience feelings of loss and separation

Generalized Anxiety Disorder (chronic worry) is characterized by

chronic, unrealistic and excessive anxiety and worry (needs to be present for 6 months)

Adjustment disorders are ______ and can occur at _____ age

common, any

Interventions for phobias are aimed at

decreasing the fear and increasing the ability to function in the presence of the phobic stimulus or situation without experiencing panic anxiety.

Grief is

deep mental and emotional anguish that is a response to the subjective experience of loss of something significant. (very individual, may last for many years)

What symptoms are common in persons with body dysmorphic disorder?

depression, and characteristics of OCD. Avoidance of some kind is also associated (only a disorder when it interferes with function).

What is a specific subtype of dissociative amnesia?

dissociative fugue

S/E of buspirone

dizziness, drowsiness, dry mouth, headache, nervousness, nausea, insomnia

Cluster B behaviors described as

dramatic, emotional, erratic

What are common complications of somatic symptom disorder?

drug abuse and dependence

S/E Clonindine

dry mouth, sedation, fatigue, hypotension

Combination of SSRI and an atypical antipsychotic has been succesfful in treating

dysphoria, mood instability, and impulsivity in pt with borderline personality disorder.

Predisposing factors to phobias: life experiences

early experiences may set the stage for phobic reactions later in life.

When this disorder is imposed on another person under the care of the perpetrator is called

factitious disorder by proxy.

Borderline Personality Disorder is designated as "borderline" because the pt tends to

fall on the border between neuroses and psychoses (back in 1800's diagnosed)

Cognitive theory for panic and generalized anxiety disorder

faulty distorted, or counterproductive thinking patterns result in anxiety that is maintained by mistaken or dysfunctional appraisal of a situation.

What is a phobia

fear cued by the presence or anticipation of a specific object or or situation, exposure to which almost invariably provokes an immediate anxiety response or panic attack even though the subject recognizes that the fear is excessive or unreasonable.

Understanding death: age 3-5

have some understanding about death but have difficulty distinguishing between fantasy and reality; believe death is reversible

Personality characteristics of somatic symptom disorder

heightened, emotionality, strong dependency needs, and a preoccupation with symptoms and oneself.

Interventions for hair pulling disorder aimed at

helping the pt to discontinue the maladaptive behavior by: - assisting with habit reversal training - learning more adaptive stress management techniques.

Somatic symptom disorders have been identified as

hysterical neuroses and were thought to occur in response to repressed severe anxiety.

Antipsychotics help with

illusions, ideas of reference, paranoid thinking, anxiety, and hostility in some pts.

The maximum therapeutic goal of crisis intervention is what?

improvement in functioning above the pre-crisis level (never give advice)

SSRIs and MAOIs help decrease what?

impulsivity and and self destructive acts in pts with personality disorders (MAOIs are not commonly used due to overdose)

where can be people with personality disorders be encountered by nurses?

in all health-care settings.

Onset of social anxiety disorder occurs

in late childhood, or early adolescence, and runs a chronic sometimes life-long course. More common in women than men.

Anosmia (KT)

inability to smell

Aphonia (KT)

inability to speak

What is the major difference between anger and aggression?

intent aggression refers to behavior that is intended to inflict harm or destruction

Anxiety may be considered pathological when

it interferes with social and occupational functioning, achievement of desired goals, or emotional comfort.

More than half of all individuals will experience a traumatic event in their lifetime, but how many will develop PTSD?

less than 10%

personality disorders are manifested in

many pts with other psychiatric and medical diagnoses.

Is paranoid personality disorder (cluster A) more common in men or women?

men

Stress is a

mental, emotional, or physical strain experienced by an individual in response to stimuli from the external or internal environment.

What type of children are at risk of anxiety disorders?

minority children and children from low socioeconomic environments.

"Good" anxiety is a

necessary force for survival. It is not the same as stress.

Conversion symptoms are those that suggest what?

neurological disease such as voluntary motor or sensory functioning (paralysis, aphonia, seizures, coordination disturbance, difficulty swallowing, urinary retention, akinesia, blindness, deafness, double vision, ansomia, loss of pain sensation and hallucinations)

The traumatic event for PTSD is described as one that is

outside the range of usual human experience.

In specific phobia the exposure to the object causes

overwhelming symptoms of panic, including palpitations, sweating, dizziness, and difficulty breathing.

Antidepressants such as sertraline (zoloft) and paroxetine (paxil) may be useful with avoidant personality disorder for what?

panic disorder.

Predisposing Factors Associated with Somatic Symptom Disorder: Learning Disorder / Illness anxiety disorder

past experience with serious or life-threatening physical illness, either personal, or that of close relatives, can predispose the person to illness anxiety disorder.

Review De-escalation Theories from lab

per Bonnie

Example of primary gain with somatic symptoms disorders

person may avoid stressful obligations or be excused from unwanted duties (avoiding something)

Example of secondary gain with somatic symptom disorders

person may become the prominent focus of attention because of the illness (getting more attention)

Example of tertiary gain with somatic symptom disorders

person may relieve conflict within the family as concern is shifted to the ill person and away from the real issue (relieving all conflict because all attention is on you)

What happens when you confront denial head on?

personality disintegration

Personality disorders occur when?

personality traits (do not adapt) and become rigid and inflexible and contribute to maladaptive patterns of behavior or impairment in functioning

Somatic symptom disorders are characterized by

physical symptoms suggesting medical disease but without demonstrable organic pathology or a known pathophysiological mechanism to account for them.

Acute stress disorder is similar to PTSD in terms of

precipitating traumatic events and symptomatology.

Assistance with problem solving during the crisis period does what?

preserves self-esteem and promotes growth with resolution

People with illness anxiety disorder are

profoundly preoccupied with their bodies and are totally aware of even the slightest change in feeling or sensation. behavioral response is unrealistic and exaggerated. (rapid heart rate = heart disease, and small sore = skin cancer)

Nursing intervention for pt with borderline personality disorder is aimed at

protection of pt from self-harm, and also to advance in development of personality by confronting his or her true source of internalized anger.

The minimum therapeutic goal of crisis intervention is what?

psychological resolution of the individual's immediate crisis and restoration to at least the level of functioning that existed before crisis period (important**)

Some instances of of conversion disorder may be precipitated by what?

psychological stress.

Dissociative disorders (DIDs) are statistically

rare

What are obsessions?

recurrent and persistent THOUGHTS, impulses, or images experienced as intrusive and stressful. Recognized as being excessive and unreasonable even though they are a product of one's mind. The thought, impulse or image cannot be expunged by logic or reasoning.

Panic disorder is characterized by

recurrent panic attacks, the onset of which are unpredictable and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort (may or may not be accompanied by agoraphobia)

OCD Personality Disorder (KT)

recurrent thoughts or ideas (obsessions) that an individual is unable to put out of his or her mind and actions that an individual is unable to to refrain from performing (compulsions). The obsessions and compulsions are severe enough to interfere with social and occupational functioning

What is the defense mechanism most used by pts experiencing amnesia (freud believed also associated with all dissociative disorders)

repression (the involuntary blocking of unpleasant feelings and experiences from one's awareness)

Freud viewed dissociation as a type of

repression, an active defense mechanism used to remove threatening or unacceptable mental contents from conscious awareness.

Side effects of benzodiazepines

sedation, dizziness, weakness, ataxia, decreased motor performance, dependence, withdrawal.

Children may experience what symptoms of disaster?

separation anxiety, nightmares, and problems with concentrating.

Onset of dissociative amnesia usually follows what?

severe psychosocial stress

Historical terms for PTSD

shell shock, battle fatigue, accident neurosis, or posttraumatic neurosis.

Barbiturates S/E

somnolence, agitation, confusion, ataxia, dizziness.

Action of noradrenergic clonidine

stimulates alpha-adrenergic receptors

Anxiety is the ______ emotional response to that _____

subjective, stressor

What is dissociative fugue?

sudden unexpected travel away from home with the inability to recall some or all of one's life.

Transition from one personality to another in DID is usually

sudden, often dramatic, and usually precipitated by stress.

What is the difference between PTSD and Acute stress disorder (ASD)?

symptoms for ASD are time limited and last for only one month following the trauma (If the symptoms last longer than 1 month, the diagnosis would be PTSD)

Renewed experience about PTSD began in

the 1970s in response to problems with vietnam veterans

Body dysmorphic disorder is characterized by

the exaggerated belief that the body is deformed or defective in some specific way

Dissociative Identity Disorder (DID) is characterized by

the existence of two or more personalities within a single individual. (Rare)

Specific phobia is

the fear of specific objects or situations that could conceivably cause harm, but the person's reaction to them is excessive, unreasonable and inappropriate.

Types of disturbance in recall: Localized amnesia

the inability to recall all incidents associated with the traumatic event fora specific period following the event (unable to remember months or years of child abuse)

Types of disturbance in recall: Generalized amnesia

the inability to recall anything that has happened during the individual's entire lifetime, including personal identity.

Types of disturbance in recall: Selective amnesia

the inability to recall only certain parts of events associated with a traumatic event for a specific period following the event

What is one crucial difference between normal and maladaptive grieving?

the loss of self-esteem does not occur in uncomplicated bereavement (loss of self-esteem precipitates depression)

In body dysmorphic disorder if a true defect is present then

the person's concern is unrealistically exaggerated and grossly excessive

Object Constancy (KT)

the phase in the separation/individuation process when the child learns to relate to objects in an effective, constant manner. A sense of separateness is established, and the child is able to internalize a sustained image of the loved object or person when out of sight

What is important to assess that leads to a person's behavioral symptoms that is crucial to planning pt care?

the precipitating stressor.

Personality Defined

the totality of emotional and behavioral characteristics that are particular to a specific person and that remain somewhat stable adn predictable over time.

Personality traits influence what

the way in which he or she perceives and relates to the environment and are quite stable over time.

A patient is considered aggressive when?

they have made physical contact

Predisposing factors to phobias: psychoanalytical theory

unconscious fears may be expressed in a symbolic manner as phobia

Understanding death: age 10-12

understand that death is final and eventually affects everyone; feelings of anger guilt, and depression are common; peer relations and school performance may be disrupted

Somatic Symptom Disorders: Illness anxiety disorder

unrealistic or inaccurate interpretation of physical symptoms or sensations, leading to preoccupation and fear of having a serious disease.

Acute Grief

usually lasts about 6-8 weeks; longer in older adults

Lithium carbonate and mood blocker propranolol (inderal) may be useful for

violent episodes observed in pts with antisocial personality disorder (caution substance abuse)

Psychosocial theory and trauma-related disorders seeks to explain what?

why some individuals exposed to massive trauma develop PTSD while others do not.

When do symptoms occur with Adjustment disorder?

within 3 months of the stressor and last no longer than 6 months (exception the related to bereavement subtype).

Most symptoms of conversion disorder resolve when?

within a few weeks.

Symptoms of PTSD may begin when?

within the first 3 months after the trauma, or there may be a delay of several months or even years.

Are anxiety disorders more common in women or men?

women

Cluster B: histrionic is more common in women or men?

women

DID is more prevalent in women or men?

women

PTSD is more common in which gender?

women

Brief episodes of depersonalization symptoms appear to be common in

young adults, particularly in times of severe stress.

Abreaction (chpt 20) (KT)

"Remembering with feeling;" bringing into conscious awareness painful events that have been repressed, and re-experiencing the emotions that were associated with w/ the events.

Predisposing Factors to Trauma Related Disorders: Biological Aspects

"addiction to trauma." - It is suggested that the symptoms related to the trauma are maintained by the production of endogenous opioid peptides that are produced in the face of arousal, and which result in increased feelings of comfort and control. - When the stressor terminates, the individual may experience opioid withdrawal, the symptoms of which bear strong resemblance to those of PTSD. - Disregulation of the opioid, glutamatergic, noradrenergic, serotonergic, and neuroendocrine pathways may also be involved in the pathophysiology of PTSD.

Give an example of a statement for reassurance of safety

"you have just been through a traumatic event. we expect that you would be feeling this way." This is an example of normalizing.

Depersonalization-Derealization Disorder is characterized by

(DETACHMENT) a temporary change in the quality of self-awareness, which often takes the form of: - feelings of unreality - changes in body image - feelings of detachment from the environment - A sense of observing oneself from outside the body

Antidepressant psychopharmacology for trauma-related disorders

- 1st line SSRIs such as (paroxetine, and setraline) - Tricylic Antidepressants (amitriptyline, and imipramine( - MAOI (phenelzine) - trazodone

Hospice

- A program that provides palliative and supportive care to meet the special needs of people who are dying and their families - provides physical, psychological, spiritual, and social care for the person for whom aggressive treatment is no longer appropriate

Phases of Crisis Intervention: Phase 4 Evaluation of crisis resolution and anticipatory planning

- A reassessment is conducted to determine whether the stated objective were achieved. - A plan of action is developed for the individual to deal with the stressor should it recur.

Nursing Intervention for the pt with an adjustment disorder is aimed at:

- Adaptive progression through the grief process - Helping the pt achieve acceptance of a change in health status - Assisting with strategies to maintain anxiety at a manageable level

Anxiety may be associated with intoxication or withdrawal from any of the following substances:

- Alcohol, sedatives, hypnotics, or anxiolytics - Hallucinogens - Caffeine - Cannabis - Others

Anxiolytics psychopharmacology for trauma-related disorders

- Alprazolam - Buspirone (further trial needed)

Names of benzodiazepines

- Alprazolam (Xanax) - Chlordiazepoxide (Librium) - Clonazepam (Klonopin) - Clorazepate (Tranxene) - Diazepam (Valium) - Lorazepam (Ativan) - Oxazepam

Areas of the brain affected by anxiety disorders

- Amygdala: fear, which is important in panic and phobic disorders - Hippocampus: associated w/ memory r/t fear responses - Locus ceruleus: arousal - Brainstem: respiratory activation, heart rate - Hypothalamus: activation of stress response - Frontal cortex: cognitive interpretations - Thalamus: integration of sensory stimuli - Basal ganglia: tremor

Cluster B personality disorders (4)

- Antisocial - Borderline - Histrionic - Narcissistic

What are certain current behaviors that are predictive of impending violence and have been called "prodromal syndrome?"

- Anxiety and tension - Verbal abuse and profanity - Increasing hyperactivity - Rigid posture - Clenched fists and jaws - Grim, defiant affect - Talking in a rapid, raised voice - Arguing and demanding - Using profanity and threatening verbalizations - Agitation and pacing - Pounding and slamming

Anxiolytic Agents (antianxiety drugs)

- Benzodiazepines - SSRIs - SNRIs - Noradrenergic agents (propranolol, clonidine) - Barbituates - Buspirone

Antihypertensives psychopharmacology for trauma-related disorders

- Beta Blocker propanolol - Alpha2 receptor agonist clonidine

Outcome criteria for trauma-related disorders ("these don't happen all at once, some pts may be able to only accomplish some goals)

- Can acknowledge the trauma and the impact on his or her life - Can demonstrate adaptive coping strategies - Has made realistic goals for the future - Has worked through feelings of survivor's guilt - Attends support group of individuals recovering from similar traumatic experiences - Verbalizes desire to put trauma in the past and progress with his or her life.

Medical conditions that may produce anxiety symptoms include:

- Cardiac conditions (MI, CHF, mitral valve prolapse) - Endocrine (hypoglycemia, hypo or hyperthryroidism, pheocromocytoma) - Respiratory (COPD, hyperventilation) - Neurological (complex partial seizures, neoplasms, encephalitis)

Cluster A: Schizoid Personality Disorder

- Characterized primarily by a profound defect in the ability to form personal relationships (withdraw from everyone and everything) - failure to respond to others in a meaningful emotional way. - Dx occurs more frequently in men - prevalence w/in the general population has been estimated at 3-7.5%

Names of SSRIs

- Citalopram (Celexa) - Escitalopram (Lexapro) - Fluoxetine (Prozac) - Paroxetine (Paxil, Pexeva) - Sertraline (Zoloft)

Tx for Trauma-related disorders

- Cognitive therapy (help individual recognize and modify trauma-related thoughts and beliefs - replace neg. thoughts with pos. ones) - Prolonged exposure therapy (can be imagined or real, desensitizing) - Group/family therapy (strongly advocated for PTSD sharing events with empathetic people - i.e. veterans) - Eye movement desensitizing and reprocessing (rapid eye movements while processing painful emotions) - Psychopharmacology

Nursing Diagnoses for Adjustment Disorders

- Complicated grieving - Risk-prone health behavior - Anxiety

Characteristics of crisis (5)

- Crisis occurs in all individuals at one time or another and is not necessarily equated with psychopathology - Crises are precipitated by specific identifiable events - Crises are personal by nature - Crises are acute, not chronic, and are resolved in one way or another within a brief period (6 weeks) - A crisis situation contains the potential for psychological growth or deterioration (What matters is the perception of the pt. If they view the situation as a crisis then treat it as such)

Types of Dissociative Disorders

- Dissociative amnesia - Dissociative identity disorder (DID) - Depersonalization-Derealization Disorder

Predisposing Factors to Dissociative Disorders: Neurobiological

- Dissociative amnesia may be r/t neurophysiological dysfunction - EEG abnormalities have been observed in some clients with DID

Evaluation for Adjustment Disorders

- Does the pt demonstrate progression in the grief process? - Does the pt discuss the change in health status and modification of lifestyle it will affect? - Does the patient set realistic goals for the future?

Names of SNRIs

- Duloxetine (Cymbalta) - Venlafaxine (Effexor XR) - Desvenlafaxine (Pristiq)

Psychodynamic Theory (Freud) for panic and generalized anxiety disorder

- Ego unable to intervene between id and superego - Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety.

Nursing Dx for illness anxiety disorder

- Fear (of having serious disease)

Predisposing Factors to Dissociative Disorders: Psychodynamic Theory

- Freud described dissociation as repression of distressing mental contents from conscious awareness. - Current psychodynamic explanations reflect Freud's concepts that dissociative behaviors are a defense against unresolved painful issues.

Personality development occurs in response to biological and psychological influences:

- Heredity - Temperament - Experimental learing - Social interaction

Predisposing Factors Associated with Somatic Symptom Disorder: Family dynamics

- In dysfunctional families, when a child becomes ill, focus shifts from the open conflict to the child's illness and leaves unresolved underlying issues the family is unable to confront openly. - Somatization brings some stability to the family and positive reinforcement to the child (called tertiary gain) (mom and dad stop fighting to take care of kid)

Kubler-Ross: 3. Bargaining

- Individual attempts to strike bargains w/ God for a second chance or for more time - Person acknowledges the loss or impending loss, but holds out hope for additional alternatives, AEB "If only I could.." or "If only I had..."

Kubler-Ross: 5 Acceptance

- Individual has not worked through the behaviors associated w/ the other stages and accepts or is resigned to loss. - Anxiety decreases, and methods for coping with the loss have been established. - Pt is less preoccupied with what has been lost and increasingly interested in other aspects of the environment. - If there is impending death, then individual is ready to die - Person may become very quiet, and withdrawn, seemingly devoid of feelings in an attempt to facilitate the passage by slowly disengaging from the environment. (Watch giraffe video)

Medical Tx modalities for Somatic Symptom Disorders

- Individual psychotherapy - Group psychotherapy - Behavior therapy - Psychopharmacology (antidepressants, tricyclic antidepressants (bad side effects), SNRIs, and SSRIs when primary symptom is pain.

Medical Tx modalities for Dissociative Disorders

- Individual psychotherapy - Hypnosis - Supportive Care - Cognitive therapy - Group therapy - Integration therapy (DID) (blending all personalities together) - Psychopharmacology

What are two nursing diagnoses for inappropriate expression of anger or for aggressive behavior?

- Ineffective coping - Risk for self-directed or other-directed violence

Nursing Dx for somatic symptom disorder

- Ineffective coping AEB numerous physical complaints - Deficient knowledge (psychological causes for physical symptoms) - Chronic pain

Tx Modalities for Personality disorders

- Interpersonal psychotherapy (not RN job) - Psychoanalytical psychotherapy (not RN job) (histrionic) - Milieu or group therapy (antisocial disorder) - cognitive behavior therapy (reinforce positive change) - dialectical behavior therapy (DBT) (not RN job) - psychopharmacology (tx for symptoms, not disorder itself)

Kubler-Ross: 4. Depression

- Mourning for lost person or for person that will be lost - Very painful stage in which individual must confront feelings associated with having lost someone or something of value (called reactive depression) Ex: mourning change in body image - feelings associated with impending loss (preparatory depression) are also confronted. Ex: impending loss of life itself - observable behaviors include: regression, withdrawal, and social isolation - interventions should only be performed when pt is ready

Predisposing Factors to Trauma Related Disorders: Learning Theory (behavioral theory)

- Negative reinforcement leads to the reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior. - Avoidance behaviors (drinking, drugs) - Psychic numbing ("I feel nothing)

Examples of barbiturates

- Nembutal (phenobarbital) - Mebaral (mephobarbital) - Amytal Sodium (amobarbital sodium) - Butisol (butabarbital sodium) - Seconal Sodium Pulvules (secobarbital sodium)

Antisocial Personality Disorder Assessment

- Not often seen in most clinical settings - most frequently encountered in prisons, jails, and rehabilitation services - when pts are seen, it is commonly a way to avoid legal consequences - sometimes they are limited to the health-care system by court order for psychological evaluation

According to the DSM-5 at least 4 of the following symptoms must be present to identify presence of panic attack

- Palpitations, pounding heart, accelerated HR - Sweating - Trembling or shaking - Sensations of SOB or smothering - Feelings of choking - Chest pain or discomfort - Nausea, or abdominal distress - Feeling dizzy, unsteady, lightheaded, or faint - Chills or heat sensation - Parethesias (numbness or tingling) - Derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself) - Fear of losing control or going crazy - Fear of dying

Nursing Dx for anxiety, OCD, and related disorders

- Panic anxiety (panic disorder and GAD) - Powerlessness (panic disorder and GAD) - Fear (phobias) - Social isolation (agoraphobia) - Ineffective coping (OCD) - Ineffective role performance (OCD) - Disturbed body image (body dysmorphia) - Ineffective impulse control (hair-pulling disorder)

Cluster A personality disorders (3)

- Paranoid personality disorder - Schizoid personality disorder - Schizotypal personality disorder (all don't want relationships)

Predisposing factors related to trauma-related disorders

- Psychosocial Theory: traumatic experience, the individual, the recovery environment - Learning Theory: avoidance behaviors, psychic numbing - Cognitive Theory: - Biological Aspects:

Predisposing Factors to OCD, and related disorders: Psychoanalytic theory

- Pts with OCD have weak, underdeveloped egos - Aggressive impulses are channeled into thoughts and behaviors that prevent the feelings of aggression from surfacing and producing intense anxiety fraught with guilt.

Characteristic symptoms of PTSD

- Re-experiencing the traumatic event (trigger) - A sustained high level of anxiety or arousal - A general numbing of responsiveness (don't feel anything) - Intrusive recollections or nightmares - Amnesia to certain aspects of the trauma - Depression; survivor's guilt - Substance abuse - Anger and aggression - Relationship problems

Nursing care of pt with a trauma-related disorder is aimed at?

- Reassurance of safety - Decrease in maladaptive symptoms - Demonstration of more adaptive coping strategies - Adaptive progression through the grieving process

Nursing Dx for Borderline

- Risk for self-mutilation r/t parental emotional deprivation - risk for suicide r/t unresolved grief - risk for other-directed violence r/t underlying rage - complicated grieving r/t maternal deprivation during rapprochement phase of development internalized as a loss, with fixation in anger stage of grieving process - Impaired social interaction r/t extreme fears of abandonment and engulfment - disturbed personal identity r/t underdeveloped ego - anxiety (severe to panic) r/t unconscious conflicts based on fear of abandonment - chronic low self-esteem r/t lack of positive feedback

The most common pt diagnoses associated with violence include:

- Schizophrenia - Major depression - Bipolar disorder - Substance abuse disorders - Neurocognitive disorders - Antisocial, borderline, and intermittent explosive personality disorders.

Types of somatic symptom disorders

- Somatic symptom disorder - Illness anxiety disorder - Conversion disorder - Pyschological factors affecting other medical condtion - Factitious disorder

Kubler-Ross: 2. Anger

- Stage where reality sets in - Feelings: sadness, guilt, shame, helplessness, and hopelessness. self-blame or blaming others may lead to feelings of anger toward self and others. - Anxiety level may be elevated, and the individual may experience confusion and a decreased ability to function independently. - Preoccupied with an idealized image of what has been lost. - Numerous somatic complaints are common

Phases of Crisis Intervention: Intervention

- The actions identified in the planning phase are implemented. - A reality-oriented approach is used - A rapid working relationship is established by showing unconditional acceptance, by active listening, and by attending to immediate needs. A problem-solving model becomes the basis for change

Kubler-Ross: 1. Denial

- The individual has difficulty believing that the loss has occurred. Might say "No, it can't be true!" - This stage may protect the individual against the psychological pain of reality.

Concepts of death: Native Americans

- The navajo of s/w conduct a cleansing ceremony before burial to prevent the spirit of the dead person from trying to consume control of someone else's spirit - the dead are buried with their shoes on the wrong feet and rings on their index fingers - they do not express grief openly and are reluctant to touch the body of a dead person

Cluster C: Dependent clinical picture

- They have a notable lack of self-confidence that is often apparent in their posture, voice, and mannerisms - typically passive and acquiescent (ready to accept something w/out protest) to desires of others - overly generous and thoughtful, while underplaying their own attractiveness and achievements - low self-worth and easily hurt by criticism and disapproval - avoid positions of responsibility and become anxious when forced into them - assume passive and submissive roles in relationships

Concepts of death: Filipino Americans

- Week-long wake that takes place in home of the deceased - among catholic families, 9 days of novenas are held in the home or church, finishing on the last day with a fiesta - wear dark clothing for 1 year after a death

Somatic symptom disorders are more commonly found in

- Women - less educated persons - rural areas

Cluster C: Dependent is characterized by

- a pattern of relying on others for emotional support - relatively common within the population - more common among women than men - more common in the youngest children of a family than older ones

Examples of loss

- a significant other - illness or debilitating conditions - developmental/maturational changes - decrease in self-esteem - personal possessions

Understanding death: elderly adults

- a time in life of the convergence of many losses - may lead to "bereavement overload - bereavement overload may result in depression

Delayed or inhibited grief

- absence of grief when it ordinarily would be expected. - potentially pathological because the person is not dealing with the reality of the loss. - remains fixed in the denial stage of the grief process - grief may be triggered much later in response to a subsequent loss

Distorted (exaggerated) grief

- all of the symptoms associated with normal grieving are exaggerated - the individual becomes incapable of managing activities of daily living - individual remains fixed in the anger stage of grief process - depressed mood disorder is a type of distorted grief response

Cluster A: Schizoid clinical picture

- aloof and indifferent to others - emotionally cold - no close friends; prefers to be alone - appears shy, anxious, or uneasy in the presence of others - inappropriately serious about everything and difficulty acting in a light-hearted manner.

Cluster B: Narcissistic characterized by

- an exaggerated sense of self worth - lack empathy - belief in an inalienable right to receive special consideration - get angry and may respond with rage - underneath is very fragile self-esteem - prevalence of the disorder is estimated at about 6% - diagnosed more often in men

Symptoms of Depersonalization-Derealization Disorder are often accompanied by

- anxiety and depression - fear of going insane - obsessive thoughts - somatic complaints - disturbance in the subjective sense of time.

Somatic symptom disorder is chronic and what symptoms are usually manifested?

- anxiety, depression, and suicidal ideation are frequently manifested. - symptoms may be vague, dramatized, or exaggerated in their presentation and and an excessive amount of time and energy is devoted to worry and concern about symptoms.

psychopharmacology for panic and GAD disorders

- anxiolytics - antidepressants (SSRIs and buspirone) - Antihypertensive agents (beta blockers such as lopressor and propanolol)

psychopharmacology for phobic disorders

- anxiolytics - antidepressants (SSRIs and buspirone) - Antihypertensive agents (beta blockers such as lopressor and propanolol)

Cluster B: Narcissistic predisposing factors

- as children, their fears, failures, or dependency needs were responded to with criticism, disdain, or neglect - parents were often narcissistic themselves - parents may have overindulged their child and failed to set limits on inappropriate behavior.

Psychosocial theory: The recovery environment variables

- availability of social support - cohesiveness and protectiveness of family and friends - the attitude of society regarding the experience - cultural and subcultural influences

Cluster C personality disorders (3)

- avoidant - dependent - OCD

Cluster C: Avoidant clinical picture

- awkward and uncomfortable in social situations - desire close relationships, but avoid them because of their fear of being rejected - perceived as timid, withdrawn, or cold and strange - they are often lonely and feel unwanted - view others as critical and betraying

Borderline predisposing factors

- biological influences (biochemical serotonergic defect, and genetic familial connection with depression) - psychosocial influences (childhood trauma or abuse, child fails to achieve task of autonomy)

Concepts of death: Vietnamese Americans

- buddhism is predominant religion - belief that birth and death are predestined - cremation is common - the 1-year anniversary of an individual's death is commemorated

Cluster B: Borderline Personality Disorder

- characterized by a pattern of intense and chaotic relationships with affective instability - fluctuating and extreme attitudes regarding other people - highly impulsive - self destructive

Adjustment Disorder Predisposing Factors: Psychosocial Theories (inadequate ego strength)

- childhood trauma, dependency, arrested development - constitutional factor (birth characteristics - developmental stage and timing of the stressor - available support systems - dysfunctional grieving process (may remain in denial or anger)

Borderline common behaviors

- chronic depression - inability to be alone - clinging and distancing behaviors (will do both) - splitting (can generate conflict with staff) - manipulation - self-destructive behaviors (cutting but is not suicidal) - impulsivity

Predisposing Factors to OCD, and related disorders: Learning theory

- conditioned response to traumatic event - passive avoidance - active avoidance

Concepts of death: Chinese Americans

- death and bereavement in the Chinese tradition are centered on ancestor worship - Chinese people have an intuitive fear of death and avoid references to it - do not openly express their emotions

Nursing Dx for psychological factors affecting medical condition

- deficient knowledge

Psychosocial theory: The individual (variables that are considered important in determining an individual's response to trauma)

- degree of ego strength - effectiveness of coping resources - presence of preexisting psychopathology - outcomes of previous experiences with stress/trauma - behavioral tendencies (temperament) - current psychosocial developmental stage - demographic factors (age, status, education)

Blanket action of antianxiety agents

- depress subcortical levels of the CNS - potentiate the inhibitory effects of GABA

Nursing Dx for conversion disorder

- disturbed sensory perception - self-care deficit

Blanket S/E of antianxiety drugs

- drowsiness, confusion, lethargy - tolerance, physical and psychological dependence (does not apply to buspirone) - potentiates effects of other CNS depressants - orthostatis hypotension - paradoxical excitement - dry mouth - blood dyscrasias

People with dissociative disorders may not be:

- eating, have fluid balance, hygiene, sleeping, skin integrity, basic housing (maslow level 1 basic) - may be at risk for injury (maslow level 2 safety)

Cluster B: Borderline Personality Disorder Clinical manifestation

- emotionally unstable - directly and indirectly self-destructive - lacks a clear sense of identity - affects about 1-2% of population - more common in women than in men - stuck at identity vs role confusion - intense fear of being abandoned - cutting behavior

Nursing care of pt with antisocial disorder

- ensuring the safety of pt and others - helping pt recognize and decrease unacceptable behaviors - assisting pt to gain insight into own behaviors - helping pt to learn to delay gratification (always a really long process. cannot change personality)

Cluster C: OCD Clinical picture

- especially concerned with matters of organization and efficiency - tend to be rigid and unbending - socially polite and formal - rank-conscious (ingratiating with authority figures, autocratic and condemnatory with subordinates) - on the surface, appear to be very calm and controlled - underneath there is a great deal of ambivalence, conflict, and hostility (anger).

Cluster B: Histionic Behavior is

- excitable - emotional - colorful - dramatic - extroverted - fun to be around - Doing things to get dependence needs met. Need attention (if not gotten they feel dejected and angered)

Antisocial common behaviors

- exploitation and manipulation of others for personal gain - belligerent and argumentative - lacks remorse - unable to delay gratification - low frustration tolerance - inconsistent owrk or academic performance - failure to conform to societal norms - impulsive and reckless - inability to function as a responsible parient - inability to form lasting monogamous relationship

Cluster C: Avoidant Personality Disorder characterized by

- extreme sensitivity to rejection (so they) - socially withdraw - prevalence is about 1% and is equally common in men and women

Cluster B: Antisocial clinical picture

- fails to sustain consistent employment - fails to conform to the law - exploits and manipulates others for personal gain - fails to develop stable relationships - doesnt follow rules - manipulates to get what they want - prevalence in US range from 2-4% in men, and 1% in women

Examples of social anxiety disorders

- fear of speaking or eating in public - fear of using public restroom - fear of writing in the presence of others - saying things or answering questions in a manner that would provoke laughter on part of others.

Anticipatory Grieving

- feelings and emotions of grief response before loss occurs - difficulty arises when family members complete process of anticipatory grief and detachment from dying person occurs prematurely - Anticipatory grieving may be positive for some people and less functional for others

Phases of Crisis Intervention: Phase 2 Planning of therapeutic intervention

- from the assessment data, the nurse selects appropriate nursing diagnoses that reflect the immediate crisis situation - desired outcome criteria are established - appropriate nursing actions are selected, taking into consideration the type of crisis as well as the individual's strengths and available resources for support

What are characteristics of anger?

- frowning - clenched fists - low-pitched voice - yelling and shouting - intense (or no) eye contact - easily offended - defensive response to criticism - passive-aggressive behavior - flushed face - emotional overcontrol - intense discomfort

Adjustment Disorder Predisposing Factors: Biological Theories

- genetics - vulnerability related to neurocognitive or intellectual development disorders

Biological aspects for panic and generalized anxiety disorder

- genetics (gene that controls manufacture of cholecystokinin has been known to induce panic attacks) - neuroanatomical - biochemical (abnormal levels of blood lactate associated) neurochemical (norepinephrine)

Biological aspects of OCD and related disorders

- genetics possible with trichotillomania - Neuroantomy: possible abnormalities in basal ganglia and orbiatlfrontal cortex with OCD - Physiology: some individuals with OCD exhibit EEG changes - Biochemical factors: possible decrease in serotonin with OCD and body dysmorphic disorder

Cluster A: Schizotypal Personality Disorder

- graver form of the pathologically less severe schizoid personality pattern - affects approximately 1-2% of population

Predisposing Factors to Dissociative Disorders: Psychological trauma

- growing evidence points to the etiology of DID as a set of traumatic experiences that overwhelm the individual's capacity to cope by any means other than dissociation - these experiences usually take the form of severe physical, sexual, or psychological abuse by a significant other in the child's life - DID is thought to serve as a survival strategy for the child in this traumatic environment.

Interventions for OCD are aimed at

- helping the pt maintain anxiety at a manageable level without having to resort to use of ritualistic behavior - developing more adaptive methods of coping with anxiety.

Interventions for body dysmorphic disorder are aimed at

- helping the pt recognize the distorted body image - helping the pt to develop a positive sense of self not based on appearance

Nursing Dx for dissociative amnesia

- impaired memory - powerlessness

Tx for Adjustment disorders

- individual psychotherapy - family therapy - behavior therapy - self-help groups - crisis intervention - psychopharmacology (although not common due to temporary effects that mask problem, and that psychoactive drugs are addictive.

Cluster C: OCD characterized by

- inflexibility about the way in which things must be done - devotion to productivity at the exclusion of personal pleasure - relatively common - perfectionistic - focus on rules - occurs more often in men - most common in older children of family

Assessment of Borderline

- instability of interpersonal relationships - unstable self-image - marked impulsivity - intensity of affect and behavior (intense emotions and expression of those emotions

Adjustment Disorder Predisposing Factors: Transactional model of stress/adaptation

- interaction between the individual and the environment (extrapersonal stressor) - type of stressor - situational factors - intrapersonal factors (ex: if person lacks resilience)

Cluster A: Schizotypal clinical picture

- magical thinking - ideas of reference (excluding delusions of reference) - illusions - depersonalization - superstitiousness - withdrawal into the self (severe isolation) - bizarre speech pattern - may decompensate when under stress and demonstrate psychotic symptoms such as delusional thoughts, hallucinations, or bizarre behaviors (usually of brief duration) - demonstrates bland, inappropriate affect - NOT HALLUCINATING (receives messages from TV, but not a hallucination)

Cluster C: Avoidant Predisposing Factords

- no clear cause is known - may be a combination of biological, genetic, and psychosocial influences - primary psychosocial influence: parental rejection and censure, which are often reinforced by peers

Reasons why advanced directives are sometimes not honored:

- not available at the time treatment decisions need to be made - advance directive is not clear - health-care proxy is unsure of pt wishes

Cluster C: OCD predisposing factors

- over-control by parents - notable parental lack of positive reinforcement for acceptable behavior - frequent punishment for undesirable behavior

Cluster B: Narcissistic clinical picture

- overly self centered - exploit others in an effort to fulfill their own desires - mood, which is often grounded in grandiosity, is usually optimistic, relaxed, cheerful, and care free. - because of fragile self-esteem, mood can easily change if they do not meet self-expectations, receive positive feedback they expect - criticism from others may cause them to respond with rage, shame, and humiliation

Characteristics of aggression

- pacing, restlessness - verbal/physical threats - threats of homicide or suicide - loud voice; argumentative - tense facial expression and body language - increased agitation, w/ overreaction - panic anxiety, leading to misinterpretation of the environment - disturbed thought processes - suspiciousness - angry mood, often disproportionate to the situation.

Predisposing factors to antisocial personality disorder

- possible genetic influence - having a disruptive behavior disorder as a child (ADHD; conduct disorder) - Hx of severe physical abuse - absent or inconsistent parental discipline - extreme poverty - removal from home - growing up w/out parental discipline - always being rescued when in trouble - maternal deprivation

Cluster C: Dependent predisposing factors

- possible hereditary - stimulation and nurturance are experienced exclusively from one source. - a singular attachment is made by the infant to the exclusion of all others

Cluster A: Schizotypal predisposing factors

- possible hereditary factor - possible physiological influence, such as anatomic deficits or neurochemical dysfunctions w/in certain areas of brain. - early family dynamics characterized by indifference, impassivity, formality - leading to a pattern of discomfort with personal affection and closeness.

Paranoid Personality Disorder Predisposing factors

- possible hereditary link - subject to early parental antagonism and harassment (early learning)

Cluster B: histrionic predisposing factors

- possible link to noradrenergic and serotonergic systems - possible hereditary factor - biogenetically determined temperment - learned behavior patterns

Cluster A: Schizoid predisposing factors

- possibly hereditary - childhood characterized as bleak, cold, unempathetic, notably lacking in nurturing.

Concepts of death: Japanese Americans

- predominant religion is buddhism - body is prepared by close family members - cremation is common

Somatic Symptom Disorders: Psychological factors affecting medial condtion

- psychological factors may play a role in virtually any medical condition - with this diagnosis there is evidence of a general medical condition that has been precipitated by or is being perpetuated by psychological or behavioral circumstances.

Assessment for Trichotillomania (hair pulling disorder)

- recurrent pulling out of one's own hair that results in noticeable hair loss. - preceded by increasing tension and results in sense of release or gratification - the disorder is not common, but occurs more often in women than in men.

Interventions for panic disorder and GAD are aimed at

- relief from acute panic symptoms - helping the client to take control of his or her own life situation, and accept those situations over which he or she has no control.

Interventions for anger or aggressive behavior

- remain calm - set verbal limits on behavior - keep diary of anger - avoid touching the pt - help determine source of anger - ignore derogatory remarks - help find alternative ways of releasing tension - role model - observe for escalation of anger - when behaviors are observed, first ensure that sufficient staff is available.

Nursing diagnosis for disasters

- risk for injury - risk for infection - anxiety (panic) - fear - spiritual distress - risk for post-trauma syndrome - ineffective community coping

Nursing Dx for antisocial

- risk for other-directed violence r/t rage reactions, negative role-modeling, inability to tolerate frustration - defensive coping r/t dysfunctional family system - chronic low self-esteem r/t to repeated negative feedback resulting in diminished self-worth. - impaired social interaction r/t negative role modeling and low-self-esteem - ineffective health maintenance, AEB demonstration of inability to take responsibility for meeting basic health practices (no care of basic needs - Jabba the hut

Nursing Dx for DID

- risk for suicide - disturbed personal identity

Cluster B: histrionic clinical picture

- self-dramatizing - attention-seeking - overly gregarious - seductive - manipulative - exhibitionistic - highly distractable - difficulty paying attention to detail - strongly independent - somatic complaints are common

Psychosocial theory: The traumatic experience specific characteristics

- severity and duration of the stressor - extent of anticipatory preparation for the event - exposure to death - numbers affected by life threat - amount of control over recurrence - location where the trauma was experienced (familiar surroundings, at home, in a foreign country)

Concepts of death: African Americans

- similar to those dominant american culture of the same religion and social class, with a blending of cultural practices from the african heritage - feelings are expressed openly and publicly

Cluster B: Antisocial has a pattern of behavior that is

- socially irresponsible - exploitative - without remorse - behavior reflects a disregard for the rights of others. (no shame, no guilt)

Psychosocial influences r/t trichotillomania

- stressful situations - disturbances in mother-child relationship - fear of abandonment - recent object loss - possible childhood abuse or emotional neglect

Techniques for dealing with aggression include:

- talking down - physical outlets - medications - call for assistance - restraints - observation and documentation - ongoing assessment - staff debriefing

The grief response is more difficult if

- the bereaved person was strongly dependent - the relationship was ambivalent one - the individual has experienced a number of recent losses - the loss is that of a young person - the bereaved person's health is unstable - the bereaved person perceives some responsibility for the loss

The grief response may be facilitated if

- the individual has the support of significant others - the individual has the opportunity to prepare for the loss

Predisposing Factors Associated with Somatic Symptom Disorder: Psychodynamic Theory

- this theory suggest that illness associated with anxiety disorder is an ego defense mechanism. Physical complaints are the expression of low self-esteem and feelings of worthlessness. - conversion disorder may represent emotions associated with a traumatic event that are too unacceptable to express and so are acceptably "converted" into physical symptoms.

Concepts of death: Jewish Americans

- traditional judaism believes in an afterlife - dying person is never left alone - no wake and viewing are part of a Jewish funeral - cremation is prohibited - 7 day period beginning with the burial is called shiva, during which mourners think only about the deceased

Examples of agoraphobia

- traveling in public transportation - being in open spaces - being in shops, theaters, or cinemas - standing in line or being in a crowd - being outside of the home alone in other situations

Understanding death: adolescents

- usually able to view death on an adult level - have difficulty perceiving their own death - may or may not cry; may withdraw - may exhibit acting-out behaviors

Concepts of death: Mexican Americans

- view death as a natural part of life - death rituals reflect catholic beliefs - burial is preceded by velorio, a festive watch over the body - mourning is called luto and is symbolized by wearing dark or black and white clothing and by subdued behavior

Types of Adjustment Disorders

- w/ depressed mood (low mood, tearfulness, or feelings of hopelessness are predominant. - w/ anxiety (nervousness, worry, jitteriness, or separation anxiety is predominant) - w/ mixed anxiety and depressed mood (combination) - w/ disturbance of conduct (violation of the rights of others or of major age-appropriate societal norms and rules) - w/ disturbance of emotions and conduct (both emotional symptoms depression, anxiety and a disturbance of conduct) - unspecified (most common and used when the maladaptive reaction is not consistent with any of the other categories)

psychopharmacology for hair-pulling disorder

-chloropromazine - amitriptyline - lithium carbonate - SSRIs and pimozide - Olanzapine

Cluster A: Paranoid Personality Disorder

-pervasive, persistent, and inappropriate mistrust of others. - individuals w/ this disorder are suspicious of others' motives and assume that others intend to exploit, harm, or deceive them - constantly on guard, hypervigilant, and ready for any real or imagined threat. - reads hidden demeaning or threatening meanings into remarks - bears grudges - quick to react with anger when perceived character or reputation attacked - has recurrent suspicious, without justification, regarding fidelity of spouse. - insensitive to others feelings - attributes shortcomings to others

Concept Map for PTSD on page 500

...

Concept map for adjustment disorder on page 507

...

Individuals w/ factitious disorder comprise about _____ % of psychiatry consultation clients

0.8-1.0%

*Kubler-Ross Stages of Grief*

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

Interventions for somatic and dissociative disorders

1. Establish therapeutic relationship 2. Encourage/help them to take care of basic needs/safety 3. Milleu (all about providing safety) 4. Supportive therapy aka counseling 5. Administer medications 6. Encourage Tx plan (group therapy, R/T, or O/T) 7. Teaching

Interventions for disaster

1. Maintain anxiety at a manageable level 2. Encourage free expression of beliefs and values about spiritual issues 3. Assistance to deal with emotional reactions in an individually appropriate manner 4. Promotion of activities to improve community functioning

What are the 3 factors that have been identified as important considerations in assessing for potential violence?

1. Past Hx of violence 2. Client diagnosis 3. Current behaviors

Nursing Dx for trauma-related disorders may include (2)

1. Posttrauma syndrome 2. Complicated grieving (loss of self, house burned down, lost everything)

What are the 3 factors that determine whether individuals experience a crisis in response to a stressful situation?

1. The individual's perception of the event 2. The availability of situational supports 3. The availability of adequate coping mechanisms

How much anxiety is TOO much?

1. When anxiety is out of proportion to the situation that is creating it. 2. When anxiety interferes with social , occupational, or other important areas of functioning.

Four primary modes of tx for DBT

1. group skills training: taught skills relevant to problems experienced by people with borderline personality disorder (core mindfulness skills, interpersonal effectiveness skills, interpersonal effectiveness, emotion modulation, and distress tolerance skills 2. Individual psychotherapy: weekly session to strengthen dysfunctional behavioral patterns, personal motivation, and skill strengthening 3. Telephone contact: therapist available to pt usually in 24 hour basis, but according to set limits by therapist. 4. Therapist consultation/team meeting: therapist regularly review their work with their pts. These meetings are focused specifically on providing support for each other, keeping the therapists motivated, and providing effective tx to pts.

How may types of personality disorders are identified in the DSM-5

10

When was the first recognition that personality disorders apart of psychosis, were cause for their own special concern was in what year?

1801, with the recognition that an individual can behave irrationally even when the powers of intellect are intact.

Buspirone takes how long to be effective?

2 weeks (10-14 days). Not recommended for prn administration

Diagnosis of PTSD first appeared in what edition of the DSM?

3rd

Systematic Desensitization (KT)

A Tx for phobias in which the individual is taught to relax and then asked to imagine various components of the phobic stimulus on a graded hierarchy, moving from that which produces the least fear to that which produces the most.

Pseudocyesis (KT)

A condition in which an individual has nearly all the signs and symptoms of pregnancy but is not pregnant; a conversion reaction

Generalized Anxiety Disorder (KT)

A disorder characterized by chronic (at least 6 months), unrealistic and excessive anxiety and worry.

Panic Disorder (KT)

A disorder characterized by recurrent panic attacks, the onset of which are unpredictable and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort.

Two students fail their introductory nursing course. One student plans to seek tutoring and retake the course next fall. The second student attempts suicide. Which factor would be influential in the development of the second student's crisis?

A lack of adequate coping mechanisms.

Specific Phobia (KT)

A persistent fear of a specific object or situation, other than the fear of being unable to escape from a situation (agoraphobia) or the fear of being humiliated in social situations (social phobia)

Predisposing Factors to Trauma Related Disorders: Cognitive Theory

A person is vulnerable to PTSD when fundamental beliefs are invalidated by experiencing trauma that cannot be comprehended and when a sense of helplessness and hopelessness prevail. ("Why did this happen to me? or survivors guilt, "why not me?")

Fugue (KT)

A sudden unexpected travel away from home or customary work locale with the assumption of a new identity and an inability to recall one's previous identity; usually occurring in response to severe psychosocial stress.

Individuals who have difficulties with stress reactions to more NORMAL events may be diagnosed with what?

Adjustment disorder

Dispositional Crisis

An acute response to an external situational stressor (Hurricane Katrina OR book ex pg 182Nancy husband abuses her and her child, she goes to ER wounds are cared for, mental health counselor provided support, and guidance in terms of presenting alternatives to her. Needs and issues clarified, and referrals for agency assistance were made)

Derealization (KT)

An alteration in the perception or experience of the external world so that it seems strange or unreal

Depersonalization (KT)

An alteration in the perception or experience of the self so that the feeling of one's own reality is temporarily lost

Crisis Intervention (KT Chpt 10)

An emergency type of assistance in which the intervener becomes a part of the individual's life situation. The focus is to provide guidance and support to help mobilize the resources needed to resolve the crisis and restore or generate an improvement in previous level of functioning. Usually lasts no longer than 6-8 weeks.

Trauma

An extremely distressing experience that causes severe emotional shock and may have long-lasting psychological effects.

What type of situation can precipitate a crisis?

Any stressful situation

Action of SSRI's

Block reuptake of serotonin into the presynaptic nerve terminal, increasing synaptic concentration of serotonin (Changing the balance of serotonin seems to help brain cells send and receive chemical messages, which in turn boosts mood)

S/E Propanolol

Bradycardia, hypotension, weakness, fatigue, impotence, GI upset, bronchospasm

Predisposing Factors Associated with Somatic Symptom Disorder: Neuroanatomical

Brain dysfuntion (impairment in information processing) has been implicated as a factor in factitious disorder.

What anxiolytic is the exception that does not depress the CNS, and is thought to produce its effects through interactions with serotonin, dopamine, and other neurotransmitter receptors?

Buspirone

Barbiturates Action

CNS depression, also produces effects in the hepatic and cardiovascular system

Predisposing Factors Associated with Somatic Symptom Disorder: Biochemical

Decreased levels of serotonin and endorphins may play a role in the etiology of somatic symptom disorder, predominantly pain.

Nursing Dx for depersonalization-derealization disorder

Disturbed sensory perception (visual/kinesthetic)

What is social anxiety disorder (social phobia)?

Excessive fear of situations in which the affected person might do something embarrassing or be evaluated negatively by others.

Factitious Disorder (KT) aka Munchausen Syndrome

Factitious disorders involve conscious, intentional feigning of physical or psychological symptoms. Individuals with factitious disorder pretend to be ill in order to receive emotional care adn support commonly associated with the role "patient"

Agoraphobia (important to know) is

Fear of being in places or situations from which escape might be difficult or in which help might not be available in the event of panic-like symptoms or other incapacitating symptoms

Predisposing factors to phobias: learning theory (behavioral theories)

Fears are conditioned responses and thus are learned by imposing reinforcements for certain behaviors

For the last year a college student continually and unrealistically worries about academic performance and love life performance. The student is irritable and suffers from severe insomnia. This behavior is associated with which diagnosis?

Generalized anxiety disorder (GAD)

S/E of SNRIs

Headache, dry mouth, nausea, somnolence, dizziness, insomnia, asthenia, constipation, diarrhea

Predisposing Factors Associated with Somatic Symptom Disorder: Genetic

Hereditary factors are possibly associated with somatic symptom disorder, conversion disorder, and illness anxiety disorder

Somatic Symptom Disorders: Factitious Disorder (aka munchausen)

INTENTIONAL: Conscious, intentional feigning of physical and/or psychological symptoms. Individual pretends to be ill in order to receive emotional care and support commonly associated with the role of "patient" (deceiving, but underlying issues not understood)

Shiva (KT)

In the Jewish-American culture, following the death of a loved one, shiva is the 7-day period beginning with the burial. During this time, mourners do not work, and no activity is permitted that diverts attention from thinking about the deceased.

Velorio (KT)

In the Mexican-American culture, following the death of a loved one, the velorio is a festive watch by family and friends over the body of the deceased before burial.

Luto (KT)

In the mexican-american culture, the period of mourning following the death of a loved on which is symbolized by wearing black, black and white, or dark clothing and by subdued behavior

Action of Benzodiazepines

Increases the affinity of the GABA receptor for GABA (GABA is thought to be decreased in anxiety disorders (allowing for increased cellular excitability)

Phases of Crisis Intervention: Phase 1 Assessment

Information is gathered regarding the precipitating stressor and the resulting crisis that prompted the individual to seek professional help

SNRIs Action

Inhibit reuptake of neuronal serotonin and norepinephrine; mild reuptake of dopamine (Changing the balance of these chemicals seems to help brain cells send and receive messages, which in turn boosts mood. Medications in this group of antidepressants are sometimes called dual-action antidepressants)

A newly admitted pt diagnosed with OCD, spends 1 hour packing and unpacking, folding and refolding personal belongings. What is most likely the reason for this behavior?

It relives anxiety

S/E of SSRI's

Nausea, diarrhea, headache, insomnia, somnolence, sexual dysfunction

Are people with personality disorders often treated in acute care settings when their primary psychiatric disorder is personality disorder?

No - w/ the exception of borderline personality (risk to self and others) and anit-social (usually court order for acting out violently. risk to self or others)

Crises of anticipated life transitions

Normal life-cycle transition that may be anticipated but over which the individual may feel a lack of control (husband diagnosed with disease that predisposes death or wife has baby quits job and husbands grades suffer because he has to make up for income)

Maturational/developmental crisis

Occurs in response to a situation that triggers emotions related to unresolved conflicts in one's life (think of erikson/freud stages of development)

Cluster A has behaviors described as

Odd or eccentric (don't want relationships)

What population can have a paradoxal reaction to antianxiety meds?

Older people, and increased anxiety will result.

Predisposing Factors to Trauma Related Disorders: Cognitive Theory is very relevant in dealing with what disorder?

PTSD

Action of buspirone

Partial agonist of 5-HT1A receptor.

What is the most widely recognized risk factor for violence in treatment setting?

Past history of violence.

Development of crisis follows a relatively predictable course. What are the four phases through which individuals progress in response to a precipitating stressor and culminate in a state of acute crises

Phase 1 - The individual is exposed to a precipitating stressor Phase 2 - When previous problem-solving techniques do not relieve the stressor, anxiety increases further Phase 3 - All possible resources, both internal and external, are called on to resolve the problem and relieve discomfort Phase 4 - If resolution does not occur in previous phases, the tension mounts beyond a further threshold or its burden increases over time to a breaking point. Major disorganization of the individual occurs, often with drastic results.

Predisposing Factors to Dissociative Disorders: Genetics

Possible hereditary factors associated with DID

Crises resulting from traumatic stress

Precipitated by an UNEXPECTED, external stressor over which the individual has little or no control and from which he or she feels emotionally overwhelmed and defeated. (raped)

What is the key to management of aggressive or violent behavior?

Prevention

Noradrenergic Agent Names

Propranolol, and clonidine

Outcomes for anxiety, OCD, and related disorders

Pt is... - able to recognize signs of escalating anxiety and intervene before reaching panic level (panic and GAD) - able to maintain anxiety at manageable level and make independent decisions about life situation (panic and GAD) - functions adaptively in the presence of the phobic object or situation without experiencing panic anxiety (phobic disorder) - verbalizes a future plan of action for responding in the presence of the phobic object or situation without developing panic anxiety (phobic disorder) - is able to maintain anxiety at a manageable level w/out resorting to use of ritualistic behavior (OCD) - demonstrates more adaptive coping strategies for dealing with anxiety than ritualistic behaviors - verbalizes a realistic perception of his or her appearance and expresses feelings that reflect a positive body image (body dysmorphia) - verbalizes and demonstrates more adaptive strategies for coping with stressful situations (hair-pulling disorder)

Hospice focus of care is on the

QUALITY of life

Borderline people are stuck in what phase of development?

Rapprochment phase (16-24 months old).

Manifestations of OCD

Recurrent obsessions or compulsions that are severe enough to be time-consuming or to cause marked distress or significant impairment.

Obsessive Compulsive Disorder (KT)

Recurrent thoughts or ideas (obsessions) that an individual is unable to put out o his or her mind and actions that an individual is unable to refrain from performing (compulsions). The obsessions and compulsions are severe enough to interfere with social and occupational functioning.

What are compulsions?

Repetitive ritualistic BEHAVIOR or thoughts, the purpose of which is to prevent or reduce distress or to prevent some dreaded event or situation. The person feels driven to perform such actions in response to an obsession or according to rules that must be applied rigidly, even though the behaviors or thoughts are recognized to be excessive or unreasonable.

Which drug is the first line defense drug for tx of trauma-related disorders?

SSRI's such as paroxetine, and setraline because they do not cause dependence, they are efficient, tolerable, and have good safety ratings.

Carlisle stated what drugs are Tx for PTSD?

SSRIs

What neurotransmitters appear to be the most significant in anxiety disorders?

Serotonin, norepinephrine, and gamma-aminobutyric acid (GABA)

*Predisposing Factors Associated with Somatic Symptom Disorder: Learning Theory *

Somatic complaints are often reinforced when the sick role relieves the individual from the need to deal with a stressful situation, whether it be within society or within the family.

Evaluation of care for the pt with a trauma-related disorder is based on what?

Successful achievement of the previously established outcome criteria. - Can the pt discuss the traumatic event w/out experiencing panic anxiety? - Has the pt learned new, adaptive coping strategies for assistance with recovery? - Does pt have flashbacks? - Can pt demonstrate successful use of coping strategies

Predisposing factors to phobias: biological aspects

Temperament - characteristics with which one is born that influence how he or she responds throughout life to specific situations (innate fears)

Delayed grief (KT)

The absence of evidence of grief when it ordinarily would be expected

What drug is commonly used for alcohol withdrawal for outpatient Tx?

The benzodiazepine Librium.

Agoraphobia (chpt 18) (KT)

The fear of being in places of or situations from which escape might be difficult (or embarrassing) or in which help might not be available in the event of panic attack

Integration (KT)

The process used with individuals with dissociative identity disorder in an effort to bring all the personalities together into one; usually achieved through hypnosis.

Mourning (KT)

The psychological process (or stages) through which the individual passes on the way to successful adaptation to the loss of a valued entity

Adjustment Disorders Outcome Criteria

The pt: - verbalizes acceptable grieving behaviors - demonstrates a reinvestment in the environment - accomplishes ADLs independently - demonstrates ability to function adequately - accepts change in health status - sets realistic goals for the future - demonstrates ability to cope effectively with change in lifestyle

Primary gain (KT)

The receipt of positive reinforcement for somaticizing by being able to avoid difficult situations because of physical complaint.

Tertiary gain (KT)

The receipt of positive reinforcement for somaticizing by causing the focus of the family to switch to the individual and away from conflict that may be occurring within the family.

Secondary gain (KT)

The receipt of positive reinforcement for somaticizing through added attention, sympathy, and nurturing.

Which Benzos are fastest acting and have shortest duration?

Xanax and ativan (so people build a tolerance quickly)

Resolution of grief process has occurred when

a bereaved individual is able to remember comfortably and realistically both the pleasures and disappointments of that which is lost.

Psychic emergency crisis

a crisis situation in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility. (acutely suicidal individuals, drug overdoses, reactions to hallucinogenic drugs, acute psychoses, uncontrollable anger, and alcohol intoxication.)

Disasters leave victims with what?

a damaged sense of safety and well-being and varying amounts of emotional trauma

Borderline Personality Disorder (KT)

a disorder characterized by a pattern of intense and chaotic relationships, with affective instability, fluctuating and extreme attitudes regarding other people, impulsivity, direct and indirect self-destructive behavior, and lack of a clear or certain sense of identity, life plan, or values.

Narcissistic Personality Disorder (KT)

a disorder characterized by an exaggerated sense of self-worth. These individuals lack empathy and are hypersensitive to the evaluation of others

Schizotypal Personality Disorder (KT)

a disorder characterized by odd and eccentric behavior, not decompensating to the level of schizophrenia.

Dissociative disorders are defined by

a disruption in the usually integrated functions of consciousness, memory, and identity.

Depersonalization is defined as

a disturbance in the perception of oneself (detachment from self)

Do genetics play a role in anxiety disorders?

a familial predisposition probably exists.

Advance Directive (chpt 28) (KT)

a legal document that a competent individual may sign to convey wishes regarding future health-care decisions intended for a time when the individual is no longer capable of informed consent. It may include one or both of the following: 1. living will in which the individual identifies the type of care he or she does or does not wish to have performed 2. a durable power of attorney for health care, in which the individual names another person who is given the right to make health-care decisions for the individual who is incapable of doing so.

Somatic Symptom Disorders: Conversion disorder

a loss or change in body function that cannot be explained by any known medical disorder or pathophysiological mechanism.

Adjustment disorder (KT) (Chpt 19)

a maladaptive reaction to an identifiable psychosocial stressor that occurs within 3 months after onset of the stressor. The individual shows impairment in social and occupational functioning or exhibits symptoms that are in excess of a normal and expectable reaction to the stressor.

Adjustment disorders are characterized by what?

a maladaptive reaction to an identifiable stressor or stressors that results in the development of clinically significant emotional or behavioral symptoms.

Disaster (KT)

a natural or man-made occurrence that overwhelms the resources of an individual or community and increases the need for emergency evacuation and medical services.

Antisocial Personality Disorder (KT) (Chpt 23)

a pattern of socially irresponsible, exploitative, and guiltless behavior, evident in the tendency to fail to conform to the law, develop stable relationships, or sustain consistent employment; exploitation and manipulation of others for personal gain is common

Splitting (KT)

a primitive ego defense mechanism in which the person is unable to integrated and accept both positive and negative feelings. In the view of of these individuals, people (including themselves) and life situations are either all good or all bad. this trait is common in borderline personality disorder.

Hospice (KT)

a program that provides palliative and supportive care to meet the special needs arising out of the physical, psychosocial, spiritual, social, and economic stresses that are experienced during the final stages of illness and during bereavement.

chronic or prolonged grieving

a prolonged grief process may be considered maladaptive when certain behaviors are exhibited: - behaviors aimed at keeping the lost loved one alive - behaviors that prevent the bereaved from adaptively performing ADLs

Definition of PTSD (slides)

a reaction to an extreme trauma, which is likely to cause pervasive distress to almost anyone, such as natural or man-made disasters, combat, serious accidents, witnessing the violent death of others, being the victim of torture, terrorism, rape, sexual abuse as children, or other crimes.

Anticipatory Grief (KT)

a subjective state of emotional, physical, and social responses to an anticipated loss of a valued entity. The grief response is repeated once the loss actually occurs, but it may not be as intense as it might have been if anticipatory grieving has not occurred.

Define crisis

a sudden event in one's life during which usual coping mechanisms cannot resolve the problem; the crisis disturbs homeostasis

Somatic Symptom Disorders: Somatic symptom disorder is

a syndrome of multiple somatic symptoms that cannot be explained medically and is associated with psychosocial distress and long-term seeking of assistance from health-care professionals.

Posttraumatic stress disorder (PTSD) (KT)

a syndrome of symptoms that develops following a psychologically distressing event that is outside the range of usual human experience (rape, war). The individual is unable to put the experience out of his or her mind and has nightmares, flashbacks and, panic attacks.

Prodromal Syndrome (KT)

a syndrome of symptoms that often precede the onset of aggressive or violent behavior. These symptoms include anxiety, and tension, verbal abuse and profanity, and increasing hyperactivity.

Flooding (KT)

aka implosion therapy, this technique is used to desensitize individuals to phobic stimuli. The individual is "flooded" with a continuous presentation (usually through mental imagery) of the phobic stimulus until no longer elicits anxiety.

A pt with borderline personality disorder have little tolerance for being

alone. they prefer a frantic search for companionship, no matter how unsatisfactory, rather than experiencing feelings of loneliness, emptiness, and boredom.

Bereavement overload (KT)

an accumulation of grief that occurs when an individual experiences many losses over a short period of time and is unable to resolve one before another experienced. This phenomenon is common among the elderly

Derealization is described as

an alteration in the perception of the external environment.

Anxiety is

an emotional ("vague, uncomfortable") response to anticipation of danger, the source of which is largely unknown or unrecognized.

Crisis reflecting psychopathology

an emotional crisis in which preexisting psychopathology has been instrumental in precipitating the crisis or in which psychopathology significantly impairs or complicates adaptive resolution.

What is a stressor?

an external pressure that is brought to bear on the individual (ex: nursing school)

Dissociative amnesia is defined as

an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness, and which is not due to the direct effects of substance use or a neurological or other medical condition.

Some types of specific phobias

animals, natural environment type, blood-injection-injury type, situational type, other type

psychopharmacology for OCD and body dysmorphia

antidepresants

Symptoms of illness anxiety disorder

anxiety and depression are common, and OCD traits frequently accompany this disorder.

What are the most common of all psychiatric illnesses?

anxiety disorders

How is anxiety distinguished from fear?

anxiety is an EMOTIONAL response, and fear is a COGNITIVE one.

Predisposing factors to phobias: cognitive theory (thinking belief)

anxiety is the product of faulty cognitions or anxiety-inducing self instructions such as: - negative self statements - irrational beliefs

what drugs are sometimes helpful with avoidant personality disorder?

anxiolytics

Which drugs are not as desirable for tx of trauma-related disorders?

anxiolytics such as alprazolam, and buspirone because they cause dependence/addiction

Cluster C behaviors are described as

anxious or fearful

What class is buspirone in?

azaspirodecanedione

Understanding death: age 6-9

beginning to understand the finality of death; difficult to perceive their own death; normal grief reactions include regressive and aggressive behaviors

alcohol mixed with what class of drugs can be deadly?

benzos

Action of noradrenergic propanolol

blocks beta adrenergic receptor activity

Examples of psychopathology that may precipitate crises include what ?

borderline personality disorder, severe neuroses, other personality disorders, and schizophrenia

Personality traits are characteristics with which an individual is

born or develops early in life