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Prolonged or intense periods of anxiety may suggest an anxiety disorder. A disorder may also be indicated if: Anxiety occurs without an external threat (“free-floating” anxiety) Anxiety impairs daily functioning Commonly perceived stressors: Stressors might be classified as: 1. Maturational stressors - experiences expected as part of the normal process es of growth and devt. for most individuals. Most individuals start school, leave school, develop relationships, beco me employed, support families, lose loved ones, and prepare for their deaths. Th ese stressors can be anticipated and plans can be made. 2. Situational stressors - less predictable, and specific actions are taken onl y when the threat is eminent or after the event has occurred. Ex. Acute illness, accidents, natural disasters, disasters of human ori gins (terrorist attacks, war), divorce, layoff from work, and chronic illness. Levels of Anxiety Mild +1 Moderate +2 Severe +3 Panic +4 Symptoms: Psychological symptoms may include: Worry or dread Obsessive or intrusive thoughts Sense of imminent danger or catastrophe Fear or panic Restlessness Irritability Impatience Ambivalence Trouble concentrating Physical symptoms may include: Rapid or irregular heartbeat Sweating, especially the palms Dry mouth Flushing or blushing Muscle tension Shortness of breath Lightheadedness or faintness Difficulty sleeping Shaking Choking sensation Frequent urination Nausea or vomiting Diarrhea Constipation Feeling of "butterflies" in the stomach Sexual difficulties Tingling sensations
Nail biting or other habitual behavior ANXIETY-RELATED DISORDERS 1. Generalized Anxiety Disorder Criteria: a. Excessive worry and anxiety. b. Difficulty in controlling the worry. c. Anxiety and worry are evident in 3 or more of the following: - Restlessness - Decreased ability to concentrate - Fatigue - Muscle tension - Irritability - Disturbed sleep Risk Factors - A risk factor is something that increases your chance of getting a disease or condition. Risk factors for GAD include: Sex: female Family member with an anxiety disorder Long-term exposure to abuse, poverty, or violence Low-self esteem Poor coping skills Smoking or other substance abuse Increase in stress Psychological symptoms include: Excessive ongoing worrying and tension Feeling tense or edgy Irritability, overly stressed Difficulty concentrating, mind going "blank" Stress Physical symptoms include: Fatigue Muscle tension Headaches Trembling Difficulty sleeping Restlessness Shortness of breath Sweating Stomach ache (abdominal pain) Heart palpitations Choking sensation Diarrhea Nausea Nursing Interventions to Reduce Anxiety: 1. Provide a calm and quiet environment. R: To identify and reduce stimulation, which includes exposure to situations and interactions with other patients that might provoke anxiety. 2. Ask patients to identify what and how they feel. R: To help patients increase their recognition of what is happe ning to them. 3. Encourage patients to describe and discuss their feelings with you. R: To help patients increase their awareness of the connection between feelings and behaviors.
4. Help patients identify possible causes of their feelings. R: To assist patients in connecting their feelings with earlier experiences. Nursing Interventions to Reduce Anxiety: • Listen carefully for patients’ expressions of helplessness and hopelessn ess. R: To assess for self-harm; patients’ might be suicidal because they wa nt to escape their pain and do not think that they will ever feel better. 6. Ask patients whether they feel suicidal or have a plan to hurt themselves. R: To assess for self-harm and to initiate suicide precautions, if nece ssary. 7. Involve patients in activities such as going for walks or playing recrea tional games. R: To help patients release nervous energy and to discourage preoccupat ion with the self Meds: Antidepressants, like SSRIs and selective serotonin-norepinephrine reupt ake inhibitors (SSNRIs). Because GAD is a chronic disorder, antidepressants are better th an benzodiazepines due to possibility of dependency and tolerance with long-term use of benzodiazepines. 2. Panic Disorder Characterized by recurrent and unpredictable bursts of terror known as p anic attacks. A panic attack is accompanied by physical symptoms that may feel s imilar to a heart attack or other life-threatening condition.
Panic Disorder Intense anxiety often develops between episodes of panic. As panic attac ks become more frequent, people begin avoiding situations that could trigger the m. Panic attacks can lead to agoraphobia, which is the fear of unknown places. Panic Disorder Causes Scientists continue to look for the exact cause or causes of panic disorder. It is believed to be related to: Family history Other biological factors Stressful life events Increased sensitivity to physical sensations Panic Disorder Risk Factors - a risk factor is something that increases your chance of getting a disease or condition. Sex: female Age: young adult History of another anxiety disorder Family history of panic disorders Panic Disorder Criteria: a. Recurrent, unexpected panic attacks. b. Panic attacks followed by a month or more of worry about having addi tional attacks, worry about the results of the attacks, and behavior changes rel ated to the attacks. c. Panic disorder possibly accompanied by agoraphobia
Panic Disorder Treatment The goal of treatment is to decrease the frequency and intensity of panic attack s. Your doctor or mental health care specialist will provide treatment. The foll owing treatments may be provided: Panic Disorder Cognitive-Behavioral Therapy This can prepare patients for situations that may trigger panic attacks. Therapy focuses on: Learning how to recognize what causes your fears Gradually changing distorted thinking patterns to more healthful ones Breathing exercises that increase relaxation Reducing fear and feelings of terror Panic Disorder Medications Your doctor or mental health care specialist may prescribe one or more of the ff : Antidepressants Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Proz ac) and sertraline (Zoloft) Panic Disorder Anti-anxiety Medicines (Benzodiazepines) Alprazolam (Xanax) Clonazepam (Klonopin) Lorazepam (Ativan) Panic Disorder Nursing Management a. Stay with the patient who is having a panic attack and acknowledge t he patient’s discomfort. b. Maintain a calm style and demeanor. c. Speak in short, simple sentences, and give one direction at a time i n a calm tone of voice. d. If patient is hyperventilating, provide a brown paper bag and focus on breathing with the patient. Panic Disorder • Allow patients to pace or cry, which enables the release of tension and energy. • Communicate to patients that you are in control and will not let anythin g happen to them. g. Move or direct patients to a quieter, less stimulating environment. Do not t ouch these patients; touching can increase feelings of panic. h. Ask patients to express their perceptions or fears about what is happening t o them. Rationale: To help patients reduce anxiety to a more manageable and com fortable level. Panic Disorder Dietary Changes Some people find that avoiding caffeine (found in coffee, tea, chocolate, colas, diet sodas) may help reduce panic attacks. 3. Obsessive Compulsive Disorder A ritualistic behavior to control anxiety Thoughts = OBSESSIONS Actions = COMPULSIONS Obsessive-compulsive disorder (OCD) is an anxiety disorder. The person s uffers from unwanted repetitive thoughts and behaviors. These obsessive thoughts and compulsive behaviors are very difficult to overcome. If severe and untreate
d, OCD can destroy the ability to function at work, school, or home. Frontal lobe Causes Tourette syndrome Trichotillomania—the repeated urge to pull out scalp hair, eyelashes, ey ebrows, or other body hair Body dysmorphic disorder—imaginary or exaggerated defects in appearance Eating disorders (such as bulimia or anorexia nervosa) Hypochondriasis Substance abuse Risk Factors A risk factor is something that increases your chance of getting a disea se or condition. Risk factors include: Age: late adolescence, early adulthood Family members with a history of OCD Other anxiety disorders Depression Tourette syndrome Personality disorder Attention deficit disorder Symptoms Obsessions—unwanted, repetitive, and intrusive ideas, impulses, or image s Compulsions—repetitive behaviors or mental acts to reduce the distress a ssociated with obsessions People with OCD may know that their thoughts and behaviors do not make s ense. And they would like to avoid or stop them. But they are often unable to bl ock their obsessive thoughts or compulsions. Common obsessions: Persistent fears that harm may come to self or a loved one Unreasonable concern with being contaminated Unacceptable religious, violent, or sexual thoughts Excessive need to do things correctly or perfectly Common compulsions: Excessive checking of door locks, stoves, water faucets, light switches, etc. Repeatedly making lists, counting, arranging, or aligning things Collecting and hoarding useless objects Repeating routine actions a certain number of times until it feels just right Unnecessary rereading and rewriting Mentally repeating phrases Repeatedly washing hands Treatments include: Medications Selective serotonin reuptake inhibitors (SSRIs) reduce OCD symptoms by a ffecting the neurotransmitter serotonin. This function is independent of their a ntidepressant effects. SSRIs include: Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Behavior Therapy (Exposure and Response Prevention)
This helps you gradually confront the feared object or obsession without giving in to the compulsive ritual linked to it. Nursing care: Ensure that basic needs of food, rest, and grooming are met. R: Patients are too busy to attend to these tasks. Reminders and specifi c directions are usually necessary. 2. Provide patients with time to perform rituals. R: Patients need to keep anxiety in check. Later, work to decrease the rituals by setting limits, but never take away a ritual, or panic might ensue. 3. Explain expectations, routines, and changes. R: To prevent an increase or escalation of anxiety. Be empathic toward patients and be aware of their need to perform ritual s. R: To convey acceptance and understanding. 5. Assist patients with connecting behaviors and feelings. R: To promote the ability to identify and understand feelings. 6. Structure simple activities, games, or tasks for patients. R: To help patients focus on alternatives to their thoughts and actions. 7. Reinforce and recognize positive nonritualistic behaviors. R: To increase patient’s self-esteem and self-worth. 4. Phobias Phobic Disorders 3 Types: 1. Agoraphobia without history of panic disorder; a fear of being in pu blic or open spaces, places, or situations in which escape might be difficult or help might not be available – for example, if the person should faint. 2. Social phobia: fear of being humiliated, scrutinized, or embarrasse d in public – for example, choking while eating in front of others or stumbling while dancing in view of others. 3. Specific phobia: fear of a specific object or situations that is no t either of the above – for example, fear of animals, flying, or heights. Nursing care 1. Accept patients and their fears with a noncritical attitude. 2. Provide and involve patients in activities that do not increase anxi ety but increase involvement, rather than promote avoidance. 3. Help patients with physical safety and comfort needs. 4. Help patients recognize that their behavior is a method of avoiding anxiety. Medication Meds traditionally have no effect on avoidant behaviors. SSRIs are used to reduce anxiety and depression and block panic attacks, if any. 5. PTSD Post-traumatic stress disorder (PTSD) is an anxiety disorder that develo ps after a traumatic event. PTSD has also been called shell shock or battle fati gue. Causes The exact cause of PTSD is unknown. PTSD is triggered by exposure to a t raumatic event. Situations in which a person feels intense fear, helplessness, o r horror are considered traumatic. PTSD has been reported in people who experien ced: War Rape Physical assault
Earthquakes Fire Sexual abuse Motor vehicle accidents Symptoms People with PTSD experience symptoms of anxiety. These symptoms fall int o three categories: Re-experiencing of the event Dreams/nightmares Flashbacks Anxious reactions to reminders of the event Hallucinations Avoidance Avoiding close emotional contact with family and friends Avoiding people or places that are reminders of the event Loss of memory about the event Feelings of detachment, numbness Arousal Difficulty falling or staying asleep Anger and irritability Difficulty concentrating Being easily startled Criteria 1. Exposure to a traumatic event involving threat of death/injury to self or oth ers, or actual injury to self or others. 2. Responses of horror, helplessness, or fear. 3. Dissociative symptoms during or immediately after the event: - Absence of emotions, numbing, detachment. - Decreased awareness or surroundings (in a daze). - Derealization or depersonalization. - Amnesia. 4. Reexperiencing or reliving the traumatic event: distressing thoughts, dreams , flashbacks, illusions. 5. Avoidance of stimuli related to trauma: feelings, thoughts, people, conversa tions, places, and activities; distress when exposed to reminders of the event. 6. Increased arousal or anxiety: sleep disturbance, hypervigilance, startle res ponse, irritability, restlessness, decreased concentration. 7. Impairment or distress in functioning – occupational, social, or other impor tant areas. 8. Onset: Within 4 weeks after the event. 9. Duration: 2 days to 4 weeks. Risk factors: Not everyone who experiences a traumatic event will develop PTSD. Sympto ms of PTSD are more likely to occur if the person has: Previous traumatic experiences A history of being physically abused Poor coping skills Lack of social support Existing ongoing stress A social environment that produces shame, guilt, stigmatization, or self -hatred Alcohol abuse Family psychiatric history Types of PTSD PTSD is categorized according to when symptoms occur and how long they l ast. There are three types of PTSD:
Acute—symptoms last between one and three months after the event Chronic—symptoms last more than three months after the event Delayed onset—symptoms don t appear until at least six months after the event Treatment
There is no definitive treatment nor is there a cure for PTSD. A variety of therapies can help relieve symptoms. You will not begin treatment for PTSD u ntil after you are completely removed from the traumatic event. You will first r eceive treatment for severe depression, suicidal tendencies, drug or alcohol abu se. Cognitive Behavior Therapy Many mental health concerns are caused by a combination of physiological and emotional triggers. CBT can help patients cope by decreasing the effects of emotional triggers. Exposure Therapy The therapist brings back the imagery of the event in a safe place. He o r she will gradually guide you through a visualization. Re-experiencing the trau ma in a controlled environment can help you let go of fear and gain control over the anxiety. In a recent randomized controlled study involving 288 female military pe rsonnel suffering from PTSD, prolong exposure was significantly more effective a t relieving, and even resolving, PTSD symptoms than supportive (non-CBT) therapy after 10 weekly sessions. * Group Therapy Meeting in a group with other survivors of trauma can be an effective an d powerful form of therapy for PTSD sufferers. Medication Medication may help with anxiety, depression, and insomnia. Usually antidepressants known as selective serotonin reuptake inhibitors (SSRIs) are prescribed. Anti-anxiety medications may be used in the short term and/or beta-block ers in the long term to calm some of the physical symptoms of severe PTSD. Prevention The events that trigger PTSD cannot be predicted or prevented. However, there are some factors that might prevent PTSD from developing after the event. Debriefing—a group meeting with trained facilitators. This allows those affected to talk about their thoughts, feelings, and reactions. Social support—A network of social support can make a difference in how people react to trauma Avoid using nicotine or other drugs, and drink alcohol in moderation Nursing Management Moderate level of Anxiety - Recognize anxiety - Insight into the anxiety - Cope with the threat - Promote relaxation response Severe/Panic level of Anxiety - Establish a trusting relationship - Self-awareness - Protect patient - Modify environment - Encourage activity
Physiological Responses, Somatoform and Eating Disorders Basic Concepts • The relationship between the mind and body • All illnesses have a psychological component: Physical disorders have a psychological component and mental disorders, a physical component Stress Theory • Alarm Reaction – the immediate response to a stressor in a localized are a. • Stage of Resistance – the body adapts and functions at a lower than opti mal level, requiring a greater than usual expenditure of energy for survival. • Stage of Exhaustion – the adaptive mechanisms become worn out and then f all. The negative effect of the stressor spreads to the entire organism. Assessment: • Physical conditions affected by psychological factors: – Cardiovascular – migraine, hypertension, angina, tension headache – Musculoskeletal – rheumatoid arthritis, low back pain – Respiratory – hyperventilation, asthma – Gastrointestinal – anorexia nervosa, peptic ulcer, irritable bowel syndr ome, obesity – Skin - eczema, pruritus – Genitourinary - impotence, frigidity, PMS – Endocrinological – hyperthyroidism, diabetes Psychological • Some people have physical symptoms without organic impairment called som atoform disorders Somatization Disorder • The person has the physical symptoms, allowing him to be taken of and to avoid the demands of adult responsibility. • Secondary gain – related to the gratification of dependency needs is a p owerful deterrent to change in many patients. Conversion Disorder • There is a loss or alteration of physical functioning. Symptoms of some physical illnesses appear without any underlying organic cause. • Primary Gain – is that the patient is unable to carry out his impulses. He also may experience secondary gain in the form of attention, manipulation oth ers, freedom from responsibilities and economic benefits. Conversion s/sx may include: • Sensory symptoms: numbness, blindness, or deafness • Motor symptoms: paralysis, tremors, mutism • Visceral symptoms: urinary retention, headaches, difficulty breathing – Patients display little anxiety or concern about the conversion symptom and its resulting disability. The classic term for this is la belle indifference
Hypochondriasis • There is a fear of illness of belief that one has an illness. Has an exa gerrated concern with physical health that is not based on any real organic diso rders. Uses information about the diseases to convince himself that he is ill o r about to become ill. • Unlike in conversion reaction, no actual loss of distortion of function occurs. Appears worried and anxious about the symptoms. A chronic behavior patte
rn by a history of visits to numerous practitioners. • If a person fakes an illness(conscious decision), the behavior is called malingering. This is usually done to avoid responsibilities the person views as burdensome.
Body Dysmorphic Disorder • The person with normal appearance is concerned about having a physical d efect. Pain Disorder • Psychological factors play an important role in the onset, severity, or maintenance of pain. Sleep Disorders 1. Insomnia – disorders of initiating sleep. Anxiety and depression are major causes. 2. Hypersomnia – disorders of excessive somnolence. Includes narcolepsy, sleep apnea, and nocturnal movement disorders such as restless legs. 3. Disorders of the sleep-wake schedule, characterized by normal sleep occurring at the wrong time. These are transient disturbances associated with jet lag and work shift changes. Usually self-limited and resolve as the body readjusts to a new sleep-w ake schedule. 4. Parasomnia – disorders associated with sleep stages. Includes sleepwalking, night terrors, nightmares, restless legs syndrome and enuresis. Often experienced by children and can have significant effect on functio ning and well-being. Consequences of sleep disorders: • Reduced productivity • Lowered cognitive performance • Increased likelihood of accidents • Higher morbidity and mortality risks. • Depression • Decreased quality of life Sleep Hygiene Behavior Strategies 1. Maintain a regular bedtime and wake-up time 7x a week. 2. Exercise daily to aid sleep initiation and maintenance 3. Schedule time to wind down and relax before bed 4. Try relaxation exercises before bedtime 5. Avoid worrying when trying to fall asleep. 6. Guard against night time interruptions 7. Earplugs may help with noisy partner 8. Bedroom should be dark, quiet, cool and comfortable. 9. Create a comfortable bed 10. A warm bath or warm drink before bed helps some people fall asleep. 11. Excessive hunger or fullness may interfere with sleep. Avoid large meals bef ore bed. 12. Avoid caffeine, excessive fluid intake, stimulating drugs and excessive alco hol in the evening and before bed. 13. Do not eat, read, work, or watch TV in bed. 14. Excessive napping may make it difficult for some people to fall asleep. 15. Maintain a reasonable weight. Excessive weight may result in daytime fatigue and sleep apnea.
16. Get out of bed and engage in other activities if not able to fall asleep. Evaluation • Decrease visits to MD’s with physical symptoms. • Decrease use of medications and more positive coping mechanisms. Anorexia Nervosa • Fear of obesity • Feels fat when thin • Loss of at least 25% of original weight • Refusal of maintain minimal body weight • Amenorrhea for 3 cycles Anorexia…. • A person with anorexia initially begins dieting to lose weight. Over tim e, the weight loss becomes a sign of mastery and control. The drive to become th inner is actually secondary to concerns about control and/or fears relating to o ne s body. Who is at risk for anorexia? • Many experts consider people for whom thinness is especially desirable, or a professional requirement (such as athletes, models, dancers, and actors), t o be at risk for eating disorders such as anorexia nervosa. What causes anorexia? • Although no organic cause for anorexia has been identified, some evidenc e points to a dysfunction in the part of the brain (hypothalamus) which regulate s certain metabolic processes. Other studies have suggested that imbalances in n eurotransmitter levels in the brain may occur in people suffering from anorexia. How is anorexia diagnosed? • There are four basic criteria for the diagnosis of anorexia nervosa that are characterized as: • The refusal to maintain body weight at or above a minimally normal weigh t for age and height. Body weight less than 85% of the expected weight is consid ered minimal. • An intense fear of gaining weight or becoming fat, even though the perso n is underweight. • Self-perception that is grossly distorted and weight loss that is not ac knowledged. • In women who have already begun their menstrual cycle, at least three co nsecutive periods are missed (amenorrhea), or menstrual periods occur only after a hormone is administered. How is anorexia treated? • A gain of between one to three pounds per week is a safe and attainable goal when malnutrition must be corrected. • The overall treatment of anorexia, however, must focus on more than weig ht gain. • Different kinds of psychological therapy have been employed to treat peo ple with anorexia. Individual therapy, cognitive behavior therapy, group therapy , and family therapy have all been successful in treatment of anorexia. • Nutritional education provides a healthy alternative to weight managemen t for the patient. Group counseling or support groups often assist the individua
l in the recovery process. The ultimate goal of treatment should be for the indi vidual to accept herself/himself and lead a physically and emotionally healthy l ife. Prognosis: • The prognosis of anorexia is variable, with some people making a full re covery. Others experience a fluctuating pattern of weight gain followed by a rel apse, or a progressively deteriorating course over many years. Bulimia • is characterized by episodes of secretive excessive eating (bingeing) fo llowed by inappropriate methods of weight control, such as self-induced vomiting (purging), abuse of laxatives and diuretics, or excessive exercise Criteria • Binge eating (sense of lack of control over eating a large amount of foo d) • Compensatory behavior to prevent weight gain (self-induced vomiting, lax atives, diuretics, enemas, fasting, excessive exercise. • Twice a week episodes for 3 months. Bulimia Nervosa and Binge Eating • A person which eats too much is designated as either bulimia nervosa (if the person can keep a normal weight) or binge eating disorder (if the person is overweight.
• The secrecy of bulimia stems from the shame that bulimics often attach t o the disorder. Binge eating is not triggered by intense hunger. It is a respons e to depression, stress, or other feelings related to body weight, shape, or foo d. Binge eating often brings on a feeling of calm or happiness (euphoria), but t he self-loathing because of the overeating soon replaces the short-lived euphori a. How is bulimia treated? • Treatment can be managed by either a physician, psychiatrist, or in some cases, a clinical psychologist. • The successful treatment of bulimia is often multidisciplinary involving both medical and psychological approaches. • The goals of treatment are to restore physical health and normal eating patterns. Medications • A number of antidepressant medications have been shown to be beneficial in the treatment of bulimia. Several studies have demonstrated that fluoxetine ( Prozac), a member of the selective serotonin reuptake inhibitor (SSRI) class of antidepressants, has been effective in the treatment of bulimia. • • • • • • • • Small frequent feedings Monitor I/O and bowel functions Monitor weight gain and lab results Encourage expression of feelings Set realistic expectations of self Encourage participation in activities Stay with client during mealtimes, and at least one hour after eating Accompany to bathroom after eating
Do not… • Indicate feelings of shock, disbelief, or disgust • Confront and judge hostilities and anger if they occur • Discuss and explain food diet
Compare clients behavior and appearance to others Allow longer than 30 min. mealtime
Personality Disorder • Personality disturbances that come together to create a pervasive patter n of behavior and inner experience that is quite different from the norms of the culture • They have disturbances in self-image • Decreased ability to have successful relationships Cluster • • • A Odd and eccentric behaviors Paranoid Schizoid
Cluster A PARANOID • Suspiciousness caused by lack of trust • Interprets remarks as demeaning or threatening • Potential for loss of control and violence • • usive • • Management Establish a trusting relationship. Be professional, honest, and non-intr Clear, simple explanations Do not involve in group therapy that involve confrontation
Schizoid Personality • Very shy, cold and aloof. • Lacks desire for close relationships, appears detached, lack of sexual e xperiences • Avoids activities • Fantasies of imaginary relationships substitute for real relationships Management • Offer support, kindness, gentle suggestions to involve in activities • Socializing activities, vocational counseling and assistance • Low doses of neuroleptic drugs for anxiety Management…. • The medication that is most recently used to treat the negative symptoms is Risperidone. Before this, there was no psychotropic medication that made an impact on the negative symptoms. Low doses of Risperdone or Olanzapine also work for the social deficits and blunted affect DRUG CLASS AND MECHANISM: Risperidone. Affects the way the brain works by interfering with communication among the brain s nerves. Nerves communicate with each other by making and releasing c hemicals called neurotransmitters. The neurotransmitters travel to other nearby nerves where they attach to receptors on the nerves. The attachment of the neuro transmitters either stimulates or inhibits the function of the nearby nerves. Ri speridone blocks several of the receptors on nerves including dopamine type 2, s erotonin type 2, and alpha 2 adrenergic receptors. It is believed that many psyc hotic illnesses are caused by abnormal communication among nerves in the brain a nd that by altering communication through neurotransmitters, risperidone can alt er the psychotic state. Risperidone was approved by the FDA in December, 1993.
Cluster • • • • •
B Dramatic or Erratic Personality Antisocial Borderline Narcissistic Histrionic
Antisocial Personality • Violates the rights of others, lack of guilt or remorse • Aggressive behavior, engages in illegal activities • Irresponsible in work and with finances, impulsive, reckless Risk factors • Substance abuse • Attention deficit hyperactivity disorder (ADHD) • A history of childhood physical, sexual, or emotional abuse • Neglect; deprivation or abandonment; associating with peers who engage i n antisocial behavior; • A parent who is either antisocial or alcoholic Antisocial Personality • Management • Set limits • Help patient be aware of consequences of his behavior • Avoid moralizing, assist in verbalizing anxious feelings and depression A client with antisocial personality disorder tells a nurse, “ life has been ful l of problems since childhood”. Which of the ff situations would the nurse explo re in the assessment? • Birth defects • Distracted easily • Hypoactive behavior • Substance abuse Which of the ff behaviors by a client with antisocial personality disorder alert s a nurse to the need for teaching related interaction skills? • Frequently crying • Having panic attacks • Avoiding social activities • Failing to follow social norms Borderline Personality • Unstable mood and interpersonal relationship, disturbed body image. • Lack of self identity • Impulsiveness • Marked shift from depression to irritability, anxiety, anger, suicidal t hreats • Self mutilating behavior • Chronic feelings of boredom • Frantic efforts to avoid real or imagined abandonment Splitting Allow pt. to perceive external objects as all good or all bad Due to borderline pt’s inability as a child to separate from the mother and become individualized Person is unable to master concepts of both positive and negative feelin gs, thoughts and perceptions Using splitting, the pt externalized the internal conflict and manipulat es the staff to act out the pt’s internal conflict. Cont… Limit setting is reassuring to the pt. Clinical supervision and a cohesive staff group are useful in avoiding g
etting caught in counter transference issues. Psyche Nursing Intervention Communication skills Establish trusting relationship Increase clients self esteem Reality orientation Maintain safe environment Provide structure Problem solving Limit setting Decision making Behavior modification Family intervention
Narcissistic Personality Narcissistic • Grandiose self-importance, fantasies of unlimited power, success, or bri lliance. • Believes he is special, needs to be admired. • Sense of entitlement (deserves to be given special treatment) • Takes advantage of others for his own benefit, lacks empathy • Arrogant, envious of others. Causes • Dysfunctional childhood as excessive pampering, extremely high expectati ons, abuse or neglect. • Genetics or psychobiology — the connection between the brain and behavio r and thinking. Risk factors: • An oversensitive temperament as a young child • Overindulgence and overvaluation by parents • Excessive admiration that is never balanced with realistic feedback • Unpredictable or unreliable caregiving from parents • Severe emotional abuse in childhood • Being praised for perceived exceptional looks or talents by adults • Learning manipulative behaviors from parents Criteria for narcissistic personality disorder to be diagnosed include: • Having an exaggerated sense of self-importance • Being preoccupied with fantasies about success, power or beauty • Believing that you are special and can associate only with equally speci al people • Requiring constant admiration • Having a sense of entitlement • Taking advantage of others • Inability to recognize needs and feelings of others • Being envious of others • Behaving in an arrogant or haughty manner Complications If left untreated, can include: • Substance abuse • Alcohol abuse • Depression
• Suicidal thoughts or behavior • Eating disorders, particularly anorexia nervosa • Relationship difficulties • Problems at work or school Treatment and drugs: • Cognitive behavioral therapy. In general, cognitive behavioral therapy h elps you identify unhealthy, negative beliefs and behaviors and replace them wit h healthy, positive ones. • Family therapy. Family therapy typically brings the whole family togethe r in therapy sessions. You and your family explore conflicts, communication and problem-solving to help cope with relationship problems. • Group therapy. Group therapy, in which you meet with a group of people w ith similar conditions, may be helpful by teaching you to relate better with oth ers. This may be a good way to learn about truly listening to others, learning a bout their feelings and offering support. Narcissistic Management • Supportive confrontation • Set limits, be consistent • Focus on the here and now to decrease patients use of fantasy Histrionic Personality • Uses physical appearance to become center of attention • Displays sexually seductive or provocative behaviors • Dramatic expression of emotion. Uses speech to impress others but lacks depth • Easily influenced by others • Exaggerates degree of intimacy with others Histrionic Personality • Management • Positive reinforcement for unselfish or other-centered behaviors • Provide support for independent problem solving and daily functioning Psyche • • • • • • • • • • • Nursing Intervention Communication skills Establish trusting relationship Increase clients self esteem Reality orientation Maintain safe environment Provide structure Problem solving Limit setting Decision making Behavior modification Family intervention
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