Week 10: Psych

Question 1

Hippocrates “four humors”

Answer 1

• Irritable and hostile (yellow bile)
• Pessimistic and melancholic (black bile)
• Overly optimistic and extraverted (blood)
• Apathetic (phlegm)

Question 2

“Moral Insanity”

Answer 2

1801: Irrational behavior with an intact intellect

Question 3

The Healthy Personality- Positive Relationships

Answer 3

• Closeness with others
• Maintain separate identities
• Open communication of feelings
• Valued but separate relationships
• Empathic acceptance

Question 4

Adaptive/Maladaptive Social Response continuum

Answer 4

Adaptive Response

• Solitude
• Autonomy
• Mutuality
• Interdependence

Middle of the Road

• Loneliness
• Withdrawal
• Dependence

Maladaptive Social Response

• Manipulation
• Impulsivity
• Narcissism

Question 5

Personality Disorder (definition)

Answer 5

• Set of patterns/traits that hinder the ability to maintain meaningful relationships, feel fulfilled and enjoy life (Stuart, 2012)
• Enduring pattern of inner experience and behavior that is pervasive and inflexible
• Prevalence estimates 4%-22% population
• Not exclusive to one gender
• Often comorbid with substance use disorders
• Continuous rather than episodic
• Frequently not diagnosed
• Few strategies for relating to others
• Infrequently treated as primary illness
• Problems with impulse control, judgment, reality testing, self-perception, mood, social and interpersonal functioning
• Approach to relationships is inflexible and maladaptive
• Behaviors provoke negative reactions from others
• Adaptation is tenuous- low resilience in stressful situations
• Inflexible and pervasive

Question 6

Etiology Personality disorder Biological

Answer 6

• Genetic influences
• Disturbances in neurotransmitters

Question 7

Etiology Personality Disorder Sociocultural

Answer 7

• Cultural influences
• High levels of crime and violence
• Immediate gratification
• Displaced aggression

Question 8

Etiology of Personality Disorders: Psychodynamic origins

Answer 8

ego development and object-relations

• difficulty with separation-individuation stage of development (1.5 -3 yrs)
• issues with abandonment, dependency, control and authority
• Most widely accepted theory

Question 9

Personality disorders 3 clusters

Answer 9

• Cluster A: ECCENTRIC: paranoid, schizoid, or schizotypal (not schizophrenic, personality styles in which people are essentially withdrawn from others, interact with people in a very odd and incomfortable way)
• Cluster B: ERRACTIC: (most frequent) antisocial (there are rules for other people but not for me), borderline (most frequently occuring), histrionic (very wide range of expressive behaviors. Makes a mountian out of a molehill), narcissistic
• Cluster C: FEARFUL (absolutely avoids others): avoidant, dependent (unable to functionwithout the support and guidance of somebody else), o_bsessive-compulsive_ (personality style in which the person’s obsessions or compulsions occupy a significant amount of time, not associated with anxiety)

Question 10

Borderline Personality Disorder

Answer 10

Pervasive instability with 5 or more:

• Efforts to avoid abandonment
• Unstable interpersonal relationships
• Unstable self image
• Impulsivity that is potentially damaging
• Recurrent self-mutilating behavior
• Affective instability
• Chronic feelings of emptiness
• Inappropriate anger
• Transient paranoia

Question 11

Interaction Patterns- Assessment (borderline personality disorder)

Answer 11

• Poor impulse control (ex: decide to cut at the drop of a hat because their friend cancelled a lunch date. Can’t handle potential or actual abandonment)
• Affective instability
• Judgment
• Projection
• Distorted self-perception
• Clinging and distancing
• Expert in “splitting”
• Expert in manipulation
• Acting out behaviors

Question 12

Case study Multi-Axial Dx

• 29 year old single woman
• Suicidal after her boyfriend broke up with her w 2 weeks ago after a very stormy year together
• History of on and off, very good or very bad relationships
• Drinking many martinis and using diazepam (Valium)
• Began stalking ex, threw a rock through his window
• Agitated and screaming “I just want to die” then ran into the street in front of an oncoming car
• Taken to emergency department and admitted with pelvic and femur fractures and various lacerations

Answer 12

Multi-Axial Diagnosis

Axis I
Substance use disorder
Axis II
Borderline personality disorder
Axis III
Pelvic fracture, femur fracture, lacerations
Axis IV
Problems with primary support group (boyfriend)
History of unstable relationships
Axis V
Current GAF 30, highest in last year, 60

Question 13

Concept Mapping for this individual

• 29 year old single woman
• Suicidal after her boyfriend broke up with her w 2 weeks ago after a very stormy year together
• History of on and off, very good or very bad relationships
• Drinking many martinis and using diazepam (Valium)
• Began stalking ex, threw a rock through his window
• Agitated and screaming “I just want to die” then ran into the street in front of an oncoming car
• Taken to emergency department and admitted with pelvic and femur fractures and various lacerations

Answer 13

#1 Risk for self harm

• Related to: parental emotional deprivation, history of unsatisfying relationships
• As evidenced by: recent history of self harming episode

Goal: The patient will not harm herself during this shift.

Interventions

• Frequent observation
• Contract
• Self harm episodes are dealt with in a matter of fact manner
• Discuss feelings as they occur
• Act as a role model
• Environmental vigilance

Evaluation:

Outcome: there will be no self harming behaviors during this shift

• No harm has occurred
• Seeks out staff when desire for self mutilation occurs

#2 Impaired social interaction

• Related to: fears of abandonment
• As evidenced by: lack of close friendships, staff splitting, blaming and recent breakup

Goal: The patient will engage in therapeutic interaction with the nurse for ten minutes twice during this shift

Nursing Intervention

• Examine and identify clinging/distancing behaviors
• Reinforce availability for 1:1 interaction
• Reinforce independent functioning
• Skilled staff members
• Explore abandonment
• Discourage dependency behaviors

Evaluation

Outcome: no clinging/distancing behaviors

• Independent with ADL
• Interacts with more than one staff member
• Fewer or no manipulative behaviors
• Accepts feedback and changes behavior

Nursing Concerns

• Risk for violence, directed at others, self
• Self-esteem disturbance
• Noncompliance with milieu structure
• Personal identity disturbance
• Substance abuse diagnoses
• Care for the nurse

Question 14

Limit Setting

Answer 14

• Specific boundaries so that significance of deviations
• can be immediately processed
• Contracting defines limits
• Designated team member delivers communications

Question 15

Medicines and borderline personality disorder

Answer 15

• aren’t medicines to fix, but can treat symptoms
• Depressed: anti-depressants
• Mood Stabilizers: Depakote, Lamictal
• Antipsychotics: Most usually inappropriate because these aren’t psychotic symptoms
• Anxiolytic Drugs: Very often used, can spell trouble because of the addiction. Would recommend Benzo’s such as Ativan or *Klonapin (long acting and least abuseable, helpful in small doses).

Question 16

4 Big problems of Older Adults

Answer 16

• Depressive Disorders
• Dementia
• Delirium
• Dying

Question 17

Depression

Answer 17

• Often comorbid with other physical illness
• Depressed persons frequently diagnosed and treated by primary care providers, cases are undertreated, or untreated (Wang, 2005)
• 58% of older adults believe depression is a normal event for this demographic
• Resistant to seeking treatment due to stigma
• Insidious problem
• Neurovegetative signs (undereating, no energy, no sleep, inability to concentrate) interfere with general health and influence other health problems
• Depression can mimic dementia
• Symptoms include lack of interest, social withdrawal, anxiety, chronic aches and pains, increased dependency
• Evidence points to depression as etiologic in stroke, cancer, epilepsy

Question 18

Depression is not

Answer 18

• Part of “normal” aging
• Inevitable
• Untreatable

Question 19

Suicide in Older Adults

Answer 19

• Older adults account for 15.7% completed suicides
• Males >75 have the highest suicide frequency: 14.7 per 100,000
• Individuals who complete suicide have seen a primary care giver within 6 weeks prior
• Firearms are the most common means (71.9%)

Question 20

Older Adult Suicide Risk Factors

Answer 20

• Recent death of a loved one
• Physical illness- fear of prolonged illness
• Uncontrolled pain
• Perceived poor health
• Social isolation
• Major changes in family, social, or occupational roles

Question 21

Depression Assesment Instruments

Answer 21

Assessment instruments specifically for older adult depression diagnosis

*Two-Question Screen for Depression: Patient Health Questionnaire 2 (PHQ-2)

• During the last 2 weeks have you been often bothered
• By having little interest or pleasure in doing things yes, no
• By feeling down, sad or hopeless yes, no

Question 22

Interventions for Older Adult Depression

Answer 22

• Most often provided by primary care professionals
• Most often treated with medication alone
• Medication alone is less effective treatment than when combined with psychotherapy
• One major episode after age 60 = treatment for life is indicated

Question 23

Nursing Interventions for Older Adult Depresssion

Answer 23

• Therapeutic alliance
• Support system
• Suicide assessment- ask the question
• Community services
• Health assessment
• Monitoring of medications- depressogenics
• Psychotherapy
• Living arrangements
• Maximize autonomy

Question 24

Dementia in Older Adults

Answer 24

• Not part of normal aging
• From the Latin “demens”
• Umbrella term for chronic condition
• Chronic and progressive in nature
• Alzheimer’s type
• Traumatic Brain Injury
• Multi-Infarct

Question 25

Alzheimer’s Dementia

Answer 25

* Chronic, progressive, irreversible * Current treatment is not curative, but minimally effective in slowing progression * Loss of premorbid cognitive and intellectual abilities- slowly insidious * Disorientation, memory loss, impaired judgment, decreased social functioning, personality change, labile mood * Diagnosis at autopsy, prior to that dx is “Dementia- most probably of the Alzheimer’s type”

Question 26

Depressogenic Medications

Answer 26

* Antihypertensives * Analgesics * CNS depressants * Antiparkinsons drugs * Sulfonamides * Cardiovascular agents (digitalis) * Long Term Steroids

Question 27

Multi Infarct Dementia

Answer 27

* Stepwise downward progression * Secondary to vascular disease or co morbid illness

Question 28

Traumatic Brain Injury

Answer 28

* As a result of accident or violence * Specific impairments dependent on injury site * Improvements are possible

Question 29

Dementia/Assessment

Answer 29

Standardized screening instruments administered by nurses- * Folstein Mini Mental Status Examination (old gold standard. Don't use much anymore bc it's copywritten. Score out of 30) * Clock Drawing Test * Montreal Cognitive Assessment (This is the new gold standard. Score of 27 or less deonstrates some impairment)

Question 30

Symptoms/Changes you see in dimensia

Answer 30

* Attention * New learning * Memory * Language * Visual perception * Emotional Regulation

Question 31

Nimenda

Answer 31

Effects neurotransmitters in the synapse to help slow the progression of dimensia. Left on unless we have to stop: Can't tolerate due to side effect (agitation, sleeplessness, bad stomach upset), Running out of Money. If medicine is stoped, you might see a steep functional decline.

Question 32

Dementia/Intervention

Answer 32

* Accommodate physical impairments * Create therapeutic alliance * Integrate verbal and nonverbal communication * Use all the senses * Involve significant others * Facilitate story * Clarify, verify, and revisit * Community agencies * Assess use of medications * Living situation

Question 33

“Elderspeak”

Answer 33

* Over accommodation * Monosyllabic wording * Exaggerated intonation * High pitch * Volume * Diminutives

Question 34

Common Errors when dealing with dimentia patients

Answer 34

* Arguing * I know more than you know * Criticizing * Labeling * I know what would be best * Everything will be just fine

Question 35

Delirium

Answer 35

* Syndrome of disturbed consciousness, attention, cognition, and perception * Complex interaction of physical health condition, cognitive functioning, and behavior * Frequently 1st symptom of underlying illness * Contributes to increased morbidity and mortality and longer illness episodes * “House of cards” for frail older adults * Acute onset syndrome * Contributes to increased morbidity and mortality of older adults * Longer hospital stays- complications of physical illness * Occurs more frequently in older adults than in younger adults- possibly due to “frail brain” of the older adult

Question 36

Identification of delerium

Answer 36

* must understand baseline of pt. cognitive status * Instruments designed to assess for delerium include Confusion Assessment Method: Onset is acute, inattention, someone who is disorganized, and has an altered level of conciousness)

Question 37

Delerium Acronym

Answer 37

* **_D_**rug- review meds * **_E_**lectrolyte imbalance * **_L_**ow oxygen (hypoxia) * **_I_**nfection * **_R_**educed sensory input * **_I_**ntracranial problem * **_U_**rinary or fecal retention * **_M_**yocardial problem

Question 38

Nursing Interventions for Delerium

Answer 38

_Environment_ * Close observation * Lighting, noise * Minimize stimulation, intervention * Restraints, as a last resort _Physical/Sensory_ * Touch * Physical presence * ADL * Sensory aids _Cognitive_ * Orientation, reorientation * Explanation, reassurance * Cueing/coaching * “Making sense” of it

Question 39

Hope

Answer 39

* Meaning of hope * “Fifth” vital sign * Meaning of relief * Resilience