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Flashcards in Week 10: Psych Deck (40):
1

Hippocrates “four humors”

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

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“Moral Insanity” 

1801: Irrational behavior with an intact intellect

3

The Healthy Personality- Positive Relationships

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

4

Adaptive/Maladaptive Social Response continuum

Adaptive Response

  • Solitude
  • Autonomy
  • Mutuality
  • Interdependence

Middle of the Road

  • Loneliness
  • Withdrawal

  • Dependence

Maladaptive Social Response

  • Manipulation
  • Impulsivity
  • Narcissism

 

 

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Personality Disorder (definition)

  • 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

 

 

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Etiology Personality disorder Biological

  • Genetic influences
  • Disturbances in neurotransmitters

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Etiology Personality Disorder Sociocultural

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

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Etiology of Personality Disorders: Psychodynamic origins

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

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Personality disorders 3 clusters

  • 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), obsessive-compulsive (personality style in which the person's obsessions or compulsions occupy a significant amount of time, not associated with anxiety)

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Borderline Personality Disorder

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

 

 

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Interaction Patterns- Assessment (borderline personality disorder)

  • 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

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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

 

 

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

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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

#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

 

 

 

 

 

 

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Limit Setting

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

 

 

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Medicines and borderline personality disorder

  • 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). 

16

4 Big problems of Older Adults

  • Depressive Disorders
  • Dementia
  • Delirium
  • Dying

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Depression

  • 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 

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Depression is not

  • Part of “normal” aging
  • Inevitable
  • Untreatable 

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Suicide in Older Adults

  • 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%)

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Older Adult Suicide Risk Factors

  • 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

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Depression Assesment Instruments

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

 

 

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Interventions for Older Adult Depression

  • 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

 


 

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Nursing Interventions for Older Adult Depresssion

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

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Dementia in Older Adults

-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

 

 

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Alzheimer’s  Dementia

  • 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”

 

 

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Depressogenic Medications

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

27

Multi Infarct Dementia

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

28

Traumatic Brain Injury

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

29

Dementia/Assessment

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)

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Symptoms/Changes you see in dimensia

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

31

Nimenda

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.

32

Dementia/Intervention

  • 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

33

“Elderspeak”

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

 

 

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Common Errors when dealing with dimentia patients

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

35

Delirium 

  • 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

 

 

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Identification of delerium

  • 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)

37

Delerium Acronym

  • Drug- review meds
  • Electrolyte imbalance
  • Low oxygen (hypoxia)
  • Infection
  • Reduced sensory input
  • Intracranial problem
  • Urinary or fecal retention
  • Myocardial problem

38

Nursing Interventions for Delerium

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

39

Hope

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

 


 

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