Psych class 2B Exam 1

Delirium

Acute, can be spontaneous, immediate, can be healed.

Disturbance in attention, Abrupt onset with periods of lucidity, Waxes and wanes, Disorganized thinking, Poor executive functioning, Disorientation, Anxiety and agitation, Poor recall, Delusions and hallucinations (usually visual)

Delirium vs. Dementia

Delirium: Acute, can be spontaneous, immediate, can be healed. Disturbance in attention, Abrupt onset with periods of lucidity, Waxes and wanes, Disorganized thinking, Poor executive functioning, Disorientation, Anxiety and agitation, Poor recall, Delusions and hallucinations (usually visual)

Dementia: Chronic. Progressive disease. Dementia is the general term used to describe a variety of conditions that develop when brain cells die and no longer function

Alzheimer’s disease is the common type – 60% to 80% of all dementias

Marked by progressive deterioration in cognitive functioning, ability to problem solve & learn new skills. CNA be genetic and envirormentally induced.

Epidemiology of delirium

• Common complication of hospitalization

  • 22% of general medical patients

  • 11% to 35% of surgical patients: stress brings on deliium, withdraw from narcotics can cause delirium.

  • Up to 80% of intensive care patients

• Multifactorial physiological causes

Secondary to another condition such as general medical condition or substance use (abuse, polypharmacy, toxin exposure)

Mot commonly encountered mental disorder in medical practice – often overlooked or misdiagnosed

High risk for the elderly

Sundowning – symptoms and behaviors become more pronounced in the evening

Risk factors for delirium

• Older age

• Infection

• Polypharmacy

• Intensive care units

• Fractures

• Surgery

• CVA

• Aphasia

• Vision impairment

• Hearing impairment

• Restraints: can cause delirium

• Change in hospital rooms

• Cognitive impairment

Secondary to another condition such as general medical condition or substance use (abuse, polypharmacy, toxin exposure)

Mot commonly encountered mental disorder in medical practice – often overlooked or misdiagnosed

High risk for the elderly

Sundowning – symptoms and behaviors become more pronounced in the evening

Clinical picture of delirium

• Disturbance in attention

• Abrupt onset with periods of lucidity

  • Waxes and wanes

• Disorganized thinking

• Poor executive functioning

• Disorientation

• Anxiety and agitation

• Poor recall

• Delusions and hallucinations (usually visual)

• Is a transient disorder - reversible If underlying condition corrected, complete recovery should occur

  
  

Which is an indication that Veronica does not have delirium?

Her problems with memory have been developing gradually.

Delirium has an abrupt onset, while Veronica’s problems with memory have been developing gradually.

Both delirium and dementia patients can exhibit signs of confusion, anxiety, agitation, and disorganized thoughts.

Four cardinal features of delirium

1.  Acute onset and fluctuating course

2.  Reduced ability to direct, focus, shift, and sustain attention

3.  Disorganized thinking

4.  Disturbance of consciousness

Assessment of delirium

• Cognitive and perceptual disturbances

  • Easily distracted 

  • Impaired memory

  • Illusions

  • Hallucinations 

• Physical needs

  • Wandering, pulling out IVs, falling

  • Self care deficits

  • Skin breakdown

  • Infections 

  • Autonomic signs:  tachycardia, sweating, flushed face, dilated pupils, high BP. looks like anxiety.

  • Changes in sleep wake patterns

  • Hypervigilance

• Moods and physical behaviors

  • Agitated or calm

  • Labile

  • Strike out from fear or anger

  • May cry, call out for help, tear off clothing, laugh uncontrollably

  • Erratic & fluctuating

• Self assessment

  • Anxiety producing due to unpredictability of patients

  • Missed diagnosis

Nursing diagnosis for delirium

• Risk for injury 

• Acute confusion

• Risk for deficient fluid volume

• Disturbed sleep pattern

• Impaired verbal communication

• Fear

• Self-care deficits

• Impaired social interaction

Outcome criteria for delirium

• Patient will remain safe and free from injury

• During periods of clarity, patient will be oriented to time, place, and person

• Patient will remain free from falls and injury while confused, with the aid of nursing safety measures

Planning for a person w/ delirium

• Ensure necessary aids and supportive home team

• Visual cues in the environment for orientation

• Continuity of care providers

Implementation for delirium

• Prevent physical harm due to confusion, aggression, or fluid and electrolyte imbalance.

• Minimize use of restraints= increases confusion

• Perform comprehensive nursing assessment to aid in identifying cause.

• Assist with proper health management to eradicate underlying cause.

• Use supportive measures to relieve distress.

6 factors to prevent delirium

sleeping, moving, stimulating the mind, eating, staying hydrated, seeing and hearing.

Evaluation for delirium

• Patient will remain safe.

• Patient will be oriented to time, place, and person by discharge.

• Underlying cause will be treated and ameliorated.

know definition

(a) amnesia: memory (b) apraxia: execution of movement, (c) agnosia: recognition of objects and (d) aphasia: speech.

Amnesia

Risk in Alzheimers. Memory loss

Agnosia

Risk factors in Alzheimers disease. A (loss of sensory ability to recognize objects): For example, a person may lose the ability to recognize familiar sounds (auditory agnosia), such as the ring of the telephone. Loss of this ability extends to the inability to recognize familiar objects (visual or tactile agnosia), such as a glass, magazine, pencil, or toothbrush.

Aphasia

Often seen in alzheimers. A (loss of language ability): Initially the person has difficulty finding the correct word, then is reduced to a few words, and finally is reduced to babbling or mutism.

Apraxia

Execution of movement. (loss of purposeful movement in the absence of motor or sensory impairment): The person is unable to perform once-familiar and purposeful tasks. For example, in apraxia of dressing, the person is unable to put clothes on properly (may put arms in trousers or put a jacket on upside down).

Major and minor neurocognitive disorders

• Progressive deterioration of cognitive functioning and global impairment of intellect (dementia)

• No change in consciousness

• Difficulty with memory, problem solving, and complex attention. execution/ apraxia is impaired in dementia

  • Mild: Does not interfere with ADLs; does not necessarily progress

  • Major: Interferes with daily functioning and independence, progressive deteri0rtion 

Dementia

Dementia is the general term used to describe a variety of conditions that develop when brain cells die and no longer function

Alzheimer’s disease is the common type – 60% to 80% of all dementias

Marked by progressive deterioration in cognitive functioning, ability to problem solve & learn new skills. CNA be genetic and envirormentally induced.

Comparison of delirium vs dementia

Delirium:Sudden, over hours to days. CONTRIBUTING/CAUSE: Hypoglycemia, fever, dehydration, hypotension; infection, other conditions that disrupt body’s homeostasis; adverse drug reaction; head injury; change in environment (e.g., hospitalization); pain; emotional stress. COGNITIVE: Impaired memory, judgment, calculations, attention span; can fluctuate through the day. LOC: Altered. ACTIVITY LEVEL: Can be increased or reduced; restlessness, behaviors may worsen in evening (sundowning); sleep/wake cycle may be reversed. EMOTIONAL STATE: Rapid swings; can be fearful, anxious, suspicious, aggressive, have hallucinations and/or delusions. SPEECH AND LANGUAGE: Rapid, inappropriate, incoherent, rambling. PROGNOSIS: Reversible with proper and timely treatment

Dementia: Slowly, over months. CONTRIBUTING/CAUSE: Alzheimer’s disease, vascular disease, human immunodeficiency virus infection, neurological disease, chronic alcoholism, head trauma.COGNITIVE: Impaired memory, judgment, calculations, attention span. LOC: not altered. ACTIVITY LEVEL: Not altered; behaviors may worsen in evening (sundowning). EMOTIONAL STATE: flat agitation. SPEECH AND LANGUAGE: Incoherent, slow (sometimes due to effort to find the right word), inappropriate, rambling, repetitious. PROGNOSIS: Not reversible; progressive

Major neurocognitive disorders

• Alzheimer’s disease

• Dementia with Lewy bodies: some Psychiatric med can cause that

• Parkinson’s disease: some Psychiatric med can cause that

• Frontotemporal dementia

• Vascular dementia

• Traumatic brain injury

• Substance-induced dementia 

• HIV infection

• Prion disease

• Huntington’s disease

• LATE-NC

Starts amygdala to hippocampus, then middle frontal gyrus (limbic system). 40% of brains ages>85 years. Very slow, just loss of memory.

Epidemiology of alzheimers

• Most common: Late-onset and female

• 5.3 million Americans have AD

• Cause is unknown – results of genetics, lifestyle, & environmental

• Brain proteins fail to function as usual

  • Tau & B-amyloid

• Greatest risk factor is advanced age

• Live 8 to 12 years after diagnosis

• Not every patient experiences same symptoms or declines as same rate

• Death usually from aspiration pneumonia or sepsis. lack of activity, malnutrition, constipation

Alzheimers disease

• Biological factors

  • Neuronal degeneration that begins in the hippocampus then spreads to the cerebral cortex

  • Cell death: accumulation of Beta-amyloid and protein tau

  • Genetics

    • Three genetic mutations which lead to the devastating early-onset form of the disease. This accounts for less than 1% of all cases

    • Susceptibility gene APOE e4 gene (supports lipid transport) raises the risk of developing the late-onset form of the disease

5 types of alzheimers disease

• Subtype 1: Hyper-plasticity: high level of brain cell growth and tau proteins (dampened microglial response)

• Subtype 2: Innate Immune Activation: Innate Immune Activation: overactive immune system resulting in atrophy of the brain and elevated tau levels. Immune suppressants may be use in future as a treatment.

• Subtype 3: RNA dysregulation: RNA dysregulation: causes issues with production of proteins, most aggressive, survival rate 5.6 year

• Subtype 4: Choroid Plexus Dysfunction: Choroid Plexus Dysfunction: disruption of the brain’s blood vessels, higher proportion of immune cell proteins, causes the worst atrophy of any subtype.

• Subtype 5: Blood-Brain Barrier Dysfunction: Blood-Brain Barrier Dysfunction: flaw in the BBB causes microbleeds and slowed cell growth. Antibody treatment may exacerbate this
  

• New criteria for diagnosis & staging using plasma markers (biologically based criteria) is now recommended.

So, what does this mean for me as a nurse?

• Get ready to draw blood.

• Research is ongoing, so new information will evolve.

• This may mean targeted diagnosis that is easier and earlier.

• New targeted treatments are being developed.

• Stay tuned!

Risk factors for alzheimers disease

• Age and family history

• Cardiovascular disease

• Social engagement and diet

• Head injury and traumatic brain injury

• Diabetes: will affect lack of nutrition and sugar in the brain

Clinical picture for alzheimers

• Alzheimer’s: 60% to 80% of all dementias

• Important to distinguish normal forgetfulness and memory deficits in dementia

• In dementia: memory loss interferes with ADLs

• AD progression

  • Mild

  • Moderate

  • Severe

Mild cognitive impairment of AD

Duration seven years: disease begins in medial temporal lobe. S/s: short term memory loss

Mild alzheimers

duration two years. Disease spreads to lateral temporal and parietal lobes. S/s:Reading problems, poor object recognition, poor direction sense.

Moderate alzheimer’s

Duration two years. Disease spreads to frontal lobe. S/S: poor judgment, impulsivity, short attention.

Severe alzheimers

Duration three years. Disease spreads to occipital lobe. S/S: visual problems

Early signs of dementia

• Missing sarcasm

• Frequent falling

• Disregard for the law

• Staring

• Eating objects

• Losing knowledge of objects

• Losing empathy

• Ignoring embarrassment

• Compulsive ritualistic behavior

• Money troubles

• Difficulty speaking

• Slow loss of interest in grooming/hygiene

• Hoarding

• Easily lost on familiar routes

• Loss of taste and smell (Alzheimer’s and Parkinson’s)

• Denial

• Confabulation (creation of stories in place of missing memories to maintain self-esteem)

• Perseveration (repetition of phrases or behavior)

• Avoidance of questions

• Memory impairment

• Disturbances in executive functioning 

• Hallucinations or Agitation

  • Check for Urinary Tract Infection

• Aphasia: Loss of language ability

• Apraxia: Loss of purposeful movement 

• Agnosia: Loss of sensory ability to recognize objects

• Agraphia: Diminished ability to read or write

• Hyperorality:excessive preoccupation with oral sensations and behaviors, often involving putting both edible and inedible objects in one's mouth- & Hypermetamorphosis: characterized by an irresistible impulse to notice and react to everything in sight-

• Sundowning

Veronica tries to refer to the electric bill, but ends up saying, “you know, the invitation. The invitation”. What is this a sign of?

Aphasia

Diagnostic tests for alzheimers

• Computed tomography scan (CT)

• Positron emission tomography (PET)

• Mental status questionnaires

  • Mini-Mental State Examination 

• Complete physical and neurological exam

• Complete medical and psychiatric history

• Review of recent symptoms, meds, and nutrition

• Check thyroid, urinary tract infection, nutrition.

Self assessment of alzheimers

• Realistic understanding of the disease

• Stress management

• Support and educational resources

• Realistic outcomes and recognition when these are achieved

• Maintaining good self-care

• good nutrition and sleep

Nursing diagnosis for alzheimers

• Risk for wandering

• Risk for injury

• Impaired verbal communication

• Impaired environmental interpretation syndrome

• Impaired memory

• Confusion

• Caregiver role strain

• Anticipatory grieving

Outcome for person w/ alzheimers

• Person/family will remain free from injury

  • Environmental safety

• Communication

• Agitation level

• Caregiver role strain

• Impaired environmental interpretation: chronic confusion

• Self-care needs

Planning for person with alzheimers disease

• Identify level of functioning 

• Target care towards the person’s immediate needs

• Connect caregivers to support services

• Assess caregivers’ needs 

  • Monitor for “burnout” or abuse

• Plan and identify appropriate community resources

Interventions for alzheimer

• Person-centered care approach

• Provide emotional support

• Health teaching and health promotion

• Referral to community supports

• Promote sleep, proper nutrition, hygiene, activity

• Structure the environment & provide routine

• Have person wear eyeglasses or hearing aids

  • “I can’t hear without my glasses

• Simplify the verbal message, break down tasks, repeat messages as needed Monitor tolerance of stimulation

• Promote independence as long as possible

• Keep all interactions calm, reassuring.

  • Don’t argue with the illness

• Time activity to coincide with client calm state.

• Reminiscence therapy 

  • Thinking about or sharing about the past

  • Keeps clients involved and increases self esteem.

• Distraction 

  • Shifting the client’s attention from triggering situation

• Time away

  • Leave the client for short periods of time when over-stimulated – ignore the outburst

• Going along

  • Provide emotional reassurance to clients without correcting their misperception or delusion

Medications for older adults

start low and go slow. medications are only used to slow progression or treat symptoms. used to treat lack of sleep, Appetite, anxiety, etc.

Pharmacological intervention for alzheimers

• Cholinesterase Inhibitors prevent breakdown of acetylcholine – minimal benefit after 1 year

  • donepezil (Aricept)

  • rivastigmine (Exelon)

    • All stages of AD

  • galantamine (Razadyne) 

    • Mild to moderate AD

    • N-methyl-D-aspartate Receptor Antagonist regulates the activity of glutamate

    • memantine (Namenda)

    • Moderate to severe AD

  •  NMDA Receptor Antagonist/Cholinesterase Inhibitor – 

    • donepezil & memantine (Namzaric)

    • Moderate to severe AD

  • Aducanumab (Aduhelm): costly, difficult to get approved. Mild to no effect. For moderate to severe AD

Anticonvulsants and antipsychotics for alzheimers

• Anticonvulsants

  • Depakote & Tegretol – used for emotional lability, aggressiveness

• Antipsychotics

  • Lower dose for elderly

  • Nighttime dose is preferred

  • Black box warning for atypical  & conventional – do not use due to increased risk of CVA & death

Antidepressants and antianxiety meds for alzheimers

• Antidepressants 

  • SSRIs - watch for discontinuation syndrome – dizziness, agitation, irritability, nausea – may occur with abrupt withdrawal – taper slowly

• Antianxiety

  • Use cautiously due to risk for further memory impairment, sedation, and falls

    • Should NOT be first line except with emergency.

Evaluation for person with alzheimers

• Safety

• Maintain highest level of functioning

• Care-giver support

Community support for ppl with alzheimers

• Transportation services

•   Supervision and care when the primary caregiver is out of the home

•   Referrals to day care centers

•   Information on support groups in the community

•   Meals on Wheels

•   Information on respite and residential services

•   Telephone numbers for help lines

•   Home health services

• Alzheimer’s Association

• AgeWays: Senior Support Services

Veronica’s AD has progressed. One morning, she attempts to brush her teeth with a spoon. Which problem is evident?

Agnosia

Acute onset of disordered thinking is most associated with:

Delirium

What is personality

• How you define yourself

• Skills you use to relate to others

• How you problem solve

• How you perceive your surroundings

• Ingrained, enduring pattern of behaving and relating to oneself and others, including, perceptions, attitudes, and emotions

Common characteristics of personality disorders

• Inflexible and maladaptive response to stress=nonfunctional

• Disability in working and loving

• Ability to evoke interpersonal conflict

• Capacity to "get under the skin" of others: don’t have empathy to feel.

• Difficulty managing impulses

Personality disorders

• Long standing, pervasive, maladaptive behavior 

• Onset in early adulthood or adolescent: learn to train behaviors as they were growing up.

• Diagnosed in adulthood (not before age 18): allow earlier stages of developmental to embrace themselves.

• Causes distress and impairment

• Does not respond usually to short term therapy or medications

• In touch with reality unless extreme stress: focused and driven to their own aims, everything else doesn’t matter.

• Not voluntary

• Believe their problems originate from the behavior of other people

Not a disease, brain injury due to trauma in early childhood mixed with genetic predisposition to temperament. HPA axis

External locus of control: most often personality disorders want to gain control.

Criteria for personality disorders

• A life-long pattern of inner experience and behavior that deviates markedly from the individual’s culture.  This pattern is manifested in two or more of the following areas:

• 1.  Cognition (perceiving & interpretation)

• 2.  Affectivity (range, intensity, lability)

• 3.  Interpersonal functioning

• 4.  Impulse control

Epidemiology of personality disorders

• U.S. Populations:  10% meets criteria (6% world-wide)

• Australian & North America have higher prevalence rate due to cultural influence?

• Frequently co-occur with disorders of mood, eating, anxiety, trauma & substance use

• Often amplify emotional dysregulation

• More common among homeless & incarcerated

• Seen in up to 50% of psychiatric patients.

May be due to behaviors & personality is viewed as deviant rather than normative based on culture, race, society

Etiology of personality disorders

• Neurobiological Factors

  • Genetics – extreme variations of normal personality traits in four areas: anxious-dependency traits, psychopathy, antisocial, social withdrawal, and compulsivity.

  • Neurotransmitter or Neuro-hormone may regulate & influence temperament.

  • Brain imaging reveals some differences in size and function of specific structures.

  • Emotional dysregulation is amplified.

  • Trauma in early childhood (HPA axis)

Etiology and risk factors for personality disorder

• Psychological Factors

  • Learning theory based on modeling

  • Defense mechanisms

• Environmental Factors

  • Childhood neglect or trauma is a risk factor

  • Genetic & Biologic traits influence the way an individual responds to the environment and at the same time, the environment is thought to influence the expression of inherited traits.

Freud: one’s childhood experiences rather than chemistry

Learning theory: children learn maladaptive responses based on modeling or reinforcement by significant others

Childhood trauma: ACEs

Etiology: diathesis stress model

• Diathesis refers  to genetic and biological vulnerabilities and includes personality traits and temperament.

• Temperament is our tendency to respond to challenges in predictable ways. (ex:  laid back or uptight)

• Stress refers to immediate influences on personality such as physical, social, psychological and emotional environment.

• Many studies have suggested a strong correlation between trauma, neglect, and other dysfunctional family or social patterns of interaction on the development of personality disorders.

Effect of clients with personality disorder on caregivers

• Overwhelming needs of clients may also be overwhelming for caregivers

• Caregivers may feel 

  • Confused

  • Helpless

  • Angry

  • Frustrated

  • Splitting is used on these caregivers

Cluster A of personality disorder

• Odd, Eccentric

• Paranoid

• Schizoid

• Schizotypal

Cluster B personality disorder

• Dramatic, Erratic, Emotional

  • Borderline

  • Narcissistic

  • Histrionic

  • Antisocial

most commonly seen

Cluster C personality disorder

• Anxious, Fearful

  • Avoidant

  • Dependent

  • Obsessive-compulsive

Paranoid personality disorder

• What does it look like?

• Mistrust, restricted affect, guarded

• Suspiciousness, hypervigilance, hostility, bears grudges

• Hypersensitive to others 

• May exhibit transient psychosis if stressed

• Grew up in households where they were the objects of excessive rage & humiliation, which resulted in feelings of inadequacy.

  • Anxious about being harmed or exploited

• How do you manage this?

• Projection is their primary defense mechanism

• Tend to reject treatment - Difficult to interview

• Psychotherapy is treatment of choice 

• Antianxiety agents may be used to improve relaxation

• Agitation & delusions may be treated with antipsychotic medications.

• Prevalence: 2-4%, M>F

Cause is unknown, but appears to be more common in families with psychotic disorders, possible genetic link.

 Childhoods are marked with threatening domestic atmosphere, extreme and unfounded parental rage, and/or condescending parental influence that cultivate profound childhood insecurities.

 Treatment:  Antipsychotics if symptoms warrant, psychotherapy—BUT building trust is a LONG haul.

Schizoid personality disorder

• What does it look like?

Detachment for social relationships - Chooses to be alone (solitary)

Does not desire nor enjoys relationships

Appears cold and detached - Fantasy life

Brief psychotic episodes in response to stress

May be able to function in solitary occupation

Depersonalization or detachment from world

Bleak childhood with little warmth from caregivers.

May be precursor to Schizophrenia or delusional disorder.  Nearly 5% prevalence

Increased prevalence with family history of schizophrenia

• How do you manage this?

• Rarely seek help unless in extreme distress.

• Therapy is not effective as they cannot relate to others.

• Don’t force this person to interact, group may be harmful without breaks.

• Problem-solving is treatment of choice, focus on social cues

• Short-term antipsychotics for psychosis under extreme stress.

  • Risperdal or Zyprexa to improve affect

  • Wellbutrin to increase pleasure in life

• M>F

schizotypal personality disorder

• Odd beliefs or magical thinking

• Severe social anxiety and interpersonal deficits

• Genetically linked to schizophrenia

• Most studied personality disorder

• Signs of disorder are present in childhood or adolescence – target for bullying

• Structural abnormalities of the brain & altered dopamine transmission

• Paranoia – misinterpret motivations of others

• Brief episodes of hallucinations or delusions

• Rigid peculiar ideas & rambling communication

• Odd appearance & inappropriate behaviours

• How do we handle it?

• Rarely seek treatment, usually only for depression.

• Behaviour modification therapy is recommended for bizarre thinking & behaviours. Outcomes are generally poor, so treatment goal is leading a satisfying solitary life

• Can be made aware of their misinterpretations of reality unlike patients with schizophrenia hold tight to delusions

• Antipsychotic, antidepressant, antianxiety medications can help.

• M>F

May be increased in families with the disorder/ schizophrenia.

 Rarely seek treatment, usually from depressive problems instead.

 Antipsychotic medication.  Behaviour modification therapy is recommended to remedy their bizarre thinking and behaviours.  Outcomes can be poor for socialization, so the goal may be to lead a satisfying solitary life.

Cluster B for dementia

Dramatic, emotional, erratic:

Antisocial

• Borderline

• Narcissistic

• Histrionic

Splitting

• Primary defense or coping style used by patients with borderline PD (& Cluster B)

• Inability to view both positive and negative aspects of others as part of a whole

• Patient labels one person “all good” and the others “all bad”

• very unsuccessful with therapy

• When all-good person has not met client's needs, that person becomes all bad

• Creates conflict in staff members

• To decrease conflict among staff

  • Open communication in staff meetings 

  • Ongoing clinical supervision 

Antisocial personality disorder what does it look like?

• May be commonly referred to as sociopaths

• Symptoms are evident by adolescence. Impulse control and conduct problems as children & adolescents.

• Around 40 years – symptoms become less

• Deceitful, manipulative, hostility, charming

• High risk taking, disregard for responsibility, exploits others, impulsivity

• Criminal misconduct & substance abuse

• Little to no capacity for intimacy

• Profound lack of empathy 

• Shallow, unexpressive & superficial affect

• Is genetically linked:  genetic risk of aggressive-disregard trait & trait of lack of concern for consequences. Incidence is higher if parent is APD

• Home life chaotic with abuse, substance abuse, DV, neglect. Prevalence 1.1%

• Brain abnormalities:

  • Reduced gray matter in prefrontal cortex and temporal poles: no empathy

  • EEG abnormalities

  • Genetic abnormality of MAOA: cannot break down DA or S

Sociopath

impulsive and dangerous,more influenced by environmental factors,

Adolesence with antisocial personality disorder

• Adolescence: lying, school vandalism, sexual promiscuity, high use of drugs/etoh – Have histories of conduct disorder

• Families have high rates of depression, substance abuse, personality disorders, divorce, and poverty

• Childhood often marked by erratic, neglectful, harsh, or abusive parenting

• Genetically linked and twin studies show predisposition – set into motion by childhood environment of inconsistent parenting, significant abuse, and extreme neglect.

• Before 15 they are diagnosed with conduct disorder

• Usually diagnosed by age 18, males more than females

• Smooth talkers, rationalize their behaviors, problems are others, not themselves

• EEG abnormalities with children and parents

• Ineffective to try to make antisocial  person feel remorse or shame due to egocentricity and unconcerned effect on others.

• Needs limit setting on behaviors

How to manage antisocial personality disorder

• Need to set limits on behavior with consistency in responses & consequences for actions: one care manager

  • Matter of fact, no “I” messages. Keep it simple.

  • Don’t forget that staff needs to support the care manager

• Assist patient to control impulsive and aggressive behaviors

• Encourage patient to verbalize anger rather than act in aggression or passive aggressive manner

• Confrontation – point out problem behavior

  • Keep patient focused on self

  • DBT

• Psychopharmacology:

  • Respond to anticonvulsants and mood stabilizing medications such as Lithium to help with aggression and impulsivity.

  • Antipsychotics for safety

  • Ritalin may help if ADHD

  • Careful use of addictive agents

• See Table 24.1, Box 24.1, Box 24.2, Box 24.3 Varcarolis

Borderline personality disorder

• What does it look like?

• Intolerance with abandonment, frantic to avoid.

• Severe impairment in functioning

• Instability of emotional control

• Identity or self image distortions

• Unstable mood and interpersonal relationships

• Emotional lability – emotions out of proportion to the circumstances

• Intense sensitivity to perceived personal rejection

• Impulsivity without considering the consequences

• Hostility, anger & irritability in relationships – may be violent toward partner or property

• Self destructive behaviors

  • Chronic suicidal ideation sometimes with multiple attempts

  • Cutting – self mutilation

  • Promiscuous sexual behavior

  • Numbing with substances

  • very impulsive to do whatever they want

• Prevalence 1.6%

What does borderline personality disorder look like?

• High mortality rate – 10% -  with high use of services

• 85% meet criteria for another mental illness

• Substance abuse is common

• Can become psychotic during periods of stress

Medical diagnoses  typically associated  with BPD: diabetes, hypertension, chronic back pain, fibromyalgia, & arthritis

• Runs in families:  genetic factors of hypersensitivity, impulsivity, & emotional dysregulation

• May have hyper-responsive amygdala with impairment in the prefrontal cortex – more vulnerable to emotionally charged communication

• Fear of abandonment more intense by a biological predisposition

• Disruption of the separation-individuation of the child from the mother in 1^st year of life

Environmental and genetic factors of Borderline personality disorder

Environmental and genetic factors play a role: BPD is 5x more common in family with a close relative with BPD.

 Usually there is a history of abuse, neglect and/or separation as a very young child (ACEs): 40-71% sexually abuse by a non-caregiver.

 Researchers feel that there is a greater vulnerability to environmental stress/neglect/abuse as young children that set the person up if there are events that trigger BPD (stressors) as a young adult. (so a molestation and neglect as a young child then a rape as a teen).

 BPD adults are > victims of rape, violence, and other crimes.

 Amygdala and prefrontal cortex have impaired regulation of emotion on scans. 

 Treatment:

First line: DBT, CBT

Psychodynamic therapy, Group therapy.

• What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation?

Maintaining consistent limits

how should a nurse manage Borderline personality disorder

• Nurse remains neutral and matter of fact when addressing superficial self-destructive behaviors with patients

• Have the patient journal about the sequence that led up to the event as well as the consequences before staff will discuss the event.

• Often respond to anticonvulsant mood stabilizing medications, low dose antipsychotics, & Omega 3 supplementation

• Naltrexone has been found to reduce self injuring behaviors

• Cognitive Behavioral Therapy (CBT)

  • Identify & change inaccurate core perception of themselves & others

• Dialectical Behavior Therapy (DBT)

  • Combines CBT with mindfulness, which emphasizes being aware of thoughts and actively shaping them

  • Begin with suicidal behaviors to destructive behaviors to quality-of-life issues

• Schema- focused Therapy

  • Parts of CBT with other forms of therapy that focus on the ways that people view themselves

  • Reframing of schemas based on BPD’s dysfunctional self image and that it affects how people respond to stress, environment, and interaction with others.

• See Table 24.3, Varcarolis

Narcissitic personality disorder

• What does it look like?

• Arrogance with grandiose view of self importance

• Need for constant admiration

• Lack of empathy

• Personal entitlement with lack of social empathy – made lead to exploitation of others

• Hypersensitive of criticism

• Feel intense shame & fear of abandonment

• Underlying self esteem is fragile/vulnerable

• May be result of childhood neglect and criticism.  Up to 6% prevalence

• The child does not learn that other people can be the source of comfort

• Hide feelings of emptiness with exterior of invulnerability & self sufficiency

• Can function socially and in high level occupations—feeds their needs.

• Not delusions of grandeur – based somewhat in reality however distorted or embellished to meet needs of self importance

• Relationships with others are shallow, rationalization to blame others and make excuses

• Result of childhood neglect and criticism – the child does not learn that other people can be sources of comfort and support

How to manage narcissistic personality disorder

• Treatment of choice is individual therapy 

  • cognitive behavioral therapy 

  • family therapy 

  • group therapy

• FIRM boundaries: don’t attack, don’t accuse

• Pharmacological:

  • Lithium may help if mood swings 

  • Antidepressants as needed

  • Stay away from Benzodiazapines!

Histrionic PD

• What does it look like?

• Attention-seeking, “Life of the party”, centre of attention

• Emotional attention-seeking behavior, “over the top”

• Self centeredness

• Low frustration tolerance, Melodramatic & impulsive; 

• May be over dressed, flirtatious, and/or seductive

• Speech is colorful and exaggerated

• Some evidence of heritability traits

• Insincere & lacks depth

• Vague physical complaints

• Begins between 3 to 5 years of age with an overly intense attachment to the opposite sex parent, which results in fear of retaliation by the same sex parent.  Child may have inborn character traits such as emotional expressiveness and egocentricity. 2% prevalence

draws attention to self, silly, colorful, frivolous, and seductive, superficial, temper tantrums, outbursts of anger, overreaction to minor events, somatic complaints

how to manage histrionic personality disorder

• Do not think they need help

  • Treatment is sought for depression when romantic relationships end.

• Psychotherapy for losses 

• FIRM BOUNDARIES

• Stay solution-focused and supportive

• Pharmacological:

  • Antidepressants  

  • antianxiety drugs as needed (NO BZDs)

Cluster C: anxious or fearful

avoidant, dependant, obsessive-compulsive

Dependant personality disorder

• Extreme dependency in a close relationship

• More common in women/youngest child

• High need to be taken care of

• Need others to make decisions for them

• Submissive, passive and clinging behavior

• Self-doubting – avoid responsibility

• Fears of separation/anxious

• Can be vulnerable to abusive relationships

  • Will go to excessive lengths to seek a “caretaker”

Result of chronic physical illness or punishment of independent behavior in childhood.

Inherited trait of submissiveness may also be a factor – which has found to be 45% heritable

Dependant personality disorder how to manage

• What does it look like?

• Needs to be take care of

  • Excessive lengths, will find a new caretaker

• Childhood trauma

• Punished as a child for independence. Disordered attachment & dependency on caregiver

• Increased risk if chronic illness present

• Inherited trait of submissiveness

• How do we manage it?

• Psychotherapy is the choice of treatment

  • Promoting independence

  • Limit setting

• Pharmacological:

  • Imipramine can be used if panic attacks

  • Other antidepressants

  • Anxiolytics (watch BZDs)

• 2-8% prevalence

avoidant personality

• Avoidant of situations that require interaction with others.

• Low self esteem associated with functioning in social situations: desires relationships but avoids them

• Extreme sensitivity to rejection

  • Linked to parental & peer rejection/criticism

  • Hypersensitive to criticism

• Fairly common, prevalence 2.4%

• Timid, withdrawn, fearful, shy: increases with age

• Reluctance to engage in unfamiliar activities

• Feelings of inferiority compared to peers

• Can be mistreated by others

• Prone to misinterpreting other’s feedback

• Genetically may be on a continuum of social anxiety disorders

• Biological predisposition to anxiety & physiological arousal in social situations

• A timid temperament in infancy & childhood

  Strongly desire close interpersonal relationships they avoid them

  Linked with parental and peer rejection and criticism.

  A biological predisposition to anxiety and physiological arousal in social situations has been suggested.  

  Genetically this disorder may be part of a continuum of disorders related to social phobia

  Diagnosis equal for males and females

avoidant personality disorder how to manage

• Individual & Group Therapy

  • Assertiveness Training

  • Combined with medications for best response

• Pharmacological:

  • SSRIs and SNRIs

  • May respond to B-adrenergic receptor antagonist (Atenolol) to reduce autonomic nervous system hyperactivity

Obsessive compulsice personality disorder

• Preoccupation with orderliness, rules, schedules. Perfectionist

• Feel genuine affection for others but do not have insight about their own difficult behavior, not bothered by it

• Rigidity, inflexible standards of self

• Persistent to goals long after self defeating

• Workaholic

• May hoard

• Fearful of imminent catastrophe – rehearse over & over how they will respond

• Highest burden of medical costs & workplace productivity losses

• Patients do no have full blown obsessions or compulsions

• Associated with excessive parental criticism, control, and shame

• Heritable traits such as compulsivity, oppositionality, lack of emotional expressiveness & perfectionism

Obsessive compulsive disorder how to handle it

• Psychotherapy or Group therapy

  • CBT

  • Exposure therapy

• Avoid power struggles with patients – need for control is high

• Pharmacological:

  • Clomipramine & SSRI

  • Risperdone

  • Aripiprazole 

Assessment of personality disorder

• Minnesota Multiphasic Personality Inventory (MMPI) to evaluate personality. MMPI is a tool—a starting point for further assessment and discussion

• Psychosocial history

  • Suicidal or aggressive thoughts

  • Hallucinations 

  • Risk of harm from self or others

  • Medications

  • Illegal substances, substance abuse history

  • Ability to handle money

  • Legal history

  • Current or past abuse

Nursing diagnoses for PD

• Risk for suicide

• Risk for other directed violence

• Risk for self-mutilation

• Anxiety

• Ineffective Coping

• Disturbed thought processes

• Social Isolation

• Chronic low self esteem

• Impaired social interaction

Nursing outcomes for PD

• Demonstrate absence of suicide ideation

• Refrain from self-mutilation

• Tolerate short interactive periods with nurse

• Develop appropriate coping skills

• Demonstrate absence of thoughts of harming others

• Identify methods of relaxation techniques

• Identify new methods of problem solving

• Identify two impulsive behaviors during stress

• Nursing Outcomes Classification (NOC) scales for measuring improvement

Nursing planning and interventions

• Promote safety – protect client from injury to self or others

• Establish trust (hard to do)

• Reality orientation

• Medication based on symptoms

• Be supportive, consistent, empathize

• Consistent team approach

• Establish boundaries in relationships

• Limit setting/structure/confrontation

• Coping skills: anger, low self esteem, teach strategies to manage anxiety

• Depends on clients identifying need to change

• Increase self esteem

• Improve social skills

• Increase independence and decision-making skills

• Journaling

• Watch APD predating on other patients

Additional treatment modalities for PD

• Consistent team approach involving many disciplines provides most comprehensive interventions.

• OT, RT, Music, Art, Group, Milieu 

• Communication between disciplines important to avoid splitting between staff

• Monitor each other and provide support for boundary issues and frequent attempts at manipulation

Evaluation for PD

• Evaluating treatment effectiveness in this client population is difficult.

Despite the relatively fixed patterns of maladaptive behavior, some motivated clients with personality disorders can change their behavior over time because of treatment.

Discharge criteria for PD

• Consider risk factor of safety for client
  and others.

• Have plan for follow-up. 

• Provide education for client and family.

Which behavior indicates that a patient diagnosed with borderline personality disorder is improving?

1. The patient informs a staff member that she is having thoughts of harming herself.

Use of splitting is most associated with which personality disorder?

borderline

Oppositional defiant disorder

Childhood disorder. Angry and irritable mood. Defiant and vindictive behavior: Spiteful, malicious revenge, frequently for 6 months
◦ Blames others, Easily annoyed by others
◦ Conflicts with authority figures, arguing, refusing to comply, Academic problems
◦ Prefer a large reward, increasing penalties do not work
◦ 8.3% adolescents

Intermittent explosive disorder

Adult Disorder 18 years or older
◦ Inability to control aggressive impulses (verbal, physical) to people, animals, property, themselves
◦ Leads to problems with
◦ Interpersonal relationships
◦ Occupational difficulties
◦ Criminal difficulties
◦ 7% of all adults in their lifetime

• Tension (environmental stimuli), explosive
  behavior/aggression, feel immediate relief
  and release feelings, delayed feelings of
  remorse, regret, embarrassment
  ◦ Increased HTN, diabetes, stress related
  disorders