mental health FINAL EXAM

personality

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

personality continued

-complex pattern of characteristics, largely outside of the person’s awareness

-distinctive patterns of perceiving, feeling, thinking, coping, and behaving

personality disorder

-an enduring pattern of deviant inner experiences and behavior

-differ from cultural expectations

-pervasive, inflexible, and stable

-leads to distress or impairment

self awareness

-patients with a PD often have challenging relationships with health care professionals

-experiences with individuals with PD can evoke aversive behaviors and feelings

-it is not uncommon for clinicians to stigmatize and negatively label patients

-a therapeutic nurse-patient relationship can be one of the most helpful interventions for these patients

cluster A :odd/eccentric

-aka: “weirds”

-paranoid personality disorder

-schizoid personality disorder

-schizotypal personality disorder (more likely to have schizophrenia than anxiety)

cluster B: dramatic, emotional, erratic (wired’s)

-most likely have mood-related disorders

-antisocial personality disorder

-borderline personality disorder

-histrionic personality disorder

-narcissistic personality disorder

cluster C: anxious/fearful (worried’s)

-most likely have anxiety-related disorders

-avoidant personality disorder

-dependent personality disorder

-obsessive-compulsive personality disorder

paranoid personality disorder

-always think someone has something against them, hold grudges, envious, never let anything go

-pervasive distrust and suspiciousness of others

-guarded, hostile, angry, and unforgiving

-outwardly argumentative and abrasive

-does not accept responsibility for own behavior

-persistent ideas of self-importance

-rigid and controlling

-holds grudges

-trusts no one

more about paranoid personality disorder

-begins in early adulthood

-more common in men

predisposing factors

-possible hereditary link (unclear)

-subject to early parental antagonism and harassment (always scolded as a kid)

nursing MGMT for paranoid personality disorder

-patients seen for other health problems (not hospitalized for personality disorder alone)

-difficult to establish relationship (Pt doesn’t trust anyone)

-if trust is established, help Pt identify problem areas

-changing thought patterns takes time

-therapeutic communication: acceptance, confrontation, reflection

schizoid personality disorder

-profound defect in the ability to form personal relationships

-failure to respond to others in a meaningful emotional way

-indifferent to others; aloof

-introverted and reclusive (socially awkward, don’t want friends/connections)

-emotionally cold

schizoid continued

-more common in men

-prevalence around 3%

predisposing factors for schizoid

-possible hereditary factor

-childhood characterized as:

-bleak

-cold

-unempathetic

-notably lacking in nurturing

nursing MGMT for schizoid

-goal is to enhance experience of pleasure, prevent social isolation, and increase emotional responsiveness to others

interventions for schizoid

-provide social skill training

-encourage social interactions

schizotypal personality disorder

-odd and eccentric

-pattern of social and interpersonal deficits

-unusual mannerisms

-void of close friends

-ideas of reference, magical beliefs

-excessive social anxieties

-stilted language

schizotypal continued

-affects about 4% of the population

-more common in men

predisposing factors for schizotypal

-hereditary (possible)

-possible physiological influence

-possible trauma-exposed

nursing MGMT for schizotypal

-dependent on degree of symptoms and level of functioning

-increase self-worth

-provide social skills training

-reinforce socially appropriate dress and behavior

-focus on enhancing cognitive skills

antisocial personality disorder

-a pattern of socially irresponsible, exploitative, guiltless behavior that reflects a disregard for the rights of others

-fail to adapt to ethical and social standards of community

-interpersonally engaging, but in reality they lack empathy or human compassion

-behaviorally impulsive

-deceitful and manipulative for personal profit or pleasure

-psychopath or sociopath

-lack of remorse, only care if it benefits them

prevalence of schizotypal

-3% in men and 1% in women

-highest rates in men with alcohol use disorder and those in forensic settings

-associated with adverse SES or sociocultural factors

other requirements for schizotypal

-must be at least 18 y/o

-with characteristics of conduct disorder as adolescent

-co-morbid with mood, anxiety, substance use

-not often seen in most clinical settings (often in jail)

predisposing factors for schizotypal

-possible genetic influence

-differences in regions of brain associated with impulsivity and fearlessness

-difficult temperament

-unstable attachments (beginning at birth)

-less trust

-parental abandonment or neglect

-loss of parent/caregiver

-physical/sexual abuse

-families with substance use and violence

-growing up in a home with domestic violence

nursing interventions for schizotypal

-identify blocks in therapeutic relationship

-identify dysfunctional thinking patterns and develop new problem-solving behaviors

-self-responsibility facilitation

-hold the patient responsible for his/her behavior

-monitor the extent to which self-responsibility is assumed

-discuss consequences of not dealing with responsibilities

-refrain from arguing/bargaining about the unit rules

-self-awareness enhancement

-encourage patients to recognize and discuss thoughts and feelings

borderline personality disorder

-more common in women

-pervasive pattern of instability

-intense and chaotic relationships

-affective instability

-fluctuating and extreme attitudes regarding other people

-highly impulsive

-lacks clear sense of identity

-directly and indirectly self-destructive (parasuicide, dichotic: flipping)

what is borderline personality disorder most STRIKINGLY identified by?

the INTENSITY and INSTABILITY of their affect and behavior

common behaviors for borderline personality disorder

-chronic depression

-inability to be alone

-clinging and distancing behaviors

-splitting/manipulation (all good/all bad, pin ppl against each other)

-unstable, insecure attachments

-over idealize/intense relationships

-dichotomous thinking

diagnostic criteria for borderline personality disorder

1. 1. frantic effort to avoid real or imagined ABANDONMENT (constantly seek reassurance) → discharge process

2. 2. pattern of unstable and intense interpersonal relationships characterized by extremes of idealization and devaluation

3. 3. identify disturbance: markedly and persistently unstable self image or sense of self

4. 4. impulsivity in at least 2 areas that are potentially self-damaging (ex: spending, sex, substance abuse, reckless driving, binge eating)

5. 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

6. 6. AFFECTIVE INSTABILITY d/t a marked reactivity of mood (ex: intense episodic dysphoria, irritability, or anxiety) usually lasting a few hours and only rarely more than a few days

7. 7. chronic feelings of emptiness

8. 8. inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights)

9. 9. transient stress-related paranoid ideation or severe dissociative symptoms

stats for borderline

-affects 2% of the population

-more common in WOMEN than men

-most frequently diagnosed personality disorder in clinical population

-comorbid with mood, eating disorders (women), and substance use (men)

predisposing factors for borderline

-biologic (brain dysfunction in limbic system)

-psychodynamic (separation individuation, projective identification)

-cognitive processes (distorted thinking)

-social theories

non-suicidal self-injury

-self harm behavior is seen in individuals with BPD

-it is a maladaptive COPING MECHANISM

-it can be compulsive, episodic, or repetitive

examples of parasuicide

-cutting, burning, scratching

-banging head

-swallowing foreign objects

risk assessment for borderline

-suicide or self-injury

-alcohol and drug abuse

prevention and tx for self-injury

-observe for antecedents of self-injurious behavior, intervening before an episode

-help develop strategies to prevent behavior

-five sense exercise

nurse-Pt relationship borderline

-establish trust

-recognize conflicting fears of abandonment and intimacy

-establish personal boundaries and limitations

model self-respect (borderline)

-observing personal limits

-being assertive

-clearly communicating expectations

abandonment/intimacy fears (borderline)

-recognize conflict

-any termination needs to be planned carefully

-establish personal boundaries and limitations

-MGMT of dissociative states

-determine triggers

dialectical behavior therapy (borderline)

-goal is to replace dysfunctional behaviors with positive ones

-problem solving, exposure, skills training, contingency MGMT, and cognitive modification

features of histrionic personality disorder

-attention seeking, life of the party

-excitable and emotional

-colorful and dramatic

-extroverted

-provocative, sexually seductive

-insatiable need for attention/approval

-helpless when others are disinterested

stats for histrionic

-around 2% of population

-no differences in occurrence, but diagnosed more in women than men

predisposing factors for histrionic

-genetic

-parental behavior, role modeling

-women with disorder report they are just like their mothers (mimic behaviors)

nursing interventions for histrionic

-allow to explore positive personality characteristics and develop independent decision making skills

-reinforce personal strengths

-convey confidence in ability to handle situations

-examine negative perceptions of self

-encourage to act autonomously

-assertiveness groups

features for narcissism

-characterized by an exaggerated sense of self worth and need for admiration

-believe they have the right to receive special consideration

-exploit others in an effort to fulfill their own desires

-criticism from others may cause them to respond with rage, shame, and humiliation

-overly self-centered

-lack empathy

stats for narcissism

-higher in men than women

-more common in only children and first born boys (especially in cultures where males have special privileges)

predisposing factors for narcissism

-as children, had their fears, failures, or dependency needs responded to with criticism, disdain, or neglect

-parents were often narcissistic themselves

-parents may have overindulged their child and failed to set limits on inappropriate behavior

characteristics of narcissism

-do not seek mental health care unless they have a coexisting medical or mental disorder

-use self-awareness skills in interacting

-nursing process focuses on the coexisting responses to other health care problems

features of avoidant personality disorder

-extreme sensitivity to rejection

-social withdrawal

-awkward and uncomfortable in social situations

-fears of criticism, rejection, and feelings of inadequacy

-extremely sensitive to negative comments and disapproval

-perceived as timid, shy, and hesitant

stats for avoidant personality

-prevalence between 2.6% general population

-15% in outpatient mental health clinics

predisposing factors for avoidant personality

-possible hereditary influences

-parental rejection and criticism

assessment for avoidant personality

lack of social contacts, a fear of being criticized, evidence of chronic low self-esteem

interventions for avoidant personality

-refrain from any negative criticism

-assist to identify positive responses from others

-explore previous achievements

-explore reasons for self-criticism

-social skills training

features for dependent personality disorder

-pervasive and excessive need to be taken care of that leads to submissive and clinging behavior

-disregard for self

-lack of self confidence

-needs excessive advice and reassurance

-avoids adult responsibilities

more features of dependent personality disorder

-more common among WOMEN than men

-more common in those less educated and widowed/divorced/separated/never married women

predisposing factors for dependent personality disorder

-result of extreme attachment and overprotection

-child learns to rely on others to meet basic needs

-do not learn to be autonomous decision makers

assessment for dependent personality

-self-worth, interpersonal relationships, and social behavior

interventions for dependent personality

-resist urge to tell them what to do/don’t give advice

-help recognize dependent patterns

-motivate them to want to change

-teach adult skills that have not been developed

-support to make their own decisions

features for OCPD

-display overall rigidity, perfectionism, and control

-difficulty making decisions and completing tasks is so involved in the details

-especially concerned with organization and efficiency

-rigid and controlling

-mood is tenseless and joyless

stats for OCPD

-one of the most prevalent personal disorders in general population (up to 8%)

-associated with higher education, employment, and marriage

predisposing factors for OCPD

-over control by parents

-frequent punishment for undesirable behavior

-child made to feel guilty when responsibilities not met

-encouraged to resist inclinations to play

nursing interventions for OCPD

-accept the patient’s need for order and rigidity

-examine the belief that underlies the dysfunctional behavior

-challenge rigid thinking

tx modalities for OCPD

-interpersonal psychotherapy

-psychoanalytical psychotherapy

-milieu/group therapy

-cognitive/behavioral therapy

-dialectical behavior therapy

-psychopharmacology

impulse control disorders

-common characteristic is IRRESISTABLE INPULSIVITY

-co-morbid with personality disorders

-intermittent exploding disorder (road rage)

-kleptomania (stealing)

-pyromania (fires)

how do you treat impulse control disorders?

pharmacologic agents, psychotherapeutic, behavioral, and social interventions

cognition

system of interrelated abilities such as perception, reasoning, judgement, intuition, and memory; allows one to be aware of oneself

memory

facet of cognition, retaining and recalling past experiences (piece of cognition)

delirium

acute cognitive impairment with multiple causes

dementia

chronic cognitive impairment differentiated by cause, not symptom patterns

delirium

-disturbance in consciousness and a change in cognition developing over a short period of time

-usually reversible if the underlying cause identified

-serious; should be treated as an emergency

diagnostic criteria

-impaired consciousness

-less aware of environment; loss of ability to focus

-problems in memory, orientation, language

-different from dementia

risk factors for delirium

-age (any age, older adults in acute care settings, can be d/t anesthesia)

-particularly common in older post-op patients

-pre-existing cognitive impairment → one of greatest risk factors

etiology for delirium

-medications

-infections

-fluid and electrolyte imbalances

-metabolic disturbances

-hypoxia

-ischemia

other contributing factors for delirium

-sensory overload/underload

-immobilization

-sleep deprivation

-psychosocial stress

interdisciplinary tx for delirium

-elimination or correction of the underlying cause

-symptomatic and supportive measures

priorities for delirium

-pay attention to life-threatening disorders

-rule out life-threatening illness

-stop all suspected medications

-monitor changes in VS, behavior, and mental status

assessment for delirium

-current and past health status

-physical examination and review of systems

-physical function

-pharmacologic assessment

interventions for delirium

-safe therapeutic environment

-maintenance of fluid and electrolyte balance

-adequate nutrition

-prevention of aspiration; skin breakdown

-administration and monitoring of medications, side effects, and drug interactions

-psychoeducation

assessment (status) for delirium

-mental status: fluctuating level of consciousness and reduced awareness of environment

-behavior (restless/agitated, lethargic and slow to respond)

interventions for delirium

-frequent interaction and support

-encouragement to express fears and discomforts

-environmental control (whiteboards, personal items)

-de-escalation techniques

-family involvement

-reality orientation

major neurocognitive disorder

-wide variety of disorders of cognitive functioning formerly called dementia

-memory

-social skills

-reasoning

-intellectual ability

-spectrum of disorders from mild to severe manifeestations

major neurocognitive disorder (s)

-alzheimer’s disease

-frontotemporal degeneration

-lewy body disease

-vascular disease

-parkinson’s disease

-huntington’s disease

-TBI

-substance/medication use

-other medical conditions/unspecified

alzheimer disease

-cognitive impairment

-emotional and behavioral changes

-physical and functional decline

-ultimately, death

types of alzheimer’s

-early onset (65 or younger): rapid progression

-late onset (older than 65): more common

diagnostic criteria for alzheimer’s

-multiple cognitive deficits

ONE OR MORE OF THE FOLLOWING:

APHASIA: alterations in language (expressive OR receptive)

APRAXIA: impaired ability to execute movement

AGNOSIA: failure to recognize or identify objects

-disturbance of executive functioning

-VISUO-SPACIO IMPAIRMENT (clock drawing test is best teller)

etiology of alzheimer’s

-beta-amyloid plaques

-neurofibrillary tangles

-neurotransmission (ACh most disrupted)

mild alzheimer’s

-loss of memory

-language difficulties

-mood swings

-personality changes

-diminished judgement

-apathy

moderate alzheimer’s

-inability to retain new info

-behavioral, personality changes

-increasing long-term memory loss

-wandering, agitation, aggression, confusion

-requires assistance w/ ADL’s

severe alzheimer’s

-gait and motor disturbances

-bedridden

-unable to perform ADL

-incontinence

-requires long-term care placement

interdisciplinary tx (alzheimer’s)

-confirmation of the diagnosis

-establishment of baseline levels in functional sphere

-establishment of a therapeutic relationship with the Pt and family

focusing on tx efforts (alzheimer’s)

-MGMT of cognitive symptoms

-delaying of cognitive decline

-treatments of non-cognitive symptoms: psychosis, mood symptoms, agitation

-support of caregivers

priority care issues (alzheimer’s)

-priorities will change throughout the course of the disorder

-initially, delay cognitive decline

-later, protect patient from hurting self

-later, physical needs become the focus of care

MGMT for mood changes (alzheimer’s)

-MGMT of depression

-MGMT of anxiety

-MGMT of catastrophic reactions

MGMT of behavioral changes (alzheimer’s)

-MGMT of restlessness and wandering

-MGMT of aberrant behavior (yelling out HELP)
-MGMT of agitated behavior

tx for mild-moderate alzheimer’s

-cholinesterase inhibitors (donepezil, galantamine, rivastigmine)

-STOP the breakdown of ACh

-S/E: N/V/D

tx for moderate-severe alzheimer’s

-NMDA antagonists (memantine)

-S/E: dizziness, HA, constipation

-amyloid beta-directed antibodies

-antipsychotics

-antidepressants and mood stabilizers

-antianxiety meds

vascular dementia

-caused by conditions that block or reduce blood flow to the brain

-second most common type of dementia

-series of small strokes damage brain tissue

-”mini-strokes” (TIAs)

-symptoms more sudden

-progression intermittent and fluctuating

(GRAPH LOOKS LIKE STAIRCASE)

neurodevelopmental disorder (kids)

-intellectual development disorder

-autism spectrum disorder

childhood psych disorders

-neurodevelopmental

-attention-deficit hyperactivity disorder

-disruptive behavior disorders

-tourette’s

disruptive behavior disorders (kids)

-oppositional defiant disorder

-conduct disorder

assessment process for children and adolescents

-similar to that of adults

-use of more specific, fewer open-ended questions (concrete thinkers)

-children need simple phrases (narrower vocab)

-corroboration of information with adult

-use of artistic and play media

-possible problems with accurate sequencing of events (less specific sense of time, less developed memory)