Mental Health Exam 4

Maladaptive Anger Excessive vs Suppressed

Excessive: directed anger seen in Coronary heart disease, metabolic syndromes, and MIs

Suppressed: arthritis, breast and colorectal, chronic pain, HTN

can be outwardly or inwardly directed

Evaluate w STAXI

Intermittent Explosive Disorder

Impulsive, maladaptive anger attacks that vary in severity. Appears in teen years

TX: SSRIs+behavioral therapy

Anger Management

Psychoeducation intervention for maladaptive but non-violent anger

Includes a teacher/coach, diadactic and experimental, group meetings, and homework. Can be gender/culture/etc specific

Goal: Modulate physiological arousal, alter irrational thoughts, and modify maladaptive anger behaviors

CBT Anger management

recommended for uncontrollable anger

Involes: Stimuli avoidance, self monitoring, response disruption, and mindfulness

Types of Aggression

Verbal: sarcasm, insults, threats

Physical: property damage and assult

Impulse aggression: occurs in situations of anger and anxiety

Instrumental: goal directed and premediatated violence not a reaction to immediate feelings

Biological Theories of Anger and Aggression

• Limbic and cerebral cortex

• Neurocognitive impairment from hx of abuse or family violence

• Inhibition of monoamine oxidase A

• Low serotonin

• Sex hormones

Psychological theory of violence: GAM

General Aggression Model

Episode=Person(Aggressive tendencies, trauma, hormones) +situational factors (exposure to violence, substances use, provacation)

Microaggression

Cumulative pro-racist attitudes that motivates biased treatment in a targeted group

EX: Where are you REALLy from, you must be good at math, i dont see color

Characteristics that my predict aggression/violence

Staring, raising voice, sarcastic, demanding, pacing, cognative impairments, discomfort like an ingrown toenail, caffine, poor diet

interventions for promoting safety

• Establish therapeutic relationship and provide concrete choices. Value patient concerns

• Develop prevention strategies: Counting to 10, breathing, removing from stiumli

Interventions for imminent aggression

De-esclate:Use nonthreatening, respect space, have access to an open door, administer Haloperidol or B52(Benadryl, haldol, lorazepam)

Two Types of Trafficking

Obtain Labor: Migraints often targets bc of temporary visas-false promises of safety and work

Commercial Sex: Foster care and disabled at risk

Warning Signs: unexplained injuries, malnourishment, poor health/dental care, lack of IDs and reluctance to speak

Social learning theory of IPV

Intergenerational transmission- you learned the violence as a child and imitates it

Imbalances of Power Theory of violence

Patriarchy has systemically protected men from arrest after IPV

Cycle of Violence

Phase 1: tension building thru verbal abuse, accusations, control and degregation

phase 2: Violence erupts and injury happens

Phase 3: Perpetrator becomes kind and promises to never do it again

What are we mandated to report

Abuse witnessed in…

• People aged under 18 or over 60

• Disabled persons

Psychosocial Assement of all ages in abuse

• Sucicide and homocide risk

• Social isolation and networks

• Self eesteem, fear, and shame

• Document sleep, appetite, startle response, flashbacks, PTSD

Three Steps in Safety Planning in Abuse

1. Discuss observable patterns of the violence (SUD, tone of voice, etc)

2. Have escape bag packed w important documents, phone numbers, and money

3. Plan for children or dependent adults for a safe space

Perpetrators of Abuse-Characteristics

• PH of abuse, SUD/AUD

• Low self esteem and the sense that someone owes them

• Oversensitivity and unreasonable expectations

• Patriarchy

PCE vs ACE

ACE SCORE: can lead to early death

PCE: can lessen the effects of ACE and encourage resillence and healthy development

HITS Assessment

How often does your partner HURT you

How often do they INSULT you

How often do they THREATEN you

How often do they SCREAM at you

Scored 1-5, greater than 10 is postive for IPV

Obsessions and common ones

Defined: Excessive, persistent, and unwanted thoughts or images that cause anxiety and distress

Common: contamination, pathologic doubt, symmetry, violence, and taboo/sexual images, scrupulosity (based on religion or mortality)

Compulsions defined and common ones

Repetitive behaviors and mental acts perfromed ritualistically to releive anxiety caused by obsessions

Common: Handwashing, cleaning, checking, arranging, counting, ordering, scrupulosity (based on religion or mortality)

Diagnosising OCD

• Onset begins in early/middle childhood. Later childhood is associated w a worse outcome

• Recurrent obsessions must take up 1 hour or more per day, cause stress, and are not caused by medications/drugs

• Insight is varied

Biologic Theories of OCD

-Multifactorial familial condition, occurs more often in first degree relative

-Neuropathologic: dysfunction in brain networks that handle danger

-Increased serotonin may stop obsession

OCD Assesment

-Physical assessment: lesions, joint damage, somatic compulsions, nutrtion if ED

-Circumferenetial speech=taking forever to get to the point

-Rate functions and secondary complications

OCD Interventions Outpatient

• Maintain skin integrity and set time limited washing

• Treat anxiety first=therapeutic communication

• Encourage resisting compulsions and find satisfying work to accomidate

• SSRIs first line w CBT and ERP (exposure -triggers- and response prevention), Clomipramine (TCA) if unsuccessful

OCD Interventions inpatient

• Explain unti routines in detail

• Intially, do not prevent rituals and validate significance. Make reasonable limits with the patient

• ID triggers and give postiive reinforcement

Trichotillomania What, Consequences, DX and TX

• Chronic hair pulling that results in hair loss

  • Ingestion causes anorexia, stomahc pain, obstruction, periontis, and anemia

    • qMay cause infection at site

• DX: Onset before 5 or in adolescence, visable hair loss

• TX: Olanzapine, chlomipramine, CBT

Paranoid Personality Disorder cluster, SS, cause, care

Cluster A-Strong genetic link

SS: pervasive mistrust of others, even ones close to them. Feel self important and unforgiving. Respect rank and have distain for weak. Need control! Constantly thinks parter is treating

Care: Create trust and focus on paranoia

Schizoid Personality Disoder Cluster SS and care

Cluster A

SS: isolated and feel joy more muted/different, not social, interested in non-human things, no self awareness (interested in themselves not others), LOW SELF EESTEEM

Care: Etry not to get frustrated by disiniterst

Schizotypal personality disorder cluster SS and care

Cluster A

SS: Magical beliefs like telepathy, alienate oneselves, referential thinking(infering meaning), dramatic, parnoid, often have MDD

Care: No meds unless MDD

Avoidant personality disorder cluster SS care

Cluster C

SS: avoid social interaction BC hypersensitive to critism, perceive themself as inferior, very anxious and depressed

Care: Refrain from criticism, LONG TERM THERAPY

Dependent Personality Disorder cluster SS and care

Cluster C

SS: Clingy and need to be taken care of, submissive. Withdrawl from adulthood, need advice, Gulible, warm and avoid tension. Parents often overprotective

Care: work on self esteem, home management, and continued therapy

Obsessive Compulsive prsonality disorder cluster SS and care

Cluster c

SS: Preoccupied w order and perfection, control with rules, workaholics, think vacation is shameful. Associated with parents being over protective and give too much responsibility

Care: anxiety attacks occur from guilt

Impulse control and Conduct disorders

Intermittent explosive disorder: severity of aggressiveness is not proprotionate to provocation

Kleptomania: cannot resist stealing

Pyromania: starts fires

BPD cluster and SS

Cluster B

SS: Extreme fear of abandonment yet unintentionally sabotage. Violate boundaries in relationships. Attribute decisions to mistakes of others, splitting (everyone is either bad or good), impulsivity, and emotional dysregulation

BPD Etiology and Care

Etiology: often born from chaotic housholds where their emotional responses were continuously trivialized and dismissed. become unsure about emotions→cannot express them causing maladaptive cognitive schemata or patterns of interpretating events

Care: High risk for self injurious behaviors! Tx w DBT a therapy created for BPD patients and mood stabilizers, atypical antipsychotics, and antideressants

Anitsocial Personality disorder cluster and SS

Cluster B

SS: Disregard for and violation of the rights of others occuring since age 15. Self-serving, exploitative, impulsive, lack feelings of obligation and remorse

Antisocial personality disorder Etiology and Care

Etiology: must be 18 with aggression towards people or animals before the age of 15. Asociated with SUD, MRI w increased fearlessness, and unsatisfactoroy attatchments in early life (abandonment, neglect, chaotic family)

TX: usually do not seek treatment often an ultimatim in a marriage/workplace. Look for SUD, determine violence, GROUP INTERVENTIONS work best

Historonic personality disorder cluster and SS

Cluster b

SS: life of the party, quick to form friendships but lack loyalty, opinionated, seductive, CONTROLLING but dependent on friends. Depressive symptoms when not center of attention

Historonic Personality Etiology and TX

Etiology: mostly in women, can co occur w GAD, OCD, SUD, and mood disorders, often says “ i am exactly like my mother”

TX: Focus on self esteem and SUD, usually do not seek mental health care

Narcissistic Personality Cluster, SS, Cause, TX

Cluster B

SS: Good at their jobs, loves to talk about their grandiocity and beauty, envious of successes or posessions

Cause: often spoiled in childhood causing superiority
TX: Usually avoid self reflection and medical care

Anorexia Symptoms, Diagnosis, and Two types

Types: restrictive (eating little and lots of exercise) binge/purge (Binge eating then purging w laxatives/enemas with restriction inbetween)

Symptoms: Usually female, behavior around food ritualistic, thin or emaciated, refuses toe eat

Dx: less than normal weight, intense fear of fatness, restricting or binge/purge in last 3 months)

Physical Complications of Starvation

• hypothyroid

• Amenorrhea

• serotnergic function blunted

• Anemia, leukopnea, thrombocytopnea

• Hyperkinetic (lack of sleep)

• Dry skin and brittle nails

• Comorbidities: anxiety/phobias, depression, OCD

Physical Complications of Purging

• Arrythmias

• Electrolyte imbalance

• abnormal taste

• GI inflammation from teeth to anus

• Seizures

Treatment of Anorexia

• Earn trust, discharge once 85% of ideal weight is obtained

• Refeed slowly, 1500 kcals-3500 kcals

• NG tube if life threatening

• REFEEDING SYNDROME: circulatory fluid overload!

• Support groups, family therapy, and nutrtional counseling

Bulimia Nervousa SS and diagnosis

SS: Binge Eat then purging by vomitting or laxative Normal body weight, social butterflies, intense need to be liked, older onset than anxorexia. Comorbid w mood disorder, SUD, and SH.

Diagnosis: Binge and purge at least once a week for 3 months

LOW STOMACH ACID=Hypercholremic alkaosis, sunjunctuctival hemorrhages, esophgus damage

Bulemia Treatment

• SSRI prozac

• Community

SSD Defined

One or more physical symptoms that take up excessive amounts of time, energy, emotion, and/or behavior. Symptoms move from one body system to the other.

Provider shopping=when doctors do not give enough attention or validity they get a new one

SSD Common complaints and Why

Complaints: PAIN in any system and FATIGUE following, dysmenorrhea, vomiting, lump and throat, burning sensation in sex organs etc.

Why: often in less educated in poorer people under high emotional distress. Found in cultures that have bigger stigma. Alexithymia=difficulty expressing and iding emotions May only get attention when ill=> can help control relationships

Treatment for SSD

-Often polypharmacy so multiple side effects or self medication w alcohol or marijuana.

SSD: LOVE BENZOS=eases symptoms so try to avoid, Duloxetine can help w anxiety and neuropathic pain

Conversion Disorder

SEVERE emotional expressed expresed through CNS symptoms

SS: Balance, paralysis, anphonia (cant make sounds), difficulty swallowing, blindness, and deafness

Factitious disorder

Intentionally causing illness/injury/or fabricating records to recieve attention

Including: Seizures, wound healing, poison injestion, false fever, creating surgical scars

Pedological Fantastica: RED FLAG fascinating story of personal triumph that blends truth

Treatment for Factitious Disorder

• Consequencies of injury are prioroty

• Replace attention seeking w positive behaviors

• Prepare for betrayal=establish trust

• LONG TERM psychotherapy

• Assess for trauma