1st Semester 2nd Final Dec2019 Flashcards
sexual health
a state fo physical, emotional, mental, and social well-being in relationship to sexuality; it is not merely the absence of disease, dysfunction, or infirmity.
In what groups are the highest incidences of STIs?
- men who have sex with men
- bisexual men
- youths between the ages of 15 and 24
What factors contribute to disparities in the STI rates?
race
poverty
access to health care
sexual practices
What are some commonly diagnosed STIs?
syphilis gonorrhea chlamydia trichomoniasis genital warts (HPV) genital herpes II (HSV)
What STIs are caused by bacteria and usually curable with antibiotics?
gonorrhea
chlamydia
syphilis
pelvic inflammatory disease (PID)
What STIs are viral and cannot be cured?
HSV types I and II
HPV
HIV
How is HIV spread?
contaminated IV needles anal intercourse vaginal intercourse oral-genital sex transfusion of blood and blood products
What are the three stages of HIV?
- Primary infection stage - lasts about a month after contracting the virus; Person experiences flulike symptoms.
- Clinical latency phase - no symptoms; HIV antibodies appear in the blood about 6 weeks to 3 months after infection
- Acquired immunodeficiency syndrome (AIDS) - a person begins to show symptoms of the disease
How long can a person live with untreated HIV?
about 10 years
What is the most common STI in the U.S.?
HPV - human papilloma virus infection
What is the most commonly reported STI in the U.S.?
Chlamydia
What is the PLISSIT model and what do the letters stand for?
The PLISSIT model is used as an assessment tool of sexuality.
P - Permission to discuss sexuality issues.
LI - Limited Info related to sexual health problems being experienced
SS - Specific Suggestions (only when the nurse is clear about the problem)
IT - Intensive Therapy (referral to professional with advanced training if necessary)
Among what groups are unintended pregnancy rates the highest?
- low income women
- women ages 18-24
- women over 40
- cohabiting women
- minority women
According to Healthy People 2020, certain ethnic groups in the United States are disproportionately affected by sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). What are the likely causes of this issue?
- Values and expectations about sexual behavior by the men or women in the culture
- Religious beliefs and cultural attitudes toward the use of contraceptives
- Educational background and knowledge of health risks associated with sexual behaviors
dyspareunia
the occurrence of pain during intercourse
What factors determine sexual activity in older adults?
- present health status
- medications
- past and present life satisfaction
- the status of marital or intimate relationships
What are the normal sexual changes that occur as people age?
- the excitement phase prolongs in both men and women
- it usually takes longer to reach orgasm
- the refractory time following orgasm increases
- sex hormones decrease
- men have erections that are less firm and shorter acting
What is the infrequency of sex in older women typically related to?
- age
- health
- sexual function of their partner
- changes due to menopause
- problems related to urinary incontinence
When should a woman be refitted for a diaphragm?
- after significant change in weight (10 lb gain or loss)
- pregnancy
When is the sexual interest most increased during pregnancy?
during the second trimester due to increased blood flow to the pelvic area
What should a nurse do who has difficulty discussing topics related to sexuality?
- explore their discomfort
- develop a plan to address it
- be aware of own personal beliefs
Approximately what percentage of unintended pregnancies end in abortion?
40%
What is the technical definition infertility?
the inability to conceive after 1 year of unprotected intercourse
What are cues that raise a question of possible sexual abuse?
- extreme jealousy
- refusal to leave a woman’s presence
What is the estimated percentage of sexual dysfunction incidences by gender?
40% men
60-80% women
What are the risk factors for erectile dysfunction in men?
Similar to those with heart disease (diabetes, hyperlipidemia, hypertension, hypothyroidism, chronic renal failure, smoking, obesity, alcohol abuse, and lack of exercise.)
What illnesses affect sexual functioning in men and women?
diabetes cancer neuropathy spina bifida spinal cord injury unstable angina uncontrolled hypertension chronic obstructive pulmonary disease HIV substance abuse depression
What medications affect sexual functioning in men and women?
antihypertensives antipsychotics antidepressants antianxiety diuretics oncological agents recreational or illicit drugs
What is the most common problems affecting women of all ages?
HSDD - hypoactive sexual desire disorder
What are factors that can contribute to HSDD?
- chronic medical conditions such as breast or gynecological cancers
- hormonal fluctuations
- pain
- depression
- anxiety
What are some strategies tat enhance sexual functioning?
- avoid alcohol (in access) and tobacco
- eat well-balanced meals
- plan sexual activity for times when feel restored
- take pain meds before intercourse if needed
- use pillows and alternate positioning to enhance comfort
- encourage foreplay
- communicate concerns and fears with health care provider and partner
Spirituality
an awareness of one’s inner self and a sense of connection to a higher being, nature, or some purpose greater than oneself.
What does spirituality depend on?
- culture
- development
- life experiences
- beliefs
- ideas about life
What are the 5 distinct but overlapping constructs used to define spirituality?
- Transcendence/Self-transcendence
- Connectedness
- Faith and hope
- Inner strength and peace
- Meaning and purpose in life
Self-transcendence
a sense of authentically connecting to one’s inner self
transcendence
the belief that a force outside of and greater than the person exists beyond the material world
Connectedness
being intrapersonally connected within oneself, interpersonally connected with others and the environment, and transpersonal connected with God, or an unseen higher power
Interpersonal relationship
connected with others and the environment
faith
allows people to have firm beliefs despite lack of physical evidence
hope
usually refers to an energizing source that has an orientation to future goals and outcomes.
agnostic
the belief that there is no known ultimate reality; They discover meaning in what they do or how they live because they find no ultimate meaning for the way things are. They believe that people bring meaning to what they do.
What are the two dimensions of spiritual well-being?
- the transcendent relationship between a person and God or a higher power
- positive relationships and connections that people have with others
reasoning faith
(belief) provides confidence in something for which there is no proof
acting faith
(action) allowed for by purpose and meaning to life through reasoning faith (belief)
How do people gain spiritual health?
by finding a balance between their values, goals, and beliefs and their relationships within themselves and others.
spiritual distress
a state of suffering related to the impaired ability to experience meaning in life through connections with self, others, the world, or a superior being.
What are factors that influence ones spirituality?
Acute illness
chronic illness
terminal illness
near-death experience
What is the intended outcome of discussions on spiritual beliefs?
therapeutic
What does the American Nurses Association Code of Ethics for Nurses require?
nurse to practice nursing with compassion and respect for the inherent dignity, worth, and uniqueness of every person.
What is involved in the Spiritual well-being scale (SWB scale)?
20 questions that assess a patient’s relationship with God and his or her sense of life purpose and life satisfaction.
What is the FICA assessment tool?
a tool that evaluates spirituality and is closely correlated to quality of life.
What does FICA stand for?
F - faith or belief
I - importance and influence
C - community
A - address (interventions to address)
What are factors to assess regarding a patient’s spiritual health?
- Faith/belief
- Life and self-responsibility
- Connectedness
- Life satisfaction
- Culture
- Fellowship and Community
- Ritual practices
- Vocation
What three factors are evident when a healing relationship develops between nurse and patient?
- realistically mobilizing hope for the nurse and patient
- finding an interpretation or understanding of the illness, pain, anxiety, or other stressful emotion that is acceptable to the patient
- helping the patient use social, emotional, and spiritual resources
What is Blessingway?
A practice that attempts to remove ill health by means of stories, songs, rituals, prayers, symbols, and sand paintings. (Navajos)
What is the religious dietary regulations of Hinduism?
Some sects are vegetarians - the belief is not to kill ay living creature
What is the religious dietary regulations of Buddhism?
Some are vegetarians and do not use alcohol - Many fast on Holy Days
What is the religious dietary regulations of Islam?
Consumption of pork and alcohol is prohibited - fast during the month of Ramadan.
What is the religious dietary regulations of Judaism?
Some observe the kosher dietary restrictions ( avoid pork and shellfish, do not prepare and eat milk and meat at the same time, etc.)
What is the religious dietary regulations of Christianity?
Baptists, evangelicals, and Pentecostals: Some discourage the use of alcohol and caffeine.
Roman Catholics: Some fast on Ash Wednesday and Good Friday. Some do not eat meat on Fridays during lent.
What is the religious dietary regulations of Jehovah’s Witnesses?
Members avoid food prepared with or containing blood
What is the religious dietary regulations of Mormonism?
Members abstain from alcohol and caffeine
What is the religious dietary regulations of Russian Orthodox Church?
observe fast days and a “no-meat” rule on Wednesdays and Fridays. During Lent all animal products, including dairy products and butter, are forbidden.
What is the religious dietary regulations of Native Americans?
(Individual rival beliefs)
What should never be done to a dying patient?
attempt to force feed them - body is shutting down and will not tolerate food.
What is the number one grieving response that affects a person’s health?
sleep disturbances
What are the physical changes that occur hours or days before death?
- increased periods of sleeping/unresponsiveness
- coolness and color changes in extremities, nose, fingers (cyanosis, pallor, mottling)
- bowel or bladder incontinence
- decreased urine output; dark-colored urine
- restlessness, confusion, or disorientation
- decreased intake of food or fluids; inability to swallow
- congestion/increased pulmonary secretions; noisy respirations (death rattle)
- altered breathing )apnea, labored or irregular breathing, Cheyne-Stokes pattern)
- decreased muscle tone, relaxed jaw muscles, sagging mouth
- weakness and fatigue
What needs to be documented during end-of-life care?
- time, date, location
- body tags
- where the body will be transferred and the time of transfer
- personal belongings
- name of health care provider certifying the death
- people notified of the death and person who comes to declare time death
- name of person making request for organ or tissue donation
- special preparations of the body
- medical tubes, devices, or lines left in or on the body
- any relevant info or family requests that help clarify special circumstances
necessary loss
changes in life
maturation loss
a form of necessary los and includes all normally expected life changes across the life span
situational loss
sudden, unpredictable external events bring about loss
actual loss
necessary loss that occurs when a person can no longer feel, hear, see, or know a person or object
perceived loss
uniquely defined by the person experiencing the loss and is less obvious to other people. (ex. loss of confidence or social status)
grief
a normal but bewildering cluster of ordinary human emotions arising in response to a significant loss, intensified and complicated by the relationship to the person or the object lost.
normal grief
(uncomplicated) - a common and universal reaction characterized by complex emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death.
anticipatory grief
before the actual loss or death occurs, especially in situations of prolonged or predicted loss like caring for patients diagnosed with dementia or ALS.
disenfranchised grief
when their relationship to the deceased person is not socially sanctioned, cannot be openly shared, or seems of lesser significance. (ex. death of a former spouse or married lover)
complicated grief
(chronic, exaggerated, delayed, masked) - a person has a prolonged or significantly difficult time moving forward after a loss. He or she experiences a chronic and disruptive yearning for the deceased; has trouble accepting the death and trusting others; and/or feels excessively bitter, emotionally numb, or anxious about the future.
What are the theorized Stages of Dying?
Denial
The person cannot accept the fact of the loss. It is a form of psychological protection from a loss that the person cannot yet bear.
Anger
The person expresses resistance or intense anger at God, other people, or the situation.
Bargaining
The person cushions and postpones awareness of the loss by trying to prevent it from happening.
Depression
The person realizes the full impact of the loss.
Acceptance
The person incorporates the loss into life.
What is the Attachment Theory stages?
Numbing
Protects the person from the full impact of the loss
Yearning and Searching
Emotional outbursts of tearful sobbing and acute distress; common physical symptoms in this stage: tightness in chest and throat, shortness of breath, a feeling of lethargy, insomnia, and loss of appetite
Disorganization and Despair
Endless examination of how and why the loss occurred or expressions of anger at anyone who seems responsible for the loss
Reorganization
Accepts the change, assumes unfamiliar roles, acquire new skills, builds new relationships, and begins to separate himself or herself from the lost relationship without feeling that he or she is lessening its importance
What are the tasks associated with the Grief Tasks Model?
Accepts the reality of the loss
Experiences the pain of grief
Adjusts to a world in which the deceased is missing
Emotionally relocates the deceased and moves on with life
What are the stages of Rando’s “R” Process Model?
Recognizing the loss Reacting to the pain of separation Reminiscing Relinquishing old attachments Readjusting to life after loss Reminiscence of the relationship by mentally or verbally anecdotally reliving and remembering the person and past experiences
What ore the processes of the Dual Process Model?
Loss-Oriented activities: (e.g., grief work, dwelling on the loss, breaking connections with the deceased person, and resisting activities to move past the grief)
Restoration-Oriented activities: attending to life changes, finding new roles or relationships, coping with finances, and participating in distractions, which provide balance to the loss-oriented state
What are the 5 Trajectories of Bereavement?
Common Grief Chronic Grief Chronic Depression Depression Followed by Improvement Resilience
ambiguous loss
a type of disenfranchised grief which occurs when the lost person is physically present but not psychologically available, as in cases of sever dementia or brain injury.
What are some factors that influence loss and grief?
- human development
- personal relationships
- nature of loss
- coping strategies
- socioeconomic status
- culture and ethnicity
- spiritual and religious beliefs
- hope
What are some common expressions of grief in toddlers?
- changes in eating and sleeping patterns
- bowel and bladder disturbances
- increased fussiness
What are some common expressions of grief in school age children?
- intense periods of emotional expression
- changes in eating
- changes in sleeping
- changes in level of social engagement
What does a critically thinking nurse integrate in order to respond to a patient’s grieving emotions with patience and understanding?
theory
prior experience
appreciation of subjective experiences
self-knowledge
In what ways can a nurse develop a good relationship with patients in order to facilitate good conversations regarding grief?
- be present
- use active listening, silence, therapeutic touch
- use open, honest communication
- ask open-ended questions
What are some normal feelings of grief that a patient may experience?
sorrow fear anger guilt or self-reproach anxiety loneliness fatigue helplessness/hopelessness yearning relief
What are some normal cognitions (thought patterns) of grief that a patient may experience?
disbelief confusion or memory problems Problems making decisions inability to concentrate feeling the presences of the deceased
What are some normal physical symptoms of grief that a patient may experience?
headaches nausea and appetite disturbances tightness in the chest and throat insomnia oversensitivity to noise sense of depersonalization (nothing seems real) feeling short of breath muscle weakness lack of energy dry mouth
What are some normal behaviors of grief that a patient may experience?
crying and frequent sighing distancing from people absentmindedness dreams of the deceased keeping the deceased's room intact loss of interest in regular life events wearing objects that belonged to the deceased
What are some diagnoses relevant for patients experiencing grief, loss, or death?
- compromised family coping
- death anxiety
- grieving
- complicated grieving
- risk for complicated grieving
- hopelessness
- pain (acute or chronic)
- spiritual distress
What does palliative care focus on?
prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness.
What is the largest misconception concerning palliative care?
that it is used only when curative treatments are no longer pursued.
hospice care
philosophy and model fr the care of terminally ill patients and their families at the end of life.
What are the four essential components of survivorship care?
- prevention and detection of new cancers and recurrent cancer
- surveillance for cancer spread, recurrence, or second cancers
- intervention for consequences of cancer and its treatment
- coordination between specialists and primary care providers
What does the survivorship care plan contain?
- important info about patient treatment
- need for future check-ups and cancer tests
- potential long-term late treatment effects
- ideas for improving the patient’s health
What are some chemotherapy-related cognitive impairments reported by cancer survivors due to the effects of chemotherapy?
- difficulty with short-term memory
- focusing
- working
- reading with comprehension
- driving
What are some interventions for CRF (cancer-related fatigue)?
- routine physical exercise
- rest
- development of good sleep habits
- eating a balanced diet
- counseling for depression that often accompanies CRF
Who are at a greater riskier developing secondary malignancies, sometimes related to the initial treatment received for the primary cancer?
children and adolescents who receive aggressive chemotherapy and radiation
What is the risk for treatment-related problems associated with?
complexity of the cancer
type, variety, and intensity of treatment
age and underlying health status of the patient
What are the late effects of chemotherapy and/or radiation?
osteoporosis heart failure diabetes amenorrhea in women sterility in men and women impaired gastrointestinal motility abnormal liver function impaired immune function paresthesias hearing loss problems with thinking/memory
chemotherapy-induced peripheral neurotoxicity
peripheral nerve damage resulting from the effects of certain chemotherapeutic agents.
what are the symptoms of neuropathy?
numbness and tingling in the hands and feet
What are some interventions to help with CRCI (cancer related cognitive impairment)?
- writing things down
- focusing on one task at a time
- allowing others to help with activities requiring focus
- reading simpler texts
- using audiobooks
- giving oneself permission to make mistakes
What are nonpharmacological interventions suggested by the NCCN to treat anxiety and depression in cancer survivors?
- education
- routine exercise
- adequate sleep
- supportive therapy
- cognitive behavioral intervention
- reassurance that anxiety and depression are common in cancer survivors
How does cancer socially effect adolescents and young adults?
cancer seriously alters social skills, sexual development, body image, and the ability to think about the plan for the future.
How does cancer socially effect adults (ages 30-59)?
family members roles and responsibilities change and can also experience changes in sexuality, intimacy, and fertility which affect their marriage
What is the most common issue facing someone battling cancer?
fatigue
What areas should be assessed in cancer survivors?
symptoms
psychosocial problems
sexuality problems
self-caregiving pattern of care
patients are mostly independent with caregivers in a standby role
collaborative care pattern
patents and caregivers share care activities and respond together to lines demands
family caregiving pattern
patients are unable to perform independently and require extensive caregiver involvement.
appraisal
how a person interprets the impact of the stressor, it is also a personal evaluation of the meaning of the event on what is happening and a consideration of the resources on hand to help manage the stressor.
What happens in the body during the fight or flight response?
Increased mental activity dilated pupils bronchiolar dilation increased respiratory rate increased heart rate increased cardiac output increased glucose increased fatty acids increased arterial blood pressure
What three structures control the response of the body to a stressor?
medula oblongata
reticular formation
pituitary gland
What does the medulla oblongata control?
HR, BP, Respirations
What does the reticular formation do?
continuously monitors the physiological status of the body through connections with sensory and motor tracts.
What does the pituitary gland do?
produces hormones necessary for adaptation to stress such as adrenocorticotropic hormone, which in turn produces cortisol.
What system is activated during the initial response to stress?
the sympathetic system
what is the general adaptation syndrome (GAS)?
a three stage reaction to stress that describes how the body responds physiologically to stressors.
What are the three stages of the general adaptation syndrome (GAS)?
- Alarm
- Resistance
- Exhaustion
allostasis
the process by which the body responds to stressors in order to regain homeostasis.
What happens during the alarm stage of GAS?
Activates the fight or flight response through the release of antidiuretic hormone (ADH), catecholamines (epinephrine and norepinephrine), and adrenocorticotropic hormone (ACTH). During this stage HR, O2 intake, blood glucose, mental acuity, blood flow to skeletal muscle, and arterial BP all increase. (sympathetic nervous system)
What happens if there is prolonged exposure to the alarm phase of GAS?
It is lethal to the human system which leads to the next stage - Resistance
What happens during the Resistance stage of GAS?
the body stabilizes and responds in an attempt to compensate for the changes induced by the alarm stage. Hormone levels, HR, BP, and cardiac output return to normal (parasympathetic nervous system)
What happens during the exhaustion stage of GAS?
continuous stress causes progressive breakdown of compensatory mechanisms. body is no longer able to resist the effects of the stressor and has depleted the energy necessary to maintain adaptation. - can result in death.
What is the difference between GAS and LAS (local adaptation syndrome)?
GAS is non-specific and involves the whole body
LAS is a more specific response and involves inflammation on a specific or local site of the body.
What are catecholamines?
hormones made by your adrenal glands, which are located on top of your kidneys such as dopamine, norepinephrine, epinephrine.
primary appraisal
evaluating an event in terms of personal meaning
secondary appraisal
the consideration of possible coping strategies or resources available to help deal with the event
What are some personal characteristics that influence the response to a stressor?
level of personal control,
presence of a social support system,
feeling of competence
coping
a person’s cognitive and behavioral efforts to manage a stressor
What are some examples of ego-defense mechanisms?
compensation conversion denial displacement identification dissociation regression
What are the three types of crisis?
- maturational/developmental - as a person moves through a stage of life
- situational - external sources such as a job change or car crash
- adventitious - major natural disaster, manmade disaster, or crime of violence
What are components of Betty Neuman’s Neuman Systems stress theory Model?
- explanation of the concepts of stress
- reaction to stress
(systems approach that explains that a stressor at one place in a system affects other parts of the system; a system is a person, family, or community
What does Pender’s Stress theory model of stress focus on?
promoting health and managing stress
Self-efficacy
refers to an individual’s belief in his or her capacity to execute behaviors necessary to produce specific performance attainments (Self-efficacy reflects confidence in the ability to exert control over one’s own motivation, behavior, and social environment.)
Self-concept
an individual’s view of self. It is subjective and involves a complex mixture of unconscious and conscious thoughts, attitudes, and perceptions. (how a person thinks about oneself)
self-esteem
how one feels about oneself
What is Erickson’s psychosocial stage associated with Birth to 1 year old and the self-concept that goes with it?
Trust vs Mistrust
- Develops trust following consistency in caregiving and nurturing interactions
- Distinguishes self from environment
What is Erickson’s psychosocial stage associated with 1 to 3 years old and the self-concept that goes with it?
Autonomy vs Shame and Doubt
- begins to communicate likes and dislikes
- increasingly independent in thoughts and actions
- appreciates body appearance and function
What is Erickson’s psychosocial stage associated with 3 to 6 years old and the self-concept that goes with it?
Initiative vs Guilt
- identifies with a gender
- enhances self-awareness
- increases language skills, including ID of feelings
What is Erickson’s psychosocial stage associated with 6 to 12 years old and the self-concept that goes with it?
Industry vs Inferiority
- incorporates feedback from peers and teachers
- increases self-esteem with new skill mastery
- aware of strengths and limitations
What is Erickson’s psychosocial stage associated with 12 to 20 years old and the self-concept that goes with it?
Identity vs Role Confusion
- accepts body changes/maturation
- examines attitudes, values, and beliefs; establishes goals for the future
- feels positive about expanded sense of self
What is Erickson’s psychosocial stage associated with mid 20s to mid 40s and the self-concept that goes with it?
Intimacy vs Isolation
- has stable, positive feelings about self
- experiences successful role transitions and increased responsibilities
What is Erickson’s psychosocial stage associated with mid 40s to mid 60s and the self-concept that goes with it?
Generativity vs Self-absorption
- able to accept changes in appearance and physical endurance
- reassesses life goals
- shows contentment with aging
What is Erickson’s psychosocial stage associated with late 60s to death and the self-concept that goes with it?
Ego integrity vs Despair
- feels positive about life and its meaning
- interested in providing a legacy for the next generation
What are factors that influence self-concept throughout life?
- sense of competency
- perceived reactions of others to one’s body
- ongoing perceptions and interpretations of the thoughts and feeling of others
- personal and professional relationships
- academic and employment-related identity
- personality characteristics that affect self-expectations
- perceptions of events that have an impact on self
- mastery of prior ad new experiences
- cultural identity
What age group has the highest self-esteem?
children
What happens to self esteem during adolescents?
it waivers
What happens to self esteem during adulthood?
it grows as adults and then goes up or down in old age depending on your life experiences.
What are the components of self-concept?
- identity
- body image
- role performance
How does culture influence identity?
Cultural identity is developed early in growth and are reinforced as an individual matures through social, family, or cultural experiences. Positive or negative cultural role modeling, identity , and past experiences influence self-care, self-concept, and self-esteem.
Identity
the internal sense of individuality, wholeness, and consistency of a person over time and in different situations.
body image
attitudes related to the body, including physical appearance, structure, or function.
role performance
the way in which individuals perceive their ability to carry out significant roles.
self-concept stressor
any real or perceived change that threatens identity, body image, or role performance
What changes affect self-concept?
changes that occur in physical, spiritual, emotional, sexual, familial, and sociocultural health affects self-concept.
identity confusion
the result of an individual who fails to maintain a clear, consistent, and continuous consciousness of personal identity.
role conflict
a person has to simultaneously assume two or more roles that are inconsistent, contradictory, or mutually exclusive
role ambiguity
unclear role expectations, which makes people unsure about what to do or how to do it, creating stress and confusion
role strain
combines role conflict and role ambiguity
role overload
having more roles or responsibilities within a role than are manageable
sick role
the expectations of others and society regarding how an individual behaves when sick.
What are some diagnosis related to self-concept?
- disturbed body image
- caregiver role strain
- disturbed personal identity
- ineffective role performance
- readiness for enhanced self-concept
- chronic low self-esteem
- situational low self-esteem
- risk for situational low self esteem
What are some behaviors suggestive of altered self-concept?
- avoidance of eye contact
- slumped posture
- unkempt appearance
- overly apologetic
- hesitant speech
- overly critical or angry
- frequent or inappropriate crying
- negative self-evaluation
- excessively dependent
- hesitant to express views or opinions
- lack of interest in what is happening
- passive attitude
- difficulty in making decisions
- self-harm behaviors
