Exam 3 Flashcards
four humors
(1) irritable and hostile choleric (yellow bile)
(2) pessimistic melancholic (black bile)
(3) overly optimistic and extraverted sanguine (blood)
(4) apathetic phlegmatic (phlegm)
clusters of personality disorders
A. odd eccentric (paranoid, schizoid, schizotypal)
B. dramatic, erratic (antisocial, borderline, histrionic, narcissistic)
C. anxious, fearful (avoidant, dependent, obsessive-compulsive)
*The Weird (A), The Wild (B), and The Willy (C)
schizoid and schizotypal
-schizoid is lesser degree of schizotypal
paranoid characterized by
pervasive, persistent, and inappropriate mistrust of others
**more common in MEN
1-4% in population
clinical picture paranoid
- on guard constantly (hypervigilant)
- trust no one
- tests honesty of others
- oversensitive
- insensitive to others feelings
- tends to misinterpret minute cues
- magnify and distort cues in environment
- does not accept responsibility for his/her own behavior
- attributes shortcomings to others
predisposing factors paranoid personality
-subject to early parental antagonism and harassment
schizoid personality disorder characterized by….
….primarily profound defect in ability to form personal relationships & failure to respond to others in meaningful emotional way
**more common in men
3-5% in population
clinical picture schizoid personality
- aloof and indifferent to others
- emotionally col
- no close friends (prefers being alone)
- appears shy, anxious, uneasy to others
- inappropriately serious about everything and difficulty acting in light-hearted manner
schizoid personality predisposing factors
- childhood characterized by:
- bleak
- cold
- unempathetic
- notably lacking in nurturing
schizotypal personality disorder characterized by
odd and eccentric but does not decompensate to level of schizophrenia
(graver form of less severe schizoid)
3% population
schizotypal clinical picture
- aloof and isolated
- behave in bland/apathetic manner
- bizarre speech pattern
- when under stress, can decompensate and demonstrate psychotic symptoms
- right on verge of psychosis (odd unusual behaviors)
- magical thinking
- ideas of reference
- illusions
- depersonalization
- superstitiousness
- withdrawal into self
predisposing factors
- physio (anatomic deficits or neurochem dysfxn)
- family dynamics (indifference, impassivity, formality)
- pattern of discomfort w/ personal affection and closeness
antisocial personality–behavior that is:
- socially irresponsible
- exploitative
- w/out remorse
- disregard for rights of others
*2-4% in men to about 1 percent in women
clinical picture of antisocial personality
- fails to sustain consistent employment or academic performance
- fails to conform to law
- fails to develop stable relationships (can’t form long-lasting monogamous relationship)
- can’t fxn as responsible parent
- belligerent and argumentative
- unable to delay gratification/impulsive/reckless
borderline personality disorder characterized by
- pattern of intense and chaotic relationships w/ affective instability (clients fall on border between neuroses and psychoses)
- fluctuating and extreme attitudes regarding other ppl
- highly impulsive
(1-2 percent of population and more common in women)
borderline clinical picture
- emotionally unstable
- directly/indirectly self-destructive (unstable self-image)
- lacks clear sense of identity
- chronic depression
- inability to be alone
histrionic personality disorder characterized by..
-colorful, dramatic, extroverted behavior in excitable and emotional people
2-3% (more common in women)
clinical picture of histrionic
- self-dramatizing
- ATTENTION-SEEKING
- overly gregarious
- seductive
- manipulative
- exhibitionistic
- EASILY influenced by others (follower)
- highly distractible
- difficulty forming close relationships
- strongly dependent
- somatic complaints common
- require constant approval and affirmation
predisposing factors histrionic personality
- link to noradrenergic and serotonergic systems
- biogenetically determined temperament
- learned behavior patterns
narcissistic personality disorder characterized by…
- exaggerated self-worth
- lack of empathy
- inalienable right to special consideration
*6% prevalence (more common in men)
narcissistic clinical picture
- exploits others to fulfill own desires
- mood (often grounded in GRANDIOSITY) is usually optimistic, relaxed, cheerful, and care-free
- mood can easily change if clients do not: meet self-expectations OR receive positive feedback that they expect
- criticism from others can cause them to respond with rage, shame, humiliation
predisposing factors personality
- as children, fears, failures, or dependency needs were responded to w/ criticism, disdain, or neglect
- narcissistic parents
- parents overindulged child/failed to set limits on inappropriate behavior
- parent lives vicariously thru child
avoidant personality disorder characterized by…
- extreme sensitivity to rejection
- social withdrawal
(1% and is equally common in men and women)
clinical picture avoidant personality disorder
- awkward and uncomfortable in social situations
- desire close relationships but avoid them because of fear of being rejected
- perceived as timid, withdrawn, or cold/strange
- view others as critical and betraying
predisposing factors personality disorder
NO CLEAR CAUSE
- combo of bio, genetic, and psychosocial
- primary psychosocial influence: parental rejection and censure (often reinforced by peers)
dependent personality disorder characterized by…
-pattern of relying on others for emotional support
relatively common, and more common in women and in youngest children of family
clinical picture of dependent personality
- have notable lack of self-confidence apparent in: Posture, Voice, Mannerisms
- overly generous and thoughtful while underplaying own attractiveness and achievements
- low self-worth and easily hurt by criticism and disapproval
- avoid positions of responsibility and become anxious when forced into them
- assume passive and submissive roles in relationships
predisposing factors dependent personality
from overprotective parents:
- stimulation and nurturance are experienced exclusively from one source
- singular attachment is made by infant to exclusion of all others
obsessive-compulsive personality disorder characterized by
- inflexibility about way in which things must be done and devotion to productivity at exclusion of personal pleasure
- relatively common and more common in men and most common in oldest children
obsessive-compulsive personality clinical picture
- esp. concerned w/ matters of organization and efficiency
- tend to be rigid and unbending
- socially polite and formal
- rank-conscious (ingratiating with authority figures and autocratic and condemnatory with subordinates)
- on surface, appear to be calm and controlled but underneath: ambivalence, conflict, hostility
- problems with decision-making
- thrive in chaos
predisposing factors
- overcontrol by parents
- notable parental lack of positive reinforcement for good behavior
- frequent punishment for undesirable behavior
who staff splits
-borderline personality disorder
patterns of interaction with borderline
- clinging and distancing behaviors
- splitting
- manipulation
- self-destructive behaviors (self-harm)
- impulsivity
psychosocial influences borderline
- childhood trauma & abuse
- fixed in rapprochment phase of development (16 to 24 mo)
- child fails to achieve task of autonomy
goals for client w/ borderline
- able to identify true source of anger
- relates to more than one staff member
- completes ADL’s independently
- express anger appropriately
antisocial personality disorder behaviors characterized by…
…reactive to perceived threats, control, and negative affect
psychopathy….
- low fear
- low empathy
- domination
- callous cruelty
- emotional insensitivity
predisposing factors antisocial personality
- disruptive behavior as child (ADHD/hyperactivity dx/conduct dx)
- hx severe physical abuse
- absent/inconsistent parental discipline
- extreme poverty
- removed from home
- growing up w/out parental figure of both sexes
- always being rescued when in trouble
DBT…
…antisocial personality tx
schizotypal tx
CBT not effective
antisocial
-do not tx w/ pharm
Freud and dissociation
-type of repression (active defense mechanism used to remove unacceptable mental contents from awareness)
**unexpressed emotions converted into physical symptoms
Richard Asher
-termed Munchausen Syndrome/Factitious Disorder
conversion dx epidemiological
- more in women
- more in adolescents and YA
- lower socioeconomic/less education/rural populations
- military personnel exposed to combat
DIDs epidemiology
*dissociative disorders
- more in women
- symptoms usually being in adolescence or early adulthood
single brief episodes of dissociation
- severe psychosocial stress
- sleep-deprived
- during travel to unfamiliar places
- intoxicated
somatic symptom dx basic definition
- chronic dx w/ symptoms beginning before age 30
- periods of remission and exacerbation
common complications of somatic symptom dx
-drug abuse
personality characteristics of somatic symptom disorder
- heightened emotionality
- strong dependency needs
- preocccupation with symptoms and oneself
illness anxiety dx
- preoccupation and fear of having serious dz
- anxiety and depression common and OC traits accompany dx
dissociative amnesia and dx
-difficult to dx in kids because mistaken for inattention or oppositional behavior
conversion dx
- loss or change in body fxn that cannot be explained by any known medical dx
- symptoms affect voluntary motor or sensory functioning suggestive of neurological disease
pseudocyesis
-false pregnancy
hereditary
- somatic symptom dx
- conversion dx
- illness anxiety dx
biochem in somatic symptoms dx
-decreased levels of serotonin and endorphins (may play role in pain)
defenses in psychodynamic theory of somatic symptom disorder (illness anxiety dx)
- ego defense mechanism
- physical complaints=expression of low-self esteem
*defense against guilt
conversion disorder psychodynamic theory
-emotions associated with traumatic event that are unacceptable to express
tertiary gain
-somatization brings some stability to fam and positive reinforcement to child
**dysfunctional fam
**shift focus away from family issue
primary gain
-may avoid obligations/be excused from unwanted duties w/ somatic complaints
secondary gain
-become prominent focus of attention because of illness
dissociative amnesia
-defined as inability to recall important personal info that is too extensive to be explained by ordinary forgetfulness (no substance use)
**onset follows severe psychosocial stress
most common types of dissociative amnesia
- localized amnesia (unable to recall incidents associated w/ stressful period)
- selective amnesia (can recall only certain incidents associated w/ stressful event for specific period after event)
- generalized type (amnesia for his/her identity and total life history)
dissociative fugue
**subtype of dissociative amnesia
-sudden, unexpected travel away from customary places or by bewildered wandering w/ inability to recall some or all of one’s past (sometimes assumes new identity)
termination of dissociative amnesia
-usually abrupt and followed by full recovery
**reoccurrences are unusual
dissociative identity disorder transition
-transition from one personality state to another may be sudden or gradual (sometimes quite dramatic)
parent in Munchausen
- depressed or anxious
- past hx of abuse
tx for Munchausen
- remove child from situation
- therapy for parent (sometimes lie in therapy tho)
depersonalization-derealization disorder
-temp change in quality of self-awareness, often taking on form of
1-feelings of unreality
2- changes in body image
3-feelings of detachment from environment
4-a sense of observing oneself from outside body
DID characteristics
-fragments of identity rather than separate personalities
DID symptoms
- voices in head
- sudden emotions have no control over
- constant change thru behavior, mem, perception, motor function
- gaps in mem
- thoughts suicide common trait
- depression & anxiety (from depersonalization and derealization)
depersonalization vs derealization
- depersonalization: disturbance in perception of oneself
- derealization: alteration in perception of external environment
s/s depersonlization-derealization disorder
- anxiety/depression
- fear of going insane
- obsessive thoughts
- somatic complaints
- disturbance in subjective sense of time
genetics and dissociative dx
-no evidence of genetic contribution
DID predisposing factors
- hx physical/sexual abuse (survival strategy for child in traumatic environment)
- depersonalizaton=evidenced w/ migraines and MJ use, responds to SSRIs (serotonergic involvement)
risk for suicide
DID
meds in somatic symptom dx
-not effective unless being used to tx underlying depression/anxiety
amobarbital
- retrieval lost mem in amnesia
- reveal historical info r/t trauma
abreaction
-recall past traumas in detail
“remembering w/ feeling”
tx w/ depersonlization-derealization
inconclusive
3 D’s in geriatric psychology
(1) delirium (reversible)
(2) dementia
(3) depression
s/s delirium
- difficulty sustaining/shifting attention
- disorganized thinking
- rambling speech (pressured/incoherent)
- disorientation to time and place
- impairment of recent mem
- misperceptions about environment (HALLUCINATIONS & DELUSIONS)
- disturbances in sleep/wake cycle/nightmares
- psychomotor activity that fluctuates between agitation and restlessness and vegetative state
autonomic manifestations of delirium
- tachy
- sweating
- flushed face
- dilated pupils
- elevated blood pressure
delirium due to medical condition
- systemic infections
- febrile illness
- metabolic disorders (electrolytes imbalances, hypoglycemia)
- hypoxia/COPD
- head trauma
- hepatic/renal failure
- migraine headaches
- seizures
- brain abscess/neoplasm
- stroke
- nutritional deficiency
- uncontrolled px
- burns
- heat stroke
- orthopedic and cardiac sx
- social isolation
precipitating factors for delirium for elderly (over 65)
- dementia
- depression
- falls
- elder abuse
med-induced delirium
- anticholinergics
- antihypertensives
- corticosteroids
- anticonvulsants
- cardiac glycosides
- analgesics anesthetics
- antineoplastic agents
- antiparkinson drugs
- H2 receptor antagonists (CIMETIDINE)
neurocognitive disorders defined as…
…cognitive fxns closely linked to particular areas of the brain
-impairment in cog fxn of thinking, reasoning, memory, learning and speaking
NCD (defined as MILD or MAJOR)
mild NCD
AKA mild cognitive impairment
early signs of dementia
major NCD
-progressive decline in cog ability in presence of clear consciousness
MANY cog deficits involved
reversible NCD
temporary dementia
- can occur as result of:
- stroke
- depression
- side effects of meds
- nutritional deficiencies (esp b12 or folate)
- metabolic disorders
- normal pressure hydrocephalus
- CNS infections
primary NCD
-ex: AD
**NCD itself is major sign of organic brain dz not directly r/t any other organic illness
secondary NCD
-ex: HIV, cerebral trauma
**caused by or r/t another dz or condition
cognition in NCDs
- abstract thinking impairment
- judgement impairment
- poor impulse control
behavior in NCDs
**conventional rules of social conduct often disregarded
-uninhibited and inappropriate behavior
language in NCDs
may or may not be affected
- trouble naming objects or language may seem vague and imprecise
- aphasia (in severe forms)
personality change in NCDs
common (accentuation or alteration of premorbid characteristics)
as dz progresses, symptoms may include:
- aphasia
- apraxia (inability to carry out motor activities despite intact motor fxn)
- irritability/moodiness/sudden outbursts
- inability to perform ADLs
- wandering away from home
- incontinence
stages of progressive symptoms of AD
- Stage 1: no apparent symptoms
- Stage 2: forgetfulness (losses in short term mem common)
- Stage 3: mild cog decline (pt. where we want to try to get tx started; interference w/ work performance which becomes noticeable to coworkers)
- Stage 4: mild-to-mod cog decline
- Stage 5: mod cog decline
- Stage 6: mod-to-severe cog decline
- Stage 7: severe cog decline
categories of etiology of NCDs
- NCD due to AD
- Vascular neurocognitive dx
- frontotemporal neurocognitive dx
- NCD due to TBI
- NCD due to Parkinson’s
- NCD due to Lewy body dementia
- NCD due to HIV infection
- substance-induced neurocognitive dx
- NCD due to Huntington’s
- NCD due to prion dz
- NCD due to another med condition
- NCD due to multiple etiologies
- unspecified NCD
NCD due to AD course of disorder
-progressive and deteriorating
predisposing factors to NCD due to AD
- neurotransmitter alterations (depression r/t alzheimer’s; acetylcholine reduction which reduces amount of NT that is released to cells in cortex and hippo)
- plaques and tangles (Tau’s)
- head trauma
- genetic factors (40% of AD pts have fam hx)
vascular NCD
- cerebrovascular dz (blood flow in brain impaired)
- more abrupt onset than seen in AD && course is more variable
**symptoms in STEPS rather than gradual deterioration (at times, symptoms tend to clear up)
etiology vascular NCD
- HTN
- cerebral emboli
- cerebral thrombosis
frontotemporal NCD
-result of shrinking of frontal and temporal anterior lobes of brain
(previously called PICK’s dz)
***predominantly main one
symptoms of frontotemporal NCD
*fall into two clinical patterns:
1-behavioral and personality changes
2-speech and language problems
NCD due to traumatic brain injury
-amnesia is the MOST COMMON neurobehavioral symptom following head trauma (posttraumtic amnesia)
- LOC
- disorientation/confusion
- neuro signs
- changes in speech, vision, personality
repeated head trauma
can result in dementia pugilistica
*syndrome characterized by:
- emotional lability
- dysarthria (slurred speech)
- ataxia
- impulsivity
NCD due to Lewy body dz
- similar to AD but progresses MORE RAPIDLY and early appearance of (1) hallucinations and (2) parkinsonian features
- depression and delusions also common
- Lewy bodies in cerebral cortex and brainstem
NCD cases and Lewy body
25% of all NCD cases
NCD due to Parkinson’s
*loss of nerve cells located in substantia nigra and decrease in dopamine activity
(cerebral changes in NCD from Park. resemble those of AD)
75% of parkinson’s clients
NCD due to HIV
-caused by brain infections w/ opportunistic organisms or by HIV-1 directly
- *symptoms:
- range from barely perceptible changes to acute delirium to profound cog impairment
substance-induced NCD
-substance rxns, overuse, or abuse (s/s persist beyond usual duration of intoxication and acute withdrawal)
- alc/sedative/hypnotic/anxiolytics/inhalants
- drugs causing anticholinergic effects
- toxins like lead/mercury
NCD due to Huntington’s
**more gene-related
- damage in basal ganglia and cerebral cortex
- declines into PROFOUND state of dementia and ataxia
NCD due to Prion dz
- insidious onset and rapid progression (dx to death in 2 yrs)
ex: infected meat products/Mad cow dz
manifestations of NCD due to prion dz
- probs w/ coordination
- other movement disturbances
- rapidly progressing dementia
development of NCD due to prion
-develop at any age but typically between 40 and 60 y/o
NCD due to another med condition
-hypothyroidism/hyperparathyroidism/ pituitary insufficiency -uremia -encephalitis -brain tumor -pernicious anemia (B12) or thiamine deficiency (B1) or pellagra (niacin deficiency) -MS -uncontrolled epilepsy -cardiopulm insufficiency -fluid/electrolyte imbalances -CNS and systemic infections -lupus
client hx/assessment for NCDs
(1) type, frequency, and severity of mood swings, personality/behavioral changes, and catastrophic emotional rxns
(2) cog changes (attn span, thinking process, prob-solving, mem)
(3) language difficulties
(4) orientation to person, place, time, situation
(5) appropriateness of social behaviors
most common mental illness in elderly
- depression (but is often misdiagnosed)
* cog symptoms of depression may mimic NCD and providers are too eager to make this dx
dx lab tests (blood and urine)
test for:
- infections
- hepatic/renal dysfxn
- DM or hypoglycemia
- electrolyte imbalance
- metabolic/endocrine dx
- nutritional deficiency
- toxic substances
janitor cells for amyloid beta
microglia
risk factors alz’s
- age
- genetics (DNA alone does not determine if we get Alz)
- sleep (glial cells work hard w/ deep sleep)
- cardio health (high BP, DM, obesity)
- **aerobic exercise decreases amyloid beta
neuroplasticity and cognitive reserve
*form more synapses (creating and strengthening new neural connections when we learn something new)
cognitive reserve=more functional synapses available
evaluation of client with NCD
- based on series of short-term goals rather than long-term goals
- Outcomes: measured in terms of slowing down process rather than stopping or curing
additional attention in delirium
- fluid/electrolyte status
- hypoxia
- anoxia
- DM probs
staff and client w/ delirium
-staff to remain w/ client at all times to monitor behavior and provide reorientation/assurance
meds for delirium
*some choose not to give meds to delirium clients as they may only compound syndrome of brain dysfxn
BUT if so:
-psychosis w/ agitation and aggression may require meds/restraint ((low-dose antipsychotics))
substance withdrawal
can use benzodiazepines for delirium w/ substance withdrawal