w6 - 25 questions Flashcards
________
- Universal huma experience
- Most basic emotion
- Feeling of apprehension, uneasiness, uncertainty or dread from a real or perceived threat
- Reponse to a threat that is unknown, vague, or conflictual
- Response to internal or external stimuli
- Symptoms are physical, emotional, cognitive, and behavioral
- Evolutionary response to impending doom – fight or flight response
Anxiety
Reactive Attachment d/o vs Disinhibited social engagement d/o?
children with ______ are withdrawn and have trouble forming attachments
children with _______ are overly friendly with strangers, lacking normal boundaries
Social Interaction:
______: Socially withdrawn.
______: Overly social.
Response to Strangers:
______: Overly familiar and indiscriminate.
______: Avoidant and wary.
Attachment Behavior:
_____: Difficulty forming specific attachments.
_____: Diffuse attachments, lacking selectivity.
RAD
DSED
RAD
DSED
DSED
RAD
RAD
DSED
Anxiety vs fear
- _______ - Feeling of apprehension, uneasiness, uncertainty or dread from a real or perceived threat (stress response from your thoughts)
- _______ – reaction to specific danger (stress response from immediate danger)
- Normal anxiety – necessary for survival
Anxiety vs fear
- Anxiety - Feeling of apprehension, uneasiness, uncertainty or dread from a real or perceived threat (stress response from your thoughts)
- Fear – reaction to specific danger (stress response from immediate danger)
- Normal anxiety – necessary for survival
Theories of anxiety d/o
Biological factors
- Genetic
- Neurobiological
Psychological factors
Cultural factors
- Anxiety may be expressed through somatic symptoms or cognitive symptoms
Environmental factors
0
Levels of anxiety
(4)
- Mild
- Moderate
- Severe
- Panic
_______ anxiety
- Occurs in the normal experience of everyday living
- Adaptive
- Can provide motivation for survival
Perceptual field – heightened
- Sees and hears more information
- Sharper observations
- Focus is flexible
- Aware of anxiety
Ability to problem solve
- Able to work effectively toward a goal and examine alternatives
Characteristics
- Slight discomfort
- Attention seeking
- Restlessness
- Easily startled
- Irritable or impatience
- Mild tension relieving behavior – tapping, lip chewing, fidgeting
Mild
_________ anxiety
Perceptual field - narrowed
- Sees and hears less information
- Some details excluded from observations
- Focus is on source of anxiety
- Less able to pay attention
Ability to problem solve
- Able to problem solve, not at optimal level
- Able to follow direction
Characteristics
Sympathetic nervous system symptoms begin:
- Tension
- Pounding heart
- Increased pulse and RR
- Perspiration
- Mild somatic symptoms – h/a, urinary frequency, backache, insomnia
- Voice tremors
- Poor concentration
- Shaking
Moderate
_________ anxiety
Perceptual field – reduced and distorted
- Focuses on details or one specific detail
- Attention is scattered
Ability to problem solve
- Feels impossible
- Unable to connect events and details
- Dazed and confused
Characteristics
- Automatic behaviors aimed at reducing or relieving anxiety
- Feelings of dread, impending doom
- Confusion
- Purposeless activity
- More intense somatic symptoms – chest discomfort, dizzy, nausea, sleeplessness
- Diaphoresis
- Withdrawal
- Loud and rapid speech
- Threats and demands
Severe
_________ anxiety
Perceptual field – non-existent
- Unable to process environment
- Focus is lost
- Depersonalization – person may feel unreal (themselves)
- Derealization – person may feel the world is unreal
Ability to problem solve
- Completely unable
- Disorganized and irrational reasoning
Characteristics
- Feelings of terror
- Immobility (freeze), severe hyperactivity (fight or flight)
- Speech – unable or unintelligible, amplified or muffled sounds
- Somatic symptoms increase – numbness, tingling, SOB, dizzy, chest pain, nausea, trembling, chills, overheating, palpitations
- Severe withdrawal
- Hallucinations or delusions
- Out of touch with reality
Panic - Most extreme level
______________ against anxiety
- Automatic coping styles
- Protection from anxiety
- Enable individual to maintain self image by blocking feelings, conflicts, or memories
- Can be healthy or unhealthy
- Not always obvious to the individual using them
Defenses mechanisms
Defense mechanisms against anxiety:
- Conversion
- Altruism
- Compensation
- Denial
_________: Deriving gratification from helping others, which serves to reduce feelings of guilt.
________: Counterbalancing perceived weaknesses by emphasizing strengths in another area.
________: Transforming anxiety into physical symptoms lacking an organic cause.
_________: Refusing to acknowledge painful subjective realities.
Altruism: Deriving gratification from helping others, which serves to reduce feelings of guilt.
Compensation: Counterbalancing perceived weaknesses by emphasizing strengths in another area.
Conversion: Transforming anxiety into physical symptoms lacking an organic cause.
Denial: Refusing to acknowledge painful subjective realities.
Defense mechanisms against anxiety:
- Displacement
- Dissociation
- Identification
- Intellectualization
__________: Redirecting emotions from their source to a substitute target.
_________: Separating thoughts, emotions, or memories from conscious awareness.
_________: Adopting beliefs, values, or behaviors of another person or group.
__________: Avoiding emotions by focusing on facts and logic.
Displacement: Redirecting emotions from their source to a substitute target.
Dissociation: Separating thoughts, emotions, or memories from conscious awareness.
Identification: Adopting beliefs, values, or behaviors of another person or group.
Intellectualization: Avoiding emotions by focusing on facts and logic.
Defense mechanisms against anxiety:
- Projection
- Rationalization
- Reaction formation
- Regression
__________: Attributing one’s unacceptable thoughts or impulses to others.
_________: Creating fictitious but credible justifications to make the irrational acceptable.
__________: Behaving in a manner directly opposite to one’s true feelings.
_______: Retreating to an earlier stage of development to avoid responsibility.
Projection: Attributing one’s unacceptable thoughts or impulses to others.
Rationalization: Creating fictitious but credible justifications to make the irrational acceptable.
Reaction Formation: Behaving in a manner directly opposite to one’s true feelings.
Regression: Retreating to an earlier stage of development to avoid responsibility.
Defense mechanisms against anxiety:
- Repression
- Splitting
- Sublimation
- Suppression
- Undoing
_________: Unconsciously blocking unacceptable thoughts, feelings, or urges.
_________: Viewing people or situations as entirely good or entirely bad.
________: Channeling unacceptable impulses into socially acceptable behaviors.
_________: Consciously pushing away unwanted thoughts, emotions, or impulses.
______: Attempting to negate or cancel out unacceptable thoughts or behaviors.
Repression: Unconsciously blocking unacceptable thoughts, feelings, or urges.
Splitting: Viewing people or situations as entirely good or entirely bad.
Sublimation: Channeling unacceptable impulses into socially acceptable behaviors.
Suppression: Consciously pushing away unwanted thoughts, emotions, or impulses.
Undoing: Attempting to negate or cancel out unacceptable thoughts or behaviors.
maladaptive vs adaptive
Use of ________ defense mechanisms:
- Problem solving
- Crying
- Talking
- Sleeping
- Exercising
- Deep breathing
- Imagery
- Relaxation
Use of _________ defense mechanisms:
- Blaming
- Negative self talk
- Obsessive compulsive behaviors
- Aggressive acting out behaviors
- Withdrawal
- Excessive eating, drinking, spending, gambling, drug use, sex
adaptive
maladaptive
Process:
1. Anxiety occurs (acute or chronic)
2. Relief behavior – defense mechanisms, coping, support systems
3. Effective mediation = __creased anxiety
OR
4. Ineffective medication = __creased anxiety
- Difficulty coping
- Extreme use of defenses or coping
- Psychotic symptoms
- Unrelieved anxiety = chronic anxiety
decreased
increased
Interventions
Mild to moderate anxiety
- Identify anxiety and triggers
- Nonverbal and verbal therapeutic communication
- Encourage pt to talk about feelings
- Clarify
- Identify feelings prior to onset of anxiety
- Problem solving, alternative solutions
- Outlets for working off excess energy
Mild to moderate anxiety: Reduce anxiety levels/prevent escalation
- Calm presence
- Recognize distress
- Listen
- Explore how anxiety was alleviated in the past
- Provide alternative coping strategies
Severe to panic anxiety
- Safety
- Always ____ with pt
- Calm
- Clear, simple statements, ____ pitched voice, speak slow
- _____ environment, minimal stimulation
- Reorient to reality if distortions
- Meds
- Risk for suicide
Mild to moderate anxiety
- Identify anxiety and triggers
- Nonverbal and verbal therapeutic communication
- Encourage pt to talk about feelings
- Clarify
- Identify feelings prior to onset of anxiety
- Problem solving, alternative solutions
- Outlets for working off excess energy
Mild to moderate anxiety: Reduce anxiety levels/prevent escalation
- Calm presence
- Recognize distress
- Listen
- Explore how anxiety was alleviated in the past
- Provide alternative coping strategies
Severe to panic anxiety
- Safety
- Always stay with pt
- Calm
- Clear, simple statements, low pitched voice, speak slow
- Quiet environment, minimal stimulation
- Reorient to reality if distortions
- Meds
- Risk for suicide
Anxiety disorders
- Most common mental health problem
- Affects all genders and ages
- Highly treatable
- Can be chronic and persistent
- Strong genetic predisposition
- S/s may begin in childhood/early adulthood
- Often recognizes thoughts/behaviors are ________ and emotion is an overreaction
- ________ used to reduce/manage the experience of overwhelming anxiety
- Allow continuation of behavior until other ________ strategies are in place
Anxiety disorders
- Most common mental health problem
- Affects all genders and ages
- Highly treatable
- Can be chronic and persistent
- Strong genetic predisposition
- S/s may begin in childhood/early adulthood
- Often recognizes thoughts/behaviors are irrational and emotion is an overreaction
- Behaviors used to reduce/manage the experience of overwhelming anxiety
- Allow continuation of behavior until other management strategies are in place
_________ anxiety disorder
- Anxiety for more than 6 months
- Excessive and persistent worry
- Accompanied by muscle tension, autonomic hyperactivity, startle, difficulty concentrating
Risk factors
- Unresolved conflict
- Cognitive misinterpretations
- Life stressors
- Genetic predisposition
- Behavioral inhibition – shyness, fear, withdrawing in unfamiliar situations
Comorbidities
- MDD
- Other anxiety d/o
- Alcoholism
Generalized
_________ anxiety disorder: Clinical course
- Chronic, fluctuating s/s
- s/s cause distress or impairment that interferes with daily life and relationships
- may have mild depressive s/s
- often present to PCP with somatic complaints like muscle aches, soreness, and GI complaints
- may have poor sleep, irritable, trembling, twitching, poor concentration, exaggerated startle, feels uneasy, fear of imminent disaster
Generalized
Anxiety Treatment: Pharmacotherapy
- Anti________ – SSRI, SNRI, TCA, MAOI, buproprion
- SSRI and SNRI are ______ line b/c of safety risks
- assess for suicide risk
- monitor for 4-8 weeks after starting antidepressant for efficacy
- can increase dose, switch drug or class, add 2nd drug - Anti _______ – benzodiazepines, buspirone
- Beta blockers
- short term physical symptoms of anxiety by bringing down HR and BP - Antihistamines – hydroxyzine
- different mechanism of action that makes it effective for reducing anxiety symptoms - Anticonvulsants
- Anti psychotics
Anxiety Treatment: Pharmacotherapy
- Antidepressants – SSRI, SNRI, TCA, MAOI, buproprion
- SSRI and SNRI are first line b/c of safety risks
- assess for suicide risk
- monitor for 4-8 weeks after starting antidepressant for efficacy
- can increase dose, switch drug or class, add 2nd drug - Anti anxiety – benzodiazepines, buspirone
- Beta blockers
- short term physical symptoms of anxiety by bringing down HR and BP - Antihistamines – hydroxyzine
- different mechanism of action that makes it effective for reducing anxiety symptoms - Anticonvulsants
- Anti psychotics
MAOIs – phenelzine, tranylcypromine, isocarboxazid
- Used less often
- Refractory depressant
- Atypical depression
- Complication – _____ crisis (when taken with ________)
- Food/drug interaction - Avoid tyramine rich foods (aged cheese, smoked meats, yeast, red wine)
- CNS stimulation
- Orthostatic hypotension
- Can lead to rapid ___crease in BP, stroke, coma
- Drug/drug interaction – antihypertensive, SSRI, indirect acting sympathomimetics (ephedrine), TCA, meperidine
MAOIs – phenelzine, tranylcypromine, isocarboxazid
- Used less often
- Refractory depressant
- Atypical depression
- Complication – HTN crisis (when taken with tyramine)
- Food/drug interaction - Avoid tyramine rich foods (aged cheese, smoked meats, yeast, red wine)
- CNS stimulation
- Orthostatic hypotension
- Can lead to rapid increase in BP, stroke, coma
- Drug/drug interaction – antihypertensive, SSRI, indirect acting sympathomimetics (ephedrine), TCA, meperidine
Bupropion vs buspirone
_________ - antidepressant
- Atypical antidepressant
- Stimulant effect
- Decreased appetite
- 1-3 weeks for effect
- Doesn’t tend to affect sexual function – often given with other antidepressants to help counter sexual s/e
- s/e – seizure, agitation, h/a, dry mouth, constipation, weight loss, GI upset, dizzy, tremor
__________ - antianxiety
- antianxiety med
- sensitive to SSRI treatment
- several weeks for effect
- less drowsiness and abuse potential
- non-habit forming and low toxicity
Bupropion - antidepressant
- Atypical antidepressant
- Stimulant effect
- Decreased appetite
- 1-3 weeks for effect
- Doesn’t tend to affect sexual function – often given with other antidepressants to help counter sexual s/e
- s/e – seizure, agitation, h/a, dry mouth, constipation, weight loss, GI upset, dizzy, tremor
buspirone - antianxiety
- antianxiety med
- sensitive to SSRI treatment
- several weeks for effect
- less drowsiness and abuse potential
- non-habit forming and low toxicity
benzodiazepines (antianxiety)
- quick onset, short term use only
- lowest dose necessary
- monitor ______ effects and risk for injury
- caution with machinery
- avoid caffeine, ________ (can be fatal), and other sedatives
- take with or without food?
- high or low addiction potential?
- tapper or d/c abruptly?
- enhances GABA action (calming, anti anxiety effect)
- promotes sleep?
- muscle relaxant
- promotes amnesia (flunitrazepam = date rape drug)
- teratogenic?
- antidote = flumazenil
benzodiazepines (antianxiety)
- quick onset, short term use only
- lowest dose necessary
- monitor sedative effects and risk for injury
- caution with machinery
- avoid caffeine, alcohol (can be fatal), and other sedatives
- take with food
- high addiction potential - use caution if hx of substance abuse
- tapper, do not d/c abruptly
- enhances GABA action (calming, anti anxiety effect)
- promotes sleep
- muscle relaxant
- promotes amnesia (flunitrazepam = date rape drug)
- teratogenic – avoid if pregnant
- antidote = flumazenil
teaching for antianxiety pharmacotherapy treatment
- don’t change dose/frequency w/o provider approval
- caution with ________
- alcohol and other antianxiety meds may cause _________ effects
- caffeine and nicotine __crease desired effect of antianxiety med
- can be excreted in breast milk?
- MAOIs – special _____ required
- Withdrawal – benzo, SSRI
- Take med _____ meals to avoid GI upset
- Drug interactions can occur
teaching for antianxiety pharmacotherapy treatment
- don’t change dose/frequency w/o provider approval
- caution with machinery
- alcohol and other antianxiety meds may cause depression effects
- caffeine and nicotine decrease desired effect of antianxiety med
- can be excreted in breast milk
- MAOIs – special diet required
- Withdrawal – benzo, SSRI
- Take med after meals to avoid GI upset
- Drug interactions can occur
Children/adolescents: ________ anxiety disorder
- Excessive worry/fear with no real cause
- Future events and past behaviors
- Social acceptance
- Family
- Finances
- Personal abilities
- School
Treatment: Children/adolescents
- CBT
- Antidepressants
- Anti-anxiety
generalized
_________ anxiety disorder
- Normal part of infant development
- Begins – 8 months
- Peaks – 18 months (should decline)
- Not normal – developmentally inappropriate levels of concern over being away from a significant other
- Fear something horrible happening, permanent separation
- Intense anxiety interferes with normal activities, sleep disturbances, nightmares, physical symptoms
Separation
________ anxiety disorder
- In adults – symptoms manifest as harm, avoidance, worry, shyness, uncertainty, lack of self-direction, impaired social and occupational functioning
Separation
__________
- Persistent irrational fear of a specific object, activity, or situation that leads to a desire for avoidance of that thing.
- The specific object, activity, or situation provokes immediate fear or anxiety and is avoided – daily functioning is compromised
- Fear/anxiety is out of proportion to the actual danger
Specific phobias
- Common phobias – dogs, spiders, heights, storms, closed spaces, tunnels, bridges, birds, insects
Specific phobias
- Medication not successful as singular treatment
- 1st line treatment – med, therapy, desensitization or flooding
__________ – individual is gradually introduced to feared object or experience through a series of steps (from least to most frightening)
- Taught how to use relaxation techniques at each step when anxiety becomes overwhelming
_________ – individual is exposed to large amounts of an undesirable stimulus to extinguish the anxiety response
- Learns through prolonged exposure that survival is possible and anxiety diminishes
Systemic desensitization
Flooding
- Most severe and persistent phobia d/o
- Intense and excessive anxiety/fear about being in places/situations from which escape might be difficult/embarrassing or where help might not be available
- Feared places are avoided
- Causes impairment in areas of functioning
- Common situations – alone outside or at home, traveling in car/bus/airplane, being on a bridge or in an elevator, being in a crowd
- Treatment – SSRIs, benzo, CBT, desensitization or flooding
Agoraphobia
________ anxiety disorder or ______ phobia
- Severe anxiety/fear provoked by exposure to a social situation that could be evaluated negatively by others
- Common situations – being criticized by others, humiliation, fear of public speaking
- Worry can occur days-weeks before dreaded situation
- May interfere with life activities and difficult to keep friends
- May have increased risk for MDD and SUD
- Treatment – SSRI and benzo
Risk factors
- Childhood mistreatment
- ACE
- Shyness
- Shy parents
Social anxiety disorder or social phobia
_______ disorder
- Chronic with exacerbations
- Sudden onset of extreme apprehension/fear usually associated with feeling impending doom
- Occurs out of the blue
- Lasts minutes
- Feelings of terror during panic attack are so severe that functioning is suspended, perceptual field is severely limited, and reality may be misinterpreted
- AUD or SUD common comorbidity
Etiology
- Genetics
- Family hx
- Early childhood stress
Epidemiology
- High associated with depression, HTN, cigarette and marijuana use
Panic disorder/attack
Panic disorder/attack: 2 key psychological symptoms
- _______ anxiety – fearful expectation of panic anxiety onset
- _______ anxiety – personal strategies used to increase feelings of control and decrease risk of panic anxiety
Anticipatory
Avoidance
s/s ________ disorder
- Chest pain or discomfort, palpitations, pounding heart, increased HR
- Sweating, trembling
- SOB
- Feelings of choking
- Nausea or GI distress
- Dizzy, lightheaded, unsteady
- Chills or hot flashes
- Paresthesia
- Derealization – feelings of unreality
- Depersonalization – detached from oneself
- Fear of losing control or dying
Panic disorder/attack
Panic disorder/attack
Treatment
- CBT
- Distraction
- Positive self talk
- Flooding
- Relaxation
- Antidepressants ____ line – SSRI, SNRI, TCA, MAOI
- Benzo ____ line
Emergency care
- Crisis
- r/o life threatening events – cardiac event
- stay with pt
- reassurance
- clear directions
- quiet environment
- walk with pt
- admin prn meds
Treatment
- CBT
- Distraction
- Positive self talk
- Flooding
- Relaxation
- Antidepressants 1st line – SSRI, SNRI, TCA, MAOI
- Benzo 2nd line
Emergency care
- Crisis
- r/o life threatening events – cardiac event
- stay with pt
- reassurance
- clear directions
- quiet environment
- walk with pt
- admin prn meds
________ disorder
- repetitive unwanted thoughts/obsessions
- repeated activities/rituals compulsions
- time consuming
- distressing to individual, family, friends
- s/s gradual onset
- time consuming and causes impairment in functioning
- stress increase = s/s increase
- cyclical: obsessive thought = anxiety = compulsive behavior = temporary relief = obsessive thought = etc…
- risk factors – childhood abuse or trauma, genetics
- often occurs with anxiety d/o
- humiliation or shame regarding behaviors
- impaired cognition
OCD
compulsions vs Obsessions
_________ – unwanted, intrusive, persistent thoughts, impulses, or images that persist and reoccur and can’t be dismissed from the mind
- seem senseless to individual experiencing it
- not consistent with individuals self perception or usual thought pattern
- common – fear of contamination, symmetry, thoughts of hurting someone
___________ – behaviors that are performed repeatedly, ritualistic, goal is to prevent or relieve anxiety and distress caused by obsessions
- performing act temporarily reduces anxiety, must be repeated for continued relief
- common – hand washing, touching things in sequence, counting things, locking and unlocking doors
obsessions
compulsions
OCD: treatment
- very difficult to treat
- SSRI – clomipramine, fluoxetine, fluvoxamine, paroxetine, sertraline
- CBT
- Exposure
- DBS
- TMS
OCD in children/adolescents: Treatment
- SSRI – clomipramine, fluoxetine, fluvoxamine, sertraline
- Exposure
- Response prevention therapy
- CBT – adolescents only
0
__________ disorder
- Preoccupation with perceived defects/flaws in physical appearance that is not observable or appears slightly to others
- Most common – skin, hair ,nose, stomach, teeth, ,weight, breasts
- Results in obsessional thinking and compulsive behaviors – check mirror, camouflaging, excessive grooming, skin picking, reassurance seeking
- Results in mental acts – comparing appearance to others
- Preoccupations are intrusive, unwanted, time consuming, difficult to control
- May lead to embarrassment, shame, anxiety, disgust, depression
- High suicide risk
Treatment
- Response to treatment is limited
- Chronic
- CBT
- SSRI
- Biofeedback
- Meditation
- Relaxation
Body dysmorphic
_________ disorder
- Persistent difficulty discarding possessions, regardless of value
- Causes distress or impairment in functioning
- Condition worsens with age
- Comorbidities - MDD, anxiety, OCD
- Safety concern!!
Hoarding
__________ disorder
- Recurrent hair pulling from any region of body
- Most common areas – scalp, eyebrows, eyelashes
- Pain may reduce anxiety
- Many are unaware of pulling behavior until they notice a wad of hair
- Causes distress or impairment in functioning
- Treatment – SSRI and behavior therapy_
Trichotillomania
_________ disorder
- Recurrent skin picking resulting in skin lesions – may include skin rubbing, squeezing, lancing, biting
- Common areas – face, arms, hands
- May relieve stress and anxiety
- May not be aware of behavior
- Causes distress or impairment in functioning
- Comorbidities – OCD, trichotillomania
- Treatment - SSRI, CBT
Excoriation
_______ abuse – physical pain or bodily harm
________ abuse – sexual contact or exposure without consent or if the victim is incapable of giving consent
________ abuse – undermining a persons self worth
_______ – failure to provide for physical, emotional, educational, and medical needs
_________ abuse – controlling persons access to economic resources making person financially dependent
Physical abuse – physical pain or bodily harm
Sexual abuse – sexual contact or exposure without consent or if the victim is incapable of giving consent
Emotional abuse – undermining a persons self worth
Neglect – failure to provide for physical, emotional, educational, and medical needs
Economic abuse – controlling persons access to economic resources making person financially dependent
_______ situation – situation puts stress on family with a violent member
- Lack of effective impulse control
- Lack of problem solving skills
- Lack of healthy support system
_______ – member of household that is violent toward another member
_________ person – family member whom abuse is perpetrated
________ – recognizes the recovery and healing process that follows victimization and doesn’t have a connotation of passivity
Crisis situation – situation puts stress on family with a violent member
- Lack of effective impulse control
- Lack of problem solving skills
- Lack of healthy support system
Perpetrator – member of household that is violent toward another member
Vulnerable person – family member whom abuse is perpetrated
Survivor – recognizes the recovery and healing process that follows victimization and doesn’t have a connotation of passivity
_________
Physical violence, rape, stalking, psychological aggression by a current/former intimate partner
Intimate partner violence
Intimate partner violence: Risk factors
- Perspective _______
- Pathological _______
- ________ abuse
- Pregnancy
- Perspective dominance
- Pathological jealousy
- Substance abuse
- Pregnancy
Cycle of violence (IPV)
1. _________ building – minor abusive events, victim ignores events out of fear, abuser rationalizes behavior
2. Acute _______ – tension peaks, triggered by events
3. _________ – tension reduces, abuser apologetic, victim abandons plans to leave
- Tension building – minor abusive events, victim ignores events out of fear, abuser rationalizes behavior
- Acute battering – tension peaks, triggered by events
- Honeymoon – tension reduces, abuser apologetic, victim abandons plans to leave
________ abuse
Intentional abuse that causes harm or creates a risk of harm to a vulnerable person
- failure to provide basic needs
- failure to protect them from harm
Older adult
Older adult abuse: risk factors
- poor ______ health
- poor _______ health
- disruptive disorders – alzheimer’s
- dependency
- hx of violence
- victim – female, 75+ years, living with relative, physical/mental impairment
risk factors
- poor mental health
- poor physical health
- disruptive disorders – alzheimer’s
- dependency
- hx of violence
- victim – female, 75+ years, living with relative, physical/mental impairment
caring for abused persons: assessment
- screen all pts
- vague symptoms – chronic pain, insomnia, hyperventilation, gynecological problems
covert vs overt signs
________ signs – minor complaints
- h/a
- back trouble
- dizzy
- accidents (falls)
_________ signs
- bruises
- scars
- burns
- wounds in various stages of healing
- head, face, chest, arms, abdomen, back, butt, genitalia
covert
overt
caring for abused persons: interview
- privately
- sit nearby
- establish rapport
- ask specifically about conflict resolution
- inform pt if you must make a referral to protective services and explain process
- do not use “abuse” or “violence”
- do not interrupt
- do not probe for answers pt is unwilling to give
0
indications of _________ abuse
- sexualized behavior
- sexualized knowledge
- sexualized play
- sexualized aggression
- drawing sexualized material
- sexual promiscuity in older children
sexual
indications of _______ abuse
- low self esteem
- feeling inadequate
- anxiety
- withdrawal
- learning difficulties
- poor impulse control
emotional abuse
indications of __________
- under nourished
- dirty
- poorly clothes
- inadequate medical/dental care
indications of ________ abuse
- needs unmet with adequate finances
- unpaid bills
- d/c utilities
- extreme dependency
neglect
economic
implementation
- nurses legally required to report abuse or suspected abuse
- cultural considerations
- counseling – safety plans, shelter, safe houses
- case management roles
- community support
- education
0
abuse: prevention
primary
secondary
tertiary
_________ – early intervention in abusive situations
- screening programs for individuals at risk
- medical treatment for injuries
- coordination of community services
________ – measures taken to prevent the occurrence of abuse
- reduce stress and influence of risk factors
- increase social support, coping skills, and self esteem
_________ – occurs in mental health setting, nurse facilitates healing and rehabilitation
- counseling individuals and families
- providing support for groups of survivors
- assisting survivors of violence to achieve their optimal level of safety, health, well being
- legal advocacy for survivors
- complementary therapies – mindfulness, stress reduction
secondary – early intervention in abusive situations
- screening programs for individuals at risk
- medical treatment for injuries
- coordination of community services
primary – measures taken to prevent the occurrence of abuse
- reduce stress and influence of risk factors
- increase social support, coping skills, and self esteem
tertiary – occurs in mental health setting, nurse facilitates healing and rehabilitation
- counseling individuals and families
- providing support for groups of survivors
- assisting survivors of violence to achieve their optimal level of safety, health, well being
- legal advocacy for survivors
- complementary therapies – mindfulness, stress reduction
______________ - unwanted sexual advances, harassment, rape
- strangers
- spousal/marital
- statutory – minors
- date/acquaintance
- drug-facilitated
- incest
- human sex trafficking
sexual assault/violence
________ rape – threats or intention of rape that is unsuccessful
__________ rape – penetration with any body part/object, or oral penetration by a sex organ of another person, without the consent of the victim
attempted rape – threats or intention of rape that is unsuccessful
completed rape – penetration with any body part/object, or oral penetration by a sex organ of another person, without the consent of the victim
sexual assault/violence: male victims more likely to
- suffer physical trauma
- be victimized by multiple perpetrators
- be raped in a locked institution
sexual assault/violence: clinical picture
- no typical presentation, emotional responses vary
- long term effects – MDD, anxiety, fear, suicide
- difficulties daily functioning
- low self esteem
- sexual dysfunction
- somatic complaints
0
sexual assault/violence: acute stress disorder vs PTSD
____________ – symptoms less than 1 month
- intrusive symptoms – memories, dreams, flashbacks
- negative thoughts, moods, feelings
- avoidance
- arousal symptoms
- disassociation
_________ – symptoms greater than 1 month
- depersonalization – feeling like they are living in a dream
- derealization – feeling like the world is dreamlike, distant, or distorted
acute stress d/o
PTSD
sexual assault/violence: assessment
- consent required – pt has right to decline all or parts
- anxiety level
- coping mechanisms
- support systems
- s/s of physical and emotional trauma
0
Trauma and stress disorders: Traumatic events
- war, military
- crime related
- natural disasters
- mass violence
- serious accident
- interpersonal trauma – abuse, neglect
- sudden and traumatic loss in any stage of life
Trauma and stress disorders: intervention stages for children
- provide safety and stabilization
- reduce/regulate arousal, emotion, memories through symptom reduction
- catch up on developmental and social skills, develop a value system
0
Acute stress disorder
____________
- diagnosed 3 days – 1 month following the traumatic event
- person continually re-experiences the events
- avoids situations that remind them of the event
- has increased anxiety that negatively affects lifestyle
- if the symptoms continue beyond 1 month = diagnosis changed to PTSD
__________
- Persistent re-experiencing highly traumatic event
- Intense fear, helplessness, horror
- Trauma exposure: direct experience, witnessing in person, learning about traumatic event happening to a close friend/family, death violent or unexpected
- Does not include exposure to tv, movies, pictures
- Symptoms may begin 1 month – years after exposure
Acute stress disorder
PTSD
Acute stress disorder: symptoms
- intrusion
- memories
- recurrent dreams
- dissociative reactions – flashbacks that seem real
- psychological or physiological distress when reminded of event – location, sounds - avoidance
- memories, thoughts, feelings
- external reminders – people, places, conversation, activities, objects - arousal
- sleep disturbances
- irritable, angry outbursts
- hypervigilance
- difficulty concentrating
- exaggerated startle - dissociative
- altered send of reality
- inability to remember event - negative mood
- inability to experience positive emotions
0
acute stress disorder: treatment
- CBT, EMDR – main treatment
- Meds – minimal evidence to support effectiveness
0
Symptoms – 4 core
- Reexperiencing – flashbacks, bad dreams, frightening thoughts
- Avoidance – avoiding things or thoughts that remind them of event
- Arousal and reactivity – easily startled, feeling tense/on edge, difficulty sleeping, angry outbursts
- Cognitive and mood – trouble remembering, negative thoughts about self/world, distorted feelings of guilt, loss of interest in enjoyable activities
- Symptoms must be present for longer than 1 month
- Severe symptoms that interfere with daily life
- Symptoms unrelated to meds, substances, illness
PTSD
PTSD: Risk factors
- Not everyone that experiences a traumatic event will develop PTSD
- Some factors are present before trauma
- Previous exposure to traumatic events – childhood
- Getting hurt, seeing others be hurt/killed
- Feeling horror, helpless, fear
- Little/no support after event
- Extra stress after event – loss of loved one, pain, injury, loss of job or home
- Hx of mental illness or substance abuse (self or family)
0
PTSD: Treatment
Trauma focused psychotherapy
- Exposure
- Cognitive processing theraoy
- EMDR
Pharmacotherapy
- SSRI – sertraline, paroxetine, fluoxetine (off label)
- SNRI – venlaflaxine (off label)
- MAOI – phenelizine (off label)
0
EMDR
- For children and adults
- 1st line for________
- Helps people process traumatic ________
- Person is encouraged to ______ about the traumatic event while also focusing on other ________ (eye movements, audio tones, tapping)
- Works through neurological and physiological changes that help process and integrate traumatic memories
EMDR
- For children and adults
- 1st line for trauma
- Helps people process traumatic memories
- Person is encouraged to think about the traumatic event while also focusing on other stimulation (eye movements, audio tones, tapping)
- Works through neurological and physiological changes that help process and integrate traumatic memories
Trauma informed care
- Must have complete picture of pts life situation, past and present, to provide effective health care with healing orientation
- Recognizing and responding to the effects of all types of trauma
- Recognizing s/s of trauma
- Actively avoiding re-traumatization
- Focus on what happened to you (not whats wrong with you)
- Can improve pt engagement, treatment adherence, health outcomes, staff wellness
0
PTSD: inpatient management
- Trauma informed care
- Provider recognition of pts who may have PTSD
- Collaboration
- Individualized care
- Inpatient issues that may affect PTSD – sleep hygiene, pain, anxiety, anger
0
________ disorder
Symptoms children
- Blaming self for event
- Reliving event in thought or play
- Sleep problems, nightmares
- Upset when memories are triggered
- Lack of positive emotions
- Hypervigilance, easy startle
- Helpless, hopeless, withdrawn
- Denying event, feeling numb
- Irritable, aggressive, self destructive
- Problems concentrating
- Detachment – people or places related to event
- Lack of interest in enjoyable activities
- Somatic symptoms – h/a, stomachaches, pain, memory problems
Preschool children symptoms
- reduction in play
- play that involves traumatic event
- social withdrawal
- negative emotions
PTSD
PTSD children: treatment
- depends on age, symptoms, general health, severity
psychotherapy
- CBT
- Play therapy
- EMDR
Pharmacotherapy
- SSRIs
o
Depersonalization and derealization disorder
- Persistent or recurrent episodes of depersonalization, derealization, or both
- May last hours – months
- Impacts life
____________ – extremely uncomfortable feeling of being an observer of one’s own body or mental process
- Focus is on the body
- Feelings of unreality, detachment, or unfamiliarity with self
- Detachment from entire self, aspects of self, feelings, thoughts, body parts or sensations
___________ – recurring feelings that one’s surroundings are unreal or distant
- Focus is on the outside world
- Person may feel like they are walking around in a fog, bubble or dream
- Person may feel like there is an invisible veil between them and the rest of the world
- Visual distortions – blurriness, widened or narrowed visual field, altered size of objects
- Auditory distortions – muting or heightening sounds
Depersonalization
Derealization
Depersonalization and derealization disorder : Treatment
- Often short lived, resolve on own
- Hypnosis
- CBT
- rTMS
- no meds effective
0
Attachment disorders (general): Treatment
- include primary caregiver(s)
- positive interactions with child/caregiver/staff
- attachment through 5 senses – hold, hug, touch, feed, talk, story telling, eating meals together
- safe and stable living situation, medical needs, safety
- nurturing, responsive, caring
- consistent caregivers
- education about d/o
0
Reactive Attachment d/o vs Disinhibited social engagement disorder?
_____________
Consistent pattern of inhibited, emotionally withdrawn behavior to adults caregivers
s/s
- withdrawal
- fear
- sadness
- irritability
- listless
- not seeking comfort or not chowing a response when comfort is given
- lack of smile
- watching others but not engaging in social interactions
- lack of asking for help
- lack of reaching out when picked up
- lack of interest in playing interactive games – peekaboo
Reactive Attachment d/o
Reactive Attachment d/o vs Disinhibited social engagement disorder?
__________
occurs in 1st 2 years of life
Child approaches/interacts with unfamiliar adults with:
- reduced reservation
- overly familiar and violates social/cultural boundaries
- doesn’t check with caregiver
- willing to go with unfamiliar person without reservation
evidence of severe social neglect
- caregiver neglects child’s basic needs
- repeated changes of caregiver (foster, institutional care) – stable attachment can’t occur
Disinhibited social engagement disorder
___________ disorder
Emotional/behavioral reaction within 3 moths of exposure to stressor
- ex: death of loved one
- distress affects ability to function
- reaction is out of proportion to stressor severity
- symptoms end by 6 months
symptoms
- anxiety
- depression
- mixed
- regressive behaviors
- fearful
- acting out
Adjustment
