Psych exam II

Helpfulness: +2
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1

Somatoform DO:

Malingering

Consciously & intentionally producing symptom for an obvious benefit.

2

Somatoform DO:

Factitious DO

Deliberate fabrication of symptoms or self-inflicted injury w/out obvious gain (like money), but possibly for the purpose of attention.
Examples: Munchausen & Munchausen by proxy

3

Somatoform DO:

Psychosomatic illness

Disease thought to be caused by psychological factors.

4

Somatoform DO:

Hypochondrias

Misinterpretation of innocent physical sensations as evidence of a serious illness.
Ex. a girl w/menstrual cramps thinks the pain is from stomach cancer.

5

Somatoform DO: Planning

* Long term care at home
* If admitted hosp. stay is short & they are DC'd as soon as the results are negative.
* Focus should be in establishing a helping relationship
* The overall goal is that people w/these DOs will live as normal life as possible.
* May never be pain free or from symptoms, but quality of life is improved

6

Somatoform DO: Implementation

* Improve function w/coping & communication skills
* Use matter of fact approach
* Use assertive training, give pt. direct means of getting their needs met & decreases symptoms
* Teaching an exercise regime can help lower anxiety levels
* Psychotherapy
* Meds: Citalopram (Celexa), Fluoxetine (Prozac) & Sertraline (Zoloft).
-SSRIs are helpful w/somatoform DOs.
-Antianxiety med approach should be monitored due to risk of dependence!

7

Somatoform DO: Evaluation

- Identifies interaction of mind, body & stress
- Increases ability to verbalize feelings
- Identifies conflicts
- Seeks to actively solve problems
- Assumes appropriate work roles
- Employs self-help strategies
- Diminished physical symptoms

8

Illness Anxiety DO: Implementation

AKA hypochondrias- many of these pt.'s have a hx of sexual or physical trauma, parental upheaval, or absence of school for health reasons.

- Cog. behavioral therapy,cognitive group therapy, hypnosis, antidepressants.
1. Offer explanations & support during diagnostic
testing
2. After physical complaints have been investigated
avoid further reinforcement (don't retake VS
each time patient complains of palpitations)
3. Spend time w/ patient at time other than when
summoned by pt. to voice physical complaint
4. Observe & record frequency & intensity of
somatic symptoms (pt. or family can give info)
5. DO NOT IMPLY THAT SYMPTOMS ARE NOT REAL
6. Shift focus from somatic complaints to feelings
or to neutral topics
7. Assess secondary gains that "physical illness"
provides pt (attention, distracts from other
problems)
8. Use straight forward approach to patient
exhibiting resistance or covert anger
9 Have pt. direct all requests to case mgr.
10. Show concern for patient, but avoid fostering
dependency needs
11. Reinforce patient's strengths & problem-solving
abilities
12. Teach assertive communication
13. Teach pt. stress reduction techniques, such as
meditation, relaxation & mild physical exercise

9

Somatoform disorders include:

~ Hypochondria's- misinterpret sensations
~ Pain disorder- Chronic pain associated w/stress
~ Conversion disorders- deficits that affect volun-
tary motor or sensory functions that suggest a
medical condition
~ Body dysmorphic disorder- Preoccupation w/an
imagined "defective body part" (MJ's nose)
~ Pseudocyesis

10

Somatoform disorders Assessment:

Should begin w/collection of data about the nature, location, onset, character & duration of the symptom(s).
1. Thorough physical exam w/ appropriate medical
tests, need to be completed
2. See info above ^
3. Ass the pt.'s ability to meet basic needs
4. Assess risks to safety & security needs of pt.
as a result of the symptoms
5. Determine whether the symptoms are under the
pt's voluntary control
6. Identify any secondary gains that the patient is
experiencing from symptoms
7. Explore the pt's cog style & ability to commu-
nicate feelings & needs
8. Assess type & amount of medication the pt. is
using.

11

Somatoform disorders: Outcome ID

Overall goal in tx of somatic symptom DOs is that people w/these DOs will eventually be able to live as normal life as possible, even if they may never be free of pain or other symptoms.
Examples of outcome criteria:
* Pt. will articulate feelings such as anger, shame
guilt and remorse
* Pt. will resume performance of work/role behavior
* Pt. will identify ineffective coping patterns

12

Dissociative disorders: Include

* These pt's don't usually seek help, except in a crisis situation.

- DID formally known as multiple personality DO;
presence of 2 or more distinct personalities that
recurrently take control of behavior

- Depersonalization DO: feel dreamy
or mechanical. Persistent or recurrent alteration
in perception of self while reality testing re
mains intact.

- Derealization- recurrent of unreality of
surroundings while reality testing is intact

- Dissociative Amnesia Induced memory loss & is
marked by the inability to recall important per-
sonal information. The amnesia occurs after a
severe physical or psychological stressor.

13

Dissociative disorders: Assessment

In order for one of the dissociative disorders to be diagnosed, medical, neurological illnesses, substance use, & other coexisting psychiatric DOs must be ruled out or identified as coexisting w/a dissociative disorder.
Collect objective data from:
physical examination, electroencephalography, imaging studies, projective tests, structured personality tests & specific questionnaires designed to identify dissociative symptoms

14

Dissociative disorders: Assessment Guidelines

1. Assess for a history of similar episode in the
past w/benign outcomes
2. Establish whether the person suffered abuse,
trauma, or loss as a child
3. Identify relevant psychosocial distress issues
by performing a basic psychosocial assessment.

15

Dissociative disorders: Identity & Memory

The nurse should consider the following when assessing memory:
* Can the pt remember recent & past events?
* Is the pt's memory clear & complete or is it
partial & fuzzy
* Is the pt. aware of gaps in memory, such as lack
of memory for events like graduation or wedding?
* Do the pt's memoried place the self w/a family,
in school, in an occupation?
- Changes in pt behavior, voice & dress might signal the presence of an alternate personality. Referring to self by another name or in 3rd person & using the word WE instead of I are indications that the pt may have assumed a new identity.

16

Dissociative disorders: Patient History

If DID is suspected, pertinent questions include the following:

1. Have you ever found yourself wearing clothes that you cannot remember buying?

2. Have you ever had strange people greet & talk to you as though they were old friends?

3. Does you ability to engage in things such as athletics, artistic activities, or mechanical tasks seem to change?

4. Do you have differing sets of memories about childhood?

17

Dissociative disorders: Mood

I the pt depress, anxious or unconcerned? Many pt's w/ DID seek help when the primary personality is depressed.

18

Dissociative disorders: Outcomes ID

Pt. will:
* Verbalize clear sense of personal identity
* Report decrease in stress (scale 1-10)
* Report comfort w/role expectations
* Plan coping strategies for stressful situations
* Refrain from injuring self

19

Dissociative disorders: Implementation

1. Ensure pt safety by providing safe, protected environment & frequent observation.

2. Provide non demanding, simple routines

3. Confirm identity of pt & orientation to time & place

4. Encourage pt to do things for self & make decisions about routine tasks.

5. Assist w/other decision making until memory returns

6. Support pt during exploration of feelings surrounding the stressful event

7. Do not overwhelm pt w/data regarding past events

8. Allow patient to progress at own pace as memory is recovered

9. Provide support during disclosure of painful experiences

10. Accept pt's expression of negative feelings

11. Teach stress reduction methods

20

Dissociative disorders: Evaluation

Tx is considered successful when outcomes are met. In the final analysis, the evaluation is positive when the following are achieved:

~ Pt safety has been maintained

~ Anxiety has been reduced & the pt has returned to a functional state.

~ Conflicts have been explored

~ New coping strategies have permitted the pt to function at a better level

~ Stress is handled adaptively, w/out the use of dissociation.

21

Personality DOs:

Antisocial personality DO
Avoidant personality DO
Borderline personality DO
Narcissistic personality DO
Obsessive compulsive DO
Schizotypal personality DO
Splitting

22

Personality disorder-

People w/personality disorder, their traits are exaggerated & rigid to the point that they cause dysfunction in their relationships.

23

Personality disorder: Schizotypal personality DO

Avoid interpersonal relationships, have unusual beliefs & may be indifferent to the reactions of other in their lives.
May have magical thinking & rituals, or hold beliefs that they can control the actions of other. They exhibit markedly strange behavior & are perceived by others as strikingly odd, strange, or eccentric.
Because of these odd styles of behavior & inattention to social conventions, they lack friends. People w/this DO are genuinely unhappy about their lack of relationships & their social anxiety & unhappiness increase over time.

24

Personality disorder: Antisocial DO
AKA-(Dyssocial personality)

Is characterized by
1. Deceit
2 Manipulation
3. Revenge
4. Harm to others w/absence of remorse for hurting
others.
* People w/ antisocial PD have a sense of ENTITLEMENT which means they believe they have the right to hurt others, take what they want, treat other unfairly, destroy the property of others, and so on (callousness).
They do not adhere to traditional values or standards of morality as boundaries for their actions. Verbally these pt's may be charming, engaging, and uncanny in their ability to find just the right angle to lure a person into their intrigue w/the intent to exploit them for money, favors, or more sadistic purposes (manipulation).

25

Personality disorder: Borderline personality DO

Have up to a 90% chance of having another psychiatric disorder & up to 40% may have 2 or psychiatric DOs.
* People w/BPD are usually raised in families in which they were subjected to constant belittling, devaluation & invalidation.
Central character of pt's w/BPD is their instability of affect marked by unstable & frequent mood changes. Feelings of anxiety, dysphonia, and irritability can be intense through short lived (emotional liability).
CHRONIC DEPRESSION IS COMMON
There's patterns of high emotional sensitivity, acute responsiveness, & slow return to normal s "emotional dysregulation."
* This cycle may lead to feelings of deadness, panic & fury as well as self-mutilation & suicide-prone behaviors. - These are common responses to threats of separation or rejection.

26

Splitting

Is the inability to integrate the positive & negative qualities of oneself or others into a cohesive image.
Example: either good, loving, worthy & nurturing, or bad, hateful, destructive, rejecting, & worthless.

27

Personality disorder: Narcissistic personality DO

Is a maladaptive social response characterized by a person's GRANDIOSE sense of personal achievements. People w/this DO consider themselves special & expect special treatment. Their demeanor is arrogant & haughty & their sense of entitlement is striking. They lack empathy for the needs or feelings of others & in fact exploit others to meet their own needs.
* If they are at fault in some way, they always blame others for the problems they themselves have caused.

28

Personality disorder: Avoidant personality DO

These people have high levels of anxiety & outward signs of fear & feelings of low self worth. People w/avoidant PD are hypersensitive to criticism or rejection; therefore they tend to avoid situations that require socialization.
* Even though they have a strong desire for affection, they are fearful of rejection, disappointment, criticism, or ridicule.
- They spend most of their time in self imposed isolation.

29

Personality disorder: OCD

These people are preoccupied w/orderliness, perfectionism, control, neatness & the achievement of perfection.
They are cautious & consider all choices in methodical & inflexible manner. THEY ARE OBSESSED W/RULES & DETAILS AND FOLLOW THEM RIGIDLY, BELIEVING THERE IS ONLY ONE WAY TO DO THINGS CORRECTLY.
* Difficulty in incorporating new ideas
* Often unable to make decisions & they have trouble completing tasks, since they persistently pursue tasks long after their actions have any consequence, & even in the face of repeated failures.
* High achievers & do well in sciences & intellectually demanding fields that require attention to detail, & they obtain their sense of self worth from work & productivity, so much so that their devotion to work may exclude pleasurable activities & friendships

30

Histrionic personality DO traits

Manipulate others through their dramatic, charming, flamboyant & sexually seductive behaviors.
Their excessively emotional behavior is an attempt to seek the kind of constant attention, love & admiration that they require.

31

Passive-aggressive personality traits

People display chronically irritable & unjustifiably blame others. They are verbally aggressive, hostile & manipulative & their interpersonal relations ships are usually marked by ambivalence & conflict.

32

Personality DO: Assessment

* Vital part of initial assessment interview

To determine if there is a hx of suicide/homicide/self mutilation, & if there are co-occurring disorders as well.

33

Personality DO: Assessment

1. Assess for suicidal or homicidal thoughts. If there are present the will need immediate attention

2. Determine whether the patient has a medical DO or another psychiatric DO that may be responsible for the symptoms (especially substance use DO)

3. View the assessment of personality functioning from within the person's ethnic, cultural, and social background

4. Ascertain whether the pt experienced a recent important loss. PDs are often exacerbated after the loss of a significant supporting person or as the result of a disruptive social situation.

5. Evaluate for a change in personality in middle adulthood or later, which signals the need for a thorough medical workup or assessment for unrecognized substance use DO

6. Be aware of the strong negative emotions these pt's may evoke in you

* Assessment hx: Important issues in assessment for PDs include the following: hx of suicidal or aggressive ideation or actions, current use of medications and illegal substances, ability to handle money & legal history.

34

Personality disorder: Outcomes ID

Realistic goal setting is based on the perspective that personality change involves one behavioral solution & one learned skill at a time. This can be expected to take much time & repetition.
Because larger steps are not realistic, outcomes need to be very modest & obtainable. For some people, overall outcome criteria might include the following:

* Minimizing self destructive or aggressive behaviors

* Reducing the effect of manipulating behaviors

* Linking consequences to functional as well as dysfunctional behaviors

* Practicing the substitution of functional alternatives during a crisis

* Initiating functional alternatives to prevent a crisis

* Practicing ongoing mgmt. of anger, anxiety, shame, and happiness

* Creating a lifestyle that prevents regression

35

Personality disorder: Planning

Pt's w/PD do not voluntarily seek treatment, they present to hospitals & etc for other reasons.

Staff will benefit from in-service instruction & supervision regarding both acknowledging & coping w/the behaviors of these DOs & learning techniques to prevent disruptions in the healthcare setting

36

Personality disorder: Implementation/manipulation

1. Assess your own reactions toward the patient. If you feel angry, discuss w/peers ways to reframe your thinking to defray feelings of anger

2. Assess pt's interactions for a short period before labeling as manipulative

3. Set limits on any manipulative behaviors: Arguing or begging, flattery or seductiveness, instilling guilt, clinging, constantly seeking attention, pitting one person, staff, group against another, frequently disregarding the rules, constant engagement in power struggles, angry, demanding behaviors.

4. Intervene in manipulative behavior:
* All limits should be adhered to by all staff
involved
* Objective physical signs in managing clinical
problems should be carefully documented
* Behaviors should be documented objectively (give
time, dates, circumstances).
* Provide clear boundaries & consequences.
* Enforce the consequences

5. Be vigilant; AVOID the following:
* Discussing yourself or other staff members
w/the patient
* Promising to keep a secret for the pt.
* Accepting gifts from the patient
* Doing special favors for the pt.

* DIALECTICAL BEHAVIOR THERAPY (DBT) HAS BEEN EXTREMELY EFFECTIVE IN PEOPLE W/BORDERLINE PD.*

37

Personality disorder: Implementation/Impulsive behaviors

1. Identify the needs & feeling preceding the impulsive acts

2. Discuss current & previous impulsive acts

3. Explore effects of such acts on self & others

4. Recognize cues of impulsive behaviors that may
injure others

5. Identify situations that trigger impulsivity & discuss alternative behaviors

6. Teach or refer pt to appropriate place to learn
needed coping skills (e.g., anger mgmt.,
assertive skills

38

Schizophrenia Spectrum DO: Cultural considerations

What is considered normal or acceptable in one culture may be seen as pathological in another. In some subculture groups, "visions" or "voices" are an integral & expected part of various religious experiences. * Hallucinations may be seen as gifted or special in some cultures

39

Symptoms of Schizophrenia: Positive symptoms

Psychotic symptoms are MOST OBVIOUS such as:

-Delusions false belief, (think they are Cleopatra)
-Hallucinations (see gremlin's in the room)
-Perceptions are not based on reality

40

Symptoms of Schizophrenia: Negative symptoms

* Alogia- poverty of though
* Avolition- Lack of motivation
* Anhedonia- inability to experience pleasure/joy
* Blunted effect- minimal emotional response
* Also feelings of emptiness

* THE A'S*

41

Symptoms of Schizophrenia: Though disorder

Schizophrenia has a profound effect on an individual's ability to think clearly or to use language appropriately (looseness of association)

42

Symptoms of Schizophrenia: Cognitive symptoms

Include the inability to understand & process information, trouble focusing attention, & problems w/working memory.
These are symptoms that most profoundly affect the individual's ability to engage in normal social/occupational experiences.

43

Symptoms of Schizophrenia: Characterological symptoms

Most often people w/schizophrenia are isolated or alienated from others. These pt's have deep feelings of inadequacy & poorly developed social skills.

44

SMI Schizophrenia is a severe mental illness

People w/schizophrenia comprise a large percentage of our homeless population.