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Maladaptive Behavior Patterns—personality disorders and abuse
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Maladaptive Behavior Patterns—personality disorders and abuse
What sort of future is coming up from behind, I really don’t know. But the past, spread out ahead, dominates everything in sight. R.M Pirsig from Zen and the Art of Motorcycle Maintenance
People with Personality Disorders have long term: Low frustration tolerance Pain intolerance Over reaction to life events Lack of impulse control Immature coping strategies (over
use of defense mechanisms) Impaired personal relationships
Nursing Issues with all PD: Balance in your expectations for
change—hope, but not a quick fix Be authentic, patient, trustworthy Have good limit setting skills Have good ego boundaries Have good team communication,
to decrease splitting
The Odd/Eccentric Group: Schizoid, Paranoid, Schizotypal Some nursing issues include:
ineffective individual copingsocial isolationdefensive coping
Paranoid Personality D/O Fear others will harm or exploit Hypervigilant and tend to be hostile
(as a response to perceived threat) Can become psychotic if stressed Nursing—be consistent, truthful, out
in the open. Approach with care and tell what is happening, what you are doing
Schizoid Personality D/O Doesn’t want relationships Flat affect, little emotion seen, not
aware there is a problem with this Few relationships, can become
delusional if stressed Nursing-build trust slowly,
consistent, not overly emotional or smothering
Schizotypal PD Has social anxiety. Wants
relationships but not skilled at getting them.
Often has eccentric thinking and/or behavior
Nursing-be consistent, trustworthy, keep clear boundaries, help ct. with very gradual change in social bx.
Dramatic/ Emotional PDs Includes Antisocial, Borderline,
Histrionic, and Narcissistic Focus more study energy on
Antisocial and Borderline Sample nursing diagnoses include:
Altered family process, ineffective individual coping, self mutilation, risk for violence, low self esteem
Antisocial PD (more men) Feels entitled, acts charming to get
way Deceitful, manipulative, vengeful Seeks risks, stimulation (drugs,
sex, crime, gambling) Has no conscience or empathy Irresponsible and unsafe
Borderline PD (more women) Overwhelmingly emotionally needy,
despairing. Angry, dysphoric, labile Lives in a crisis and creates a crisis if
too calm Abandonment issues are key Self destructive behavior and
mutilation occur Splitting, dichotomous thinking
Histrionic PD Dramatic, flambouyant Charming, intense, but shallow in
relationships Center of attention, if not gets
upset and creates stir May have dramatic ups and downs.
Narcissistic PD Self absorbed and self centered Overestimates own self worth as a
defense to cover self doubt Grandiose. Wants attention, praise,
admiration. If this doesn’t happen, becomes upset/angry/vengeful
Very critical. Little tolerance for imperfection
Anxious and Fearful PD: avoidant, dependent, and obsessive compulsive
Of all three, dependent is most common
Nursing diagnosis can include:Self esteem disturbanceAnxietyHopelessnesspowerlessness
Avoidant PD Often co-occurs with social phobias See social isolation Very sensitive to criticism and
afraid of being judged negatively Feels rejected a lot, fears being
rejected Low self esteem
Dependent Personality D/O Passive, submissive, self sacrificing Few self initiated behaviors Little decisionmaking Tolerates maltreatment, being
bossed Urgent need to be in relationship in
which someone else is in control
Obsessive Compulsive PD R/t OCD Thrifty, saving, verbose, organized Critical of self and others Rigid emotionally; taskmasters,
have a hard time expressing emotion
Abuse: Incidence is high 1.8-2.9 million battered women each yr
in US. Battering is single most common cause of injury to women. 8% women are battered before or during pregnancy.
2 million reported cases of child abuse each yr in US (2000-5000 die)
0.5-1 million cases of elder abuse in US yearly.
Why abuse continues ( a few reasons) Society legitimizes violence and
privacy Intergenerational –acting like we
have seen growing up Structural inequality of abused
persons Stockholm syndrome (discuss)
Power and Control Issues-ways abusers act Threats and coercion Economic restriction Intimidation(pets, weapons, breaking) Emotional abuse Isolate the abused person Denial Threaten loved ones (esp. children)
Cycle of Violence Tension building—tension,
blaming, aggression in abuser Abuse (battering) episode—acute
episode of abuse Calm/honeymoon—acts calmer,
nicer, may apologize/gifts/promises. In severe abuse this may be minimal
Myths that create problems in stopping abuse If the abuse was that
bad the victim would tell or get out
Victim deserves it Abuse only occurs
among the poor and uneducated
Families should be kept together at all costs
If it weren’t for drugs and alcohol, the abuse wouldn’t have occurred
Victims are lying or exaggerating to get attention
Batterers are uneducated men who can be spotted easily
Families should always be kept together
Abusers typically: Victims of abuse
in youth Lack empathy,
and minimize seriousness of abuse
Controlling Jealous Impulsive
Low frustration tolerance
Angry, violence focused
Attribute failure to others’ behavior
Traditional views Often
alcohol/drug abuse
Some Assessment findings that hint at abuse: Frequent ER visits Withdrawn/
depresd Inconsistent
physical findings Multiple suicide
attempts Overprotective
family member
Alcohol or other drug abuse
One car accident Delay in seeking
medical care Injury to head,
sexual organs Injuries in various
stages of healing
Some assessment questions What happened? Have you been in
a fight? Tell me about it.
The injuries you have look like the kind I have seen when___. Have you been hurt in this way?
Are you involved in an abusive relationship? Tell me about it.
Some nursing interventions Make time and
privacy to talk Listen and
validate, not judge Document
impartially and completely
Ask. Don’t assume info will be offered
If abuse is suspected but denied, give info anyway (privately)
Assist with practical needs
Remember the legal issues involved with children and elders
Educational Interventions Cycle of violence Community resources Danger of homicide, esp re leaving
the abuser Safety planning Self esteem issues—redefine self
as the survivor
Safety Plans-a few basics Cash, checks, keys, credit card,
essentials bag, hidden out of home Copies of all vital docs hidden out
of home Code system, older kids involved Route of escape, tell trusted
people
Security Plan if you leave Bring kids with you or go back for
them with police Lock everything, all the time Private mail/phone Picture of abuser to people who
may see Don’t keep it a secret, it is not your
fault
Some other Intervention Issues Be wary of marriage counseling,
people who advise to stay with abuser, abusive parent at all costs
Note, there are mandatory reporting laws for children and elders.
Can’t heal trauma well when still under future risk. Safety is paramount.
Post-traumatic Stress Disorder Exposure to trauma Re-experiencing traumatic event Numbing Avoidance of reminders of event Anxiety/arousal responses Distress in important areas of
functioning
Re-experiencing the event Intruding
reminders/memories/flashbacks Nightmares Acting or feeling like the event(s)
re-occurring Leads to anxiety and acute
distress
Types of Avoidance Thought/feelings/conversations
about the event Stays away from people and places
associated with event Repression Lack of participation with others,
detachment, short sense of future
Treatment of PTSD Antianxiety agents for short term
relief Antidepressants, particularly
SSRI’s At risk for developing substance
abuse due to self-medication for distress
Rape-types Blitz rape—out of the blue, fast Confidence rape—more of a set up
involved, may know victim and repeat, use threats
Inability to consent issue— Aggression or Sexual Expression?
Rape Intervention-a few points Collecting Evidence while
maintaining dignity, respect in initial response
Privacy, time to talk, one to one contact, rape counselor, follow up
Anticipatory Guidance Community Resources
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