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148 Cards in this Set

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  • Back
With any illness, what is the first thing we look for as nurses?
We look to see if the patient can care for themselves (ADLs, any impairment).

When it is a mental disorder, always first rule out any actual physical/medical condition and substance use/abuse.
Describe somatoform disorders.
Somatoform disorders are characterized by physical sx suggesting medical disease, but without demonstrable organic pathology, They are classified as mental disorders because pathophysiological processes are not demonstrable or understandable by existing laboratory procedures, and there is either evidence or strong presumption that psychological factors are the major cause of the symptoms.
Historically, what were somatoform disorders called.
Hysterical neurosis.
Define somatization.
The process by which psychological needs are expressed in the form of physical symptoms. Somatization is thought to be associated with repressed anxiety; anxiety is displaced into bodily symptoms.

Physical symptoms are associated with psychological factors or conflicts. Clients are not in control of their symptoms, which are unconscious and involuntary.
How do clients with somatoform disorders seek out care?
They seek out medical care but not mental health care for diagnosis and treatment.

The disorder usually runs a fluctuating course, with periods of remission and exacerbation. Clients often receive medical care from several physicians, sometimes concurrently, leading to the possibility of dangerous combinations of treatments (polypharmacy). They have a tendency to seek relief through overmedicating with prescribed analgesics or antianxiety agents. Drug abuse and dependence are common complications of somatization disorder. When suicide results, it is usually in association with substance abuse.
What are the diagnostic criteria for somatization disorder?
Each of the following must be met:
-Hx of many physical complaints before age 30 and impairs social, occupational, or other important areas of functioning.
-4 pain symptoms: Hx of pain related to at least 4 different sites or functions (i.e., head, abdomen, back, joints, etc.)
-2 gastrointestinal symptoms: Hx of at least 2 GI Sx other than pain (i.e., nausea, bloating, vomiting, diarrhea, etc.)
-1 sexual symptom: Hx of at least 1 sexual or reproductive symptom other than pain (i.e., sexual indifference, erectile dysfunction, etc.)
-1 pseudoneurological symptom: Hx of at least one symptom of deficit suggesting a neurological condition not limited to pain (i.e., impaired coordination or balance, seizures, etc.)
-all Sx cannot be explained by known general medical condition
What is the prevalence of somatization disorder?
80% women

The lifetime prevalence of somatization disorder in the general population is estimated to be 0.2-2% in women and 0.2% in men. Tendencies toward somatization are apparently more common in those who are poorly educated and from the lower socioeconomic classes.
Name predisposing factors of somatization disorder.
-increase in first-degree relatives
-chronic emotional abuse might be a major etiology
-emotional and social stress can precipitate disorder
-genetic link, developmental learning, sociocultural factors, and personality can predispose, precipitate, and maintain disorder
Is somatization reinforced?
Yes, they are reinforced by learning behaviors.

Somatic complaints are often reinforced when the sick role relieves the individual from the need to deal with a stressful situation, whether it be within society or within the family. The sick person learns that he or she may avoid stressful obligations, may postpone unwelcome challenges, and is excused from troublesome duties (primary gain); becomes the prominent focus of attention because of the illness (secondary gain); or relieves conflict within the family as concern is shifted to the ill person and away from the real issue (tertiary gain).
What is somatic pain disorder?
-Severe pain in one or more anatomic sites that causes significant distress or impairment in functioning; no organic basis exists.
-Location or complain of pain remains constant.
-Chronic pain often associated with depression.

Psychological implications in the etiology of the pain complaint may be evidenced by the correlation of a stressful situation with the onset of the symptom.
What is the diagnostic criteria for somatic pain disorder?
-Pain is one or more anatomical sites that is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.
-The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
-Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.
-The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).
-The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia (difficult or painful sexual intercourse).
What are the personal gains to the patient with somatic pain disorder?
Additional psychological implications may be supported by the facts that (1) appearance of the pain enables the client to avoid some unpleasant activity (primary gain) and (2) the pain promotes emotional support or attention that the client might not otherwise receive (secondary gain).
What is the prevalence of somatoform pain disorder?
-occurs at any age

Pain disorder (previously called somatoform pain disorder) is diagnosed more frequently in women than in men by about 2 to 1. Its onset can occur at any age, with the peak ages of onset in the 40s and 50s.
What is the biochemical theory behind the etiology of somatization pain disorder?
Decreased levels of serotonin and endorphins may play a role.
What is the genetic theory behind the etiology of somatization pain disorder?
There is an increased incidence in first-degree relatives.
What is the family dynamic theory behind the etiology of somatization pain disorder?
Harmony around the illness, replacing family discord.

Some families have difficulty expressing emotions openly and resolving conflicts verbally. When this occurs, the child may become ill, and a shift in focus is made from the open conflict to the child's illness, leaving unresolved the underlying issues that the family cannot confront openly. Thus, somatization by the child brings some stability to the family, as harmony replaces discord and the child's welfare becomes the common concern. The child in turn receives positive reinforcement for the illness. This shift in focus from the family discord to concern for the child is sometimes called tertiary gain.
What is the psychodynamic theory behind the etiology of somatization pain disorder?
Unexpressed emotions.
What are the nursing interventions regarding somatization pain disorder?
-Empathize with the client, but limit discussion of symptoms to avoid reinforcement and secondary gains.
-Teach the client about the mind-body connection (knowledge deficit related to relationships of stress and migraines).
-Work on identifying triggers; use pain scales.
-Assertiveness training.
What is hypochondriasis?
-Preoccupation with fear of having, or the idea that one has, a serious disease for at least 6 months.
-Misinterpretation of bodily signs and sensations.
-Hypersensitive to symptoms of anxiety which heightens anxiety and physical symptoms.
-Preoccupation persists despite medical evaluation.
-Preoccupied with disease processes and organ functions.
-Clients are less threatened by physical complaints than poor self-esteem.
-Tend to use somatic symptoms as ego defenses.

-Sx get worse as anxiety gets worse.

Occasionally medical disease may be present, but in the individual with hypochondriasis, the symptoms are excessive in relation to the degree of pathology.
What is the prevalence of hypochondriasis?
-Usually occurs ages 20-30 in men and women

Hypochondriasis affects 1-5% of the general population. The disorder is equally common among men and women, and the most common age of onset is in the early adulthood.
What comorbities are often associated with hypochondriasis?
Anxiety, depression, and OCD traits are common.
What is "doctor shopping?"
Hypochondriacs often have a long history of "doctor shopping" and are convinced they are not receiving the proper care.

They tend to hoard drugs from prior doctors, even if expired. And often don't report those to current physicians.
Name predisposing factors regarding hypochondriasis.
-Studies have shown an increased incidence of hypochondriasis in first-degree relatives, implying a possible inheritable predisposition.
-Some psychodynamicists view hypochondriasis as an ego defense mechanism. Physical complaints are the expression of low self-esteem and feelings of worthlessness, because it is easier to feel something wrong with the self.
-Another view of hypochondriasis is related to a defense against guilt. The individual views the self as "bad," based on real or imagined past misconduct, and views physical suffering as the deserved punishment required for atonement.
-Learning theory: Past experience with serious or life-threatening physical illness, either personal or that of a close family member, can predispose an individual to hypochondriasis. Once an individual has experienced a threat to biological integrity, they may develop a fear of recurrence. The fear of recurring illness generates an exaggerated response to minor physical changes, leading to hypochondriacal behaviors.
What is the diagnostic criteria for hypochondriasis?
-Preoccupation with fears of having, or the idea that one has, a serious disease, based on the person's misinterpretation of bodily symptoms.
-The preoccupation persists despite appropriate medical evaluation and reassurance.
-The client's belief is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder).
-The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
-The duration of the disturbance is at least 6 months.
-The preoccupation is not better accounted for by generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, a major depressive disorder episode, separation anxiety, or another somatoform disorder.
What is conversion disorder?
-Loss of, or change in, body function resulting from a psychological conflict; the physical symptoms of which cannot be explained by any known medical disorder or pathological mechanism.
-Psychological factors, conflicts, stressors are associated with or precede the development of this disorder.
-Clients are unaware of the link between anxiety and physical symptoms.
Is a client with conversion disorder concerned for themselves?
No, often these people express a relative lack of concern for the functional alteration. This lack of concern is identified as "la belle indifference" and is often a clue to the physician that the problem may be psychological rather than physical.
Name some examples of conversion disorder.
-Examples include paralysis caused by anxiety.

Conversion symptoms affect voluntary motor or sensory functioning suggestive of neurological disease and are therefore sometimes called "pseudo neurological." Examples include:
-paralysis
-aphonia (loss of ability to speak through disease of or damage to the larynx or mouth; not aphasia)
-seizures
-coordination disturbance
-difficulty swallowing
-urinary retention
-akinesia (loss or impairment of the power of voluntary movement)
-blindness
-deafness
-double vision
-anosmia (loss of smell)
-loss of pain sensation
-hallucinations

Pseudocyesis (false pregnancy) is a conversion symptom and may represent a strong desire to be pregnant.
What are the psychological gains regarding conversion disorder?
When an individual achieves primary gain, the conversion symptoms enable the individual to avoid difficult situations or unpleasant activities about which they are anxious. Conversion symptoms promote secondary gain for the individual as a way to obtain attention or support that might not otherwise be forthcoming.
Is conversion disorder a chronic condition?
No, the problem resolves itself as anxiety decreases.

Most symptoms of conversion disorder resolve within a few weeks. About 20-25% of clients will experience a recurrence of symptoms within 1 year of the first episode.
What is the priority nursing Dx for conversion disorder?
The nursing diagnosis of Anxiety is prioritized: direct relationship.
What is the diagnostic criteria for conversion disorder?
-One or more Sx or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.
-Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.
-The symptom of deficit is not intentionally produced or feigned (as in factitious disorder or malingering).
-The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, by the direct effects of a substance, or as a culturally sanctioned behavior or experience.
-The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning and warrants medical evaluation.
-The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder.
What is the prevalence of conversion disorder?
Lifetime prevalence rates of conversion disorder vary widely. Statistics within the general population have ranged from 5-30%. The disorder occurs more frequently in women than in men and more frequently in adolescents and young adults than in other age groups. A higher prevalence exists in lower socioeconomic groups, in rural populations, and among those with less education.
Name predisposing factors of conversion disorder.
-Studies have shown an increased incidence of conversion disorder in first-degree relatives, implying a possible inheritable predisposition.
-The psychodynamic theory of conversion disorder proposes that emotions associated with a traumatic event that the individual cannot express because of moral or ethical unacceptability are "converted" into physical symptoms. The unacceptable emotions are repressed and converted to a somatic hysteria symptom that is symbolic in some way of the original emotional trauma.
What is body dysmorphic disorder?
-Preoccupation with an imagined defect in appearance. If the defect is present, concern is excessive.
-Preoccupation causes significant impairment in social/occupational functioning or causes marked distress.

-formerly called "dysmorphophobia"
Name some examples of body dysmorphic disorder.
-The most common complaints involve imagined or slight flaws of the face or head, such as thinning hair, acne, wrinkles, scars, vascular markings, facial swelling or asymmetry, or excessive facial hair. Other complaints may have to do with some aspect of the nose, ears, eyes, mouth, lips, or teeth.
What comorbidities are often associated with body dysmorphic disorder?
Comorbidities = MDD, OCD, social phobia, psychotic disorder.

This disorder if closely associated with delusional thinking.
What is the prevalence of body dysmorphic disorder?
-Age of onset is adolescence to 30’s.

Body dysmorphic disorder is rare, although it may be more common than once believed. In the practices of plastic surgery and dermatology, reported rates of body dysmorphic disorder range from 6-15%. Psychiatrists see only a small fraction of cases. A profile of these clients reveals that they are usually in the late teens or 20s and unmarried.
What is the etiology of body dysmorphic disorder?
-Biological factors: imbalance in neurotransmitters, i.e. serotonin; genetic component
-Psychosocial factors: repression of anger, hostility, aggression; guilt, low self-esteem; abuse; communicating helplessness; misinterpretation of bodily sensations.
Name some potential nursing diagnoses for these disorders.
-Ineffective coping
-Ineffective role performance
-Impaired social interaction
-Disturbed body image
-Disturbed sleep pattern
-Pain, acute or chronic
-Self-care deficit
-Powerlessness
-Interrupted family processes
Name some client expected outcomes regarding these disorders.
-Client will identify ineffective coping patterns
-Client will verbalize feelings
-Client will resume responsibilities of work and family-related activities
-Client will show sensitivity to others
-Client will attend to basic care needs
-Client will report improvement in sleep
Tell me about polypharmacy and the medications for these disorders.
-Client may be taking “too much” medication.
-Medication for pain should be used temporarily and sparingly.
Which meds are good for treating anxiety and depression?
SSRI’s for treatment of anxiety and depression.
What's a good short-term therapy drug for these disorders?
Anxiolytics are good short-term therapy. We don't want patients to get addicted to these benzos.
What's a good long-term therapy drug for these disorders?
BuSpar can be used for long-term therapy.

(But they won't work until for 2 weeks, so you have to give the patients something in the meantime.)
What is dissociation?
-Removal from conscious awareness of painful feelings, memories, thoughts, or aspects of identity as a result of extreme stress or trauma.
-Unconscious defense mechanism that protects from the emotional pain of experiences that have been repressed.
-Helps to endure and survive intense emotion, physical pain, or both.

99.9-100% related to extreme trauma; pt doesn't know they're doing it.

The splitting off of clusters of mental contents from conscious awareness, a mechanism central to hysterical conversion and dissociative disorder.
Define dissociative disorders.
Dissociative disorders are defined by a disruption in the usually integrated functions of consciousness, memory, identity, or perception.
Name the four types of dissociative disorders.
1. Dissociative Amnesia
2. Dissociative Fugue
3. Dissociative Identity Disorder (DID)
4. Depersonalization Disorder
What is dissociative amnesia?
-Loss of memory of important personal events that were traumatic or stressful (one or more episodes).
-Precipitant causes severe psychosocial stress, such as the threat of physical injury or death.
-Not the result of neurological trauma or substance use/abuse. <-- need to rule out


Sometimes, it's the only way a person knows how to survive: wartime, displacement, tsunami, sexual/physical abuse.
Name the four types of dissociative amnesia.
According to powerpoint:
1. Recent amnesia - can occur immediately after a traumatic event
2. Localized amnesia - cannot remember events during a specific time period
3. Selective amnesia - can recall some events during a specific period
4. Generalized amnesia - unable to recall lifetime of events

According to book (pg. 677):
1. Localized Amnesia
2. Selective Amnesia
3. Continuous Amnesia
4. Generalized Amnesia
5. Systematized Amnesia
Describe localized amnesia.
The inability to recall all incidents associated with the traumatic even for a specific time period following the event (usually a few hours to a few days).

Example: The individual cannot recall events of the automobile accident and events occurring during a period after the accident (a few hours to a few days).
Describe selective amnesia.
The inability to recall only certain incidents associated with the traumatic event for a specific period after the event.

Example: The individual may not remember events leading to the impact of the accident but may remember being taken away in the ambulance.
Describe continuous amnesia.
The inability to recall events occurring after a specific time up to and including the present.

Example: The individual cannot remember events associated with the automobile accident and anything that has occurred since. That is, the individual cannot form new memories, although they are apparently alert and aware.
Describe generalized amnesia.
The rare phenomenon of not being able to recall anything that has happened during the individual's entire lifetime, including their personality identity.
Describe systematized amnesia.
With this type of amnesia, the individual cannot remember events that relate to a specific category or information (i.e., one's family) or to one particular person or event.
What is the prevalence of dissociative amnesia?
Dissociative amnesia is relatively rare, occurring most frequently under conditions of war or during natural disasters. However, in recent years, there has been an increase in the number of reported cases, possibly attributed to increased awareness of the phenomenon, and identification of cases that were previously undiagnosed. It appears to be more common in women than men. Dissociative amnesia can occur at any age but is difficult to diagnose in children because it is easily confused with inattention or oppositional behavior.
What is dissociative fugue?
-Sudden, unexpected travel away from home or work with a loss of memory about the past.
-Assumption of a new identity (partial or complete) or a confusion about one’s identity.
-Travel and behavior appear normal to casual observers.
-Escape or flight from an intolerable event/stress.

-Has nothing to do with Alzheimer's or dementia. Sometimes these people are not found for quite a while and take on a new identity.
How long does dissociative fugue last?
-Fugue state lasts from a few days, weeks to a few months and usually accompanied by amnesia.
What is the prevalence of dissociative fugue?
Dissociative fugue is also rare and occurs most often under conditions of war, natural disasters, or intense psychosocial stress.
What is depersonalization disorder?
-Experiences of feeling detached from, or an outside -observer of one’s body or mental processes.
-Feelings of unreality, detachment from the environment.
-An altered sense of self as a response to overwhelming stress.
-Significant impairment in social or occupational functioning.

-caused by some trigger or anxiety.

Depersonalization (a disturbance in the perception from oneself) is differentiated from derealization, which describes an alteration in the perception of the external environment.
What is the prevalence of depersonalization disorder?
The symptom of depersonalization is very common. It is estimated that approximately half of all adults experience transient episodes of depersonalization. The Dx of depersonalization disorder is made only if the symptom causes significant distress or impairment in functioning.

The disorder occurs more often in women than it does in men and is a disorder of younger people, rarely occurring in individuals older than 40 years of age.

The incidence of depersonalization disorder if high under conditions of sustained traumatization, such as military combat or prisoner-of-war camps. It has also been reported in many individuals who endure near-death experiences.
What is dissociative identity disorder (DID)?
-Existence of 2 or more identities or sub-personalities that take control of the person’s behavior.
-Anxiety is removed from conscious awareness, which helps person survive extreme emotional pain/trauma.
-The person (host) is unaware of the other personalities (alters), but the alters may be aware of each other to some degree.
-Clients can experience memory problems, depersonalization, derealization, identity confusion, time loss, voices conversing with one another, and voices that are persecutory.
-Alter personalities have feelings and behaviors associated with the trauma.
-Cognitive distortions.

-when the individual changes identity, they don't feel the anxiety anymore; during periods of high anxiety, they will switch identities
-the host is unaware of the other identity, but the alters is aware of it

Generally, there is amnesia for the events that took place when another personality was in the dominant position, and the client reports "gaps" in autobiographical histories.
What was DID formerly called?
Multiple personality disorder
What is the general etiology of these dissociative disorders?
-Related to long history of trauma, abuse
-Dysfunction in areas of brain affecting memory: hippocampus
-Excessive cortical arousal
-Repression of distressing mental contents from conscious awareness (psychodynamic theory)
-More common among first-degree biological relatives (genetics)
Name some potential nursing diagnoses regarding dissociative disorders.
-Disturbed personal identity
-Disturbed body image
-Ineffective coping
-Anxiety
-Risk for other-directed violence
-Risk for self-directed violence
-Ineffective role performance
-Spiritual distress
Describe milieu management.
-Provide emotional security, empathy, acceptance, support
-Occupational therapy, art therapy
-Decrease isolation
-Stress management
-Safety plan
-Support groups after hospital stay
What is specific about the etiology of DID and how it can be used in treatment?
Etiology of DID based on childhood abuse. Discussing a past history can help to connect traumatic events to the need for multiple personalities, and support a successful outcome.
Being able to recall traumatic or stressful events is the first step in dealing with stressors, causing DID.

Not a nursing intervention but important to know:
The goal of therapy for the client with DID is to optimize the client's function and potential. The achievement of integration (a blending of all the personalities into one) is usually considered desirable, but some clients choose not to pursue this lengthy therapeutic regimen. Intensive, long-term psychotherapy with the DID client is directed toward uncovering the underlying psychological conflicts. This process, abreaction, or "remembering with feeling," is so painful that clients may actually cry, scream, and feel the pain that they felt at the time of abuse.
Can medication directly treat these disorders?
Nope. Medication does not eliminate the dissociative disorder. However, they can treat symptoms of anxiety and depression.
What is individual psychotherapy (for somatoform disorders)?
The goal of psychotherapy is to help clients develop healthy and adaptive behaviors, encourage them to move beyond their somatization, and manage their lives more effectively. The focus is on personal and social difficulties that the client is experiencing in daily life as well as the achievement of practical solutions for these difficulties.
Name the maladaptive eating regulation responses.
-Anorexia nervosa
-Bulimia nervosa
-Binge eating disorder
-Night eating disorder
-Obesity
What mental disorders should all eating disorders be differentiated from?
-affective disorders
-histrionic, borderline, and narcissistic personality disorders
-schizophrenia
-OCD
-substance abuse
What is the comorbidity regarding adolescents and eating disorders?
-depression 50-70%
-substance abuse
-Anorexia: 75% anxiety disorder, 25% OCD
-Bulimia: anxiety disorder, PTSD, substance abuse, mood disorders
-Binge eating disorder: depression, panic disorder, borderline personality disorder
Name some of the consequences of eating disorders.
-self-injurious behavior 34.6% (eating disorder NOS and bulimia nervosa)
-have higher rate of C-sections and postpartum depression
-irritable bowel syndrome
-osteoporosis
What are some biological etiologies of eating disorders?
-hypothalamus = appetite regulation center for neurotransmitters and hormones related to feeding and satiety
-low serotonin: decreased satiety
-low dopamine: role in obesity and being eating
-surgery/GI problems as a child
-gene links: twin studies (56% concordance rate in anorexia)
What are some neuroendocrine / neurobiological influences in eating disorders?
-melancholic and atypical depression
-variant of a depressive disorder
-similar neuroendocrine abnormalities as found in depression
-low levels of cholecystokinin found in bulimia nervosa
What are some sociocultural theories regarding eating disorders?
-societal values of being thin
-influence of role conflict, vulnerability to opinions of others in adolescence
-lack of approval
What is the psychological model regarding eating disorders?
-issues of control in anorexia
-issues of affective instability with poor impulse control in bulimia
-childhood trauma (abuse)
What is the prevalence of eating disorders?
-lifetime prevalence of anorexia for women is 3.7%, 1.3% for bulimia
-onset is 15-24 years of age
-female athletes, dances, male body builders
-later onset for men
Name predisposing psychodynamic issues regarding eating disorders.
-rigidity
-ritualism
-meticulousness
-perfectionist
-risk avoid ant
-maturity issues
-self-esteem issues
-emptiness
-loneliness
-boredom
-tension
-grief, loss
-shame, guilt
What are the family psychodynamic factors that predispose eating disorders?
-history of medical/surgical issues
-history of separations, deaths
-history of sexual abuse
-family eating issues
-rigidity and control by parents
What are the sociocultural models regarding eating disorders?
-westernized countries
-cultural ideal is thinness; "You can never be too thin or too rich." Pro Ana websites
-$5 billion industry
-50% of U.S. women are on a diet
Describe anorexia nervosa.
-established in 1873 by Sir William Gull
-self-imposed starvation
-refusal to eat includes: self-induced vomiting, compulsive exercising, abuse of laxatives, diuretics
-onset usually between 12-18 years of age or late teens and early 20s
What are the two types of anorexia nervosa?
-restricting type: has not engaged in binge eating or purging behavior
-binge eating/purging type: engages in binge eating or purging behavior (diuretics, laxatives, enemas, vomiting)
What do you expect to find in assessing a patient with anorexia nervosa?
-over dependence
-feels helpless, powerless, and ineffective
-ward off panic
What are the mortality rates for anorexia nervosa?
-after 10 years, it is 6-7%
-after 20-30 years, it is 18-20%
-mortality ranges from 5-15%, the highest mortality of any psychiatric disorder
-suicide occurs in 2% of the population
-1/3 of deaths in eating disorders are attributed to suicide
What are the two P's in the psychodynamic theory of anorexia nervosa?
-powerlessness
-perfectionism
Perfectionism includes...
-lack of self-esteem
-worth can only be measured by accomplishments
-never really "good enough"
-by controlling her food, she will develop the "perfect body" and gain a sense of perfection
-dependent upon opinions of others, although often don't believe them
-they are their own worst critic
Powerlessness includes...
-see themselves as inadequate and powerless
-lack control
Describe the pursuit of thinness in anorexia nervosa.
-body image disturbances
-pride
-become withdrawn
-isolation
-unable to identify hunger and satiety
-lack of awareness
-identity disintegrates
What are some cognitive distortions in anorexia nervosa?
-overgeneralization: "I was happy at a size 6. I must get back to that weight."
-All-or-nothing: "If I allow myself to gain weight, I will blow up like a balloon."
-personalization and self-reference: "People won't like me unless I am thin."
-emotional reasoning: "When I am thin, I feel powerful."
-magnification: "If I gain weigh, my weekend will be ruined."
What are the physical features of patients with anorexia nervosa?
-skeletal muscle atrophy and atrophy of breast tissue
-amenorrhea for 3 cycles
-lanugo on face and body
-hair loss on scalp
-painless salivary gland enlargement
-skin dryness, cracking, blotchy, yellowish discoloration
-bowel distention
-slowed reflexes
-calluses on the knuckles
What are the food behaviors of patients with anorexia nervosa?
-skip meals or takes only tiny portions
-ritualistic ways
-disgusted with food formerly liked
-low fat food
-diet soda
-food labels
-vomit food
-binge food
-purge
-obsessed with food
-hiding and disposing of food
-socially withdrawn and isolated
-uses exercises, preoccupation with food, manipulation and lying as a means to keep losing weight
What are some physiological complications with anorexia nervosa?
-malnutrition with hypo-albuminemia
-chronic inflammatory bowel disease
-esophageal erosions, ulcers
-infections
-pre-pubertal state
-pituitary shuts down ovulation
-amenorrhea
-prolonged amenorrhea
-tooth and gum erosion
-renal calcification due to dehydration
-shrinkage of stomach
-disuse atrophy
-hypothermia
-dehydration - renal damage
-decreased left ventricular muscle mass
-reduced cardiac output
-death
What is bulimia nervosa?
-extreme overeating (binging) usually done in a two hour period
-self-induced vomiting and abuse of laxatives, diuretics, and enemas to prevent weight gain
-vigorous exercise; use of diet pills
-binge eating and purging occurs at least twice per week for 3 months
-fasting between episodes
Name the two types of bulimia nervosa.
-purging type: person regularly engages in self-induced vomiting or misuse of laxatives, diuretics, and enemas
-non-purging type: person uses other means such as fasting or excessive exercise, but does not regularly engage in purging
What is the onset of bulimia nervosa?
-onset is late teens and early 20s
-frequently (25%) have a period of anorexia prior to developing bulimia
-sometimes refer to themselves as "failed anorexics"
-generally more impulsive and rebellious

-may have had one or more suicide attempts
-perceive their families as more dysfunctional and controlling
-unduly influenced by body shape and weight
-morbid fear of fatness and weight gain
-about 10% are within their expected body weight
-33-50% have history of being overweight
-10-30% have previous history of anorexia nervosa
-report significant impairment
-at risk for impulsive behaviors
What is the usual course of bulimia nervosa?
-chronic and intermittent over a period of many years
-binge periods alternate with periods of restrictive eating, complicating diagnosis and treatment
-males are being diagnosed more often than in the past
What are the physical signs and symptoms of bulimia nervosa?
-malnutrition
-hair loss
-brittle nails
-fatigue and weakness
-insomnia
-mood changes
-dental cavities: erosion of tooth enamel and discoloration due to stomach acid
-"chipmunk facies" appearance due to enlargement of parotid glands and submaxillary/submandibular glands, hoarseness, throat irritation
-electrolyte imbalance, dehydration, arrhythmias
-anxiety and mood disorders
-substance use/abuse
-personality disorders
-muscle weakness
-constipation
-menstrual irregularities
-high serum amylase levels
-lower levels of serotonin in bulimia
What is the psychosocial impact of bulimia nervosa?
-perceived by others as perfect
-depression
-childhood trauma
-parental obesity
-history of unsatisfactory sexual relationships
-self-worth issues
Describe binge eating disorder.
-binge eating within 2 hour period of large amounts of food without purging/fasting
-lack of control over eating during episode
-3 or more criteria: eats rapidly, uncomfortably full, large amounts eaten when not hungry, eats alone, guilt/depression/disgust
-2 days a week for 6 months; marked distress

-most common eating disorder in the U.S.
-8 million men and women
-3 times the number of those diagnosed with anorexia and bulimia
Describe obesity.
-plays a role in binge-eating disorder
-does not engage in behaviors to rid the body of excess calories
-BMI of 30.0 or greater (World Health Organization)
-hyperlipidemia (elevated triglyceride and cholesterol levels)
-hyperglycemia, DM, arthritis, cardiac
What are the predisposing factors for obesity?
-genetics
-lesions in hypothalamus
-hypothyroidism
-lifestyle
-stress
-depression
What are the assessment guidelines for eating disorders?
-Complete H & P: medical and psych
-Explore patient’s perceptions
-Eating habits and history of dieting
-Methods used to achieve control
-Value attached to specific weight
-Mental status exam
-Interpersonal and social functioning
-Occupational functioning
-Family system
-Nutritional assessment
-Oral assessment
-Inspect for enlarged parotid glands
What are the nursing diagnoses for eating disorders?
-Imbalanced nutrition: Less than or more than body requirements
-Deficient fluid volume
-Decreased cardiac output
-Disturbed body image
-Low self-esteem
-Ineffective denial
-Anxiety (moderate to severe)
-Ineffective coping
-Risk for injury (electrolyte imbalance)
-Powerlessness
What are the nursing outcomes for anorexia and bulimia nervosa?
-Has achieved and maintained at least 80% of expected body weight: gains 2-3 pounds per week for age and size
-Vital signs, blood pressure, lab studies are within normal limits
-Drinks 125ml of fluid each waking hour
-Establishes a healthy pattern of eating
-Verbalizes knowledge of consequences of fluid loss from self-induced vomiting
-Verbalizes situations that precipitate anxiety
Describe therapeutic alliance in treating patients with an eating disorder.
-Patient must trust the staff in order to participate
-Deny that they have a problem, refuse treatment, or feign compliance (express support and acceptance, communicate that you respect ability to make healthy and effective choices if presented with choices in an appropriate way, empathize understanding and praise for positive efforts, provide hope)
-Promote positive self-concept and perceptions of body image
-Cognitive behavioral model is effective for bulimia
-Help patient to restructure eating to interrupt cycle of eating and purging
-Treat comorbid disorders
-Structured milieu: observation during and after meals; health teaching; psychotherapy
-SSRIs can be helpful
-Monitor activity level
-Empathy is critical but should be tempered with firmness and limit setting
-Recovery is slow and manipulation is frequent
Describe the re-feeding syndrome.
-Prolonged fasting: the body conserves muscle and protein breakdown by switching from ketone bodies to fatty acids as the main energy source
-The liver decreases its rate of gluconeogenesis thus conserving muscle and protein
-Intracellular minerals become severely depleted during this period
-Insulin secretion is suppressed and glucagon secretion is increased
-During re-feeding, insulin secretion resumes resulting in increased glycogen, fat and protein synthesis
-Re-feeding increases the basal metabolic rate
-Syndrome can occur at the beginning of treatment for anorexia nervosa when patients are reintroduced to a healthy diet
-Shifting of electrolytes and fluids increase cardiac workload and heart rate, which can lead to acute heart failure
-Must re-feed SLOWLY; may start with liquid diet via NG feedings
-Closely monitor the re-feeding rate
-Start slowly, at a rate that delivers 15 to 20 kcal/kg/day (about 1,000 kcal/day for adults) for the first 1 to 3 days, before gradually advancing to the desired daily levels over 5 to 7 days
-Advance nutritional support when the serum electrolytes are close to the normal range or are actively being replaced
Describe the treatment for anorexia nervosa.
-Involve pt. in establishing target weight and interventions to achieve it
-Negotiate food intake
-Supervision during meals
-Limit discussion about food: focus is on emotional issues
-If edema and bloating occur with return to normal eating, reassure pt. this is temporary
-Food journal, recording type of food eaten, and feelings associated with eating and exercise.
-CBT to teach pt. how to change abnormal thoughts and behavior. Treatment of choice
Describe the treatment of bulimia nervosa.
-Interrupt the binge-purge cycle and pt. regain control
-Aware of factors that result in bingeing
-Learn new cognitive coping techniques to help control bingeing.
-CBT
What are the overall treatment goals of eating disorders?
-Medical stabilization
-Nutritional rehabilitation and weight restoration (74% to 90% rule)
-Return to normal eating patterns
-Able to recognize hunger and satiation
-Reduce bingeing and purging
-Improve interpersonal and intrapersonal thinking
-Restore normal exercise patterns
-Family therapy: to open up communication and deal with conflicts
-Encourage to talk about stressful issues
-Learn to enjoy food
-Eat at a table, make mealtime a pleasant experience
-Eat with utensils to help pt. slow down
-Eat frequent small meals with snacks
-SSRI antidepressants used to improve weight gain and decrease depressive symptoms
-Low dose neuroleptic drugs are prescribed to manage anxiety and severe obsessive thinking (Zyprexa)
Give some examples of nursing evaluative measures regarding eating disorders.
-Patient did not purge after scheduled meals during hospital stay.
-Patient identified 2 coping skills to deal with increased anxiety.
-Patient participated in group therapy daily.
-Patient ate 5 small meals each day.
Describe violence.
-physical force employed to violate, damage or abuse
-resulting from unexpected force or injury rather than from natural causes
-abusive or unjust use of power
What individuals are affected by family/partner violence?
-half of Americans have experienced violence
-1 million Americans over 60 are abused in the domestic setting
-men, women, children, siblings, partners, and the elderly are victims
-all socioeconomic, religious, cultural, and educational groups are represented
-nearly 5.3 million intimate partner victimizations occur each year among U.S. women ages 18 and older. The violence in nearly 2 million injuries and nearly 1,300 deaths (CDC 2003)
-Estimates indicate more than 1 million women and 371,000 men are stalked by intimate partners each year
-44% of women murdered by their intimate partner had visited an emergency department within 2 years of the homicide, 93% of whom had at least one injury visit
-firearms were the major weapon type used in intimate partner homicides from 1981 to 1998

-Battering frequently escalates during pregnancy
-Homicide is the second leading cause of traumatic death for pregnant and postpartum women
-from 1991-1999, for every 100,000 live births in the U.S., at least 2 women died as a result of homicide during pregnancy or within one year of pregnancy

-There is real danger of escalation to violence
Name the types of violence.
-emotional violence
-physical
-sexual
-neglect
-financial
What are the myths of violence?
Myth: Most abuse victims are women... 3-40% are men

Myth: The victim's behavior causes the abuse... it is unpredictable and a patter of behavior from the abuser

Myth: Men/women have the right to keep "them" in line... no person has the right to hurt another

Myth: The battered person is masochistic... people stay for economic reasons, fear of deportation, no place else to go

Myth: Family violence is more common in lower socioeconomic groups... present in all cultures, social and educational classes

Myth: You should not intervene in a family unit... intervention prevents death and future generations of violence

Myth: Victims hide the abuse... when they try to speak out they are met with disbelief

Myth: The victim can change/control the situation... these are coping mechanisms that try to help the person feel in control

Myth: Alcohol and stress are the major causes... abuse is a learned behavior, not an uncontrollable reaction

Myth: Violence occurs only between heterosexual couples... the rates are the same for all couples

Myth: Pregnancy protects a victim... battering frequently escalates during a pregnancy
What are the requirements for violence?
-perpetrator
-vulnerable person
-crisis situation
Describe the perpetrator (a requirement for violence).
-comes from a history of violence, neglect, abuse
-low self-esteem
-authoritarian orientation
-social isolation
-child to provide them with unquestioned love or seen as the cause of their problems
-violent outbursts
-low tolerance for frustration
-history of drug or alcohol abuse
-extreme pathological jealousy
Describe the vulnerable person (a requirement for violence).
-pregnant women
-women moves toward independence
-children: under 3 years of age
-adolescents, but overlooked at a group
-elders: their dependency; white female over 75 years of age living with a relative and having a physical or emotional impairment; care giver role strain
Describe the crisis situation (a requirement for violence).
-isolation with increasing tension
-feels incapable when dealing with present situation
-poor impulse control
-violence is an attempt to CONTROL
Describe the cycle of violence.
-tension-building stage
-acute battering stage
-honeymoon stage
-escalation/de-escalation
When should you suspect abuse?
-history of injury does not match injury patterns
-multiple levels of injury/neglects: head injuries, fractures, burns, bruising, delay in treatment
Name some clinical nursing assessment guidelines DON'Ts.
-do not try to prove abuse
-do not display shock, anger, or disapproval of the situation or the perpetrator
-do not place blame
-do not allow victim to feel it is their fault
-do not probe or press for answers that the victim is not willing to give
-do not conduct interview with group
-do not force child or anyone to remove clothing
Name some clinical nursing assessment guidelines DO's.
-conduct interview in private
-be honest and direct
-use a language the client understands
-be understanding and attentive
-inform and explain if it is necessary to make a referral: child abuse, elder abuse, assault
-assess safety and reduce danger
What should take place during the initial interview?
-questions are open ended and require a descriptive response
-establish trust
-use assessment screen
-complete danger assessment
-notify appropriate resources: CPS, rape counseling... (Bay Area Women Against Rape, BAWAR), safe houses
What are some nursing outcome criteria and planning interventions?
-cessation of abuse reported
-cessation of abuse
-the RN is often the first point of contact
-JCAHO requires staff education on family violence
-plans should focus on victim's safety
-planning needs to include abuser
What are the nursing interventions for primary prevention?
-identify people who are very stressed or at risk
-reduce stress
-reduce influence of risk factors
-increase social support
-increase coping skills
-increase self esteem
What is VAWA?
The Violence Against Women Act (VAWA) of 2000

On January 5, 2006, President Bush signed into law:

H.R. 3402, the "Violence Against Women and Department of Justice Reauthorization Act of 2005," which reauthorizes the Violence Against Women Act for FYs 2007-2011, makes amendments to criminal and immigration law, consolidates major law enforcement grant programs and authorizes appropriations for the Department of Justice for FYs 2006-2009.
What is the California Law regarding violence?
You must report physical injury even if the person is being treated for something else.

California is one of six states - including Colorado, Kentucky, New Hampshire, New Mexico, and Rhode Island - with specific laws on reporting suspected cases of intimate partner violence.
What are the nursing interventions for secondary prevention?
-early intervention into abusive situations
-screening programs for people at risk
-crisis nurseries
-school screening
-safe houses
-legal services: BAWAR, California Coalition Against Sexual Assault
What are the nursing interventions for tertiary prevention?
-nursing facilitating healing and rehabilitative services
-mental health services: counseling, family therapy, behavioral therapy
-handout: change process for domestic violence victims
Who is most likely to develop PTSD?
-magnitude of the stressor and uncontrollability of the event
-sexual victimization: real or perceived responsibility and betrayal
-prior vulnerability: genetics, early age of onset, lack of functional support, concurrent life stressors
-those who report greater perceived threat, horror, fear: "person's perception of the event"
-social environment that produces shame, guilt, stigmatizes, or self-hatred: "social support"
Are children resilient to violence-induced PTSD?
No!
-Witnessing violence - particularly at home - actually changes the brains of young children.
-The neural systems that determine social interaction are laid down early in life, when the brain is most malleable; 90% of the core brain structures are organized by age 3
-Thus, as the brain absorbs and encodes information from the child's daily life and family relationships, it forms internal templates that will guide the child on how to survive in the world.
-The brain stem - which regulate fundamental functions like heart rate, body temperature, the fight-or-flight instinct - stays a perpetual low-level state of alarm
Discuss the association between biology, hormones, and PTSD?
-lower levels of cortisol but higher levels of adrenalin and norepinephrine may explain why they continue to feel anxious long after the trauma: norepinephrine stimulates the amygdala to put down vivid memories
-the hippocampus and anterior cingulate cortex help modulate the amygdala; they do not respond well to PTSD
-thyroid functioning is enhanced
-they also have elevated levels of CRF (corticotropin releasing factor) that switches on the stress response making them more susceptible to startling
-higher than normal levels of natural opiates
What are the co-occuring psychiatric disorders with PTSD for children?
In children...

-lack hope for the future, exhibited by behavior problems and conduct disorders
-misdiagnosed with ADD and ADHD, exhibited by substance abuse and sexual behavior
-poor school attendance, exhibited by low IQ, low reading ability, increased aggression, low rate of high school graduation

-California has the highest ratio of counselors to students (934:1), 1/3 of school districts have no counseling program
What are the co-occuring psychiatric disorders with PTSD for men?
88%
-alcohol abuse or dependence
-major depression
-conduct disorders
-drug abuse or dependence
What are the co-occuring psychiatric disorders with PTSD for women?
79%
-major depression
-phobias
-social phobias
-alcohol abuse or dependence
Name that last several April Sexual Assault Awareness Month themes.
2005 Campaign
“Decide to end sexual violence.”

2006 Campaign
“Build healthy, respectful relationships”.

2007 Campaign
“Prevent Sexual Violence…in our communities “

2008 Campaign
“Decide to End Sexual Violence”

2009 Campaign
“Prevent Sexual Violence...in our workplaces”

2010 Campaign
“Prevent Sexual Violence...on our campuses”
What is sexual assault?
-nonconsensual vaginal, anal, or oral penetration obtained by force, threat or when person not able to give consent
-usually male to female: 10% male to male and usually penetrated by a heterosexual with multiple rapes, more often seen in prisons or max security hospitals
-1 in 6 women and 1 in 33 men will be victims of an attempted or completed rape
-psychological response is the same for women and men
Describe the types of Rape Trauma Syndrome.
Compound Reaction:
-includes alcohol/drug abuse
-previous conditions reactivated

Silent Reaction:
-unable to describe or discuss rape
-abrupt changes in sexual relationships
-phobias
-nightmares
Describe the acute phase of Rape Trauma Syndrome.
Acute phase is two weeks:
-shock, numbness and disbelief: "It doesn't seem real," or minimization, "I am fine. I don't want to talk about it."
-disorganization: restless, crying
-somatic complaints: bruises, soreness, headache, nausea, insomnia, anorexia
Describe the long term reorganization phase of Rape Trauma Syndrome.
Two or more weeks after:
-intrusive thoughts: flashbacks, re-living the incident, nightmares
-increased motor activity: moving, trips, changing phone number, "The assailant will return"
-fears and phobias: fear of indoors or outdoors, fear of being alone, fear of crowds, fear of sexual encounters
Name the predisposing factors to anger and aggression.
-modeling: "monkey see, monkey do"
-operant conditioning: a behavior is reinforced with positive reward
-socioeconomic and environmental factors: poverty, drugs, etc.
-biochemical: hormones control inhibition and excitation of aggressive impulses such as eli/norepi, and dopamine
-neurophysiological: tumors, encaphalitis, seizures can change areas of the cerebrum which can affect aggressive behavior
What is the best nursing intervention for violence?
Prevention!
What are some indicators for potential violence?
-past history
-diagnosis
-current behavior
What is prodromal syndrome?
Anxiety, tension, verbal abuse, profanity and increased hyperactivity. Behaviors associated with this syndrome are rigid posture, clenched fists, pacing, slamming, pounding, and talking rapidly.

The behaviors indicated are emergent and call for immediate attention, seen as an indication of a violent act to occur.
Describe anger vs. aggression behaviors.
Anger:
-clenched fists/teeths
-defensive response
-yelling/shouting
-discomfort
-easily offended

Aggression:
-pacing
-restlessness
-verbal threats
-shouting obscenities
-threats of homicide or suicide
-disturbed thought process
Describe de-escalation techniques for violence.
Step 1: Use a calm voice, identify consequences, distract with positive activities, walk outdoors, relaxation techniques, reduce stimuli and loud noises.

Step 2: Time out, quiet time or seclusion, offer PRN medication.

Step 3: When all other steps fail, give PRN medication, unlocked seclusion, that can lead to locked seclusion
What are nursing diagnosis and outcomes for violence?
Ineffective coping and risk for self directed or other directed violence.

Outcomes:
-Be able to recognize when angry and seek support
-Take responsibility for one’s own feelings of anger
-Demonstrate ability to exert control over feelings
-Be able to diffuse anger before losing control..ie prodromal syndrome
-Use anger in a constructive manner
-Do not harm oneself or anyone else
-Use the problem-solving process to seek solutions to anger
What is the first indicator of aggression?
Prodromal Syndrome