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55 Cards in this Set

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Impulsivity and insight
impulsive decision making (vs. contemplative) is usually maladaptive, generally not consistent w/ self-awareness. Often has negative consequences. Inadequate insight/poor judgment often evident in pts who act out on feelings, rather than verbalizing them and seeking mature resolutions. Impulsivity in pt with good insight may be due to unconscious feelings interfering with more appropriate course
MSE 166
Insight
ability to be self-aware, conscious of one's own feelings, ideas, underlying motivations about a particular issue (clinically with one's psychologic condition) Includes thinking about consequences of decisions/actions, and therefore, ability to empathize
MSE 165
Insight - prerequisites
include capacity for abstraction, ability to communicate (speech and language), intact cognitive function, absence of thought d/o, euthymic mood, stable affect, absence of maladaptive defense mechanisms that distort perception of internal/external realities or alter motivation to relate openly with another person.
MSE 165
Judgment - affected by?
individuals level of insight, cognitive abilities, intelligence, thinking processes, mood, personality, life circumstances.
MSE 166
Judgment - determination of appropriateness
is subjective, evaluated both in context of societal standards and in comparison to examiner's own judgments.
MSE 166
Judgment - appropriateness relative to complexity of decision
Most would agree that crossing street into oncoming traffic is unwise, but it's more complex to consider soundness of foregoing chemo in terminal cancer pt with widespread mets, even in society that usually precludes suicide.
MSE 166
Insight/judgment - relation to responsibility for one's actions/decisions
Not necessarily related. Pts are responsible for own actions except under rare circumstances, e.g. severe psychosis.
MSE 167
Insight - past, present and future capability to make sound decisions, and the psychiatrists responsibility
Examiner cannot predict future judgments or actions; it is relevant to try to recognize an individuals's usual patterns of formulating judgments and use that info to help pt to gain insight into how/why such judgments are formed, building a framework for possibly improving future judgments, decisions, behaviors.
MSE 167
Insight - detailed definition
ability to be aware of internal (mind) and external (others, environment) realities to extent these are knowable. Implies subtle nuances, meanings, symbols, feelings, thoughts available to conscious awareness. Begins w/ awareness/understanding of one's own feelings/thoughts/reactions to others/situations. Then, requires comparison of how one feels/thinks about issue/problem w/ what others do; permits conscious awareness of one's conformity/non- w/ societal norms. Thus, insight = awareness of how one's personality traits/behaviors contribute to Sx, interpersonal problems, etc. Psychologically mature pt should have this capacity.
MSE 167
Insight - practically speaking, assessment during MSE involves what?
focuses on whether pts recognize that they are ill, comprehend how problems deviate from norm, understand effect on others, appreciate that treatment may help.
MSE 167
Insight assessment - questions to ask
Are you ill? What brings you in? Have you had thoughts others consider abnormal or which are abnormal for you? Do you realize your family thinks you're depressed? If you leave AMA what will happen? What do you think is wrong with you? Do you think there is anything that will help you feel better?
MSE 167-8
Insight - relation to IQ, cognition, defense mechanisms, personality
Insight presupposes intact intellectual/cognitive function, but not synonymous w/ IQ. Has emotional components, is somewhat culturally bound, is impacted by one's Defense mechanisms and personality style. Unconscious feelings may impede self-awareness. Many aspects of self-awareness, including one's own psychologic state, social circumstances, medical condition, etc. and degree of insight may vary in different areas.
MSE 168
Insight and defense mechanisms - fluctuation w/ stress, mood,
e.g. pt with CP and MI may leave AMA due to fright. Manic pt with unabashed hypersexuality in church may feel embarrassed when euthymic. During episode of mania, pt may use projection and denial, but more mature defense mechanisms when euthymic.
MSE 168
Insight - informed consent
IC requires pt to make judgment/decision about proposed procedure, requiring certain level of knowledge/insight regarding nature, risk/benefits, side effects, complications, consequences of foregoing. Anything that prevents insight may impede complete IC
MSE 168
Insight, informed consent - common obstacles
include cognitive deficits, altered mood, psychosis. e.g. Alzheimer's pt may not be able to remember risks/benefits; depressed pt may devalue life impeding realistic consideration of risks/benefits of ECT; schizophrenic man with delusion of being female may seek sex change operation. Exhaustive technical knowledge not necessarily required for IC; thresholds vary according to gravity of risks
MSE 168
Insight/Judgment - e.g.s of disorders whose symptoms contribute to impairment
Drug/EtOH dependence, depression, mania, psychosis, anxiety d/o, dementia, delirium, ADD, impulse control d/o, OCD, CNS d/o, conversion d/o, factitious d/o
MSE 169
Insight - relation to choice of defense mechanisms
those who use psychotic, immature, and neurotic defense mechanisms are less capable of achieving full insight than those who use more mature mechanisms
MSE 169
Insight - actively psychotic pts w/ paranoid schizophrenia
may not appreciate that they are mentally ill, or how treatment can be helpful
MSE 169
Insight - mania/narcissism
manic pts usually so immersed in elated/hyperactive states they are not aware of or are unconcerned with how their behavior affects others; may be having so much fun they do not realize they are behaving abnormally relative to usual self or society. Manics and narcissistic PD pts tend to be grandiose about their capabilities, diminishing their ability to be realistically aware of their condition/limitations.
MSE 169
Insight - conversion d/o
Extreme lack of insight. By its nature, this d/o implies a lack of conscious awareness of the underlying psychologic conflict that is masked/symbolized by presenting somatic Sx.
MSE 169
Insight - factitious d/o
Pts purposefully portray illness, but are not conscious of own motivations for being pt.
MSE 169
Insight - psychosis
psychosis from any cause involves psychotic and immature DMs that are not compatible w/ being insightful, e.g. projecting onto another person one's own feelings (e.g. that doctor has sexual feelings for pt when converse is true), denial of reality in face of notable data (e.g. believing one is dead), delusional ideation (pt who believed he called the plays of a football game through TV)
MSE 169
Insight - addiction
EtOH/drug abuses frequently deny additions and consequences, externalize blame, do not take responsibility for selves, vigorously resist others' efforts to confront problem.
169-70
Externalization
involves use of external factors to rationalize actions instead of acknowledging internal impulses/feelings, e.g. "I stayed at bar all night b/c my old lady would have been on my case the second I came home" rather than "I stayed at the bar all night b/c I can't control urge to drink"
MSE 170
Insight - Borderline Personality D/o
unable to see gray zones of relativeness, which is not conducive to gaining full awareness of an issue or situation w/ appreciation into nuance, details and ambiguity, tends to lead to splitting
MSE 170
Insight - depressed, suicidal pts
have negatively distorted views of the world and themselves, which diminishes ability to appreciate positive aspects of living
MSe 170
Insight - demented, delirious, amnestic, brain-injured pts
all cognitively impaired. b/c of attentional, memory, language, or abstraction deficits, often not capable of being insightful. Frontal lobe damage from EtOH, stroke, surgery, head trauma directly alters executive functions, reducing capacity for conceptual thinking, self-knowledge. Those w/ significant prefrontal lobe damage from stroke, tumor, subcortical lesions, head trauma also often lack insight, may even be disinhibited.
MSE 170
Insight - anosognosia
extreme lack of insight, often result of nondominant parietal lobe damage. Typically deny suffering functional impairment of brain damage; may not recognize paralyzed arm as own.
MSE 170
Insight - blindspots
Intense religious beliefs may lead to concrete, fundamentalist interpretations of liturgy/teachings. Mildly depressed child of narcissistic parent may not see pattern of dating self-centered partners and connection to seeking to conquer and secure affection from narcissistic in lieu of parent. Minimization of illness
MSE 170-1
Insight - la belle indifference
e.g. in MS/conversion d/o pt; impairs insight into illness
MSE 171
Insight - questiosn about approach to major life stresses, relationships, past illnesses, family conflicts, occupational issues
can help to elucidate level of self-awareness. How did you cope w/ your wife's death? What did you do to keep from punching your boss? How do you handle your children when they skip school? How long did it take you to get to ER after CP began? When you had that headache medication side effect, did you tell your doctor or stop on your own? Did you stop drinking when you were dx with liver dz?
MSE 171
Insight - documentation
Explain level of insight, specifics. E.g.: Insight is limited; he recognizes that he is unhappy but feels his frequent angry outbursts are justified and victims 'got what they deserved'
171
Judgment - relationship to insight
judgment is a process of consideration and formulation regarding a particular issue or situation that can lead to a decision or action. Better and more complete person's insight, the more likely the judgment is to be sound. Snap judgment may be sound, but generally more contemplation needed to produce good judgment
MSE 172
Judgment - pts who "act out" feelings; ADD pts
Those who act out their feelings or ideas are prone to make judgments that are poorly thought out; often these people have difficulty conceptualizing and thinking deeply b/c their verbal skills are inferior to their performance skills. This occurs in the ADD child or adult, e.g. People who behave impulsively and w/ minimal forethought are also likely to produce hasty judgments w/ resultant negative consequences; those who have personality d/o fall into this category
MSE 172
Judgment - drugs
Judgment may be impaired due to intoxication, though alcohol-dependent persons have impaired judgment even in nonintoxicated states such that they complicate their lives by drinking in the first place.
MSE 173
Judgment - Depression
Impaired, as negative and pessimistic feelings distort reality. May culminate in suicidal acts.
MSE 173
Judgment - manics
Manics are insensitive to others' feelings and have poor judgment regarding their social behaviors. Often insult or embarrass others w/ their jokes or actions. Euphoric manics have an unrealistically happy view of the world and do not recognize potential negative consequences of their behaviors. They may go on spending sprees when they have insufficient funds to pay for them, engage in socially improper behaviors such as parading nude on their front lawns, or self-assuredly risk harm to themselves, such as when driving too fast or provoking fights they cannot win
MSE 173
Judgment - ADD
Inability to maintain attention long enough to make sound decisions may lead to rash, impulsive behavior.
MSE 173
Judgment - Obsessive pts
Spend a great deal of time thinking, but have difficulty formulating judgments because they get caught up in details or are rigidly bound by rules. May brood and ruminate for days, force themselves to make a decision, and then make the "wrong" one.
MSE 173
Judgment - Schizophrenics
Schizophrenics who are actively psychotic may not be fully capable of sophisticated decision making b/c of delusions, thought disorder, or unrealistic distortions due to referential thinking.
MSE 173
Judgment/disinhibition - delirium, dementia, prefrontal cortex damage, Huntington's, MR, Stroke
Delirious/Demented pts may be unable to make sound, informed decisions due to cognitive deficits. Prefrontal - difficulty with higher-level conceptualization, difficulty w/ abstract reasoning. May be disinhibited/impulsive. Huntington's pts often disinhibited, have difficulty w/ higher-level (like prefrontal). MR usually not capable of abstraction, may lack social nuance appreciation. Stroke pts may have damage to areas of brain required for language, cognition, executive functions
MSE 173-4
Judgment - assessment questions
Traditional questions are the fire in a theater and stamped envelope on the ground questions. Better to ask individualized questions to assess contemplation about future/past decisions. E.g. What do you think we should do about these hallucinations you're having? How will you explain to your spouse your decision to sell drugs to pay for the new car? Could you try to imagine your funeral after you kill yourself? Who will attend and how will they react? What makes you think that you don't have to take your medicine? If you had a magic wand and could wave it to change your situation, what would your life be like?
MSE 175
Judgment - defense mechanisms creating interference
More mature styles increase the likelihood of making sound decisions. Denial, projection, repression, externalization, dissociation adversely affect judgment; humor, altruism, suppression less likely to do so.
MSE 175
Mature Defense Mechanisms - name 4
Altruism, humor, sublimation, suppression
MSE 175
Neurotic Defense Mechanisms - name 5
Repression, displacement, dissociation, reaction formation, intellectualization
MSE 175
Immature Defense Mechanism - name 5
Splitting, externalization, idealization, projection, acting out
MSE 175
Psychotic defense mechanisms - name 2
denial, distortion
MSE 175
Defense Mechanisms - Documentation in MSE
Specific mention generally not required, unless particularly relevant to pt's current situation/condition. E.g. if there is striking repetitious pattern, when it impedes w/ cooperation w/ MSE, when impacts significantly on current crisis/complaint, before embarking on analytic psychotherapy For borderline, e.g. "manipulates, projects, and splits". For OCPD, intellectualizes and displaces. If mentioned, defense mechanisms should be incorporated into Insight/Judgment portion
MSE 176-7
Acting out - clinical correlations
Conduct-disordered children and borderline and antisocial personality disordered adults often act out their feelings, usually with negative consequences, e.g. rebellious/illegal activities, or suicidal gestures.
MSE 177
Altruism (vs. masochism)
mature defense mechanism in which person gains gratification/satisfaction from helping others in order to feel better about oneself. Both receiving/giving parties benefit. In Masochism, a more primitive process, peson sacrifices himself and receives pain/hardship in return.
MSE 177
Anosognosia - accompanying lesions
Usually seen accompanying R hemisphere lesions affecting parietal lobe. These pts ignore L half of bodies or visual fields. B/l frontal lobe lesions, b/l occipital lobe lesions (Anton's syndrome), and many amnesias can also cause this.
MSE 177
Vallaint's stages of defense mechanism maturation
Psychotic (normal in preschool children and in dreams; abnormal in adults, as in those using primary process thinking and thought d/o, including schizophrenics, manics, psychotic depressives, and severe personality disordered pts, esp. borderline) to immature (normal in children and young adolescents; abnormal in adults, as in personality disorders) to neurotic (common in adults, especially in stress) to mature (common in psychologically healthy adults)
MSE 178
Dissociation
Neurotic defense mechanism in which the personality is temporarily altered to avoid emotional distress. Conversion d/o and fugue states are e.g. of escaping from one's usual self-awareness b/c of an upsetting event or feeling. Dissociation is not a healthy response to adversity b/c the precipitating psychologic conflict is not available for conscious awareness, understanding, or resolution.
MSE 178-9
Externalization
Tendency to blame events, persons, or organizations external to oneself for the things that occur in or affect one's life. Inherent in this is the inability to take responsibility for one's feelings, actions, decisions, behaviors. Immature defense mechanism related ot projection, denial. Primary DM of alcoholics and other drug-dependent pts, as well as some personality-d/o pts
MSE 179
Projection
Person unconsciously attributes to (projects onto) another person his/her own feelings, ideas, impulses, particularly undesirable ones. Undesirable feelings/opinions are separated from oneself and attached (projected) to another person who is then "blamed" or held responsible for these unwanted feelings. Primitive way of thinking/coping. Occurs in personality d/o, inc. borderline, paranoid, narcissistic; and in psychoses
MSE 181