personality disordera and cycle of violence and abuse
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Maladaptive Behavior Patternspersonality disorders and abuse
What sort of future is coming up frombehind, I really dont know. But thepast, spread out ahead, dominateseverything in sight. R.M Pirsig from Zenand the Art of Motorcycle Maintenance
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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 ofdefense mechanisms) Impaired personal relationships
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Nursing Issues with all PD:
Balance in your expectations forchangehope, but not a quick fix
Be authentic, patient, trustworthy
Have good limit setting skills
Have good ego boundaries
Have good team communication, todecrease splitting
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The Odd/Eccentric Group:
Schizoid, Paranoid, Schizotypal
Some nursing issues include:
ineffective individual copingsocial isolation
defensive coping
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Paranoid Personality D/O
Fear others will harm or exploit
Hypervigilant and tend to be hostile (asa response to perceived threat) Can become psychotic if stressed
Nursingbe consistent, truthful, out inthe open. Approach with care and tellwhat is happening, what you are doing
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Schizoid Personality D/O
Doesnt want relationships
Flat affect, little emotion seen, notaware there is a problem with this
Few relationships, can becomedelusional if stressed
Nursing-build trust slowly, consistent,not overly emotional or smothering
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Schizotypal PD
Has social anxiety. Wants relationshipsbut not skilled at getting them.
Often has eccentric thinking and/orbehavior
Nursing-be consistent, trustworthy,
keep clear boundaries, help ct. withvery gradual change in social bx.
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Dramatic/ Emotional PDs Includes Antisocial, Borderline,
Histrionic, and Narcissistic
Focus more study energy on Antisocialand Borderline
Sample nursing diagnoses include:
Altered family process, ineffectiveindividual coping, self mutilation, riskfor violence, low self esteem
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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
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Borderline PD (more women) Overwhelmingly emotionally needy,
despairing. Angry, dysphoric, labile
Lives in a crisis and creates a crisis iftoo calm
Abandonment issues are key
Self destructive behavior and mutilationoccur
Splitting, dichotomous thinking
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Histrionic PD
Dramatic, flambouyant
Charming, intense, but shallow inrelationships
Center of attention, if not gets upsetand creates stir
May have dramatic ups and downs.
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Narcissistic PD Self absorbed and self centered
Overestimates own self worth as adefense to cover self doubt
Grandiose. Wants attention, praise,admiration. If this doesnt happen,
becomes upset/angry/vengefulVery critical. Little tolerance for
imperfection
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Anxious and Fearful PD: avoidant,
dependent, and obsessive compulsive
Of all three, dependent is most common
Nursing diagnosis can include:Self esteem disturbance
Anxiety
Hopelessness
powerlessness
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Avoidant PD
Often co-occurs with social phobias
See social isolationVery sensitive to criticism and afraid of
being judged negatively
Feels rejected a lot, fears being rejected
Low self esteem
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Dependent Personality D/O
Passive, submissive, self sacrificing
Few self initiated behaviors Little decisionmaking
Tolerates maltreatment, being bossed
Urgent need to be in relationship inwhich someone else is in control
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Obsessive Compulsive PD
R/t OCD
Thrifty, saving, verbose, organized
Critical of self and others
Rigid emotionally; taskmasters, have ahard time expressing emotion
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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 batteredbefore or during pregnancy.
2 million reported cases of child abuse eachyr in US (2000-5000 die)
0.5-1 million cases of elder abuse in USyearly.
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Why abuse continues ( a few
reasons) Society legitimizes violence and privacy
Intergenerational acting like we haveseen growing up
Structural inequality of abused persons
Stockholm syndrome (discuss)
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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)
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Cycle of Violence
Tension buildingtension, blaming,aggression in abuser
Abuse (battering) episodeacuteepisode of abuse
Calm/honeymoonacts calmer, nicer,
may apologize/gifts/promises. In severeabuse this may be minimal
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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 occursamong the poor anduneducated
Families should be kepttogether at all costs
If it werent for drugsand alcohol, the abusewouldnt have occurred
Victims are lying orexaggerating to getattention
Batterers areuneducated men whocan be spotted easily
Families should alwaysbe kept together
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Abusers typically: Victims of abuse in
youth
Lack empathy, andminimizeseriousness of abuse
Controlling
Jealous
Impulsive
Low frustrationtolerance
Angry, violencefocused
Attribute failure toothers behavior
Traditional views Often alcohol/drug
abuse
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Some Assessment findings
that hint at abuse: Frequent ER visits
Withdrawn/depresd
Inconsistent physicalfindings
Multiple suicide
attempts Overprotective
family member
Alcohol or otherdrug abuse
One car accident Delay in seeking
medical care
Injury to head,
sexual organs Injuries in various
stages of healing
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Some assessment questions What happened?
Have you been in a
fight? Tell me aboutit.
The injuries youhave look like the
kind I have seenwhen___. Have youbeen hurt in thisway?
Are you involved inan abusive
relationship? Tell meabout it.
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Some nursing interventions Make time and
privacy to talk
Listen and validate,not judge
Documentimpartially and
completely Ask. Dont assume
info will be offered
If abuse issuspected but
denied, give infoanyway (privately)
Assist with practicalneeds
Remember the legalissues involved withchildren and elders
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Educational Interventions Cycle of violence
Community resources
Danger of homicide, esp re leaving theabuser
Safety planning
Self esteem issuesredefine self as thesurvivor
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Safety Plans-a few basics Cash, checks, keys, credit card,
essentials bag, hidden out of home
Copies of all vital docs hidden out ofhome
Code system, older kids involved
Route of escape, tell trusted people
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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 Dont keep it a secret, it is not your
fault
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Some other Intervention
Issues Be wary of marriage counseling, people
who advise to stay with abuser, abusiveparent at all costs
Note, there are mandatory reportinglaws for children and elders.
Cant heal trauma well when still underfuture risk. Safety is paramount.
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Post-traumatic Stress Disorder Exposure to trauma
Re-experiencing traumatic event Numbing
Avoidance of reminders of event
A
nxiety/arousal responses Distress in important areas of
functioning
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Re-experiencing the event Intruding
reminders/memories/flashbacks
Nightmares
Acting or feeling like the event(s) re-occurring
Leads to anxiety and acute distress
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Types ofAvoidance Thought/feelings/conversations about
the event
Stays away from people and placesassociated with event
Repression
Lack of participation with others,detachment, short sense of future
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Treatment of PTSD Antianxiety agents for short term relief
Antidepressants, particularly SSRIs
At risk for developing substance abusedue to self-medication for distress
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Rape-types Blitz rapeout of the blue, fast
Confidence rapemore of a set upinvolved, may know victim and repeat,use threats
Inability to consent issue
Aggression or Sexual Expression?
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Rape Intervention-a few
points Collecting Evidence while maintaining
dignity, respect in initial response
Privacy, time to talk, one to onecontact, rape counselor, follow up
Anticipatory Guidance
Community Resources