Abuse

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