Abuse

Slide 1: 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

Slide 2: 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 

Slide 3: 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

Slide 4: The Odd/Eccentric Group: Schizoid, Paranoid, Schizotypal Some nursing issues include:  ineffective individual coping social isolation defensive coping

Slide 5: 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

Slide 6: 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

Slide 7: 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.

Slide 8: 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

Slide 9: 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 

Slide 10: 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 

Slide 11: 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. 

Slide 12: 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

Slide 13: 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

Slide 14: 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 

Slide 15: 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

Slide 16: Obsessive Compulsive PD R/t OCD  Thrifty, saving, verbose, organized  Critical of self and others  Rigid emotionally; taskmasters, have a  hard time expressing emotion

Slide 17: 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.

Slide 18: 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) 

Slide 19: 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) 

Slide 20: 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

Slide 21: Myths that create problems in stopping abuse If it weren’t for drugs If the abuse was that   and alcohol, the abuse bad the victim would tell wouldn’t have occurred or get out Victims are lying or  Victim deserves it  exaggerating to get Abuse only occurs attention  among the poor and Batterers are  uneducated uneducated men who can be spotted easily Families should be kept  Families should always together at all costs  be kept together

Slide 22: Abusers typically: Low frustration Victims of abuse in   tolerance youth Angry, violence  Lack empathy, and  focused minimize Attribute failure to  seriousness of abuse others’ behavior Controlling  Traditional views  Jealous  Often alcohol/drug  Impulsive abuse 

Slide 23: Some Assessment findings that hint at abuse: Alcohol or other Frequent ER visits   drug abuse Withdrawn/depresd  One car accident  Inconsistent physical  Delay in seeking  findings medical care Multiple suicide  Injury to head,  attempts sexual organs Overprotective Injuries in various   family member stages of healing

Slide 24: Some assessment questions What happened? Are you involved in   an abusive Have you been in a  fight? Tell me about relationship? Tell me it. about it. The injuries you  have look like the kind I have seen when___. Have you been hurt in this way?

Slide 25: Some nursing interventions Make time and If abuse is   privacy to talk suspected but Listen and validate, denied, give info  not judge anyway (privately) Document  Assist with practical  impartially and needs completely Remember the legal  Ask. Don’t assume  issues involved with info will be offered children and elders

Slide 26: 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

Slide 27: 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 

Slide 28: 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

Slide 29: 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.

Slide 30: 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

Slide 31: Re-experiencing the event Intruding  reminders/memories/flashbacks Nightmares  Acting or feeling like the event(s) re-  occurring Leads to anxiety and acute distress 

Slide 32: 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

Slide 33: 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

Slide 34: 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? 

Slide 35: 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 