By D. Zakosh. Virginia Wesleyan College. 2019.
Use of these techniques enhances self-esteem and facilitates client’s interpersonal relationships lyrica 150 mg free shipping. Discuss adaptive methods of stress management: relaxation techniques purchase generic lyrica canada, physical exercise buy lyrica line, meditation, breathing exer- cises, or mental imagery. These techniques may be employed in an attempt to relieve anxiety and discourage the use of physical symptoms as a maladaptive response. Client verbalizes an understanding of the relationship between psychological stress and physical symptoms. Client demonstrates the ability to use therapeutic techniques in the management of stress. During periods of intoler- able stress, the individual blocks off part of his or her life from consciousness. The stressful emotion becomes a separate entity, as the individual “splits” from it and mentally drifts into a fan- tasy state. Dissociative Amnesia: An inability to recall important per- sonal information, usually of a traumatic or stressful nature. The extent of the disturbance is too great to be explained by ordinary forgetfulness. Localized Amnesia: Inability to recall all incidents asso- ciated with a traumatic event for a speciﬁc time period following the event (usually a few hours to a few days). Selective Amnesia: Inability to recall only certain incidents associated with a traumatic event for a speciﬁc period fol- lowing the event. Continuous Amnesia: Inability to recall events subse- quent to a speciﬁc time up to and including the present. Systematized Amnesia: With this type of amnesia, the individual cannot remember events that relate to a speciﬁc category of information, such as one’s family, or to one particular person or event. A sudden, unexpected travel away from home or customary work locale with assumption of a new identity and an inability to recall one’s previous identity. The existence with- in the individual of two or more distinct personalities, each of which is dominant at a particular time. The original person- ality usually is not aware (at least initially) of the existence of subpersonalities. When there are more than two subperson- alities, however, they are usually aware of each other. Transi- tion from one personality to another is usually sudden and often associated with psychosocial stress. Characterized by a temporary change in the quality of self-awareness, which often takes the form of feelings of unreality, changes in body image, feelings of detachment from the environment, or a sense of observing oneself from outside the body. Some clinicians have suggested a possible correlation between neurological alterations and dissocia- tive disorders. Although available information is inadequate, it is possible that dissociative amnesia and dissociative fugue may be related to alterations in certain areas of the brain that have to do with memory. These include the hippocam- pus, mammillary bodies, amygdala, fornix, thalamus, and frontal cortex. Freud (1962) believed that dis- sociative behaviors occurred when individuals repressed distressing mental contents from conscious awareness. He believed that the unconscious was a dynamic entity in which repressed mental contents were stored and unavail- able to conscious recall. Current psychodynamic explana- tions of dissociation are based on Freud’s concepts. These experiences usually take the form of severe physical, sexual, and/or psychological abuse by a parent or signiﬁcant other in the child’s life. It has been sug- gested that the number of an individual’s alternate per- sonalities may be related to the number of different types of abuse he or she suffered as a child. Individuals with many personalities have usually been severely abused well into adolescence. Sudden travel away from familiar surroundings; assumption of new identity, with inability to recall past. Assumption of additional identities within the personality; behavior involves transition from one identity to another as a method of dealing with stressful situations. Common Nursing Diagnoses and Interventions (Interventions are applicable to various health-care settings, such as inpatient and partial hospitalization, community outpatient clinic, home health, and private practice. Client will verbalize understanding that he or she is employ- ing dissociative behaviors in times of psychosocial stress. Client will verbalize more adaptive ways of coping in stress- ful situations than resorting to dissociation. Long-term Goal Client will demonstrate ability to cope with stress (employing means other than dissociation). Presence of a trusted individual provides feeling of security and assurance of freedom from harm. This infor- mation is necessary to the development of an effective plan of client care and problem resolution. Help client understand that the disequilibrium felt is acceptable—indeed, even expected—in times of se- vere stress. Client’s self-esteem is preserved by the knowl- edge that others may experience these behaviors in similar circumstances. As anxiety level decreases (and memory returns), use explo- ration and an accepting, nonthreatening environment to encourage client to identify repressed traumatic experiences that contribute to chronic anxiety. Have client identify methods of coping with stress in the past and determine whether the response was adaptive or Dissociative Disorders ● 195 maladaptive. In times of extreme anxiety, client is unable to evaluate appropriateness of response. This information is necessary for client to develop a plan of action for the future. Assist cli- ent in the selection of those that are most appropriate for him or her. Depending on current level of anxiety, client may require assistance with problem-solving and decision- making. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors. Identify community resources to which the individual may go for support if past maladaptive coping patterns return. Client is able to demonstrate techniques that may be used in response to stress to prevent dissociation. Client verbalizes an understanding of the relationship between severe anxiety and the dissociative response. Obtain as much information as possible about client from family and signiﬁcant others (likes, dislikes, important peo- ple, activities, music, pets).
If a legal answer to the complaint is not received by the deadline discount lyrica online mastercard, the court may issue a default judgment granting the relief sought by the plaintif lyrica 75 mg amex. Tis may consist of only an informal discussion with the patient’s attorney discount lyrica 75mg overnight delivery, providing copies of treatment records, or signing a notarized statement. Tis request may also be formal- ized by the issuance of a subpoena requiring testimony, in the form of either a deposition or actual trial testimony. In the case of deposition testimony, reasonable compensation for time away from the ofce should be agreed upon. Whenever sworn testimony is required, the matter of compensation should be broached with the party that issued the subpoena and whether or not testimony is sought as an expert or merely as a fact witness. Afer reviewing the evidence provided, the dentist is asked to render an opinion in the form of a verbal or written report. Te dentist may then be asked to provide sworn testimony, in the form of either a deposition or testimony at trial. In order to testify as an expert, the dentist must qualify by means of special training, education, or experience. In order for a plaintif to prevail in a standard of care case, there are essential elements of professional negligence that must be proven by a “preponderance of the evidence. If all of these elements cannot be proven to the satisfaction of the jury, the defendant will almost always prevail. Usually, the most difcult parts of the case to establish are causation and damages. For this reason, it is ofen more prudent to examine the evidence for causation and damages and work backward from there. Te opinions of a dental expert must address what the legal system requires, not what the dental community desires. Te essential ele- ments that must be established are: Negligence of another: Tere must be negligence on the part of some- one else. Relevant negligence: Te negligence of another must be related to the injury that is claimed (ofen chronologically). Causation negligence: Te injury in question would not have occurred except for the negligence of another. However, in today’s litigious society, some individuals fle meritless claims against corporations in the belief that these companies will settle for an amount less than the cost of going to trial. Te unfortunate consequence of this shortsighted strategy on the part of corporations is that their willingness to settle based on the amount of the claim has led to a dramatic increase in the number of personal injury claims fled. Tere is probably more fraud in personal injury claims than any other part of the civil litigation process. Te claim may be based on a deviation from accepted methodology in the feld of expertise, rather than on a technically incorrect opinion itself. An expert witness has an obligation to conduct himself or herself within certain professional guidelines. Professional guidelines for expert witnesses are ofen not as well recognized as those relating to the clinical practice of dentistry. One who acts as an expert witness must be aware of what is required in this regard. Based on the possibility of civil litigation, prudence would dictate sufciently broad professional liability insurance coverage for these activities. In some cases, liability insurance covering clinical practice may extend to these activi- ties also. However, do not make such an assumption unless a written clause in the policy or a policy rider states that forensic consulting is covered. Other possibilities for liability coverage for forensic consulting include government agency coverage, homeowner’s umbrella coverage, or a separate policy for forensic consulting only. Dentists providing forensic consulting services for a government agency may have coverage as a government agent or be aforded qualifed immunity in conjunction with ofcial duties. Intentional miscon- duct by the expert may void any of these coverages or protections, similar to the rules on awarding punitive damages. Te foundation case establishing bitemarks in American jurisprudence is a 1954 Texas criminal case, Doyle v. State,6 wherein the court accepted the testimony of a frearms examiner who had made plaster casts of a piece of cheese found at a crime scene that bore several bitemarks and another plaster cast of a piece of cheese bitten by the Jurisprudence and legal issues 391 suspect in the case. Te frearms examiner, using “caliper measurements,” testifed that both pieces of cheese had “been bitten by the same set of teeth. State of Indiana, the court accepted the testimony of a dentist in his frst bitemark case based upon his years of practice and teaching experience in conjunction with his training in the feld, which consisted of attendance at lectures and advanced reading. Te court stated, “Te determination of whether or not a witness is qualifed to testify as an expert lies in the sole discretion of the trial court and may not be set aside unless there is manifest error or abuse of discretion. While many appeals mention the fact that dental identifcation was utilized to establish the identity of a victim, the issue itself is not part of the appeal argument and is only mentioned in passing. Brigano a dentist who was also the coroner testifed that the den- tal records and the teeth he examined in the body “matched … perfectly. Te Fourth Amendment claim was denied due to the lack of any reasonable expectation of privacy by a defendant over what a person knowingly exhibits (in this case his smile) to the public coupled with the fact that a dental examination does not constitute a “search” (quotation marks in original). State a dentist identifed a skull with- out the use of mathematics/percentages, but rather by comparison and based on the outline of a single flling, the bone pattern, and the outline of another tooth. Te court was satisfed that even without specifc forensic training, the dentist was qualifed to make the identifcation and that any objections by the defense should go to the weight given the testimony by the jury rather than to its admissibility. Although there was minor variation in two antemortem dental charts used in the process, the court accepted the expert dentist’s opinion without the use 392 Forensic dentistry of probabilities or without any declaration that the body was in fact the victim to the exclusion of all other individuals in the world. Singletary,14 and later afrmed on appeal,15 a dental identifcation using casts, records, x-rays, and an unusual dental feature cited by the forensic dentist was sufcient to establish the identity. Mayens16 confrms the business record foun- dation for admission of dental records used in identifcations. A New York case afrmed the granting of an order to exhume cremains and deliver them to Drs. Because the body was not recovered for over two years, dental identifcation was the sole means of positive identifcation. Te forensic dentist is aforded an opportunity to interact with individuals and systems outside the normal realm of dental practice. Both general dentists and dental specialists enter with equal foot- ing in the feld. However, success requires dedication and a willingness to learn and become comfortable with the legal system, the legal profession, law enforcement, and the world of the coroner/medical examiner. Te forensic dentist must be dedicated to the pursuit of the truth and must adhere to the highest ethical standard. A good forensic dentist can, without breach- ing ethical standards, be a good witness—one that advances the cause of justice by presenting the truth on the stand and fulflling the expert’s role to educate the attorneys, the judge, and the jury about the dental facts at issue.
The physician must physician reissue a new order for restraints every 4 hours for adults and every 1 to 2 hours for children and adolescents discount lyrica 150mg with mastercard. Observe the client in restraints every 15 minutes (or ac- cording to institutional policy) buy lyrica in india. Ensure that circulation to extremities is not compromised (check temperature buy lyrica 75mg on-line, color, pulses). Continuous one-to-one monitoring may be necessary for the client who is highly agitated or for whom there is a high risk of self- or accidental injury. As agitation decreases, assess client’s readiness for restraint removal or reduction. Possible Etiologies (“related to”) [Lack of trust] [Panic level of anxiety] [Regression to earlier level of development] [Delusional thinking] [Past experiences of difﬁculty in interactions with others] [Repressed fears] Unaccepted social behavior Schizophrenia and Other Psychotic Disorders ● 113 Deﬁning Characteristics (“evidenced by”) [Staying alone in room] Uncommunicative, withdrawn, no eye contact [mutism, autism] Sad, dull affect [Lying on bed in fetal position with back to door] [Inappropriate or immature interests and activities for develop- mental age or stage] Preoccupation with own thoughts; repetitive, meaningless actions [Approaching staff for interaction, then refusing to respond to staff’s acknowledgment] Expression of feelings of rejection or of aloneness imposed by others Goals/Objectives Short-term Goal Client will willingly attend therapy activities accompanied by trusted staff member within 1 week. Long-term Goal Client will voluntarily spend time with other clients and staff members in group activities. Be with the client to offer support during group activities that may be frightening or difﬁcult for him or her. Antipsychotic medications help to reduce psychotic symp- toms in some individuals, thereby facilitating interactions with others. Discuss with client the signs of increasing anxiety and techniques to interrupt the response (e. Maladaptive behaviors such as withdrawal and suspiciousness are manifested during times of increased anxiety. Give recognition and positive reinforcement for client’s vol- untary interactions with others. Positive reinforcement en- hances self-esteem and encourages repetition of acceptable behaviors. Possible Etiologies (“related to”) [Inability to trust] [Panic level of anxiety] [Personal vulnerability] [Low self-esteem] [Inadequate support systems] [Negative role model] [Repressed fears] [Possible hereditary factor] [Dysfunctional family system] Deﬁning Characteristics (“evidenced by”) [Suspiciousness of others, resulting in: • Alteration in societal participation • Inability to meet basic needs • Inappropriate use of defense mechanisms] Goals/Objectives Short-term Goal Client will develop trust in at least one staff member within 1 week. Long-term Goal Client will demonstrate use of more adaptive coping skills as evidenced by appropriateness of interactions and willingness to participate in the therapeutic community. Schizophrenia and Other Psychotic Disorders ● 115 Interventions with Selected Rationales 1. Encourage same staff to work with client as much as possible in order to promote development of trusting relationship. Avoid laughing, whispering, or talking quietly where client can see but not hear what is being said. Suspicious clients often believe others are discussing them, and secretive be- haviors reinforce the paranoid feelings. Suspicious clients may believe they are being poisoned and refuse to eat food from the individually pre- pared tray. Mouth checks may be necessary following medication administration to verify whether client is swallowing the tablets or capsules. Suspicious clients may believe they are being poisoned with their medication and attempt to discard the pills. Activities that encourage a one-to-one relationship with the nurse or therapist are best. The nurse should avoid becoming defensive when angry feelings are directed at him or her. Verbalization of feelings in a nonthreaten- ing environment may help client come to terms with long- unresolved issues. An assertive, matter-of-fact, yet genuine approach is least threatening and most therapeutic. A suspicious person does not have the capacity to relate to an overly friendly, overly cheerful attitude. Client is able to appraise situations realistically and refrain from projecting own feelings onto the environment. Client is able to recognize and clarify possible misinterpreta- tions of the behaviors and verbalizations of others. Client appropriately interacts and cooperates with staff and peers in therapeutic community setting. Possible Etiologies (“related to”) [Panic level of anxiety] [Withdrawal into the self] [Stress sufﬁciently severe to threaten an already weak ego] Deﬁning Characteristics (“evidenced by”) [Talking and laughing to self] [Listening pose (tilting head to one side as if listening)] [Stops talking in middle of sentence to listen] [Rapid mood swings] [Disordered thought sequencing] [Inappropriate responses] Disorientation Poor concentration Sensory distortions Goals/Objectives Short-term Goal Client will discuss content of hallucinations with nurse or thera- pist within 1 week. Long-term Goal Client will be able to deﬁne and test reality, eliminating the occurrence of hallucinations. Observe client for signs of hallucinations (listening pose, laughing or talking to self, stopping in mid-sentence). An attitude of acceptance will encourage the client to share the content of the hallucination with you. This is important in order to prevent possible injury to the client or others from command hallucinations. Use words such as “the voices” instead of “they” when referring to the hallucination. Say “Even though I realize that the voices are real to you, I do not hear any voices speaking. If client can learn to interrupt escalating anxiety, hallucinations may be prevented. Involvement in interpersonal activities and explanation of the actual situation will help bring the client back to reality. For some clients, auditory hallucinations persist after the acute psychotic episode has subsided. Listening to the radio or watching television helps distract some clients from attention to the voices. Client is able to recognize that hallucinations occur at times of extreme anxiety. Client is able to recognize signs of increasing anxiety and employ techniques to interrupt the response. Long-term Goal Depending on chronicity of disease process, choose the most realistic long-term goal for the client: 1. By time of discharge from treatment, client’s speech will re- ﬂect reality-based thinking. By time of discharge from treatment, client will be able to differentiate between delusional thinking and reality. Convey your acceptance of client’s need for the false belief, while letting him or her know that you do not share the belief. It is important to communicate to the client that you do not accept the delusion as reality. Use reasonable doubt as a therapeutic technique: “I understand that you believe this is true, but I personally ﬁnd it hard to accept. Discuss techniques that could be used to Schizophrenia and Other Psychotic Disorders ● 119 control anxiety (e. If the cli- ent can learn to interrupt escalating anxiety, delusional thinking may be prevented.
They were encouraged to shift their focus from those activities they could no longer perform to those that they could enjoy buy lyrica with a mastercard. Activity goals were scheduled and pleasant activities were reinforced at subsequent groups best purchase for lyrica. Time 1 to time 2 The results showed signiﬁcantly diﬀerent changes between the two groups in all their ratings buy lyrica american express. Compared with the control group, the subjects who had received cognitive behavioural treatment reported lower pain intensity, lower functional impairment, better daily mood, fewer bodily symptoms, less anxiety, less depression, fewer pain-related bodily symptoms and fewer pain-related sleep disorders. Time 1 to time 2 to time 3 When the results at six-month follow-up were included, again the results showed sig- niﬁcant diﬀerences between the two groups on all variables except daily mood and sleep disorders. The role of adherence The subjects in the treatment condition were then divided into those who adhered to the recommended exercise regimen at follow-up (adherers) and those who did not (non-adherers). The results from this analysis indicate that the adherers showed an improvement in pain intensity at follow-up compared with their ratings immediately after the treatment intervention, whilst the non-adherers ratings at follow-up were the same as immediately after the treatment. Conclusion The authors conclude that the study provides support for the use of cognitive– behavioural treatment for chronic pain. The authors also point to the central role of treatment adherence in predicting improvement. They suggest that this eﬀect of adherence indicates that the improvement in pain was a result of the speciﬁc treatment factors (i. However, it is possible that the central role for adherence in the present study is similar to that discussed in Chapter 13 in the context of placebos, with treatment adherence itself being a placebo eﬀect. Placebos and pain reduction Placebos have been deﬁned as inert substances that cause symptom relief (see Chapter 13). Beecher (1955) suggested that 30 per cent of chronic pain suﬀerers experience pain relief after taking placebos. A sham heart bypass operation involved the individual believing that they were going to have a proper operation, being prepared for surgery, being given a general anaesthetic, cut open and then sewed up again without any actual bypass being carried out. The individual therefore believed that they had had an operation and had the scars to prove it. However, the results suggested that angina pain can actually be reduced by a sham operation by comparable levels to an actual operation for angina. This suggests that the expectations of the individual changes their perception of pain, again providing evidence for the role of psychology in pain perception. The psychological treatment of pain includes respondent, cognitive and behavioural methods. These are mostly used in conjunction with pharmacological treatments involving analgesics or anaesthetics. The outcome of such interventions has tradition- ally been assessed in terms of a reduction in pain intensity and pain perception. Recently, however, some researchers have been calling for a shift in focus towards pain acceptance. This methodology encourages the participant to describe their experiences in a way that enables the researcher to derive a factor structure. From their analysis the authors argued that the acceptance of pain involves eight factors. These were taking control, living day-by-day, acknowledging limitations, empowerment, accepting loss of self, a belief that there’s more to life than pain, a philosophy of not ﬁghting battles that can’t be won and spiritual strength. In addition, the authors suggest that these factors reﬂect three underlying beliefs: (i) the acknowledgment that a cure for pain is unlikely; (ii) a shift of focus away from pain to non pain aspects of life; and (iii) a resistance to any suggestion that pain is a sign of personal weakness. In a further study McCracken and Eccleston (2003) explored the relationship between pain acceptance, coping with pain and a range of pain-related outcomes in 230 chronic pain patients. The results showed that pain acceptance was a better predictor than coping with pain adjustment variables such as pain intensity, disability, depression and anxiety and better work status. The authors of these studies suggest that the extent of pain acceptance may relate to changes in an individual’s sense of self and how their pain has been incorporated into their self- identity. In addition, they argue that the concept of pain acceptance may be an import- ant way forward for pain research, particularly, given the nature of chronic pain. Self-reports Self-report scales of pain rely on the individuals’ own subjective view of their pain level. Describe your pain: no pain, mild pain, moderate pain, severe pain, worst pain) and descriptive questionnaires (e. Some self-report measures also attempt to access the impact that the pain is having upon the individuals’ level of functioning and ask whether the pain inﬂuences the individuals’ ability to do daily tasks such as walking, sitting and climbing stairs. Observational assessment Observational assessments attempt to make a more objective assessment of pain and are used when the patients’ own self-reports are considered unreliable or when they are unable to provide them. For example, observational measures would be used for children, some stroke suﬀerers and some terminally ill patients. Observational measures include an assessment of the pain relief requested and used, pain behaviours (such as limping, grimacing and muscle tension) and time spent sleeping and/or resting. Physiological measures Both self-report measures and observational measures are sometimes regarded as unreliable if a supposedly ‘objective’ measure of pain is required. In particular, self- report measures are open to the bias of the individual in pain and observational measures are open to errors made by the observer. Such measures include an assess- ment of inﬂammation and measures of sweating, heart rate and skin temperature. However, the relationship between physiological measures and both observational and self-report measures is often contradictory, raising the question ‘Are the indi- vidual and the rater mistaken or are the physiological measurements not measuring pain? However, the gate control theory, developed in the 1960s and 1970s by Melzack and Wall, included psychological factors. As a result, pain was no longer understood as a sensation but as an active perception. Due to this inclusion of psychological factors into pain perception, research has examined the role of factors such as learning, anxiety, fear, catastrophizing, meaning, attention and pain behaviour in either decreasing or exacerbating pain. As psychological factors appeared to have a role to play in eliciting pain perception, multi- disciplinary pain clinics have been set up to use psychological factors in its treatment. Recently, researchers have suggested a role for pain acceptance as a useful outcome measure and some research indicates that acceptance, rather than coping might be a better predictor of adjustment to pain and changes following treatment. Early models of pain regarded the physical aspects of pain as ‘real’ and categorized pain as either ‘organic’ or ‘psychogenic’. Such models con- ceptualized the mind and body as separate and conform to a dualistic model of individuals. Recent models of pain have attempted to integrate the mind and the body by examining pain as a perception that is inﬂuenced by a multitude of diﬀerent factors. However, even within these models the mind and the body are still regarded as separate. It is often assumed that changes in theoretical perspective over time represents improvement with the recent theories reﬂecting a better approximation to the truth of ‘what pain really is’. However, perhaps these diﬀerent theories can also be used themselves as data to show how psychologists have thought in the past and how they now think about individuals. For example, in the past pain was seen as a passive response to external stimuli; therefore, individuals were seen as passive responders.