Barkley Review Part II

Primary provider
24/7 intervention
ongoing treatment and support
direct in-home assistance
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Terms in this set (86)
Freud Defense Mechanisms: unconscious processes, relieve anxiety 1. Compensation 2. Denial 3. Displacement 4. Identification 5. Intellectualization 6. Introjection 7. Isolation 8. Projection 9. Rationalization 10. Regression 11. Sublimation 12. Suppression 13. Undoing1. Compensation: strengthen one to hide another 2. Denial: refuse to face negative behavior 3. Displacement: take it out on someone else 4. Identification: attach to something positive 5. Intellectualization: focus on intellectual component, not emotions 6. Introjection: conform feelings for approval 7. Isolation: accepting reality without emotional response 8. Projection: projecting your own thoughts/feelings onto someone else 9. Rationalization: excuse and justify mistakes 10: Regression: act younger to feel better 11. Sublimation: divert negative energy into positive behavior 12. Suppression: suppress thoughts from being conscious 13. Undoing: attempt to undo thought/actionTherapy focused on the past Interpretation Free AssociationPsychodynamic Psychotherapy (Freud) Interpretation: discussing meaning of behavior Free Association: divulge thoughts/behavior immediately without censorshipDevelopmental Stages Birth to 3yo Focus on separation-individuationObject Relations Theory (Mahler)Internalization of experiences with othersKlein & Fairburn"Good enough Mother" Allows children to develop their true selvesWinnicottPeople seek confidence, self esteem and order to build their self-esteemKohutLooks at how people attach to each otherRelational ModelsSupportive Psychotherapy vs. Expressive PsychotherapySupportive: focus on problem solving, support, for moderate-severe mental illness Expressive: dealing with defense mechanisms (best for BPD)For patients with mature (and primitive) defense mechanisms and some object constancyPsychoanalytic PsychotherapyInterpersonal relationships determine our sense of security, who we are Good Me Bad Me Not MeInterpersonal Theory (Sullivan) Good Me: positive feedback, pleasure, contentment Bad Me: negative feedback, anxiety, discomfort Not Me: intense feelings, horror, dread, loathingCoping Strategies Interpersonal Theory 1. Security Operations 2. Selective Inattention 3. Dissociation1. Security Operations: measures to decrease anxiety 2. Selective Inattention: not paying attention to details that cause anxiety 3. Dissociation: not acknowledging things that cause anxiety1-3. Ego States (PAC) 4. Strokes 5. Structural Analysis 6. Transactional Analysis 7. Family Modeling 8. Analysis of Games & Rackets 9. Script AnalysisTransactional Analysis (Berne) 1. Parent: shoulds, oughts 2. Adult: objective, not emotional or judgmental 3. Child: feelings, impulsive acts 4. Strokes: feedback 5. Structural Analysis: patient becomes aware of ego states 6. Transactional Analysis: social interactions are analyzed to determine ego states 7. Family Modeling: imagining past situations, influence of significant others in interactions 8. Analysis of Games & Rackets: understanding transactions with others 9. Script Analysis: life patterns are evaluatedStrokes (Transactional Analysis) 1. Positive Strokes 2. Negative Strokes 3. Unconditional Strokes 4. Conditional Strokes 5. Games 6. Rackets 7. Life Scripts5. Games: repetitive, unconscious transactions between people where both parties end up experiencing rackets 6. Rackets: substitute feelings instead of authentic feelings 7. Life Scripts: life story we made up as childrenIndividual is responsible for his/her own environment Must accept personal responsibility Increased awareness of self Focused on PRESENTGestalt TherapyUnconditional Positive Regard Every patient has the ability to become aware of their problem and solve it Therapist helps the patient find their own path, not about probing Therapist Qualities: genuineness, warmth, empathy, active listening, reflectionPerson-Centered Therapy (Carl Rogers)Used for substance use disorders Collaborative Support clients in making change 1. Relational Component 2. Technical ComponentMotivational Interviewing 1. Relational Component: empathy 2. Technical Component: reinforcement of change talkTypes of Motivation 1. Amotivation 2. Extrinsic 3. Intrinsic1. Helpless 2. Activities with pay off 3. Self-rewardingOARSOpen-ended questions Affirmations Reflective listening SummariesStages of Change Model 1. Pre-contemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance 6. Relapse1. Pre: not considering change 2. Contemplation: ambivalent about change 3. Preparation: commit and plan 4. Action: implement and revise 5. Maintenance: integrate change into lifestyle 6. RelapseChange 1. Preparatory Phase 2. Predictive Phase (DARN-CAT)1. Preparatory Phase: desire, ability, reason, need 2. Predictive Phase: commitment, activation, taking stepsCBT 1. Schemas 2. Primary Thinking 3. Secondary Thinking 4. Socratic Dialogue 5. Downward Arrow 6. Labeling Distortions 7. Assertiveness Training 8. Cognitive Restructuring1. Schemas: world views, all encompassing 2. Primary Thinking: negative and irrational 3. Secondary Thinking: positive and rational 4. Socratic Dialogue: lead the patient to discovering and idea 5. Downward Arrow: if this is true, then what happens? 6. Labeling Distortions: all or nothing, catastrophizing 7. Assertiveness Training: help patients express needs/wants (helpful in family/couples therapy) 8. Cognitive Restructuring: alter dysfunctional thinking, improve feelings/behaviorAll behavior is a result of its consequences Encourage/discourage specific behavior using reinforcement, reinforcement comes after behaviorApplied Behavioral Analysis/Operant ConditioningSomething of monetary value in exchange for not using drugsContingency ManagementInvoluntary behavior is based on neutral stimulus (learned) Stimulus comes before behaviorStimulation-Response Model/Classical ConditioningIndividual experiences, actions of others, and environment influence behaviorSocial Cognitive Theory (Pavlov)All psychopathology has similar irrational beliefs rooted in childhood Examine validity of beliefsRational Emotive Therapy (Ellis)Change and acceptance Pt always does the best they can Pt cannot fail - therapist/treatment fails Therapist qualities: oriented to change, acceptanceDBT4 Elements of DBT1hr weekly therapy group skills training weekly skills coaching PRN team consultation to ensure treatment fidelityStages of DBT (1-4)1. focus on therapy engaging/interfering and life-threatening behaviors, diary cards are essential 2. non-traumatizing therapy, regulation of emotions 3. skills, self-awareness, dealing with trauma, exposure therapy 4. self-efficacy, interdependence, self-fulfillment, decreasing therapy sessionsHildegard Peplau's 6 Nursing Subroles ***PMHNP main role1. Mother-Surrogate: provide basic needs 2. Technician 3. Manager: manage environment 4. Socializing Agent 5. Health Teacher 6. Counselor/Psychotherapist: PMHNP main roleStages of Therapy 1. Pretreatment 2. Beginning 3. Middle 4. End Phase/Termination 5. F/u1. Pretreatment: patient identifies goals, expected time for resolution 2. Beginning: develop therapeutic alliance, ID issues, set limits, contract for number of sessions/payment 3. Middle: increase awareness, clarify, confront, interpret resistance, monitor progress 4. End Phase/Termination 5. F/u PRNPhases of Therapeutic Relationship 1. Orientation 2. Working Phase 3. Termination1. Orientation: 1+ meetings, establish relationship, work on communication, ID roles 2. Working Phase: gather info, positive change, work through resistance, discuss termination 3. Termination: goals are met, review accomplishments, discuss guidelines for future communicationIndividuals learn how to differentiate themselves within a family 1. Fusion 2. Cutoffs 3. Emotional Reactivity 4. TrianglesFamily Systems Therapy 1. Fusion: people borrow/lend one another 2. Cutoffs: immature separation 3. Emotional Reactivity: react without separating thoughts, feelings 4. Triangles: person A focuses on person C to manage anxiety with person B (de-triangulation allows for differentiation)Strategies families have developed to deal with issues becomes a problemStrategic Family TherapyFamily therapy with: 1. Subsystems 2. Boundaries 3. Enmeshment 4. DisengagementStructural Family Therapy 1. Subsystems: subgroups within a family connect 2. Boundaries: emotional walls 3. Enmeshment: not enough boundaries 4. Disengagement: rigid boundariesShort term (10-15 sessions) family therapy that uses multiple different theoriesEmotionally Focused Family TherapyRecovery is the most important goal Individuals improve their health/wellness, live.a self-directed life, strive to reach full potential Adherence to treatment is a predictor of recovery 1. Concordance 2. Person-Centered 3. Exchange-Centered 4. Community-CenteredRecovery Model of Care 1. Concordance: partnership with pt, not authoritative, communication is key 2. Person-Centered: sense of hope, self-determination 3. Exchange-Centered: taking on social roles 4. Community-Centered: social connections, community integrationL-a-acetylmethadol (LAAM)alt to methadone effective for up to 36hrs, dosed three times per weekRisk for ETOH use disorder in amount consumed per week or per day Men WomenMen: 14 drinks per week, 4 drinks per day Women: 7 per week, 3 per daySBIRT CAGE AUDITSBIRT: Screening, Brief Intervention and Referral Tool (for substance use) AUDIT: Alcohol Use Disorders Identification TestETOH Withdrawal Onset of 1. Seizures 2. DT's1. Seizures: 7-48hrs 2. DT's: 48-72hrsCIWA Score >15 8-14 0-8>15: immediate pharm intervention 8-14: initiate pharm intervention 0-8: supportive treatment, continue monitoringTreatment for: 1. Wernicke's Encephalopathy 2. Alcohol Deterrent1. Prophylactic: IV Thiamine 250mg daily X3-5 days Treatment: IV Thiamine 500mg daily X3-5 days, then 250mg X3-5 days (Healthy drinkers PO Thiamine 300mg daily during detox) 2. Disulfiram (Antabuse) Acamprosate (Campral)COWS Score (treatment) 0-14 >150-14: Clonidine >15: Clonidine +/- Phenobarbital, methadoneFDA approved meds for mood dysregulation in childrenFluoxetine, Fluvox, Sertraline (7+) Depakote (3+) Lithium (7+) Olanzapine (Zyprexa), Quetiapine, Abilify, Arsenapine (Saphris), Lurasidone (10+) Carbamazepine (13+)Palilalia Echolalia CoprolaliaPalilalia: repeating one's own sound/words Echolalia: repeating the last heard word/phrase Coprolalia: saying socially unacceptable wordsPharm Treatments for TourettesPimizide (Orap) Haldol ClonidinePharm Treatment EnuresisImipramine (OD can cause cardiac arrhythmia) Desmopressin (DDAVP): nocturnal enuresis Oxybutynin: daytime incontinenceLow Na Low K Low Cl Elevated CO2 Metabolic AlkalosisAnorexia /BulimiaSigns of AnorexiaVery low BMI Lanugo Hypothermia Bradycardia Loss of SubQ tissue, pubic/scalp hair Pigmentation of chest/abdomen Distended abdomenSigns of BulimiaFull facies: parotid/submaxillary swelling Tachycardia Orthostatic hypotension Russell's Sign: scratches/calluses over knuckles petechiae, subconjunctival hemorrhage abdominal tendernessIncidence of anxiety in the US12-25%1. Moderate Anxiety 2. Severe Anxiety1. Moderate: inability to concentrate, impaired learning, perceptual distortions, restless, muscle tension 2. Severe (pathologic): limited attention/concentration, increased somatic symptoms, behavior aimed at relieving anxiety, response not proportional to threat, response continued beyond threat, impaired functioning1. Medicare A 2. Medicare B 3. Medicare C 4. Medicare D1. A: inpatient, SNF, home health, hospice 2. B: physician services, outpatient hospital services, labs, diagnostic procedures, medical equipment 3. A + B = C 4. D: Rx coverageIncident to Billing- Billing under a licensed physician (or other health care provider), can be billed at 100% of physician fee (80% of bill is payed by Medicare, 20% by patient, NP is payed 85%) - physician must be present in the office - physician must perform initial eval and subsequent intermittent evalsSteps of Quality Improvement-Conducting an assessment -Setting specific goals for improvement -Identifying ideas for changing current practice -Deciding how improvements in care will be measured -Rapidly testing practice changes -Measuring improvements in care -Adopting the practice change as a new standard of careRoot Cause Analysisfollows sentinel event (death or serious injury) experts analyze underlying cause and effect through why questions identify risks determine potential improvementsLACE ModelLicensure Accreditation Certification Educationmeta-analysis vs. meta-synthesisAnalysis: uses quantitative studies to test hypothesis Synthesis: uses qualitative studies to build new theoriesPICOTPatient Intervention Comparison Outcome Timeframe1. Level of significance (p-value) 2. Confidence Interval1. p-value = <.05 is statistically significant 2. Confidence Interval: smaller interval is more preciseInternal Validity vs. External ValidityInternal: treatment lead to outcome External: generalizability of resultsProstate CA Screening40: 1+ first degree relative with prostate CA at early age 45: African American, 1+ first degree relative with prostate CA <65yo 50: avg risk, expected to live >10 yearsDepression NT and part of brainSerotonin Locus CoreolusAnxiety NT and part of brainElevated Serotonin, Norepinephrine Decreased GABA Raphe Nuclei, AmygdalaPsychosis NT and part of brainElevated Dopamine Basal Ganglia1. frontal lobe 2. parietal lobe 3. occipital lobe 4. temporal lobe1. Frontal: Personality, decision making, movement, sense of smell, Broca's Area (speech) 2. Parietal: identify objects, spacial relations, pain/touch, Wernicke's Area (understanding language) 3. Occipital: vision 4. Temporal: short term memory, speech, musical rhythmErickson 1. Trust vs. Mistrust 2. Autonomy vs. Shame and Doubt 3. Initiative vs. Guilt 4. Industry vs. Inferiority 5. Identity vs. Role Confusion1. infancy. Goal: develop trust. Failure: difficulty giving/receiving 2. 18mo to 3yo. Goal: gain self control, willpower. Failure: lack of confidence 3. 3yo to 6yo. Goal: identify and direct activities. Failure: inadequacy, guilt 4. 6yo to 12yo. Goal: self confidence, peer recognition. Failure: low self esteem, poor interpersonal skills 5. 12yo to 20yo. Goal: develop identity. Failure: lack of direction, self confidenceClozaril Monitoring, Dosing12.5, 25-50, max 900 >2000, 1500, 1000NMS Treatment Hot, stiff and out of itDantrolene, Amantadine BromocriptineSerotonin Syndrome TreatmentCyproheptadine Dantrolene2C19 1A2 2D6 3A42C19 - Asians 20%, AA 19% 1A2 - Cigarettes 2D6 - Caucasians 3A4 - all meds, grapefruit juice, carbamazepineLithium Tox Monitoring>1.2 5-7 days after dose change, initiationDoxepin ClassTCACauses side effect/contraindication of liver toxPhenobarbital, Depakote, CarbamazepineSelegilineAnti-parkinson med and MAOI