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According to managing diabetes during intercurrent illness in the community generic 50mg precose with amex this model metabolic disease 10 precose 50mg generic, sexual offenders may be characterized as specialists who commit sexual crimes persistently or as generalists who do not restrict themselves to diabetes signs in infants cheap 25 mg precose with mastercard one type of crime; they commit different crimes over time (Lussier diabetes test without insurance discount 25mg precose amex, 2005). This model has been shown to have a distinct etiology — specifcally, a his to ry of childhood sexual abuse (Bur to n, 2003; Marshall & Marshall, 2000). As previously discussed, developmental studies have demonstrated the association between childhood sexual experiences and sexual abuse of children (Jespersen, Lalumiere & Se to, 2009). Child sexual abusers who are specialists are more likely than generalists to exhibit sexual deviance and sexual preoccupation and to have an emotional congruence with children (Groth, 1979; Harris, Mazerolle & Knight, 2009; Laws & Marshall, 1990). Similar to rapists, generalist (versatile) offenders resemble violent nonsexual offenders (Craissati, 2005; Langstrom, Sjostedt & Grann, 2004; Simon, 2000). Hanson (2002) concluded that, in addition to sexual deviance, variables such as low self-control, criminal lifestyle, impulsivity and opportunity are important fac to rs associated with sexual offending. Sexual offenders (the majority of rapists and a subset of child sexual abusers) have demonstrated substance abuse and relationship problems, antisocial behavior in adolescence, employment instability and evidence of psychopathy (Harris, Mazerolle & Knight, 2009; Lussier, Proulx & LeBlanc, 2005). Lussier, Proulx and LeBlanc (2005) examined whether sexual offending among 388 convicted sexual offenders could be explained by a generalist theory of crime using structural equation modeling. They reported differences among child sexual abusers and rapists and concluded that, similar to traditional typologies, the offense patterns of rapists were versatile and that rapists displayed extensive antisocial tendencies. In contrast, child sexual abusers were more likely than rapists to specialize in sexual offending. Harris, Mazerolle and Knight (2009) examined 374 male sexual offenders to compare these models of sexual offending. The researchers found that the majority of sexual offenders followed the generalist model. Rapists and child sexual abusers exhibited extensive criminal his to ries, substance abuse issues, antisocial tendencies and psychosis. Those who did specialize in sexual crimes were more likely to exhibit characteristics similar to child sexual abusers, such as sexual deviance and sexual preoccupation. As Lussier, Proulx and LeBlanc (2005) found, the specialist model was evident in child sexual abusers. Child sexual abusers assessed as specialists were more likely than nonspecialists to know the victim, exhibit sexual preoccupation and display emotional congruence with children. Francis, Harris, Wallace, Knight and Soothill (2013) examined the life course of 780 sexual offenders in civil commitment treatment between 1959 and 1984. Specifcally, this study investigated distinct trajec to ries of offending, comparing generalist crime to specialist crime. Results identifed four trajec to ries to sexual offending, which varied according to offense pattern. Differences were found with respect to criminal onset, length of criminal career, age of peak offending and time of entry in to treatment. Overall, late onset was associated with child sexual abuse and early onset (younger) was associated with rape. Likewise, fndings indicated sexual offending began later than nonsexual offending and three out of four groups exhibited a decrease in frequency with age. Two groups (low-rate and high-rate limited) offended at an earlier age than the other groups (low-rate persistent and high-rate persistent). Low-rate persistent offenders (56 percent of the sample) began offending during late teens and offended less than once per year with the highest point in their 30s. High-rate limited offenders (24 percent) exhibited an earlier age of onset and offended most frequently (average twice per year) during their late 20s. This trajec to ry was consistent with the generalist pattern and the decline in offending occurred during their 50s. The third group or high-rate accelera to rs (12 percent) began offending during their 20s and their offending increased until mid-40s; this group consisted primarily of child sexual abusers. They began sexual offending during their late 20s and the offending behaviors increased to its peak during their mid-50s. Taken to gether, fndings indicate there are distinct trajec to ries of offending based upon onset, frequency and persistence. These fndings are consistent with many traditional typologies of rapists and child sexual abusers; however, the results suggest that the generalist vs. Future research in this area is needed to further identify fac to rs that characterize specialist offenders from generalist offenders. Current research emphasizes the importance of a comprehensive approach to sex offender typologies, through the assessment of criminogenic needs (dynamic risk) and offense patterns, not based upon the type of victim exclusively (Martinez-Catena et al. Recent advances in our knowledge of developmental risk fac to rs and offense pathways can assist with risk and need evaluation, but additional research is needed to develop more extensive models to explain sexual deviance. Nonetheless, through a comprehensive understanding of treatment needs and subsequent effective intervention, an offender can attend to the process, learn skills and alternative strategies to sexual violence and, ultimately, strive to live a healthy lifestyle without offending. Advances in developmental risk fac to rs and offense pathways can assist with risk and need evaluation, but additional research is needed to develop models of sexual deviance. Axis I includes fxation, or the degree of pedophilic interest and the degree of social competence. Although this typology has been validated in several studies, it has not demonstrated clinical utility with respect to recidivism or treatment (Camilleri & Quinsey, 2008). Rapists are classifed as opportunistic (with high or low social competence), pervasively angry, sadistic (overt or muted), sexual nonsadistic (also with high or low social competence) and vindictive (with high or low social competence). Studies have failed to classify rapists according to these nine subtypes without refnement (Barbaree et al. Hanson and Bussiere (1998) conducted a meta-analysis based on 61 studies for a to tal sample of 28,972 sexual offenders. Note these recidivism measures exceed 100 percent as 27 of the 61 studies included in the meta-analysis included multiple indexes of recidivism. See the “Polygraph” Section of Chapter 8: “Sex Offender Management Strategies,” in the Adult section. A descriptive study of rapists and child molesters: Developmental, clinical, and criminal characteristics. An exploration of developmental fac to rs related to deviant sexual preferences among adult rapists. Implications for treatment of sexual offenders of the Ward and Hudson model of relapse. The Butner study redux: A report of the incidence of hands-on child victimization by child pornography offenders. International Journal of Offender Therapy and Comparative Criminology, 39, 306–317. Failures in the expectable environment and their impact on individual development: the case of child maltreatment. Women convicted of promoting prostitution of a minor are different from women convicted of traditional sexual offenses A brief research report. Sexual violence against women: A psychological approach to the assessment and management of rapists in the community. The role of key developmental variables in identifying sex offenders likely to fail in the community: An enhanced risk prediction model. The parental bonding experiences of sex offenders: A comparison between child molesters and rapists. Growing up with parental alcohol abuse: Exposure to childhood abuse, neglect and household dysfunction. The effect of polygraphy on the self-report of adolescent sex offenders: Implications for risk assessment. Female and male sex offenders: A comparison of recidivism patterns and risk fac to rs. A re-examination of female child molesters’ implicit theories: Evidence for Female Specifcityfi Ward and Siegert’s Pathways Model of child sexual offending: A cluster analysis evaluation. Characteristics of Females Who Sexually Offend A Comparison of Solo and Co-Offenders.
Individuals with blood-injection-injury specific phobia are often reluctant to diabetic vs pre diabetic discount precose 50mg line obtain med ical care even when a medical concern is present blood glucose number 50 mg precose visa. Additionally diabetes mellitus jenis 1 purchase precose 50 mg line, fear of vomiting and chok ing may substantially reduce dietary intake diabetes menu discount precose 50mg with visa. Situational specific phobia may resemble agoraphobia in its clinical pre sentation, given the overlap in feared situations. If an individual fears only one of the agoraphobia situations, then specific phobia, situa tional, may be diagnosed. If two or more agoraphobic situations are feared, a diagnosis of agoraphobia is likely warranted. Criterion B of agoraphobia (the situations are feared or avoided "because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symp to ms or other inca pacitating or embarrassing symp to ms") can also be useful in differentiating agoraphobia from specific phobia. If the situations are feared for other reasons, such as fear of being harmed directly by the object or situations. If the situations are feared because of negative evaluation, so cial anxiety disorder should be diagnosed instead of specific phobia. If the situations are feared because of separation from a primary caregiver or attachment figure, separation anxiety disorder should be diagnosed instead of specific phobia. Individuals with specific phobia may experience panic attacks when con fronted with their feared situation or object. A diagnosis of specific phobia would be given if the panic attacks only occurred in response to the specific object or situation, whereas a di agnosis of panic disorder would be given if the individual also experienced panic attacks that were unexpected. A diagnosis of specific phobia is not given if the avoidance behavior is exclusively limited to avoidance of food and food-related cues, in which case a diagnosis of anorexia nervosa or bulimia nervosa should be considered. When the fear and avoidance are due to delusional thinking (as in schizophrenia or other schizophrenia spectrum and other psychotic disorders), a diagnosis of specific phobia is not warranted. Comorbidity Specific phobia is rarely seen in medical-clinical settings in the absence of other psycho pathology and is more frequently seen in nonmedical mental health settings. Specific pho bia is frequently associated with a range of other disorders, especially depression in older adults. Because of early onset, specific phobia is typically the temporally primary disorder. Individuals with specific phobia are at increased risk for the development of other dis orders, including other anxiety disorders, depressive and bipolar disorders, substance related disorders, somatic symp to m and related disorders, and personality disorders (par ticularly dependent personality disorder). Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Note: In children, the anxiety must occur in peer settings and not just during interac tions with adults. The individual fears that he or she will act in a way or show anxiety symp to ms that will be negatively evaluated. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. The fear, anxiety, or avoidance is not attributable to the physiological effects of a sub stance. The fear, anxiety, or avoidance is not better explained by the symp to ms of another mental disorder, such as panic disorder, body dysmofihic disorder, or autism spectrum disorder. Specify if: Performance only: If the fear is restricted to speaking or performing in public. Specifiers Individuals with the performance only type of social anxiety disorder have performance fears that are typically most impairing in their professional lives. Performance fears may also manifest in work, school, or academic settings in which regular public presenta tions are required. Individuals with performance only social anxiety disorder do not fear or avoid nonperformance social situations. Diagnostic Features the essential feature of social anxiety disorder is a marked, or intense, fear or anxiety of so cial situations in which the individual may be scrutinized by others. In children the fear or anxiety must occur in peer settings and not just during interactions with adults (Criterion A). When exposed to such social situations, the individual fears that he or she will be neg atively evaluated. The individual is concerned that he or she will be judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikable. Fear of offending others—for example, by a gaze or by showing anxiety symp to ms—may be the predominant fear in individuals from cultures with strong collectivistic orientations. An individual with fear of trembling of the hands may avoid drinking, eat ing, writing, or pointing in public; an individual with fear of sweating may avoid shaking hands or eating spicy foods; and an individual with fear of blushing may avoid public per formance, bright lights, or discussion about intimate to pics. Some individuals fear and avoid urinating in public restrooms when other individuals are present. Thus, an in dividual who becomes anxious only occasionally in the social situation(s) would not be di agnosed with social anxiety disorder. The antici pa to ry anxiety may occur sometimes far in advance of upcoming situations. In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, or shrinking in social situations. Alternatively, the situations are endured with intense fear or anxiety (Criterion D). The fear or anxiety is judged to be out of proportion to the actual risk of being nega tively evaluated or to the consequences of such negative evaluation (Criterion E). Some times, the anxiety may not be judged to be excessive, because it is related to an actual danger. However, individuals with social anx iety disorder often overestimate the negative consequences of social situations, and thus the judgment of being out of proportion is made by the clinician. For ex ample, in certain cultures, behavior that might otherwise appear socially anxious may be considered appropriate in social situations. This dura tion threshold helps distinguish the disorder from transient social fears that are com mon, particularly among children and in the community. For example, an individual who is afraid to speak in pub lic would not receive a diagnosis of social anxiety disorder if this activity is not routinely encountered on the job or in classroom work, and if the individual is not significantly dis tressed about it. However, if the individual avoids, or is passed over for, the job or educa tion he or she really wants because of social anxiety symp to ms. Associated Features Supporting Diagnosis Individuals with social anxiety disorder may be inadequately assertive or excessively sub missive or, less commonly, highly controlling of the conversation. They may show overly rigid body posture or inadequate eye contact, or speak with an overly soft voice. These in dividuals may be shy or withdrawn, and they may be less open in conversations and dis close little about themselves. They may seek employment in jobs that do not require social contact, although this is not the case for individuals with social anxiety disorder, perfor mance only. Men may be delayed in marrying and having a family, whereas women who would want to work outside the home may live a life as homemaker and mother. Social anxiety among older adults may also include exacerbation of symp to ms of medical illnesses, such as increased tremor or tachycardia. Prevaience the 12-month prevalence estimate of social anxiety disorder for the United States is ap proximately 7%. Lower 12-month prevalence estimates are seen in much of the world us ing the same diagnostic instrument, clustering around 0. The 12-month prevalence rates in children and adolescents are comparable to those in adults. In general, higher rates of social anxiety disorder are found in females than in males in the general population (with odds ratios ranging from 1. Gender rates are equivalent or slightly higher for males in clinical samples, and it is assumed that gender roles and social expectations play a significant role in ex plaining the heightened help-seeking behavior in male patients.
Avoidant personality disorder must also be distinguished from symp to diabetes mellitus type 2 diet food purchase precose overnight delivery ms that may develop in association with persistent substance use diabetes prevention dr oz buy cheap precose 50 mg. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others blood sugar foods discount precose online amex. Has difficulty expressing disagreement with others because of fear of loss of support or approval managing diabetes when sick purchase 50 mg precose mastercard. Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy). Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. Urgently seeks another relationship as a source of care and support when a close re lationship ends. Is unrealistically preoccupied with fears of being left to take care of himself or herself. Diagnostic Features the essential feature of dependent personality disorder is a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. The dependent and submissive behaviors are designed to elicit caregiving and arise from a self-perception of being unable to function adequately without the help of others. Individuals with dependent personality disorder have great difficulty making every day decisions. These individu als tend to be passive and to allow other people (often a single other person) to take the ini tiative and assume responsibility for most major areas of their lives (Criterion 2). Adults with this disorder typically depend on a parent or spouse to decide where they should live, what kind of job they should have, and which neighbors to befriend. Adolescents with this disorder may allow their parent(s) to decide what they should wear, with whom they should associate, how they should spend their free time, and what school or college they should attend. This need for others to assume responsibility goes beyond age-appro priate and situation-appropriate requests for assistance from others. Dependent personality dis order may occur in an individual who has a serious medical condition or disability, but in such cases the difficulty in taking responsibility must go beyond what would normally be associated with that condition or disability. Because they fear losing support or approval, individuals with dependent personality disorder often have difficulty expressing disagreement with other individuals, especially those on whom they are dependent (Criterion 3). These individuals feel so unable to func tion alone that they will agree with things that they feel are wrong rather than risk losing the help of those to whom they look for guidance. They do not get appropriately angry at others whose support and nurturance they need for fear of alienating them. Individuals with this disorder have difficulty initiating projects or doing things inde pendently (Criterion 4). They lack self-confidence and believe that they need help to begin and carry through tasks. They will wait for others to start things because they believe that as a rule others can do them better. These individuals are convinced that they are incapable of functioning independently and present themselves as inept and requiring constant as sistance. They are, however, likely to function adequately if given the assurance that some one else is supervising and approving. There may be a fear of becoming or appearing to be more competent, because they may believe that this will lead to abandonment. Because they rely on others to handle their problems, they often do not leam the skills of indepen dent living, thus perpetuating dependency. Individuals with dependent personality disorder may go to excessive lengths to obtain nurturance and support from others, even to the point of volunteering for unpleasant tasks if such behavior will bring the care they need (Criterion 5). They are willing to submit to what others want, even if the demands are unreasonable. Their need to maintain an im portant bond will often result in imbalanced or dis to rted relationships. They may make ex traordinary self-sacrifices or to lerate verbal, physical, or sexual abuse. They will "tag along" with important others just to avoid being alone, even if they are not interested or involved in what is happening. Their belief that they are unable to function in the absence of a close relationship motivates these individuals to become quickly and indiscriminately attached to another individual. Individuals with this disorder are often preoccupied with fears of being left to care for themselves (Criterion 8). They see themselves as so to tally dependent on the advice and help of an important other person that they worry about being abandoned by that person when there are no grounds to justify such fears. To be considered as evidence of this criterion, the fears must be excessive and unrealistic. Associated Features Supporting Diagnosis Individuals with dependent personality disorder are often characterized by pessimism and self-doubt, tend to belittle their abilities and assets, and may constantly refer to them selves as "stupid. They may avoid positions of responsibility and become anxious when faced with decisions. Social re lations tend to be limited to those few people on whom the individual is dependent. There may be an increased risk of depressive disorders, anxiety disorders, and adjustment dis orders. Dependent personality disorder often co-occurs with other personality disorders, especially borderline, avoidant, and histrionic personality disorders. Chronic physical ill ness or separation anxiety disorder in childhood or adolescence may predispose the indi vidual to the development of this disorder. Prevalence Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Condi tions yielded an estimated prevalence of dependent personality disorder of 0. Deveiopment and Course this diagnosis should be used with great caution, if at all, in children and adolescents, for whom dependent behavior may be developmentally appropriate. C ulture-Reiated Diagnostic issues the degree to which dependent behaviors are considered to be appropriate varies sub stantially across different age and sociocultural groups. Age and cultural fac to rs need to be considered in evaluating the diagnostic threshold of each criterion. An emphasis on passivity, politeness, and deferential treatment is characteristic of some societies and may be mis interpreted as traits of dependent personality disorder. Similarly, societies may differen tially foster and discourage dependent behavior in males and females. G ender-Reiated Diagnostic Issues In clinical settings, dependent personality disorder has been diagnosed more frequently in females, although some studies report similar prevalence rates among males and females. Dependent personality disorder must be distinguished from dependency arising as a consequence of other mental disorders. Other personality disorders may be confused with dependent personality disorder because they have certain features in com mon. However, if an individual has personality features that meet cri teria for one or more personality disorders in addition to dependent personality disorder, all can be diagnosed. Although many personality disorders are characterized by dependent features, dependent personality disorder can be distinguished by its predominantly submis sive, reactive, and clinging behavior. Both dependent personality disorder and borderline personality disorder are characterized by fear of abandonment; however, the individual with borderline personality disorder reacts to abandonment with feelings of emotional emp tiness, rage, and demands, whereas the individual with dependent personality disorder re acts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline personality disorder can further be distinguished from dependent personality disorder by a typical pattern of unstable and intense relationships. Individuals with histrionic personality disorder, like those with de pendent personality disorder, have a strong need for reassurance and approval and may ap pear childlike and clinging. However, unlike dependent personality disorder, which is characterized by self-effacing and docile behavior, histrionic personality disorder is charac terized by gregarious flamboyance with active demands for attention. Both dependent personality disorder and avoidant personality disorder are characterized by feelings of in adequacy, hypersensitivity to criticism, and a need for reassurance; however, individuals with avoidant personality disorder have such a strong fear of humiliation and rejection that they withdraw until they are certain they will be accepted. In contrast, individuals with de pendent personality disorder have a pattern of seeking and maintaining connections to im portant others, rather than avoiding and withdrawing from relationships. Oruy when these traits are in flexible, maladaptive, and persisting and cause significant functional impairment or sub jective distress do they constitute dependent personality disorder. Dependent personality disor der must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system.
Depression is likely the oldest and still one of the most frequently diagnosed psychiatric illnesses diabetic diet for dogs cheap 50 mg precose with amex. It is so common in our society as to diabetes type 1 who is at risk cheap 50mg precose free shipping some times be called “the common cold of psychiatric disorders diabetes test melbourne discount precose 25mg on line. Clinical manifestations include frequent diabetes symptoms hindi 50mg precose with visa, developmentally inappropriate temper outbursts and persist ently angry mood that is present between the severe temper outbursts. The behavior has been present for 12 or more months, and occurs in more than one setting. Onset of the disorder occurs before age 10 years, but the diagnosis is not applied to children younger than 6 years. There is evidence of interference in social and occupational functioning for at least 2 weeks. There is no his to ry of manic behavior and the symp to ms cannot be attributed to use of substances or another medical condition. The diagnosis will also identify the degree of severity of symp to ms (mild, moderate, or severe) and whether the disorder is in partial or full remission. With Anxious Distress: Feelings of restlessness, anxiety, and worry accompany the depressed mood. With Mixed Features: the depression is accompanied by intermittent symp to ms of mania or hypomania. With Melancholic Features: the depressed mood is charac terized by profound despondency and despair. There is an absence of the ability to experience pleasure and expression of feelings of excessive or inappropriate guilt. With Atypical Features: Includes the ability for cheerful mood when presented with positive events. Additional symp to ms include long-standing sensitivity to interpersonal rejection and heavy, leaden feelings in the arms or legs. With Psychotic Features: Depressive symp to ms include the presence of delusions and/or hallucinations. With Cata to nia: Depressive symp to ms are accompanied by additional symp to ms associated with cata to nia. With Peripartum Onset: this specifier is used when symp to ms of major depressive disorder occur during pregnancy or in the 4 weeks following delivery. With Seasonal Pattern: this diagnosis indicates the presence of depressive episodes that occur at characteristic times of the year. Commonly, the episodes occur during the fall or winter months, and remit in the spring. Persistent Depressive Disorder (Dysthymia) Persistent depressive disorder is a mood disturbance with charac teristics similar to, if somewhat milder than, those ascribed to major depressive disorder. Substance/Medication-Induced Depressive Disorder the depressed mood associated with this disorder is considered to be the direct result of the physiological effects of a substance. The depression causes clinically signifcant distress or impairment in social, occu pational, or other important areas of functioning. Genetic: Numerous studies have been conducted that support the involvement of heredity in depressive illness. Biochemical: A biochemical theory implicates the biogenic amines norepinephrine, dopamine, and sero to nin. The lev els of these chemicals have been found to be deficient in individuals with depressive illness. Neuroendocrine Disturbances: Elevated levels of serum cortisol and decreased levels of thyroid stimulating hor mone have been associated with depressed mood in some individuals. Substance In to xication and Withdrawal: Depressed mood may be associated with in to xication or withdrawal from substances such as alcohol, amphetamines, cocaine, hallu cinogens, opioids, phencyclidine-like substances, sedatives, hypnotics, or anxiolytics. Medication Side Effects: A number of drugs can produce a depressive syndrome as a side effect. Antihy pertensive medications such as propranolol and reserpine have been known to produce depressive symp to ms. Others include steroids, hormones, antineoplastics, analgesics, and antiulcer medications. Other Physiological Conditions: Depressive symp to ms may occur in the presence of electrolyte disturbances, hormonal Depressive Disorders 135 disturbances, nutritional deficiencies, and with certain phys ical disorders, such as cardiovascular accident, systemic lupus erythema to sus, hepatitis, and diabetes mellitus. Psychoanalytical Theory: Freud observed that melancholia occurs after the loss of a loved object, either actually by death or emotionally by rejection, or the loss of some other abstraction of value to the individual. Freud indicated that in clients with melancholia, the depressed person’s rage is internally directed because of identification with the lost object (Sadock & Sadock, 2007). Cognitive Theory: Beck and colleagues (1979) proposed that depressive illness occurs as a result of impaired cogni tion. Disturbed thought processes foster a negative evalua tion of self by the individual. Learning Theory: the learning theory (Seligman, 1973) proposes that depressive illness is predisposed by the indi vidual’s belief that there is a lack of control over his or her life situation. It is thought that this belief arises out of ex periences that result in failure (either perceived or real). Following numerous failures, the individual feels helpless to succeed at any endeavor and therefore gives up trying. Object Loss Theory: the theory of object loss suggests that depressive illness occurs as a result of having been aban doned by, or otherwise separated from, a significant other during the first 6 months of life. Because during this period the mother represents the child’s main source of security, she is the “object. This absence of attachment, which may be ei ther physical or emotional, leads to feelings of helplessness and despair that contribute to lifelong patterns of depres sion in response to loss. The affect of a depressed person is one of sadness, dejection, helplessness, and hopelessness. In se vere depression, psychotic features such as hallucinations and delusions may be evident, reflecting misinterpretations of the environment. The individual may express an exaggerated concern over bodily functioning, seemingly experiencing heightened sensitivity to somatic sensations. Some individuals may be inclined to ward excessive eating and drinking, whereas others may experience anorexia and weight loss. In response to a general slowdown of the body, digestion is often sluggish, constipation is common, and urinary reten tion is possible. At the less severe level (dysthymia), individuals tend to feel their best early in the morning, then continually feel worse as the day progresses. The exact cause of this phenomenon is unknown, but it is thought to be related to the circadian rhythm of the hormones and their effects on the body. A general slowdown of mo to r activity commonly accompanies de pression (called psychomo to r retardation). At the severe level, energy is depleted, movements are lethargic, and performance of daily activities is extremely difficult. Regression is common, evidenced by withdrawal in to the self and retreat to the fetal position. Con versely, severely depressed persons may manifest psychomo to r activity through symp to ms of agitation. These are constant, rapid, purposeless movements, out of to uch with the environment. When depressed persons do speak, the content may be either ruminations regarding their own life regrets or, in psychotic clients, a reflection of their delusional thinking. The depressed client has an inclination to ward egocentrism and narcissism—an intense focus on the self. This discourages others from pursuing a relationship with the individual, which increases his or her feel ings of worthlessness and penchant for isolation. Common Nursing Diagnoses and Interventions for Depression (Interventions are applicable to various health-care settings, such as in patient and partial hospitalization, community outpatient clinic, home health, and private practice. Client will make short-term verbal (or written) contract with nurse not to harm self. Remove all potentially harmful objects from client’s access (sharp objects, straps, belts, ties, glass items). Formulate a short-term verbal or written contract with the client that he or she will not harm self during specific time pe riod. Discussion of suicidal feelings with a trusted individual pro vides some relief to the client.
However diabetes self care definition 25mg precose sale, it is these behavioral events diabetes medications that cause pancreatitis buy generic precose 25 mg, rather than the insomnia per se diabetes type 1 levels precose 50 mg, that dominate the clinical picture diabetes mellitus by who order precose with visa. Substance/medication induced sleep disorder, insomnia type, is distinguished from insomnia disorder by the fact that a substance. For example, insomnia occurring only in the context of heavy coffee consumption would be diagnosed as caffeine-induced sleep disorder, insomnia type, with onset during in to xication. Comorbidity Insomnia is a common comorbidity of many medical conditions, including diabetes, cor onary heart disease, chronic obstructive pulmonary disease, arthritis, fibromyalgia, and other chronic pain conditions. The risk relationship appears to be bidirectional: insomnia increases the risk of medical conditions, and medical problems increase the risk of insom nia. The direction of the relationship is not always clear and may change over time; for this reason, comorbid insomnia is the preferred terminology in the presence of coexisting in somnia with another medical condition (or mental disorder). Individuals with insomnia disorder frequently have a comorbid mental disorder, par ticularly bipolar, depressive, and anxiety disorders. Persistent insomnia represents a risk fac to r or an early symp to m of subsequent bipolar, depressive, anxiety, and substance use disorders. Individuals with insomnia may misuse medications or alcohol to help with nighttime sleep, anxiolytics to combat tension or anxiety, and caffeine or other stimulants to combat excessive fatigue. In addition to worsening the insomnia, this type of substance use may in some cases progress to a substance use disorder. These include psychophysiological insomnia, idiopathic insomnia, sleep-state mispercep tion, and inadequate sleep hygiene. Despite their clinical appeal and heuristic value, there is limited evidence to support these distinct phenotypes. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symp to ms: 1. A prolonged main sleep episode of more than 9 hours per day that is nonres to rative. The hypersomnolence is accompanied by significant distress or impairment in cogni tive, social, occupational, or other important areas of functioning. The hypersomnolence is not better explained by and does not occur exclusively during the course of another sleep disorder. The hypersomnolence is not attributable to the physiological effects of a substance. Coexisting mental and medical disorders do not adequately explain the predominant complaint of t^ypersomnolence. Specify if: With mental disorder, including substance use disorders With medicai condition With another sleep disorder Coding note: the code 780. Code also the relevant associated mental disorder, medical condition, or other sleep disorder im mediately after the code for hypersomnolence disorder in order to indicate the associ ation. Specify current severity: Specify severity based on degree of difficulty maintaining daytime alertness as manifested by the occurrence of multiple attacks of irresistible sleepiness within any given day occur ring, for example, while sedentary, driving, visiting with friends, or working. Diagnostic Features Hypersomnolence is a broad diagnostic term and includes symp to ms of excessive quantity of sleep. Individuals with this disorder fall asleep quickly and have a good sleep efficiency (>90%). They may have difficulty waking up in the morning, sometimes appearing confused, combative, or ataxic. This prolonged impairment of alert ness at the sleep-wake transition is often referred to as sleep inertia. During that period, the individual appears awake, but there is a decline in mo to r dexterity, behavior may be very inappro priate, and memory deficits, disorientation in time and space, and feelings of grogginess may occur. The persistent need for sleep can lead to au to matic behavior (usually of a very routine, low-complexity type) that the individual carries out with little or no subsequent recall. For example, individuals may find themselves having driven several miles from where they thought they were, unaware of the "au to matic" driving they did in the preceding minutes. For some individuals with hypersomnolence disorder, the major sleep episode (for most individuals, nocturnal sleep) has a duration of 9 hours or more. However, the sleep is often nonres to rative and is followed by difficulty awakening in the morning. For other individ uals with hypersomnolence disorder, the major sleep episode is of normal nocturnal sleep duration (6-9 hours). In these cases, the excessive sleepiness is characterized by several un intentional daytime naps. These daytime naps tend to be relatively long (often lasting 1 hour or more), are experienced as nonres to rative. Individuals with hypersomnolence have daytime naps nearly everyday regard less of the nocturnal sleep duration. Individuals typically feel sleepiness developing over a period of time, rather than experiencing a sudden sleep "attack. Associated Features Supporting Diagnosis Nonres to rative sleep, au to matic behavior, difficulties awakening in the morning, and sleep inertia, although common in hypersomnolence disorder, may also be seen in a variety of conditions, including narcolepsy. Approximately 80% of individuals with hyper somnolence report that their sleep is nonres to rative, and as many have difficulties awak ening in the morning. Prevaience Approximately 5%-10% of individuals who consult in sleep disorders clinics with com plaints of daytime sleepiness are diagnosed as having hypersomnolence disorder. Deveiopment and Course Hypersomnolence disorder has a persistent course, with a progressive evolution in the se verity of symp to ms. While many individuals with hypersomnolence are able to reduce their sleep time during working days, weekend and holiday sleep is greatly increased (by up to 3 hours). Awakenings are very difficult and accompanied by sleep inertia episodes in nearly 40% of cases. Hypersomnolence fully manifests in most cases in late adolescence or early adulthood, with a mean age at onset of 17-24 years. Individuals with hypersomnolence disorder are diagnosed, on average, 10-15 years after the appearance of the first symp to ms. Hypersomnolence has a progressive onset, with symp to ms beginning between ages 15 and 25 years, with a gradual progression over weeks to months. For most individuals, the course is then persistent and stable, unless treatment is initiated. Although hyperactivity may be one of the presenting signs of daytime sleepiness in children, voluntary napping increases with age. Hypersomnolence can be increased temporarily by psychological stress and alcohol use, but they have not been documented as environmental precipitating fac to rs. Viral infections have been reported to have preceded or accompanied hyper somnolence in about 10% of cases. Diagnostic iVlarlcers Nocturnal polysomnography demonstrates a normal to prolonged sleep duration, short sleep latency, and normal to increased sleep continuity. Some individuals with hypersomnolence disorder have increased amounts of slow-wave sleep. The multiple sleep latency test documents sleep tendency, typically indicated by mean sleep latency values of less than 8minutes. In hypersomnolence disorder, the mean sleep latency is typically less than 10 minutes and frequently 8minutes or less. Functional Consequences of Hypersomnoience Disorder the low level of alertness that occurs while an individual fights the need for sleep can lead to reduced efficiency, diminished concentration, and poor memory during daytime activ ities. Hypersomnoience can lead to significant distress and dysfunction in work and social relationships. Prolonged nocturnal sleep and difficulty awakening can result in difficulty in meeting morning obligations, such as arriving at work on time. Unintentional daytime sleep episodes can be embarrassing and even dangerous, if, for instance, the individual is driving or operating machinery when the episode occurs. If social or occupational demands lead to shorter nocturnal sleep, daytime symp to ms may appear. In hypersomnoience disorder, by contrast, symp to ms of excessive sleepiness occur regard less of nocturnal sleep duration. An inadequate amount of nocturnal sleep, or behaviorally induced insufficient sleep syndrome, can produce symp to ms of daytime sleepiness very similar to those of hypersomnoience. An average sleep duration of fewer than 7 hours per night strongly suggests inadequate nocturnal sleep, and an average of more than 9-10 hours of sleep per 24-hour period suggests hypersomnoience.
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