Caring for Abused Persons

1. Caring for Abused Persons Chapter 35

2. Self-esteem: how one feels about oneself. Its components are self-acceptance, self-worth, self-love and self-nurturing.

3. Abuse • Most abuse of women, children and elderly is intimate violence (perpetrator loved and trusted person). • World is no longer safe. • Empowerment is foreign. • Empowerment is the promotion of the continued growth and development of strength, power and personal excellence.

4. Woman Abuse • Significant health problem crossing all racial, ethnic and SES lines • 2-4 million women abused each year • Single, divorce separated women at highest risk • Violence begins early in dating relationship • Dynamics of intimate relationships • Chronic syndrome characterized by emotional abuse, degradation, restrictions on freedom, abuse, threats, stalking and isolation from family • Core pattern of coercive control

5. Battering, Rape and Sexual Assault • Single greatest cause of injury to women • Women are aware that they are in danger of being killed. • Sexual assault occurs once every 6.4 minutes. • Types of rapists: • Power (55%) • Attack people own age, using intimidation and minimal physical force • Premeditated • Anger (40%) • Target either very young or old • May use extreme force resulting in injury • Sadistic (5%) • Most dangerous • Premeditated, often torture or kill victims • Derive erotic gratification

6. Child Abuse • Can take several forms, varies from state to state • Prevalence unknown • Child neglect most common • Failure to protect child • Physical neglect • Medical neglect • Physical - severe spanking, kicking, shoving or any other type of physical action • Sexual abuse - ranges from mild (covert) to severe (overt) • Incest • Sexual abuse by a non-family member • Pedophilia

7. Child Abuse (cont.) • Emotional abuse • Acts of omission, co-mission that psychologically damage the child • Types • Rejecting • Isolating • Terrorizing • Ignoring • Corrupting • Munchausen’s by proxy (factitious disorder) • Children of battered women

8. Elder Abuse • Estimated at 1.5 million cases • Neglect (58.5%) • Physical abuse (15.7%) • Financial/material mismanagement (12.3%) • Emotional (7.3%) • Sexual (.04%) • Risks • Older age • Impairment in ADL • Dependency on caregiver • Isolation, stressful events • History of intergenerational conflict

9. Biologic Theories • Neurologic problems • Traumatic brain injury, seizure disorder (post-ictal), dementia • Orbitofrontal cortex damage • Disruption of neurotransmitter system • Links with substance abuse

10. Psychosocial Theories • Psychopathology theory • Type I - antisocial and violent in many situations • Type II - antisocial and abuse family members • Type III - dysphoric-borderline, only family • Social learning theory • Men who view violence as children become violent as adults. • Social • Acceptance of violence as normal • Family stress theory

11. Dynamics of Woman Abuse • Feminist theories • Men perpetuating control over women • Patriarchal society • Power inequity • Borderline personality organization • Consistent with cycle of violence • Why women stay in relationships • Economic • Responsible for maintenance of marriage, family

12. Dynamics of Woman Abuse (cont.) • Traumatic bonding • Explains why women stay in relationship • Emotional attachments formed because of intermittent abuse • Structural components of relationship • Power imbalance • Intermittency in abuse • Cycle of violence

13. Biologic Responses • Depression • Acute stress disorder (ASD) • New disorder in updated DSM-IV • Barrage of stress-related events persists for two days • If lasts longer, becomes PTSD • Post-traumatic stress disorder (PTSD) • Dissociative identity disorder (DID)

14. Post-traumatic Stress Disorder • Lifetime prevalence: 1 to14% • More prevalent in women than men • 30% of women develop PTSD after exposure to a traumatic event, 15% of men • May develop anytime after trauma • Young and elderly more sensitive

15. PTSD • Hyperarousal • Stress system goes on permanent alert • Dopamine hyperactivity • Behavioral sensitization • Intrusion • Re-live as if it were continually recurring • Flashbacks, nightmare vivid • Amygdala involved in memory • Avoidance and numbing • Develop periods of dissociation

16. Dissociative Identity Disorder • Formerly multiple personality disorder • Two or more distinct identities with unique personality characteristics and inability to recall important information about self • Prevalence unknown

17. Dissociative Identity Disorder • Etiology unknown, but causative factors include: • A traumatic event • A psychological or genetic vulnerability • Formative environmental factors • Absence of external support

18. Substance Abuse and Dependence • Association between childhood abuse, PTSD and substance abuse is well-established. • Survivors who experience PTSD, depression and other forms of hyperarousal or emotional distress often abuse substances that inhibit noradrenergic activity and lessen stress.

19. Psychological Responses • Low self-esteem • Alienation from self (painful feelings that go to the core) • Alienation from others (painful feelings from being disconnected to others) • Guilt and shame • Blame self for abuse • Prevent victims from seeking medical care and reporting abuse • Anger • Chronic irritability, unexpected or uncontrollable feelings of anger

20. Social and Interpersonal Responses • Problems with intimacy • Difficulty forming trusting relationships • Sexual problems common • Revictimization • Victims usually become victims again • High risk for dissociative disorders • Alexithymia may add risk for revictimization

21. Assessing for Abuse • Health care providers often miss abuse or re-victimize the patient by blaming. • Establishing a nurse-patient relationship is the most important step. • Lethality assessment first • Assessment questions

22. Biologic Assessment • Past seven present medical history, ADLS • Document injuries. • Observe for: • Elevated pulse and BP • Sleep and appetite disturbances • Nightmares • Memory difficulties • Substance abuse

23. Psychological Assessment • Mental status evaluation • Suicide assessment • Observe for: • Anhedonia • Difficulty concentrating • Feelings of worthlessness or guilt • Thoughts of suicide or death

24. Social Assessment • Social networks and support • Daily activities • Financial support • Assess restriction of freedom • Degree of dependency in relationship

25. Sexual Assault • Assess for injuries. • Collect evidence for forensic evaluation. • Someone specially trained should conduct it.

26. Nursing Management: Children • Careful physical assessment • Safety of child • Breaking the silence • Increasing self-esteem • Dealing with loss • Learning to trust • Learning to protect oneself • Assertive conflict resolution • Empowerment

27. Nursing Management: Elderly • Accurate assessment • Determining danger • Interventions depend on acceptance • Included in mandatory reporting • Improving functional level • Involving other family members

28. Biologic Interventions • Restoring physical health • Teaching sleep hygiene, promoting exercise • Administering and monitoring medications • PTSD -benzodiazepine, -blockers and antidepressants (SSRIs- Zoloft) • Referring to treatment center for substance abuse

29. Psychological Interventions • Assisting with psychotherapy or counseling • Providing education • Behavioral interventions • Anxiety management • Measuring gains in small steps

30. Social Interventions • Family interventions • Parenting skills • Leisure skills • Household organization • Working in the community • Assistance in developing support networks • Home visits

31. Special Considerations in Sexual Assault • Early treatment crucial • Diminish survivor distress • Supportive, caring, non-judgmental • Unwanted pregnancies • STD, HIV • Interventions • Education • Counseling • Emotional support

32. Evaluation and Treatment Outcomes • Depends on the setting • Follow-up important • Referral for treatment of disorders resulting from abuse (ASD, PTSD and other anxiety disorders, DID, major depression, substance abuse)