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This dis- order is characterized by a pervasive pattern of perfec- tionism and inflexibility purchase 40 mg esomeprazole free shipping gastritis diet . Interpersonal relationships have a formal and serious quality cheap esomeprazole 40 mg fast delivery gastritis skin symptoms, and others often perceive these individuals as stilted or “stiff cheap esomeprazole 20 mg with mastercard gastritis diet 2014. Oppositional defiant disorder in childhood or adolescence is a predisposing factor. Many of the behaviors associated with the various personal- ity disorders may be manifested by clients with virtually every psychiatric diagnosis, as well as by those individuals described as “healthy. Individuals with personality disorders may be encountered in all types of treatment settings. They are not often treated in acute care settings, but because of the instability of the borderline client, hospitalization is necessary from time to time. The indi- vidual with antisocial personality disorder also may be hospital- ized as an alternative to imprisonment when a legal determination is made that psychiatric intervention may be helpful. Because of these reasons, suggestions for inpatient care of individuals with these disorders are included in this chapter; however, these inter- ventions may be used in other types of treatment settings as well. Undoubtedly, these clients represent the ultimate challenge for the psychiatric nurse. The term “borderline” came into being because these clients’ emotionally unstable behavior seems to fall on the border between neurotic and psychotic. Cummings and Mega (2003) have suggested a possible serotonergic defect in clients with borderline personality disorder. Cummings and Mega (2003) stated: These functional imaging studies support a medial and orbitofrontal abnormality that may promote the impulsive aggression demonstrated by patients with the borderline personality disorder (p. The decrease in serotonin may also have genetic implications for borderline personality disorder. Sadock and Sadock (2007) report that depression is common in the family backgrounds of clients with borderline person- ality disorder. They stated: These patients have more relatives with mood disorders than do control groups, and persons with borderline personality disorder often have mood disorder as well (p. Studies have shown that many indi- viduals with borderline personality disorder were reared in families with chaotic environments. Lubit and Finley- Belgrad (2008) stated, “Risk factors [for borderline per- sonality disorder] include family environments character- ized by trauma, neglect, and/or separation; exposure to sexual and physical abuse; and serious parental psychopa- thology such as substance abuse and antisocial personality disorder. In some instances, this disorder has been likened to posttraumatic stress disorder in response to childhood trauma and abuse. For example, symptoms such as intrusion, avoidance, and hyperarousal may emerge during psychotherapy. Awareness of the trauma-related nature of these symptoms can facilitate both psychotherapeutic and pharmacological efforts in symptom relief (p. This theory suggests that the basis for borderline personality lies in the ways the child relates to the mother and does not separate from her. Mahler and associates (1975) define this process in a series of phases described as follows: • Phase 1 (Birth to 1 month), Autistic Phase. The child views the self as an extension of the parenting figure, although there is a developing awareness of external sources of need fulfillment. The child is beginning to recognize that there is separ- ateness between the self and the parenting figure. This phase is characterized by increased locomotor function- ing and the ability to explore the environment indepen- dently. This is frightening to the child, who wants to regain some lost closeness but not return to symbiosis. The child wants the mother there as needed for “emotional refueling” and to maintain feelings of security. In this phase, the child completes the individuation process and learns to relate to objects in an effective, constant manner. A sense of separateness is established, and the child is able to internalize a sus- tained image of the loved object or person when out of sight. The theory of object relations suggests that the individual with borderline personality is fixed in the rapprochement phase of development. This fixation occurs when the mother begins to feel threatened by the increasing autonomy of her child and so withdraws her emotional support during those times or she may instead reward clinging, dependent behaviors. In this way, the child comes to believe that “To grow up and be independent = a ‘bad’ child. In addition, because object constancy is never achieved, the child continues to view objects (people) as parts—either good or bad. Symptomatology (Subjective and Objective Data) Individuals with borderline personality always seem to be in a state of crisis. Their affect is one of extreme intensity and their behavior reflects frequent changeability. These changes Personality Disorders ● 281 can occur within days, hours, or even minutes. Often these individuals exhibit a single, dominant affective tone, such as depression, which may give way periodically to anxious agitation or inappropriate outbursts of anger. Depression occurs in response to feelings of abandonment by the mother in early childhood (see “Predisposing Factors”). Underlying the depression is a sense of rage that is sporadically turned inward on the self and externally on the environment. Seldom is the individual aware of the true source of these feelings until well into long- term therapy. Because of this chronic fear of aban- donment, clients with borderline personality disorder have little tolerance for being alone. They prefer a frantic search for companionship, no matter how unsatisfactory, to sitting with feelings of loneliness, emptiness, and boredom (Sadock & Sadock, 2007). The client with borderline person- ality disorder commonly exhibits a pattern of interaction with others that is characterized by clinging and distancing behav- iors. When clients are clinging to another individual, they may exhibit helpless, dependent, or even childlike behaviors. They overidealize a single individual with whom they want to spend all their time, with whom they express a frequent need to talk, or from whom they seek constant reassurance. Acting-out behaviors, even self-mutilation, may result when they cannot be with this chosen individual.

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The German psychologist [1] Wolfgang Köhler (1925) carefully observed what happened when he presented chimpanzees with a problem that was not easy for them to solve purchase 20mg esomeprazole gastritis diet , such as placing food in an area that was too high in the cage to be reached buy cheap esomeprazole 40mg line gastritis chronic cure. He found that the chimps first engaged in trial-and-error attempts at solving the problem buy cheap esomeprazole 40mg on-line the gastritis diet, but when these failed they seemed to stop and contemplate for a while. Then, after this period of contemplation, they would suddenly seem to know how to solve the problem, for instance by using a stick to knock the food down or by standing on a chair to reach Attributed to Charles Stangor Saylor. Köhler argued that it was this flash of insight, not the prior trial-and-error approaches, which were so important for conditioning theories, that allowed the animals to solve the problem. The second group never received any reward, and the third group received a reward, but only beginning on the 11th day of the experimental period. As you might expect when considering the principles of conditioning, the rats in the first group quickly learned to negotiate the maze, while the rats of the second group seemed to wander aimlessly through it. The rats in the third group, however, although they wandered aimlessly for the first 10 days, quickly learned to navigate to the end of the maze as soon as they received food on day 11. By the next day, the rats in the third group had caught up in their learning to the rats that had been rewarded from the beginning. It was clear to Tolman that the rats that had been allowed to experience the maze, even without any reinforcement, had nevertheless learned something, and Tolman called this latent learning. Latent learning refers to learning that is not reinforced and not demonstrated until there is motivation to do so. Tolman argued that the rats had formed a “cognitive map‖ of the maze but did not demonstrate this knowledge until they received reinforcement. Observational Learning: Learning by Watching The idea of latent learning suggests that animals, and people, may learn simply by experiencing or watching. Observational learning (modeling) is learning by observing the behavior of others. To demonstrate the importance of observational learning in children, Bandura, Ross, and Ross [3] (1963) showed children a live image of either a man or a woman interacting with a Bobo doll, a filmed version of the same events, or a cartoon version of the events. In all three conditions, the model violently punched the clown, kicked the doll, sat on it, and hit it with a hammer. Video Clip: Bandura Discussing Clips From His Modeling Studies Take a moment to see how Albert Bandura explains his research into the modeling of aggression in children. The researchers first let the children view one of the three types of modeling, and then let them play in a room in which there were some really fun toys. To create some frustration in the children, Bandura let the children play with the fun toys for only a couple of minutes before taking them away. If you guessed that most of the children imitated the model, you would be correct. Regardless of which type of modeling the children had seen, and regardless of the sex of the model or the child, the children who had seen the model behaved aggressively—just as the model had done. Bandura and his colleagues had demonstrated that these children had learned new behaviors, simply by observing and imitating others. Observational learning is useful for animals and for people because it allows us to learn without having to actually engage in what might be a risky behavior. Monkeys that see other monkeys respond with fear to the sight of a snake learn to fear the snake themselves, even if they have [4] been raised in a laboratory and have never actually seen a snake (Cook & Mineka, 1990). As Bandura put it, the prospects for [human] survival would be slim indeed if one could learn only by suffering the consequences of trial and error. For this reason, one does not teach children to swim, adolescents to drive automobiles, and novice medical students to perform surgery by having them discover the appropriate behavior through the consequences of their successes and failures. The more costly and hazardous the possible mistakes, the heavier is the reliance on [5] observational learning from competent learners. These children are not only the victims of aggression, but they also see it happening to their parents and siblings. Because children learn how to be parents in large part by modeling the actions of their own parents, it is no surprise that there is a strong correlation between family violence in childhood and violence as an adult. Children who witness their parents being violent or who are themselves abused are more likely as adults to inflict abuse on intimate partners or their children, and to be victims of intimate violence (Heyman & Slep, [6] 2002). In turn, their children are more likely to interact violently with each other and to [7] aggress against their parents (Patterson, Dishion, & Bank, 1984). Research Focus: The Effects of Violent Video Games on Aggression The average American child watches more than 4 hours of television every day, and 2 out of 3 of the programs they watch contain aggression. It has been estimated that by the age of 12, the average American child has seen more than 8,000 murders and 100,000 acts of violence. At the same time, children are also exposed to violence in movies, video games, and virtual reality games, as well as in music videos that include violent lyrics and imagery (The Henry J. It might not surprise you to hear that these exposures to violence have an effect on aggressive behavior. The evidence is impressive and clear: The more media violence people, including children, view, the more aggressive they are likely [9] to be (Anderson et al. The relation between viewing television violence and aggressive behavior is about as strong as the relation between smoking and cancer or between studying and academic grades. People who watch more violence become more aggressive than those who watch less violence. It is clear that watching television violence can increase aggression, but what about violent video games? Youths spend countless hours playing these games, many of which involve engaging in extremely violent behaviors. The games often require the player to take the role of a violent person, to identify with the character, to select victims, and of course to kill the victims. These behaviors are reinforced by winning points and moving on to higher levels, and are repeated over and over. A recent meta-analysis by Anderson and [10] Bushman (2001) reviewed 35 research studies that had tested the effects of playing violent video games on Attributed to Charles Stangor Saylor. The studies included both experimental and correlational studies, with both male and female participants in both laboratory and field settings. They found that exposure to violent video games is significantly linked to increases in aggressive thoughts, aggressive feelings, psychological arousal (including blood pressure and heart rate), as well as aggressive behavior. Furthermore, playing more video games was found to relate to less altruistic behavior.

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The minimum amount of intraperitoneal fluid needed for detection by ultra- sound is approximately 70 cc discount esomeprazole 40mg line gastritis diet 91303. It is considered an unstable fracture and is associated with C2 fractures 40% of the time purchase esomeprazole 20 mg mastercard gastritis kaj je. On plain radi- ograph order esomeprazole 40mg online gastritis erythema, it is best seen on the open-mouth odontoid view as the lateral masses are shifted laterally. It is associated with diving accidents and in this scenario, “spearing” in a football game, which places an increased axial load to the cervical spine. Trauma Answers 151 (a) Odontoid fractures occur when there is a fracture through the odontoid process of the C2 vertebra. This injury disrupts all of the cervical ligaments, facet joints, and causes a triangular fracture of a portion of the vertebral body. The most likely cause is cardiac tam- ponade, which occurs in approximately 2% of anterior penetrating chest traumas. The most effective method for relieving acute pericardial tamponade in the trauma setting is thoracotomy and incision of the pericardium with removal of blood from the pericardial sac. However, patients in traumatic arrest typically require surgical, rather than medical intervention. Pericardiocentesis is indicated for patients with suspected cardiac tamponade who have measurable vital signs that are stable. When a tooth is missing from a patient, 152 Emergency Medicine the possibility of aspiration or entrapment in soft tissues should be consid- ered. Replantation is most successful if the tooth is returned to its socket within 30 minutes of the avulsion. A 1% chance of successful replantation is lost for every minute that the tooth is outside of its socket. If the patient cannot replant the tooth, then he or she should keep the tooth under his or her tongue or in the buccal pouch so that it is bathed in saliva. If that cannot be achieved, then the tooth can be placed in a cup of milk (e) or in saline. The best transport solution is Hank solution, which is a buffered chemical solution. This patient received a score of 3 for eye opening to verbal command, 4 for disorientation, but conversant, and 6 for obeying verbal commands. However, the liver occupies the most space in the abdomen and therefore is the most common organ injured. The stomach, colon, and spleen (c, d, and e) are less commonly injured than the liver and small bowel in pene- trating abdominal trauma. Ribs usually break at the point of impact or at the posterior angle, which is structurally the weakest area. Rib frac- tures occur more commonly in adults than in children owing to the relative inelasticity of the adult chest wall compared to the more compliant chest wall of children. The presence of two or more rib fractures at any level is associated with a higher incidence of internal injuries. The treatment of patients with simple acute rib fractures includes adequate pain relief and maintenance of pulmonary function. Older patients may require better analgesia with opioids, but care must be taken to avoid over sedation. Con- tinuing daily activities and deep breathing is important to ensure ventila- tion and prevent atelectasis. If there is a question about the patient’s ability to cough, breathe deeply, and maintain activity, particularly if two or more ribs are fractured, it is preferable to admit the patient to the hospital for aggressive pulmonary care. Although they may decrease pain, they also promote hypoventila- tion leading to atelectasis and pneumonia. The progressive accumulation of air under pressure in the pleural cavity may lead to a shift of the mediastinum to the contralateral hemithorax. The physical examination may reveal decreased or absent breath sounds over the involved side, as well as subcutaneous emphysema. The preferred site for insertion is the fourth or fifth intercostal space at the anterior or mid- axillary line. The tube should be positioned posteriorly and toward the apex so that it can effectively remove both air and fluid. It is more likely to occur after a penetrating trauma to the chest rather than a blunt trauma. Patients with this lesion have ipsilateral motor paralysis and contralateral loss of pain and temperature distal to the level of the injury. This syndrome has the best prognosis for recovery of all of the incomplete spinal cord lesions. Patients typically exhibit flaccid paralysis with loss of sensory input, deep tendon reflexes, and urinary bladder tone. Patients often have greater sensorimotor neurologic deficits in the upper extremities compared to the 156 Emergency Medicine lower extremities. Its hallmark is preservation of vibratory sensation and proprioception because of an intact dorsal column. Its presentation may include variable motor and sensory loss in the lower extremities, sciatica, bowel and bladder dysfunction, and saddle anesthesia. A score of 14 to 15 is associated with minor head injury, 9 to 13 indicates moderate, and 8 or less is associated with severe head injury. If there is an active scalp bleed, staples can be rapidly placed to limit bleeding until definitive repair can take place. It is administered if there are signs of impending or actual herniation (eg, fixed and dilated pupil). It is one of the most commonly overlooked injuries resulting from blunt chest trauma. Trauma Answers 157 The paradoxical motion of the chest wall is the hallmark of this condition, with the flail segment paradoxically moving inward with inspiration and outward with expiration. Neck trauma is caused by three major mechanisms, including penetrating, blunt, and strangulation, which can affect the airway, digestive tract, vascu- lar, and neurologic systems.

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