D. "Let's set some guidelines and goals for your visit here."



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-Alexithymia: Inability to describe emotions in a verbal manner
-Behavioral sensitization:
-Cycle of Violence (3 phases): Escalation, Acute, and Deescalation.

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Cycle of Violence

-Escalation: batterer controls and isolates victim


-Acute: batterer uses threats and instills fear
-Deescalation: batterer promises to change

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Key Terms

-Dissociation: Unconscious defense mechanism, protects individual from painful emotions.


-DID:
-Fear Conditioning:

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Key Terms (cont)

-Neglect: Failing to provide physical or emotional care


-Protective Order:
-Traumatic Bonding:

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Type of Abuse

-Partner
-Child


-Elder

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Priorities of Care (VADR)

V-Validate


A-Assess
D-Document
R-Referel

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Ecchymosis Time Line

Red: 0-2days


Blue/Purple: 2-5 days
Green: 5-7 days
Yellow: 7-10 days
Brown: 10-14 days

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Strongest Point on Body

-Elbow


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Biological Responses to Abuse

-Depression
-Mood Disorders
-Substance Abuse
-ASD
-PTSD 
-DID

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Psychological Responses to Abuse

-Low self esteem


-Guilt
-Same
-Anger

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Social Responses to Abuse

-Intimacy Problems 


-Revictimization

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Long Term Effects on Children

-Repeat abuse patterns


-Relationship problems
-Personality disorders
-Mood disorders
-Low self esteem

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Assessment

Does injury match explanation? Physical Hx, Neurologic exam, Asses for internal injuries and broken bones; assess mental status; Document verbal statements/physical finding; Are kids involved?

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Nursing Diagnosis: intimate partner violence

Risk for injury, acute/chronic pain, risk for trauma, risk violence, social isolation, disturbed sleep pattern, powerlessness, disturbed personal id, disabled family coping

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Interventions



Safe environment/private space, Active listening, meeting needs of children, determine availability of safe place, escape plan, provide info to press charges

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Intimate partner violence safety plan

Quickest route out of home and workplace, tell neighbors about abuse, have code word, have safe place, pack a bag with clothes valuables phone meds shelter info

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elder abuse assessment



Fear of being w/ caregiver, malnutrition, skin lesions, medical/dental needs, passive withdrawn and emotionless, concern over finances/missing valuables

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Elder abuse outcomes

Abuse has ceased, plans to maintain safety, feels more comfortable at home, follow-up visits with less anxiety and tension

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Elder Abuse interventions



Provide tx, involve adult protective services, id stressors, notify community agencies

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Why involve APS

Arrange for housing services, Obtain medical services, address personal needs, provide service coordination: case management/ referral to appropriate services

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Elder abuse evaluation



acknowledgement of abuse, acceptance of intervention, removed from situation, evaluation ongoing

Lorazepam

Drug of choice
Use with caution with hepatic dysfunction

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Alprazolam

Paradoxical with personality disorders and elderly

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Diazepam


Rapid onset of calming and sedating
Long half-life; use with caution in elderly

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Haloperidol

Favorable side effect profile


Due to risk of neuroleptic malignant syndrome, keep hydrated check vital signs, and test for muscle rigidity

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Chlorpromazine

Very sedating


Injections can cause pain; watch for hypotension

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Risperidone

Calms while treating underlying condition


Watch for hypotension
Increased risk of stroke in elderly

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Olanzapine

Useful in patients unresponsive to haloperidol


Calms while treating underlying condition
Avoid when using lorazepam
Increased risk of stroke in elderly

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Ziprasidone

Use cautiously with QT prolongation


Less sedating

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Aripiprazole

Avoid when using lorazepam

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Haloperidol, lorazepam, & diphenhydramine or benztropine



Acute setting
Men who are young and athletic are at increased risk of dystonia

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Perphenazine, lorazepam, & diphenhydramine or benztropine

If they have trouble taking haloperidol

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SSRIs


Antisocial personality disorder, schizophrenia, dementia, brain injury

Reduces irritability, impulsivity, and aggression


Stabilizes mood
Use with caution in bipolar people

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Lithium

Antisocial personality disorder, prison inmates, mental retardation, brain injury

TSH levels measured prior to treatment
Due to anti-aggressive properties, blood levels can be lower than those necessary to treat bipolar mania

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Anticonvulsants

Prison inmates, antisocial/boarderline personality disorders, substance use, ADD, brain injury, schizophrenia

Significantly reduces impulsve aggression
Similar doses with bipolar disorder
Multiple drug interactions
Periodic blood levels
Monitor CBC and LFTs

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Gabapentin

Anxiety disorder, personality disorders

No interactions with other anticonvulsants

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Benzodiazepines

Anxiety disorder

Potential for abuse, dependance, and withdrawal
May cause paradoxical aggression

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Second-generation antipsychotics

Schizophrenia, psychosis, mania, borderline personality disorder, mental retardation

Clozapine superior to others
Fewer side effects and greater adherence than first generation
Risperidone reduces irritability in autistic disorder

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Beta-blockers

Schizophrenia, brain injury, dementia, mental retardation

Propranolol contraindicated with asthma, COPD, and IDDM
Sedation side effects may explain anti-aggressive effects

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Psychostimulants

ADD/ADHD in children and adults

Potential for addiction and abuse

Crises


• acute and time-limited (Usually lasting 4 to 6 weeks)
• associated overwhelming emotions of increased tension, helplessness, and disorganization. 
• State of crisis is produced by three interconnected conditions:
(1) hazardous event poses a threat
(2) emotional need that represents earlier threats and increased vulnerability
(3) inability to respond adaptively

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Factors Influencing Outcome of a Crisis

• the realistic perception of the event


• adequate situational supports
• adequate coping mechanisms.

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Types of Crisis

(1) developmental, or maturational, crises


(2) situational crises
(3) disasters, or adventitious crises

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Maturational Crisis

• based on Erik Erikson;s eight stages of ego growth and development


• Each stage represents a time where physical, cognitive, instinctual, and sexual changes prompt an internal conflict or crisis, which results in either psychosocial growth or regression. 
• Each developmental stage represents a maturational crisis (that is, a critical period of increased vulnerability and heightened potential—a turning point).
• When a person arrives at a new stage, formerly used coping styles are no longer effective, and new coping mechanisms have yet to be developed. Thus for a time the person is without effective defenses. 
• This often leads to increased tension and anxiety, which may manifest as variations in the person's normal behavior. 
• Examples of events that can precipitate a maturational crisis include leaving home during late adolescence, marriage, the birth of a child, retirement, and the death of a parent. Successful resolution of these maturational tasks leads to development of basic human qualities.
• Factors may disrupt individuals' progression through the maturational stages. For example, alcohol and drug addiction disrupts progression through the maturational stages. Unfortunately, this interruption occurs too often among individuals during their adolescent years. When the addictive behavior is controlled (e.g., by the late teens or mid-20s), the young person's growth and development resume at the point of interruption. 
• Example: a young person whose addiction is arrested at 22 years of age may have the psychosocial and problem-solving skills of a 14-year-old.

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Situational Crisis

• arises from events that are extraordinary, external rather than internal, and often unanticipated 


• Examples of events that can precipitate a situational crisis include the loss or change of a job, the death of a loved one, an abortion, a change in financial status, divorce, and severe physical or mental illness. 
• Whether or not these events precipitate a crisis depends on factors such as the degree of support available from caring friends, family members, and others; general emotional and physical status; and the ability to understand and cope with the meaning of the stressful event. 
• As in all crises or potential crisis situations, the stressful event involves loss or change that threatens a person's self-concept and self-esteem.

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Adventitious Crisis

• not a part of everyday life; it results from events that are unplanned and may be accidental, caused by nature, or human-made. 


• Can result from (1) a natural disaster (e.g., flood, fire, earthquake), (2) a national disaster (e.g., acts of terrorism, war, riots, airplane crashes), or (3) a crime of violence (e.g., rape, assault or murder in the workplace or school, bombing in crowded areas, spousal or child abuse).
• commonly experienced, post-trauma phenomena include acute stress disorder, posttraumatic stress disorder, and depression. 
• a person's vulnerability to a stressful event depends to a certain extent on the newness, intensity, and duration of the stressful event.
• also possible to experience more than one type of crisis situation simultaneously, and as expected, the presence of more than one crisis further taxes individual coping skills

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4 Phases of Crisis

Phase 1:
• A person confronted by a conflict or problem that threatens the self-concept responds with increased feelings of anxiety. 


• The increase in anxiety stimulates the use of problem-solving techniques and defense mechanisms in an effort to solve the problem and lower anxiety.

Phase 2:
• If the usual defensive response fails and the threat persists, anxiety continues to rise and produce feelings of extreme discomfort.


• Individual functioning becomes disorganized. 
• Trial-and-error attempts at solving the problem and restoring a normal balance begin.

Phase 3:
• If the trial-and-error attempts fail, anxiety can escalate to severe and panic levels, and the person mobilizes automatic relief behaviors, such as withdrawal and flight. 


• Some form of resolution (e.g., compromising needs or redefining the situation to reach an acceptable solution) may be made in this stage.

Phase 4:
• If the problem is not solved and new coping skills are ineffective, anxiety can overwhelm the person and lead to serious personality disorganization, depression, confusion, violence against others, or suicidal behavior.

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Nurses Initial Intervention



• initial task → promote a sense of safety by assessing the patient's potential for suicide or homicide. 

Ask:
• Do you feel you can keep yourself safe?


• Have you thought of killing yourself or someone else? 
• If yes, have you thought of how you would do this?

• After establishing that the patient poses no danger to self or others, the nurse assesses three main areas: 


(1) the patient's perception of the precipitating event
(2) the patient's situational supports, and
(3) the patient's personal coping skills.

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Foundation for Crisis Intervention

• A crisis is self-limiting and usually resolves within 4 to 6 weeks.


• At the resolution of a crisis, the patient will emerge at one of three different functional levels → either a higher level of functioning, the same level of functioning, or a lower level of functioning. The goal of crisis intervention is to return the patient to at least the pre-crisis level of functioning.
• The form of crisis resolution depends on the patient's actions and others' interventions.
During a crisis, people are often more receptive than usual to outside intervention. 
• The patient in a crisis situation is assumed to be mentally healthy, to have functioned well in the past, and to be presently in a state of disequilibrium.
• Crisis intervention deals only with the patient's present problem and resolution of the immediate crisis (e.g., the "here and now").
• The nurse must be willing to take an active, even directive, role in intervention, which is in direct contrast to conventional therapeutic intervention that stresses a more passive and nondirective role.
• The patient is encouraged to set realistic goals and plan a focused intervention with the nurse.

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Assessing Personal Coping Skills

• assess the patient's personal coping skills by evaluating the patient's anxiety level and identifying the patient's established patterns of coping. 


• Common coping mechanisms may be overeating, drinking, smoking, withdrawing, seeking out someone to talk to, yelling, fighting, or engaging in other physical activity.
• Sample questions to ask include: 
(1) What do you usually do to feel better?
(2) Did you try it this time? If so, what was different?
(3) What helped you through difficult times in the past?
(4) What do you think might happen now?

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Vicarious Traumatization

• Professionals whose work with crisis survivors exposes them indirectly (vicariously) to severe trauma can themselves sometimes develop a form of traumatization from listening to their patients' trauma experiences


• has a more acute onset that follows a specific event then would burnout
• Patient may be uncomfortable having further contact with trauma cases.

What are two common features of defense mechanisms?

1. They all occur on an unconscious level, we are not aware of.

2. They all deny, distort, or falsify reality to make it less threatening.

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What is Transference?



When the patient experiences feelings toward the nurse or therapist that were originally held toward significant others in his/her life. When these feelings occur, they become available for exploration, which helps the patient better understand certain feelings and behaviors.

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What is Countertransference?

The health care workers unconscious, personal response to the patient, underscoring the importance of maintaining self-awareness and seeking supervisory guidance as therapeutic relationships progress.

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What types of clients are the best candidates for brief psychotherapy?



Relatively healthy and well-functioning individuals, who have a clearly circumscribed area of difficulty and are intelligent, psychologically minded, and well motivate for change.

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Operant Conditioning

A type of learning in which behavior is strengthened if followed by a reinforcer or diminished if followed by a punisher.

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Systemic Desensitization



Form of behavior modification therapy that involved the development of behavioral tasks customized to the patient's specific fears; these tasks are presented to the patient while using learned relaxation techniques.

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Aversion Therapy

A behavior therapy in which an aversive stimulus is paired with a stimulus that elicits an undesirable response.

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Biological Model of Mental Illness focuses on what four issues?



1. Neurological 3. Chemical
2. Biological 4. Genetic

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The Health-Illness Continuum

Mental Health ---------->Mental Illness


No specific dividing line - many gray areas
Dynamic: Person does not remain at the same point constantly. There is always the potential for growth or change.

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Factors that Increase Susceptibility to Development of Mental Illness:

A. Stressful event (or likely an accumulation of multiple stressful events.


B. Pathophysiology (organic causes): disease processes, infection.
C. Physical trauma to the brain: e.g. injury, chemical substances
D. Genetics
E. Environmental Factors
Mental illness is often the result of a combination of >1 of these factors

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Developmental Considerations:

What is considered normal at one age may be viewed as abnormal at a different age.


Examples:
- Egocentrism - preoccupation with self
- Anthropomorphism - the attribution of human characteristics or personification behavior to a god, animal, or object.

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Gender Considerations

Stereotypical beliefs regarding females (weak, emotional) and males (strong, assertive). Result: more females in the mental healthcare system--more males are in prison.

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The DSM Classification System: Multi-axial assessment



Axis I - Major Psychiatric Diagnosis (schizophrenia, depression, bi-polar, PTSD)
Axis II - Personality Disorders & Mental Retardation (antisocial, autism)
Axis III - Medical Conditions
Axis IV - Social and Environmental problems (external stressors: domestic violence, homeless, divorce, unemployed, incarceration).
Axis V - Highest Level of Functioning: Rated on the Global Assessment of Functioning (GAF) Scale.

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Considerations related to psychiatric treatment:

A. Cultural Beliefs against having emotional problems, stigma of being labeled "crazy" for receiving psychiatric care.


B. Historical events and experiences with the healthcaare system in the US leading to mistrust and suspicion.
C. Complexity of the Mental Healthcare System
D. Personal Considerations Related to Seeking Psychiatric Care: Ambivalence is a natural part of crisis situation

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FHPs related to Mental Illness

Physical appearance: (e.g. apparel, hair, skin, body odor, grooming, posture):


EG. Disheveled, well groomed, heavily made up, younger/older looking than biologic age, tense, under/overweight

Non-Verbal Behaviors (differentiate from medication side effects):


EG. Gait, activity level, gestures, mannerisms, psychomotor activity (Echopraxia, catatonia, waxy flexibility, cooperative, bored, angry, flirtatious

Speech Patterns


EG. Rate, amount, style, tone (pressured to hesitant, loud to inaudible, spontaneous, slurred, monotonous, talkative/taciturn, dysarthria, echolalia, preservation, aphasia)

Thought Process / Intellectual Performance:


EG. Loose associations, tangential thinking, word salad, neologisms, circumstantial thought (lost in details), thought blocking (blank), flight of ideas, confabulation concrete/abstract, 

Insight:
EG. Extent of the client's awareness of illness and maladaptive behaviours.

Mood/Affect:

Personal Strengths: (Client's statements and/or your assessments)

Stress-Coping: (stressors - coping mechanisms)

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Schizophrenia

Most common form of psychosis: a psychotic disorder characterized by disorganized thoughts, hallucinations, and delusions. For the majority of individuals, illness consists of acute episodes and periods of stability with reduced symptoms - especially when effectively treated. 


Prodromal symptoms before 1st break - late teens, early 20s

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Psychosis

A severe emotional and behavioral disorder that includes symptoms of gross distortion of a person's mental capacity, ability to recognize reality, inability to relate to others, or perform ADLs.

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Schizophrenia Signs and Symptoms:



In the acute phase of schizophrenia, individual is overwhelmed by anxiety. He/she is unable to think logically, and unable to distinguish between reality-unreality.

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Major Classifications of Schizophrenia:

Disorganized: incoherent speech, inappropriate behavior and affect: delusions and hallucinations; odd behaviors (e.g. grimacing, pacing, etc.) Primary defense mechanism: regression. Considered the most severe form of schizophrenia.


Paranoid: Dominant features: delusions of persecution, grandiose delusions, hallucinations. Highly suspicious. Primary defense mechanism: projection.
Catatonic: dominant features: Severe abnormal motor behaviors. withdrawal phase: motor retardation (e.g. stupor, mutism, waxy flexibility). Excited phase: hyperactivity, agitation, shouting.

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Assessment of a client with schizophrenia: Key components:

Assess for potential for harm to self and others:


--Command Hallucinations
--Risk for suicide: esp. related to depression and hopelessness.
Determine whether client has had a medical exam to rule out physical causes.
Assess wheter the client is using ETOH or drugs
Assess client's medication regimen. Is the client taking rx meds as ordered?

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Nursing Care for Schizophrenia

A. Maintain Client Safety: Objects brought on to the unit must be safe, medications, decreased environmental stimulation, limit setting, clear expectations, direct, simple, clear communication, restraints, seclusion only if needed for safety.


B. Build relationship gradually--if too fast/intense, client will withdraw. Take cues from the client. Convey non-judgmental, accepting attitude.
C. Ensure basic physiologic needs are met: sleep/rest, fluids, nutrition, hygiene.

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Tangential speech

When a pt. starts to talk to you about something and goes right into something else, pt goes on a tangent.

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Types of Psychiatric Hospital Admissions:



A. Voluntary
B. Involuntary (civil commitment): court-ordered admission to psychiatric hospital. Only two legal grounds for involuntary commitment: 
Danger to self and others
Gravely disabled
Note: individuals involuntarily committed to psychi hosp maintain all rights. Except the right to leave the hospital.

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Restraints and Seclusion are an authorized intervention only when:

1. A behavior is physically harmful to the client, another person, or property.


2. A behavior is potentially dangerous.
3. The client anticipates that a controlled environment (seclusion) would be helpful and he/she requests seclusion.

What is a Developmental crisis?

Puberty, Ericksons stages etc.

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What is a traumatic crisis?

Unpredictable event such as Hurricanes, Fires, Tornadoes, nuclear accident, murder, robbery etc.

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What is a existential crisis?



When people question the meaning of life or one's existence. After a student commits suicide. Think it's a wonderful life.

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