STRESS LEADS TO ANXIETY

Produced by change in environment

Individual perceives change as

Challenging

Threatening

Damaging

Stress leads to a variety of psychological responses

*Anxiety is the most common response

ANXIETY (unidentified)

vs.

FEAR (identified)

Anxiety has an unknown or unrecognized source

Fear is a reaction to a specific threat

CATERGORIES

of

ANXIETY

Normal anxiety=

Healthy life force necessary for survival

Acute or State Anxiety=

Crisis threatens sense of security

Chronic or Trait Anxiety=

Long-term anxiety (i.e., chronic fatigue, insomnia)

Discomfort in relationships or poor job performance.

PEPLAU'S CLASSIFICATION

4 LEVELS

of

ANXIETY

Mild

Moderate

Severe

Panic

p. 214 Table 12-1

MILD ANXIETY

Occurs in everyday life/living (coping skills)

Increases perception, improves problem sovling

Mainfested Restlessness

Irritability

Mild tension- relieving behaviors

Alert to what is going on

Healthy confrontation

NSG INTERVENTIONS:

Relaxation techniques

Square breathing

deep breathing

MODERATE ANXIETY

Escalation from normal experience

Decrease in productivity (selective inattention) & learning

Manifested by:

Increased HR

Perspiration

Mild somatic s/sx

Perception narrows

learning & prob. solving still take place, but are compromised

NSG INTERVENTIONS:

Encourage to talk about feelings

Encourage walking & exercise

SEVERE ANXIETY

Greatly reduced perceptual field

Learning & prob. solving not possible

Manifested by:

Erratic,

uncoordinated

impulsive behavior

hyperventilation

N/V

chest pain

crying

completely self absorbed

Focused on details of one thing

Can become nonfunctional

Cog. probs. solving difficulties

Feelings of dread

Focused on causitive factors of anxiety

NSG INTERVENTIONS:

Maintain calm manner

speak slowly

appropriate meds are last resort

PANIC

Results in loss of reality focus

Markedly disturbed behavior occurs

Manifested by:

Confusion

Shouting

Screaming

Withdrawl

dilated pupils

shaking/tremors

inability to speak

feeling of choking

unable to focus on enviro.

State of terror

People feel like they are dying

NSG INTERVENTIONS:

Reduce stimulus, low stimulus enviro.

administer appropriate meds

****Call behavioral CODE****

NSG INTERVENTIONS

for

MILD ANXIETY

to

MODERATE ANXIETY

Use therapeutic communication & listening;

open-ended statements

Broad openings

Seeking Clarification

Exploration

Importance of NURSE to stay calm, recognizing client's stress

NSG INTERVENTIONS

for

SEVERE ANXIETY

and

PANIC ANXIETY

Reduce enviro. stimulus;

remove pt to quiet area

remain w/pt

Gross motor activity to drain tension

Therapeutic comm. techniques;

firm, short, simple statements

reinforce reality

Meds & restraints;

use ONLY after least restrictive measures fail

DEFENSES

vs.

ANXIETY

DEFENSE MECHANISMS:

Automatic coping styles

Protect people from Anxiety

Maintain self-image by blocking

feelings

conflicts, & memories

Can be healthy or unhealthy

PROPERTIES

vs.

DEFENSE MECHANISMS

Major means of managing conflict & affect

Relatively unconscious

Discrete from one another

Hallmarks of major psychiatric disorders

Can be reversible

Can be adaptive as well as pathological

HEALTHY,

INTERMEDIATE,

&

IMMATURE
DEFENSE MECHANISMS

HEALTHY=

Altruism,sublimation, suppression

INTERMEDIATE=

Repression, displacement, reaction, formation, undoing, rationalization

IMMATURE=

Passive aggression, acting-out behaviors, dissociation, devaluation, idealization, splitting, projection, denial. 

 *ANXIETY DISORDERS*

Panic Disorders

Generalized anxiety disorders (GAD)

Obessive Complusive Disorder (OCD)

Posttraumatic Stress Disorder (PTSD)

Behaviors used to control anxiety

Rigid

Repetitive

Ineffective

Functioning that the degree of anxiety intereferes w/include:

The person

The person's occupation

The person's social interactions

FACTS

on

ANXIETY DISORDERS

PREVALANCE:

Most common form of psychiatric disorder in U.S.

Affects approx. 13.3% of adult population

COMORBIDITY:

Major Depression

Substance Abuse

THEORY

of

ANXIETY

GENETIC CORRELATES:

Tend to cluster in families

BIOLOGICAL FACTORS:

Aminobutyrica acid/benzodiazepine theory

Sodium lactate/carbon dioxide theory

Norepinephrine theory

Stress-related change in brain anatomy

PSYCHOLOGICAL FACTORS:

Simund Freud

Harry Stack Sullivan

Learning theories

Cultural Considerations

PANIC DISORDERS (PD)

Panic Disorder with agoraphobia=

Combo of panic-attack symptoms & agoraphobia.

Panic Disorder w/outagoraphobia

DSM-IV-TR criteria p.218, fig. 12-2

AXIS I

Recurrent panic attacks, or @least one of the attacks has been followed by 1 month of worrying about having another atack.

change in behavior.

AGORAPHOBIA

Intense excessive anxiety or fear about being in places or situations from which escape might be difficult or embarassing  or in which help might not be available of a panic attack occured.

PANIC ATTACKS

sudden onset of extreme apprehension or fear, usu. asst. w/feelings of impending doom.

CARE PLAN

for

PANIC DISORDERS

1) pt's anxiety will decrease to mod. by a date

a) if hyperventilation occurs, instruct pt to take slow, deep breaths. Breathing w/the pt may be helpful

b) Keep expectations minimal & simple

2) Pt will gain mastery over Panic episodes by date

a) Help pt connect w/feelings before onset of attack

  "What were you thinking about just before attack?"

b) help pt recognize s/sx resulting from anxiety, not   from a catastrophic physical prob.

EX. Explain physical s/Sx of anxiety

Discuss the fact that anxiety causes sensations similar to those of physical events, like a MI.

c) identify effective therapies for panic episodes

d) teach pt abd breathing to be immediately used when anxiety is detected

e) Teach pt to use pos. self talk

       "I can control my anxiety"

f) teach pt & family about meds for pt's attacks 

PHOBIAS

Specific phobias

Social anxiety Disorder (SAD)

DSM-IV-TR

p. 218 fig. 12-2

AXIS I

Common Phobias

p. 220 14-4

PHOBIAS

cont.

1)Irrational fear of an object or situation that persists although the person may recognize it as unreasonable

2) Types of PHOBIAS

Agoraphobia

Social Phobia

Specific Phobia

3) anxiety is severe if the object, situation, or activity cannot be avoided.

SOCIAL PHOBIA

Social anxiety Disorder (SAD)

Fear or situations where one might be seen & embarrassed or critized

EX. speaking to authority figs, public speaking, performing.

SPECIFIC PHOBIA

Fear of a single object, activivty, or situation

EX. snakes, closed spaces, flying

OBSESSIVE COMPULSIVE DISORDER

(OCD)

DSM-IV-TR

p. 218 fig. 12-2

AXIS I

Common obsessions & compulsions

p. 221 Table 12-5

OCD

cont.

1) either obsessions or compulsions

a) preoccupation w/persistent intrusive thoughts, impulses, or images (obsessions)

OR

b) Repetitive behaviors or mental acts that the pt feels driven to perform in order to reduce distress or prevent a dreaded situation (compulsion)

2) Person knows the obsessions & compulsions are excessive & unreasonable

3) The obsession & compulsion can cause increased distress & it is time consuming

COMMON OBSESSIONS

&

COMPULSIONS

of

OCD

Doubt, need to check

"did i turn off the stove"

Sexual imagery or ideation

"pat his but" near man

Need for order

"everything must be in it's place"

Violence

"i should kill her" when pt sees a blonde woman

Germs or dirt

"everything is dirty!"

GENERALIZED ANXIETY DISORDER

(GAD)

Excessive worrying or anxiety about numerous things that lasts for 6 months or longer

DSM-IV-TR

p. 218 fig. 12-2

AXIS I

Care plan for GAD

p. 222 table 12-6

CARE PLAN FOR

GAD

1) pt will state immediate distress is relieved by end of session

stay w/pt

speak slowly

use short simple sentences

assure pt that you are in control and can assist them

give brief directions

Decrease stimuli, provide quiet enviro.

After assessing level of anxiety; adminsiter appropriate anxiolytic agent

2) pt will be able to identify source of anxiety by date

encourage pt to discuss preceding feelings

link pt's behavior to feelings

Teach cognitive therapy principle:

*Anxiety is the result of a dysfunctional appraisal of a situation

*anxiety is the result of automatic thinking

Ask questions to clarify & dispute logic:

"what evidence do you have?"

"Are you basing that conclusion on fact or feeling?'

have pt give an alternative interpretation

3) pt will identify strengths & coping skills by date

provides awareness of self as individual w/some ability to cope

have a pt write assessment of strengths

reframe situation in ways that are positive

POSTTRAUMATIC STRESS DISORDER

(PTSD)

Flashbacks

avoidance of stimuli asst. w/trauma

experience of persistent numbing responses

Persistent symptoms of increased arousal

DSM-IV-TR criteria

p. 223 fig. 12-3

AXIS I

Duration >1 month

Acute: duration < 3 months

Chronic: duration > 3 months

Delayed: onset of symptoms is @least 6 months after stress/event

PTSD

cont.

The person experienced, witnessed, or ws confronted w/an event that involved actual, threatened death to self or others, responding in fear, helplessness, or horror.

Event is persistently reexperienced

Persistent avoidance of stimuli asst. w/trauma

persistent symptoms of increased arousal (>2)

falling asleep, outbursts of anger, diff. concentratin

NSG PROCESS:

ASSESSMENT GUIDLINES

Determine if anxiety is primary or secondary (due to medical condition)

Use of Hamilton Rating Scale: comprehensive data r/t anxiety

determine potential for self harm/suicide

perform psychosocial assessment

determine beliefs & background

CONSIDERATION

for

OUTCOME SELECTION

for pts with

ANXIETY DISORDERS

reflect pt values & ethical enviro. situations

be culturally relevant

be documenting as measurable goals

include a time estimated of expected outcomes

NSG INTERVENTIONS

for

ANXIETY DISORDERS

Reduce anxiety

Enhance coping

Instill HOPE

Enhance self-esteem

Use relaxation techniques

counseling

Milieu therapy

Promotion of self-care activities

Psychobiological interventions

Health teaching

p. 231 tab. 12-12

p.232 tab. 12-13

p. 233 Box 12-1

MEDS

for

ANXIETY DISORDERS

BZAs: short-term tx only

cause dependence

Buspirone: management of anxiety disorders

Selective serotonin reuptake inhibitors (SSRIs):

****1st line of TX for all anxiety disorders****

Selective norepinephrine reuptake inhibitors (SNRIs):

venlafaxine approved for PD, GAD, SAD.

TRICYCLIC ANTIdepressants (TCAs):

**2nd & 3rd line of TX**

Other MEDS

&

CAM therapies

OTHER MEDS.:

B-blockers

Antihistamines

Anticonvulsants

CAM therapy (effectiveness unproven):

Kava kava

Valerian Root

Gotu Kola

St. John's wort

SOMATOFORM DISORDERS

Physical symptoms suggest a physical disorder

Dx test are neg. for physical illness

Symptoms are linked to psychobiological factors

DISSOCIATIVE DISORDERS

Disturbances in the normally well-intergrated continuum of conscious, memory, identity, & perception

EX. Rare childhood trauma

SOMATOFORM DISORDERS

differentiated

from

Malingering:

intentionally producing symptoms to achieve an enviro. goal

Factitious Disorder:

fabrication of symptoms or self-inflicted injury to assume the sick role

Psychosomatic illness:

a general medical condition affected by stress or psychological factors

TYPES

of

SOMATOFORM DISORDERS

Somatization Disorder

Hypochodriasis

Pain Disorder

Body Dysmorphic Disorder

Conversion Disorder

SOMATOFORM DISORDER

Frequent symptoms:

pain

dysphagia

nausea

bloating

constipation

palpitations

dizziness

SOB

significant functional impairment

Course of illness chronic & relasping

Suicide threats & gestures common

HYPOCHODRIASIS

Misinterpretation of physical sensations

Dx tests are neg.

Depression & anxiety disorders common

HX of childhood trauma possible

PAIN DISORDER

Dx tests r/o organic cause

Discomfort leads to impairment

Suicide is a serious risk

Usu. sites of pain: head, face, lower back, pelvis

BODY DYSMORPHIC DISORDER

Preoccupation w/an imagined defective body part

Obsessional thinking & compulsive behavior

Impaired social, academic, & occupational functioning

Major depression, OCD, & social phobia common

CONVERSION DISORDER

Presence of deficits in voluntary motor or sensory functions

Common symptoms:

involuntray movements

seizures

paralysis

abnormal gait

anesthesia

blindness

deafness

"La belle indifference" vs distress

Comorbid conditions:

depression

anxiety

other somatoform disorders

personality disorders

CONVERSION DISORDER

cont.

Symptoms that affect voluntary motor or sensory function that suggests a physical condition

-dysfunction not congruent w/functioning of the nervous system

Pt's attitiude toward symptoms

-lack of concern ("la belle indifference")

or

marked stress

SOMATOFORM DISORDERS:

assessment

Symptoms & unmet needs

voluntary control of symptoms

secondary gains

cognitive style

ability to comm. feelings & emotional needs

dependence of meds

NSG PROCESS:

assessment guidelines

for

Somatoform disorders

collect data about nature, location,, onset,characteristics, & duration of s/sx

-determine if s/sx are under voluntary control

Identify ability to meet basic needs

Identify any 2* gains= benefits of sick role

Identify ability to comm. emotional needs (b/c often lacking)

Determine meds/substance abuse

NSG DX

&

outcomes identification

Common Nsg Dx:

Ineffective coping

Outcomes identification:

Overall goal: pt will live as normal as possible

NSG Process:

Planning

&

Implementation

Long-term TX/interventions usu. on outpt basis

Focus on interventions on establishing relationship

-address ways to help pt get needs met other than by somatization

Collaborate w/pt's family

Somatoform Disorders:

Basic NSG

Interventions

Promotion of self-care activities

health teaching

case management

psychobiological interventions

NSG

Communicating

w/somatoform client

Take s/sx seriously

-after physical complaint investigate, avoid further reinforcement

Spend time w/pt other than when complaints occur

Shift focus from somatic complaints to feelings

Use matter of fact approach to pt resistance or anger

Avoid fostering dependence

Teach assertive comm.

TX

of

Somatoform Disorders

Case management:

useful to limit health care costs

Psychotherapy:

cognitive & behavioral therapy

group therapy helpful

Meds:

Antidepressants- SSRIs

short-term use of antianxiety meds

-dependence risk

NSG process:

Evaluation

w/somatoform disorder client's

Important to establish measurable behavioral outcomes as part of planning process

Common for goals to be partially met:

clients w/SD have strong resistance to change

DISSOCIATIVE DISORDERS

Depersonalization Disorder

Dissociative amnesia

Dissociative Fugue

Dissociative identity Disorder

DEPERSONALIZATION DISORDER

Alteration in perception of self

Disturbing experiences of:

feeling a sense of deadness of the body

seeing oneself froma distance

perceiving limbs to be larger/smaller than normal

Reality testing remains intact

DISSOCIATIVE AMNESIA

Inability to recall important personal information:

generalized amnesia

localized amnesia

selective amnesia

DISSOCIATIVE FUGUE

Sudden unexpected travel away from customary locale

Inability to recall one's identity & some or all of the past

During FUGUE state client's tend to live simple quiet lives

When remembering former identity, client becomes amnesic for time spent in fugue state

DISSOCIATIVE IDENTITY DISORDER

Presence of 2 or more personality states

Primary personality (host) usu. not aware of alters

Alternate personality (alters) or subpersonalities take control of behavior

Alters often aware of each other

Each thinks & behaves as a separate individual

DISSOCIATIVE DISORDERS:

NSG assessment

Identity & memory

Client HX

Moods

Use of alcohol & other drugs

Impact on client & family

Suicide Risk

NSG process:

Assessment guideline

for

DISSOCIATIVE DISORDERS

r/o medical illness, substance abuse, & other psychiatric disorders

Note signs of dissociative disorder(s)

-changes in behavior, voice, dress

referring to self by another name or in 3rd person

partial memory or memory gaps

disorientation to time, place, person

presence of blackouts

NSG process:

Assessment

of

Dissociative Disorders

Gather info about events in client's life & HX of injury, epilepsy, & physical/mental/sexual abuse

Note mood changes

Determine HX of substance abuse

Determine effect on pt probs. on family, daily functioning, & occupation

Determine suicide risk

NSG process:

DX

&

Outcomes Identification

Common Nsg DX:

Disturbed personal Identity

Common goals:

Develop trust

Correct faulty perceptions

Encourage pt to remain in present

NSG process:

Planning

&

Implementing

Planning:

select implementation focused on safety & crisis interventions when pt is hospitalized

Implementation:

Guided by assessment data collected

NSG Interventions

for clients

w/Dissociative Disorders

Offer emotional presence during recall of painful events

Teach info about:

illness

coping skills

stress management

Provide safe enviro. as part of the milieu TX

TX for

Dissociative Disorders

Psychotherapy:

**Primary TX offered**

most effective

Techniques used include:

psychoeducation, talking throught truama, safety planning, journaling, & artwork

Medications:

Antidepressants & antianxiety meds for comorbid conditions

Basic

NSG Interventions

of the

Dissociative Disorders

Milieu therapy

Health teaching

Psychobiological interventions

NSG process:

Evaluation

of client

w/Dissociative Disorder

Identified outcomes are the basis of eval:

Have the pt's safety needs been met?

Anxiety decreased?

Have conflicts been explored?

Does pt use new coping skills to fucntion better?

Is stress handled w/out use of DISSOCIATION?