Stress-induced Physiological Responses

Stress-induced Psychological Responses:

*Crisis

*Acute stress disorder

*Post-Traumatic stress disorder

Somatoform Disorders:

* Hypochondrias

*Somatization

*Somataform pain disorder

*Malingering

CRISIS

Orgin of modern crisis intervention

*Crisis intervention is a subject of interest to all health professionals

*It is a distinct form of treatment for people with certain debilating emotions

Crisis

*The person loses control of feelings/thoguhts and suffers extreme emotional turmoil-crisis

*Crisis is a struggle for equilibrium & adjustment when problems are perceived as unsolvable. Person faces an obstacle which seems insurmountable. Crisis is an imbalance between the magnitude of a problem & the means one has to cope with the threat.

*crisis occurs in all individuals

*An opportunity for emotional growth

*crisis is not considered a psychiatric mental disorder

CRISIS

{cont'd}

* A crisis state exists when a person's anxiety increases to the point where he/she feels helpless and unable to function.

*Temporary state of disequilibrium-the crisis is self-limiting & usually resolves in 4-6 weeks(except death which takes 1-2 years). Crisis seems to have a natural termination regardless of outcomes because it is impossible to tolerate the subjective distress of crisis any longer.

CRISIS

{cont'd}

* Because the crissi state is usally self-limiting, crisis interventions is short-term therapy desigened to assist the person and sometimes the family, to cope with the immediate situation and to regain coping skills.

Crisis

{cont'd}

*Personality disorganizations-->previous patterns of adapting become ineffective, therefore, abandoned leads to impaired thinking and reasoning

*Debilatating emotions-->anxiety, depression, physical complaints. Attempts are made to redefine problem withdraw or avoid.

*Materational-->Internal source

-New developmental stage is reached

-Old coping skills no longer helpful.

-Ineffective defense mechansisms until new coping skills develdop

-preschoolf, puberty, adolescence, old age

*Situational-->from an external source

-loss of a job or loved one

-Severe illness

-Divorce

Types of Crisis Situations

{con'td}

*Adventious-->Unplanned and accidental

-Natural disaster(flood, hurricanes,etc)

-crime of violence(assault)

Five Phases of Crisis

Precrisis-->usual coping strategies, no symptoms,denies stress

Impact-->Usual strategies are not effective, anxiety and confusion increase. Stress felt, often minimized.

Crisis-->anxiety increases and new ways of coping are used in an effort to minimize anxiety. Recognition of the problem , however denies it is out of control

Five Phases of Crisis

Adaptive-->Redefining the threat and perception of crisis is realsitic.  Best results of coping strategies are effective and support is available.

Postcrisis-->crisis can have positive/negative effects

postive-bettter ways of coping with stress

negative-maladaptive coping strategies

ASSESSMENT

*The precipitating event and the client's perception of problem.

*client's strengths and coping skills

*Nature and strength of clients situational supports

*Nurse lables his/her perception of problem and compare with client

ASSESSMENT

*Analyze feelings associated with the crisis acknowledge then sort put excess

*explore problem solving behaviours and coping skills, test them rehearse

NURSING DIAGNOSIS

*Ineffective individual coping

-r/t inadequate support syste,s, perception of problem as overwhelming

*anxiety

*Compromised family coping

*Altered thought process

-A/E/B altered attention span, distractibility, disorientation to time, place, person or events

outcome criteria for client in crisis

*Goal-->return to pre crisis lvl. of functioning

*Congruent with client's

-needs

-Values

-Cultural expectations

*Safety

-If client is potentially suicidal or homicidal

*Reduce anxiety

-Some inner resources can be used

PRINCIPLES OF TREATMENT

*Focus on the problem-issue oriented

*Assist person to gain realsitic perception of the threat

*Obtain support of family and friends

*Assess coping skills, encourage discussion about feelings and thoughts

PRINCIPLES OF TREATMENT

*Problem sove-explore ways to deal with threat

*Nurses takes active role, is directive. Assumption that the client has a hsitory of adequate functioning.

*Decreases stress and protect victim

*assist to mobilize support and reach solutions. Returns to previous level.

INTERVENTIONS

*Ensure safety

*Focus on problem at hand

*Defuse potential violence

*Decrease client's anxiety

*make appropriate referrals

*Client susceptibility to outside intervention

Types of crisis interventions

* Telephone crisis-->hotlines, staffed by trained volunteers

*ED crisis counseling

*Mobile crisis Units-->go out into communty.

EVALUATION

* Crisis resolution: 1 of 3 functional lvls:

-individual functions more effectively

-individual functions about the same as before

-functioning is at a lower lvl that pre-crisis

*Goal of crisis intervention: Maintain at least a pre-crisis lvl of func. in resolving the threat or stressor

Anxiety Disorders

acute Stress Disorder(ASD)

Posttraumatic stress disorder(PTSD)

*A group of disorders that can occur when stress and resulting anxiety are not relieved with ordinary use of defense mechansims.  Teh individual experiences increased subjective psychological pain and discomfort.

*Behaviours used to control anxiety are rigid, repetive, ineffective

*The degree of anxiety interefers with functioning

*Persistent, chronic and disabling, especially without treatment

Anxiety Disorders

acute Stress Disorder(ASD)

Posttraumatic stress disorder(PTSD)

{cont'd}

*An avoidance pattern can develop when an individual fears becoming anxious-leads to increased phobias

*there is no break with reality and usually the person does not need to be hospitilized

*Usually develops in adolescence or early adulthood.

*Prevalence

-most common form of psychaitric disorder in USA

-Affects approximately 13.3% of the adult opulation with more than twice as women as men

*Posttrauamtic stress disorder occurs only in response to an extreme or traumatic life experience

eg. natural disasters such as earthquakes, accidental human-made disasters, such as auto crashes and intentional human-made disaster

*Delayed repeated re-experiencing of a traumatic event

ACUTE STRESS DISORDER(ASD)

if under 4 weeks you suffer from it

*symptoms occuring within 4 weeks of traumatic event, between 2 dyas and 4 weeks.

*The disassociative experience my occur during the trauma experience or immediately afterward.

PTSD

(If over 4 weeks you suffer from it)

*Symptoms occuring from 1 mth after traumatic event.

*Acute within 3 months,chronic 6 months

S/S unwanted, intrusive and impaired functioning; thoughts & dissociation that occurs

Characteristic Symptoms

*RE-experience of the traumatic event by way of intrusive recollections. dreams,etc

*Perceptual distortions, including illusions

*Memory impairement and ofter dissociative experiences.

*Feelings of being pressured or confused. Detached, estranged,numbing of responsiveness

Charactersitic Symptoms

{cont'd}

Characteristic Symptoms

{cont'd}

* Sustained high lvl of anxiety or arousal.

*soamtic symptoms such as fatigue, headache and muscular pain

*sleep disturbances

*The individual may seek other forms of releif eg. chemical/substance(always assess)

Characteristic Symptoms

{cont'd}

Nursing interventions

* Reassure client these exp. are common occurrences after a traumatic event. That the client is not going crazy

*Stay with the client until experiences subside

*Encourage verbalization of feelings.

*Offer reassurance and empathy as needed

*

Nursing interventions

{cont'd}

* Pharmacologic treatment

-antidepressants

-antianxiety especially benzodiazepines

Anxiety Disorders Interventions

*Basic lvl Nursing

-Counseling

-Mileu therapy

-Promotion of self-care activities

-Psychobiological interventions

-Health teaching

*Advanced Practice Interventions

-Cognitive therapy

-Behavioral therapy

-Cognitive-behavioral therapy

Medications used with

Anxiety Disorders

*Antidepressants

-Selective serotonin reuptake

inhibitors(SSRIs)common use

-Trycyclics(TCA's)

-Monomine oxidas  inhibitors(MAOI'S)

*Anxiolytics

-Benzodiazepines

Benzodiazepines

trade name/generic name

Libirum{chlordiazipine}, valium{diazepam}, Serax{lorazepam}, Ativan{alprazolam}, Xanax

Side effects

-Common-sedation, drowsiness,lower bP, lethargy, ataxia,. sedation usually disappears within 1-2 weeks of treatment.

-Other side effects-nausea, vomiting, diarrhea, constipation, urinarty retention, rasjes, urticaria, pruitus

Benzodiazepines

{cont'd}

*Because benzodiazepines are metabolized in the liver, they must be admisntered with caution to elderly cleints or to clients with liver disease.

*Generally used short term due to trisk of dependence and tolerance.  Withdrawal symptoms may appear follwoing abrupt discontinuation after suing high dosages for prolonged period. Decrease dosage grad. to avoid psosib. of withdrwal symptoms. Physical & psychological dependence after 3 mths.

Benzodiazepines

{cont'd}

* Coontraindications-suicide attempt or history of alcohol abuse, liver disease or damage, pregnancy(the use of benzo during the 1st trimester has been linked to physical dependency in enonates)

**DO NOT USE**

Client Education about Anti-anxiety Drugs

*The name of the drug, its dosage, and the exact scheduele for talking it.

*What to do if dose is missed. (Don;t double up, start time when missed dose is taken)

*Where and how to obtain prescription refills

*The most common side effects and their management

*Not to abruptly stop taking the medication because of the risk of withdrawal

Client Education about Anti-anxiety Drugs

{cont'd}

*To operate a motor vehicle or other machinery with extreme caution.

*The signs of dependency and tolerance

*That alcohol consumption is not permitted while the cleint is taking these drugs. {death can occur}

Herbals

* Kava Kava- may interact with any drugs metabolized by liver.  Enchances efgfects of CNS depressants such as benzodiazepines and alcohol.

*Valerian-extracts interact with the GABA and benzodiaze. receptors

Anxiety Disorders

*Group of disorders that can occur when stress and resulting anxiety are not relieved with ordinary use of defense mechanism.

*The degree of anxiety interferes with functioning.

*Persistent, chronic and disabling, especially without treatments

*Usually develops in adolescences or early adulthood

Prevalance

Most common form of psychiatric disorder in United States

-Affects approximately 13.3% of the adult population

-More than twice as women as men.

Comorbidity

{major depression}

Anxiety Disorders

primary goal of treating anxiety disorders is to use anxiety as meas to increase their committmement to reality & growth toward maturity

Anxiety simultaneously is an adaptation and a stressor.

Long term through anxiety is a non-productive adaptation because it prevents the system from directly dealing with the stressor.

Anxiety is considered maladaptive because it replaces feelings of anxiety with feeling of pleasure and comfort

Somatoform Disorders

* Hypochondrias

*Somatization disorder

*Somatoform pain disorder

*Conversion Disorder

Somatoform Disorders

* Somatization is the expression of psychological conflicts through physiucla conditions and symptoms.  The somatoform disorders are characterized by phsyiologic complaints and symptoims in the absence of organic findings

*Stredss acted out through physical symptoms that are real to the individual

Somatoform disorders

*Physical symptoms suggest a physical disorder

*Diagnostic tests are negative for physical illness

*Symptoms are linked to psychological factors.

*Somatoforms are differentiated from

-maingering-->intentional producing symp. to acheive and environemnetal goal

-Factitious disorder-->fabrication of symp. or self-inflcited injury to assume the sick role

-Psychosomatic illness-->A general medical condition affected by stress or psycholgical factors

Primary vs Secondary Gain

* Primary Gain

-anxiety relief resulting from the use od defense mechanisms and symptoms formation.

*Secondary Gain

-Any benefit the individual obtains are as a result of the symptom.(financial,personal attention, being able to avoid responsb)

-Both reinforces symtpoms and maladaptive behavioral styles.

Hypochondrias

-Preoccupation for at least 6 mths with or fear of having a serious disease despite medical test and reassurances

-There is an impaired social or occupational functions always present.

-Diagnostic tests are negative

-It generally occurs in adolescences & becomes chronic

Hypochondrias

{cont'd}

-Defense mechanism is denial

-Depression/anxiety disorders is common

Somatization Disorders

*Most freq. symptoms

-pain, dyspahgia, nausea, bloating, constipation,palpitations,dizziness,SOB

*Significant fucntional impairement

*Course of illness chronic and relasping

*Suicide threats and gestures common

Conversion Disorder

* A psychological condition in which an anxiety-provking impulses is converted unconciously inot functional (sensory and motor)symptoms.

*Absence of tissue pathology, psychologenic cause, symptoms do not correspond to logical stimulus

*Little or no effect elicited by physical treatment

Conversion Disorder

S/S

Involuntary movements, siezures, pralysis, abnormal gait, anesthesia, blindness, deafness

The symptoms do serve to meet the immediate needs of the cleint, and are associated with secondary gain

Conversion Disorder

Most common

-"La belle indifference" is an attitude of indifference. The client does not display concern about the symptoms. The anxiety has been relived by the conversion disorder.

Defense mechanism primarily used are repression and conversion.

Conversion Disorder

corbid conditions

Somatoform Disorders

Assessment

*Symptoms and unmet needs

*Voluntary ctrl of symptoms

*Secondary gains

*Cognitive style

*Ability to communicate feelings & emotional needs

*Dependence on medication

Nursing diagnosis for clients with Somatoform Disorders

*Ineffective individual coping:

-r/t unresolved conflicts(anxiety disorders)

-r/t repressed anxiety(conversion disorders)

-r/t un-met dependency needs (conversion disorders)

-r/t confusion and disorientation (disassociative disorders, PTSD)

*Altered family process

-r/t inability to express feelings(anixeity disorder)

-r/t knowledge deficit(of fmaily) concerning health problem(gneralized anixiety disorder)

Nursing diagnosis for clients with Somatoform Disorders

{cont'd}

*Anxiety

-r/t threat to self-concept

-r/t fear of being out of ctrl.

-r/t persistent intrusive thoguhts

*Disturbance in self-concept

-r/t chronic anxiety

-r/t loss of job or abiltty to work

Somatoform disorders Interventions

* Basic lvl Nursing

-Promotion of self-care activities

-Health teaching

-case management

-Psychological interventions

*Advanced Practicce Interventions

-Psyhotherapy