Anxiety & Anxiety Disorders II
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Anxiety disorders versus anxiety
Anxiety disorders are chronic and impair the following:
- Daily routines
- Social functioning
- Occupational functioning
When is it NOT considered an "anxiety disorder"?
Due to medical condition such as endocrine d/o, COPD, CHF, and neuro disorders.
Recurrent, unexpected, intense periods of exreme apprehension and terror without a clear precipitant.
Symptoms of a panic attack:
- Chest pain
- Abdominal distress
- Hot flashes
- Going crazy
- Losing control
Adverse effects of panic disorder:
- Limits social activities
- Interferes with work and social relationships
When panic attacks are unexpected and recurrent they made be called:
After at least one attack the client has concerns about more attacks in the future.
Worries about the implications of future attacks and has a change in behavior.
Fear of the marketplace where fear focuses on being in places or situations where there is no escape or leaving would be difficult or embarrasing.
Which type of panic disorder?
recurrent, unexpected panic attacks followed by at least one month of persistent concern about having another panic attack and how this would adversely impact their life.
Panic disorder without agoraphobia
Which type of panic disorder?
recurrent, unexpected panic attacks along with social withdrawal and isolation related to the fear of having future attacks (50% experience this)
panic disorder WITH agoraphobia
Primary or Secondary gain?
Relief of anxiety by performing certain behaviors (such as staying at home)
Primary or Secondary gain?
Attention received from others due to behaviors (such as relief from daily responsibilities)
Treatment of panic disorders:
- Cognitive behavioral techniques - reframe catastrophic thinking and self awareness issues
- Deep breathing and relaxation
- Medications such as anxiolytics, antidepressants, and alpha adrenergic agonsist.
Nursing process for panic disorder:
- Assessment - signs and symptoms
- Nursing diagnoses - Risk for injury, Anxiety, Fear, Social isolation, Disturbed Sleep, Altered nutrition
- Goals - Injury prevention, Improved coping, Adequate sleep and nutrition
Nursing interventions for panic disorder:
- Safe environment
- Decrease stimuli
- Remain with the client
- Display a calm demeanor
- Therapeutic communication
- Mutual problem solving
- Relaxation techniques
Client and family teaching - avoid secondary gain behaviors.
- Review breathing control and relaxation techniques
- Discuss positive coping strategies
- Medication and follow up
- Time management and goal directed activities
- Participation at the community level in support groups
Persistent, excessive, irrational fear of a particular object or situation that can lead to avoiding the feared object or situation.
Fear of the marketplace where one may avoid public places and in extreme cases may never leave home.
Irrational fear of an object or situation for at least 6 months in persons older than 18 years of age.
Broad categories of specific phobias:
- Natural environment
Examples of specific phobias:
- Acrophobia - fear of heights
- Astrophobia - fear of thunderstorms
- Claustrophobia - when confined
- Glossophobia - of talking
- Hematophobia - of blood
- Hydrophobia - of water
- Mysophobia - of germs
- Pyrophobia - of fire
- Zoophobia - of animals
How the DSM-IV defines "specific phobia":
- Client has marked persistent excessive or unreasonable fear. Presence of the object/situation or "anticipation" can provoke fear.
- Exposure causes market anxiety
- Client recognizes their fear is irrational
- Attempts to avoid or endure distress and disability to usual activities.
The client experiences severe anxiety, possibly panic when confronted with situations involving people such as making a presentation, eating out, meeting new people, or being the "center of attention".
Diagnosis or seriousness of phobias:
- Based on how phobic behavior affects the client's lives.
- Is there marked distress?
- Does it present difficulties with interpersonal relationships or interfere with the client's occupation?
Treatment of phobias:
- Psychopharmacology - anxiolytics, SSRI, beta blockers
- Behavior therapies such as desensitization, exposure treatment, flooding and cognitive restructuring.
Statistics about phobias:
- Specific phobias more common among women
- Men are more likely to experience social phobias
- Peak onset is childhood to mid 20's
- Specific phobias continue into adulthood and are life long in 80%.
The therapist progressively exposes the client to their phobic object in a safe setting and teachers relaxation strategies.
The complexity and intensity of the exposure is gradually increased
Once the client's anxiety is manageable they are encouraged to confront the source of their phobia.
The therapist "floods" the patient with information that causes anxiety.
There is sort o "give and take" communication pattern.
The therapy is considered successful once the client doesn't react adversely to the information.
Client has intrusive thought of unrealistic obsessions and in an effort to control these thoughts they engage in compulsive behaviors.
Obsessive compulsive disorder (OCD)
Common types of obsessions:
- Repeated thoughts about:
- -Aggression or horrific impulse
- -Sexual imagery
Clinical examples of compulsions:
- Checking rituals - is the door locked? is the coffee pot off?
- Counting rituals - ceiling tiles, steps taken, desks in class
- Praying or chanting
- Touching, rubbing, or tapping
- Ordering - vacuuming in one direction
- Rigid performance - only dress one way
- Aggressive urges - to harm one's spouse or child
When a person suffers from OCD, why do they do it, are they aware of what they are doing, how do they feel about their actions, how do they feel if they try to resist their urges.
Statistics about OCD:
- Onset as young as childhood, commonly seen in 20's
- Equal sex distribution
- Gradualonset and maybe exacerbated by stress
- Manageable in 80%
Treatment of OCD:
Combined behavior therapy and medication
To confront the situations they have been deliberately avoiding.
Delaying or avoiding their rituals.
Empowerment of the client is to recognize that the anxiety will recede and they do not need to engage in their ritualistic behaviors.
Extensive assessment tool using 14 criteria examples such as:
How much time do you spend having obsessive thoughts or performing compulsive behaviors?
Range from none to greater than 8 hours a day.
Yale - Brown Obsessive Compulsive Scale
Nursing process for OCD:
Diagnoses: Ineffective coping, fatigue, social isolation
Goals: Client will follow a daily routine, spend less time on rituals and or exhibit an improved communication pattern.
Nursing interventions for OCD:
Convey "acceptance" for the client.
- Establish trust by:
- allowing time for rituals
- mutual goal setting - set limits
- active listening - therapeutic communication
- Identify triggers
- teach coping mechanisms
- follow daily routine
- medication compliance
Family education for OCD:
- Supportive role of family
- Open communication
- Family therapy
- Medication and therapy compliance
- Prognosis is good with early recognition and therapeutic intervention.
Client has worries or feels anxious 50% of the time for at least 6 months.
Exhibits at least three of the following symptoms:
Generalized Anxiety Disorder
Often seen by non-psychiatrist providers.
Tenders to diminish client's quality of life and that is the rationale for treatment.
Cognitive therapy improves the results and outcomes of pharmacology treatment.
Generalized anxiety disorder
A subconscious effort to regain control over a traumatic situation - allowing the m id to remove the painful even from it's memory.
Underlying causes of dissociative disorders:
- Trauma - person may separate themselves from the memory
- Abuse- especially during childhood
- Effect of early abuse - may cause poor neurodevelopment (limbic, left brain)
- Gender - 3-9 times more common among women
May occur both during and after the event.
Onset may be sudden or gradual transient or chronic
Rare in the general population.
Cannot remember important personal information
Leaves their current setting of home or work and relocates elsewhere unable to remember past identity.
Displays two or more distinct identities - yet, doesn't know important personal information - "multiple personalities" formerly described this disorder
"Detached" from their body or mental processes yet in touch with reality.
Cannot recall details about a traumatic event for a certain amount of time - such as after an MVA.
Local and selective amnesia
Has no recollection of their former life.
Cannot recall events that occurred before a certain time.
Categorical or speciic to a certain person or place.
A disturbing pattern of coping demonstrated by an individual who has experienced a traumatic event, combat, natural disaster, assault, etc.
Cardinal symptoms of PTSD:
- Recurrent nightmares
Symptoms of PTSD:
- Reliving the event
- Avoiding reminds of the event
- Being on guard or experiencing hyperarousal
- Cues in the environment remind the brain of the original trauma
- The cues result in fight or flight responses.
Intense memories of event, thrashing in sleep, diaphoresis upon awakening, reliving the trauma, flashbacks, intense distress with memory.
Outbursts of anger, cannot tolerate crowds or public transportation, poor concentration, exaggerated startle response, hyperawareness of surroundings
Avoidance of thoughts, feelings people, and places associated with trauma, general lack of interest, emotional numbness and detachment from life, unable to have strong emotional reactions, and a sense of a foreshortened future.
Numbing and avoidance
Statistics about PTSD:
- Can occur at any age
- Those with a past history of combat, victims of violence, or experiencing a natural disaster have a 60% risk factor.
Treatment of PTSD:
Encourage patient to talk about the event and use a system of gradual re-exposure.
May use inpatient setting and or medications such as anxiolytics or antidepressants.
- Cognitive behavior therapy
- -Targeting thoughts
- -Putting conscious back together with dissociative disorders
Interventions for PTSD
- For clients experiencing flashbacks or other forms or temporary loss of
- touch with reality such as PTSD and dissociative disorders.
Safety for PTSD:
Client management while promoting self-care. Use of a "safe haven" when self - destructive thoughts or impulses are present.
Focus on the "here and now" using nursing techniques that are clam and reassuring.
Grounding "in the person"
Encourage the client to move out of a fetal position into one of increased control such as walking or standing.
Techniques that assist with coping:
- Deep breathing, relaxation
- Distractions such as physical activity, music, conversations, hobbies
- Assess for and discourage the use of drugs or alcohol as coping techniques
- Journaling to identify triggers.
Symptoms occur withing first month after traumatic even but do not persist longer than 4 weeks.
Acute stress disorder
Symptoms occur more than 3 months after the traumatic event
50% of persons with this have complete recovery within three months.
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