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Define anxiety and when it becomes pathologic
- Anxiety: apprehension, uneasiness, uncertainty, or dread from a real or perceived threat. Anxiety is a normal response. Normal anxiety is necessary for survival
- Anxiety becomes pathologic when it interferes with every day life
What are the physical manifestations of anxiety?
- Increased HR and BP
- Palpations, flushing, sweating
- Sensation of choking
- Increased Urination
- *fight or flight response
What are the cognitive components of anxiety?
- Decreased attention
- Decreased concentration
- Thought blocking
What are the levels of anxiety as delineated by Peplau?
- Anxiety rated on a level of 1-4 and exists along a continuum
- 1. Mild Anxiety
- 2. Moderate Anxiety
- 3. Severe Anxiety
- 4. Panic
Describe the different levels of anxiety
- Mild (+):
- What is experienced in every day life
- Person is alert
- Sees, hearts and grasps more than usual
- Goal oriented learning is enhances
- Able to recognize anxiety
- Moderate (++):
- Perceptual field is narrowed, but person can attend to more if directed to do so
- Selective attention
- Mild somatic symptoms
- Problem-solving capacity still available
- Severe (+++):
- Perceptual field is greatly reduced
- Preoccupation with one detail or focus on several details at once (scattering)
- Requires direction to change focus
- Intese somatic symptoms present
- Feelings of impending doom
- Usually medicated
- Panic (++++):
- Attention is severely narrowed or speed of scatter is sharply increased
- Feelings of awe, dread, terror are common; psychosis can occur
- Rational communication and behavior disappear, fight/flight takes over
- Exhaustion/death can occur if panic continues for prolonged period
What are the s/s of a panic attack?
- Similar to panic anxiety
- Derealization- familiar objects become strange
- Depersonalization- see self from a distance (out of body experience)
- Parathesias- numbness
- Fear of going crazy
What are the DSM-5 criteria of a panic disorder?
- Recurrent Panic Attacks (15-20 min duration)
- At least one attack followed by persistent concern of having another, worry about losing control, significant change in behavior r/t the attacks
Describe a panic disorder accompanied by agoraphobia
- Graduation restriction of activities/travel
- Anxiety about being in places where escape might be difficult
- Fear of being alone in open or public places. may not leave home
What interventions can be taken during a panic attack?
- Stay with the client during panic attack
- Maintain calm, supportive attitude
- Offer reassurance
- Speak using simple words, brief messages, slow delivery
- Decrease environmental stimuli
- Instruct to take slow, deep breaths
- Keep expectations minimal and simple
- Help connect feelings with attack onset
- Health client recognize symptoms as anxiety, not as physical problem
- Identify therapies- behavioral, medication
- teach abdominal breathing and positive self talk
What Benzodiazepines (BZDs) are commonly used for panic disorders? What are their side effects? What teaching needs to be done?
- Alprazolam (Xanax)
- Lorazapam (Ativan)
- Clonazepam (Klonopin)
- Axazepam (Serax)
- SE: resp depression (fast acting CNS depressant)
- Teaching: do not take with other CNS depressants. Physically and psychologically addicting. Do not stop abruptly for a risk of rebound seizures. No longer effective after 4mo if taken round the clock, must be taken PRN.
- Contraindicated for pregnant or BF
What non BZD medications can be used for anxiety? What is the gold standard?
- Buspirone (Buspar): cannot be given PRN, must be given around the clock.No sedation effect (not CNS depressant), effects seratonin level
- Propranalol (Inderal): beta blockers can be used for social anxiety PRN
- SSRIs: the gold standard for long term anxiety management
- -sertraline (Zoloft)
- -Fluoxetine (Prozac)
- -Paroxetine (Paxil)
- -Fluvoxamine (Luvox)
- -Citalopram (Celexa)
What is generalized anxiety disorder (GAD)?
- Excessive anxiety or worry about multiple issues which lingers six months or more can indicate generalized anxiety disorder
- Must have 3 of the following:
- -restless or feeling on edge
- -easily fatigued
- -muscle tension
- -sleep disturbances (common)
What is substance-induced anxiety disorder?
- Develop with the use of a substance of within a month of stopping use of the substance
- Symptoms of anxiety, panic attacks, obsessions, and compulsions
What is separation anxiety disorder?
- Developmentally Inappropriate levels of concern over being away from a significant other
- Typically diagnosed prior to age 18
- Symptom duration of one month
- Normal activities and sleep impaired
What are healthy defense, intermediate defenses, and immature defenses against anxiety?
- Healthy defenses:
- Intermediate Defenses:
- -reaction formation
- Immature Defenses:
- -passive aggressive
What is a phobia?
- Fear cued by the presence or anticipation of a specific object or situation. Exposure invariably provokes an immediate anxiety response or panic attack even though he/she recognizes that the fear is excessive or unreasonable
- Stimulus is avoided or endured with marked distress
What is a social phobia? What are the DSM-5 criteria?
- Marked or persistent fear of one or more social activities
- Exposure produces anxiety
- Person recognized fear is excessive
- Interferes significantly with person's routine
- Fear not related to effects of a substance
- Fear unrelated to general medical or psychiatric condition
What interventions can be done for phobias?
- Systematic Desensitization. Either in vitro (imagery) or in vivo (live)
- Flooding-implosion therapy
- Group Therapy
- Cognitive therapy
Name the different Obsessive-Compulsive Disorders
- Body dysmorphic disorder
- Hoarding disorder
- Hair pulling or skin picking disorders
What is OCD?
- -unfruitful attempt to ignore or suppress thoughts
- -recognizes thoughts as product of mind
- -Ritual acts followed according to rigid rules
- -aimed at preventing or reducing distress or preventing some dreaded event (not done for pleasure)
- -Compulsive act is not realistic to prevent event
- Run-On Rituals:
- -OCD behaviors and activities take up more than 1hr/day
What are some mental health comorbidities for OCD?
- Major Depressive disorder
- Social phobia
- Eating disorders
- Substance abuse
- Personality disorders
What are some OCD manifestations that may be found upon assessment?
- Washing: fear of contamination
- Checking: doubt they have done something important
- Doubters and Sinners: fear doom if not perfect
- Counters and arrangers: magical thinking/superstition about order, symmetry or number
What is the etiology of OCD?
- Biological:neurotransmitter imbalance (Sertonin), enlarged basal gland
- Psychoanalytic: overuse of defense mechanism "undoing", fixation at anal stage, underdeveloped egos, conflict between ego and id
- Cognititve-behavioral: compulsion is reinforced by reduction in anxiety
What are the characteristics of a hoarding disorder?
- Difficulty discarding possessions of limited/no value with marked distress
- Accumulation results in little to no usable personal space
- The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functions (including safety)
What are some Interventions for OCD?
- Anticipate needs, esp for information
- Focus on client rather than rituals
- Monitor nutrition/sleep and encourage meals/rest
- Avoid hurrying client
- Do not forbid rituals, give positive reinforcement for non-ritualistic activity
What therapy and medications can be used for OCD?
- Prevent/treat self inflicted therapy
- Cognitive therapy (stop thoughts by thinking of stop sign, snapping rubber band)
- Tricyclic Antidepressent Clompramine (Anafril) works great. S/E are cardiac
What is body dysmorphic disorder?
- Exaggerated belief that body is flawed/deformed/defective in some way
- Social and occupational impairment occurs r/t excessive anxiety
- Numerous visits to plastic surgeons and dermatologists
Name the somatoform disorders? What are they?
- 1. Conversion disorder
- 2. Illness Anxiety disorder (hypochrondriasis)
- 3. Factitious disorders
- History of many physical complaints over a series of years, s/s cannot be medically explained and are they intentionally produced or feigned
- Results in tx being sought, significant impairment in functioning
What is the etiology and outcome for somatic symptom disorder?
- Etiology: children learn to gain affection, care attention through illness, family systems unable to deal with conflict- child becomes ill and received focus
- Outcome: client will demonstrate ability t cope with stress by means other than preoccupation with physical symptoms
What is conversion disorder?
- Loss or change in body function
- Physical symptoms (such as paralysis, blindness, deafness, dysphasia) cannot be medically explained
- Primary gain: s/s prevent internal conflict/painful issues from attaining awareness
- Secondary gain: enables client to avoid difficult situation or obtain support that might otherwise not be forthcoming
- Goal: client demonstrates more adaptive coping strategies for dealing with stress
What is Hypochondriasis?
- Misinterpretation of physical sensations
- Over-concerned for health and preoccupied with symptoms leading to extreme worry and fear
- Course of illness is chronic and relapsing
What are factitious disorders?
- Munchausen Syndrome: deliberate/conscious sickening of self for attention
- Munchausen By Proxy: sickening another for attention
- Malingering: physical complaint for financial gain
What is adjustment disorder?
- precipitated by a stressful event
- debilitating cognitive, emotional, and behavioral symptoms that negatively impact normal functioning
- May include combo of depression, anxiety, and conduct disturbances
- Milder form of PTSD
What is PTSD? What 3 cluters of s/s are associated with it? What are some common causes?
- Re-experiencing of the trauma
- Avoidance of stimuli associated with trauma
- Increased physical arousal and alt in mood
- Common causes include war, terrorism, natural disasters, violence/abuse, accidents/injury
What interventions can be used for PTSD? What medications?
- Remain with clients during flashbacks
- Allow client to talk at own pace
- Acknowledge themes and feelings
- Debrief immediately following experience
- Grief and loss therapy
- Beta blockers: decreased ANS hyperarousal by inhibiting NOR (Inderal)
- Benzo: increases inhib effect of GABA (use PRN, highly addictive)
- Mood Stabilizer: stabilize CNS
- Antidepressents: increases serotonin
What are dissociative disorders? Name three types
- Occur after signif trauma
- Respond with severe interruption of consciousness, unconscious defense mechanisms
- This protects the individual against overwhelming anxiety through emotional separation
- Dissociative amnesia: inability to integrate memories
- Dissociative fugue: sudden travel away from home
- Dissociative Identity Disorder: multiple personality disorder, almost always a result of childhood abuse. Integration therapy is the treatment
What is the difference between anger and aggression? What can anger co-exist with in adults and children?
- Anger is an emotion, aggression is an action
- Adults: Depression, PTSD, Mania, psychosis, Alzheimer
- Children: ADHD, oppositional defiance, impulsivity
What are Mileu's characteristics conducive to violence? Who is most at risk?
- Inexperienced staff
- Provocative or controlling staff
- Poor limit setting
- *history of violence is the best predictor of future violence
- Most at risk:
- substance abusers
- cognitive defects
- those who feel ignored
- those with unreal expectations
- those who feel threatened or frightened
What are some warning signs or precursors to violence?
- Signs of anxiety or tension
- Profanity, argumentativeness
- Loud voice or stony silence
- Intense glaring or eye contact
- Carrying a dangerous object
- Recent acts of violence
- Challenging and threatening- verbal, written, or gestures
What are some de-escalating techniques for aggressive/violent clients/situations?
- Maintain a client's dignity and self-esteem
- Stay calm
- Assess the situation; identify stressors and what client sees as need
- Use calm voice, non threatening body language
- Be empathetic, genuine, honest
- Maintain large personal space
- Don't argue
- Give clear options
- Assess for own personal safety