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What is the most common of all psychiatric illnesses? Does it occur more common in men or women? Who is pre-disposed
Anxiety; it occurs more commonly in women (2:1); it has a family predispsition; usually co-occurs/comorbidty
what is anxiety? When is considered pathologic? What is fear? Is anxiety normal?
- apprehension, uneasiness, uncertainty, uneasiness, or dread from *real or perceived threat
- Pathologic: when it is persistant, and not logical
- Fear: a reaction to specific danger
- It is normal, and necessary for survival
What goes hand in hand with anxiety?
depression (make eachother worse)
What part of the brain is enlarged in patients with anxiety and phobias? Which part links the memories to fear responses? which part "controls how you act" What does the brain stem do? basal ganglia?
- The amygdala;
- the hypocampus
- the brain stem
- increases rr and hr
- causes tremors
What does anxiety look like?(physiologically)
increase in heart rate and BP, SOB, Palpitations, flushing, sweating, sensation of choking, tremors, nausea vomiting, increased urination
What are the cognitive components of anxiety?
decreased attention, decreased concentration, forgetfulness, thought blocking
What is the mild level of anxiety?
Mild: + , person is alert, sees, hears & grasps more than usual; goal oriented learning is enhanced; able to recognize anxiety; *What is experienced in everyday life (nail biting, fidgeting)
What is the moderate level of anxiety?
- moderate: ++ perceptual field is narrowed, but person can attend to more if directed to do so
- selective inattention, mild somatic symptoms, problem solving capacity is still available (shaking, Head ache, upset stomach)
What is the severe level of anxiety?
- severe: +++
- perceptual field greatly reduced
- requires direction to change focus; intense somatic symptoms present; feeling of impending doom; dazed
What is the panic level of anxiety?
- Panic level: ++++ 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, flight/fight takes over
- exhaustion/death can occur if panic continues for prolonged period
- marked disturbed before hallucinations shouting, crying, screaming) *patient cannot stay like this for long, can lead to death
What is panic disorder according to DSM-5?
recurrent panic attacks (15-20 minutes duration) at least one attack followed by: persistent concern about having another, worry about losing control; significant change in behavior r/t attacks; can be with or without Agoraphobia
What is agoraphobia?
gradual 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 ( will not go on a plane, bus, no crowds, won't drive on bridge, worry about having a panic attack
What are the interventions for panic disorders?
- *stay with the patient during panic attack (safety)
- maintain calm(anxiety is transferred), supportive attitude, offer reassurance, speak using simple words, brief messages, and a slow delivery; decrease environmental stimuli; slow deep breaths, keep expectations minimal and simple, help connect feelings with attack onset; help client recognize symptoms as anxiety, not a physical problem; identify therapies, teach abdominal breathing and positive self talk
What meds are most commonly used for short term use? What are the examples of those drugs?
- Alprazolam (xanax): 0.75-4mg/day
- Lorazapan (ativan): 2-6:mg/day
- Clonazepam (Klonopin): 1.5-4mg/day
- oxazepam (serax): 30-120mg/day
What are the side effects of benzos?
CNS depressants, decreased RR and HR *do not take with alcohol*
What other non-benzo meds are used for anxiety?
- buspirone (Buspar): 15-30mg/day *most common, no CNS depress, cannot be prn)
- Beta blockers (propranolol, Inderal: 30-80mg/day
- SSRIs: selective seritonin reuptake inhibitors (first line therapy; anti-depress, much more effective long term, can't reallyoverdose less side effects, no sedation)
- sertraline (zoloft)
- fluoxetine (prozac)
- Paroxetine (paxil)
- Fluvoxamine (luvox)
- citalopram (celaxa
What is generalized anxiety disorder?
- excessive worry or anxiety about multiple issues which lingers six or more months and occurs more days then not
- difficult to control worry
- and has 3 or more of the following: restlessness of feeling on edge
- easily fatigued; irritability; muscle tension; sleep disturbance common**)
What is substance induced anxiety disorder?
- all the symptoms of anxiety, panic attacks, obsessions and compulsions that develop with the use of the substance
- r/t starting, stopping, and using illegal drugs
What is separation anxiety?
- developmentally inappropriate levels of concern over being away from a significant other; typically diagnosed prior to age 18; symptom duration is one month; normal activates and sleep impaired
- can result in panic disorders/panic attacks
Why are defense mechanisms used for anxiety?
- some are healthy: altruism, sublimination, suppression, humor
- intermediate: repression, displacement, reaction formation, somatization, rationalism, undoing
- never appropriate (immature): passive aggressive, projection, disassociation, denial, splitting ( hallmark of borderline, sees person as all good or all bad)
What are defenses against anxiety?
defense mechs: autonomic coping styles, protect people from anxiety, maintain self-imae by blocking(feelings, conflicts, memories) can be healthy or unhealthy
What are phobias?
- fear cued by the presence or anticipation of a specific object o situation. Exposure invariably provokes an immediate anxiety response or a panic attacks, even though he/she recognizes that the fear is excessive or unreasonable.
- The phobic stimulus is either avoided or endured with marked distress; classified according to the stimulus
What is social phobia? What is the DSM5 criteria?
- Spotlight shunners: expecting the worst; is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively
- DSM: marked or persistent fear of one or more social situations
- 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 conditions
What are the phobia-interventions?
- Systemic desensitization
- in vitro- imagery
- flooding (implosion therapy)
- group therapy
- cognitive therapy
What is obsessive compulsive disorder?
- OCD: (thought) unfruitful attempt t ignore or suppress thoughts; recognizes thoughts as product of own mind
- Compulsion (act): ritual acts followed according to rigid rules, aimed at preventing or reducing distress or preventing some dreaded event; compulsive act is not realistic to prevent event
What are Obsess. Compuls. run on rituals?
Run on rituals: obsessive-compuls. behaviors and activities take up more than 1hr/da. for some, rituals take hours to complete and become a major life activity
What other diseases do OCD suffers usually have?
- Panic disorder, social phobia, eating disorders, substance abuse, personality disorders
How can most forms of OCD be classified?
- Washers: fear contamination
- Checkers: doubt they have done something important (close/lock door)
- Doubters and sinners: fear of doom of not perfect
- Counters and arrangers: magical thinking/superstition about order, symmetry or number
What is the biological, psychoanalytic and cognitive-behavioral etiology of OCD?
- Biological: neurotransmitter imbalance (serotonin)
- there is an enlarged basal ganglia
- psychoanalytical: Overuse of defense mechanism "undoing"
- fixation at anal stage, underdeveloped egos, conflict between ID and EGO
- Cog-behavioral: compulsion is reinforced by reduction in anxiety
What are the characteristics of hoarding disorder?
- difficulty discarding possessions of limited/no value. Marked distress associated with discarding
- Accumulation results in little to no useable personal space
- The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others)
What are the interventions for OC disorders?
- anticipate needs, especially for information
- *focus on client rather than on rituals
- monitor nutrition/sleep; encourage meals/rest
- avoid hurrying client
- *** Do not arbitrarily forbid rituals; give positive reinforcement for non ritualistic activity
- prevent/treat self inflicted injury
- cog therapy: ** thought monitoring/blocking Ex. pivture STOP sign; rubber band on arm)
What meds are used for anxiety?
- TCA-Clomipramine ( anafranil)
What are the characteristics of body dysmorphic disorder?
- picture going to fun house with mirrors; **exaggerated belief that body is deformed/flawed/defective in some way
- ex: slight flaws in face, acne, wrinkles, nose
- social and occupational impairment occurs r/t excessive anxiety
- numerous visits to plastic surgeons and dermatologists
What are the somatoform disorders?
- (somatic symptom disorders)
- Conversion disorder
- illness anxiety disorder(hypochondriasis)
- factitious disorders
What are the characteristics of somatic symptom disorders?
- hx of many physical complaints
- occurs over a period of years
- results in tx being sought, significant impairment in functioning
- S&S cannot be explained by a medical condition; NOR are the intentionally produced or feigned
What is the etiology and outcome/goal of somatic symptom disorder?
- etiology: children learn to gain affection, care, attention through illness; family systems unable to deal with conflict, child becomes ill, focus is on them (learned behavior)
- Outcome: client will demonstrate ability to cope with stress by means other than preoccupation with physical symptoms
What is conversion disorder? What is the primary gain for the client? What is the secondary gain? What is the goal? What is la belle indifference?
- Loss or change in body function; the physical symptoms of which cannot be explained by any medical disorder. ex: paralysis, blindness, deafness, difficulty swallowing
- Primary gain: conversion S &S serve to prevent internal conflict/painful issues from attaining awareness
- secondary goal: enables client to avoid difficult situation or to obtain support that might otherwise not be forthcoming; S & S usually occur after a situation that produces extreme psychological stress
- Goal: client demonstrates more adaptive coping strategies for dealing with stress
- La belle: is a bland affect ex "oh whatever, who cares that I cant see"
What is hypochondriasis?
- misinterpretation of physical sensations
- over concerned for health and preoccupied with symptoms; extreme worry and fear
- course of illness chronic and relapsing
What are the factitious disorders?
- Munchausen syndrome- undergo painful tests even though nothing is wrong to get attention
- Munchausen by proxy- usually in children
What is adjustment disorder?
- precipitated by stressful event
- debilitating cognitive, emotional, and behavioral symptoms that negatively impact normal functioning; responses to stressful event may include combinations of depression, anxiety and conduct disturbance
What is PTSD?
re-experiencing of the trauma; avoidance of stimuli associated with trauma; persistent symptoms of increased arousal; alterations in mood
What are the three clusters of PTSD symptoms?
- physical arousal
What are the causes of PTSD?
- Natural disasters
What are the interventions for PTSD? When is the best time to debrief, and what should the nurse encourage?
- Therapeutic nurse-client relationship: safe, trusting environment
- Remain with client during flashback; allow client to talk about trauma at own pace; acknowledge themes and validate feelings;
- debriefing: immediately following experience (encourage detailed description of event-multisensory experience)
- grief and loss therapy
What medications are used for PTSD?
- Beta blockers: decrease ANS hyperarousal by inhibiting norepinephrine (Inderal)
- Benzos: increase inhibitory effect of GABA (se prn.. addictive qualities)
- Mood stabilizers: stabilize CNS
- antidepressants: increase serotonin
What is dissociative disorders?
- occurs after significant adverse experience/trauma; individuals respond to stress with severe interruption of consciousness
- *Unconsciousness defense mechanism
- protects individual against overwhelming anxiety through emotional separating
What is dissociative amnesia? fugue? identity disorder?
- diss. amnesia: inability to integrate memories
- diss. fugue: sudden travel away from home with no explanation
- diss. identity disorder: multiple personality disorder
What is the difference between anger and aggression?
- anger: emotion
- aggression: an action
Describe anger in children vs adults
- Children: anger co-exists with *ADHD, oppositional defiant disorder and impulsivity
- Adults: anger co-exists with *depression, PTSD, mania, Psychotic disorder, and Alzheimer's
What are the Milieu characteristics conducive to violence? What is single best predictor of future violence?
- inexperienced staff
- provocative or controlling staff
- poor limit setting
- **History of violence is the single best predictor of future violence**
Who is most "at risk" for violence?
- Substance abusers
- cognitive defects
- those with unreal expectations
- those who feel ignored
- those who feel frightened and/or threatened
What are warning signs/ precursors to violence?
- restlessness/ hyperactivity
- signs of anxiety and tension
- profanity, argumentativeness
- loud voice or stony silence
- intense glaring eye contact
- carrying a dangerous object
- recent acts of violence
- challenging and threatening- verbal, written or gestures
What are de-escalating techniques for violence?
- maintain client's dignity and self esteem
- stay calm
- assess situation; identify stressors and what client sees as his 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