Understanding Anxiety Disorders: Symptoms, Defenses, and Types, Exams of Nursing

Download Understanding Anxiety Disorders: Symptoms, Defenses, and Types and more Exams Nursing in PDF only on Docsity! NUR 2145 Chapter 12: Anxiety and Related Disorders • For some people, however, anxiety-related symptoms become severely debilitating and interfere with normal functioning. • Anxiety can also affect individuals through physical symptoms, such as fatigue, pain, or numbness. • Anxiety: a feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat; a vague feeling of dread related to an unspecified or unknown danger; effects at a deeper level • Fear: a reaction to a real or perceived specific danger. • Normal anxiety: healthy reaction; provides us with energy to carry out everyday tasks and strive toward goals; motivates us to make and survive change; and prompts constructive behaviours. LEVELS OF ANXIETY • Mild anxiety: occurs in the normal experience of everyday living, allows an individual to perceive reality in sharp focus. ➢ Symptoms: slight discomfort, restlessness, irritability, or mild tension- relieving behaviours • Moderate anxiety: the person sees, hears, and grasps less information and may demonstrate selective inattention, in which only certain things in the environment are seen or heard unless they are pointed out. ➢ Symptoms: moderate anxiety include tension, pounding heart, increased pulse and respiratory rate, perspiration, and mild somatic symptoms (gastric discomfort, headache, urinary urgency). • Severe anxiety: may focus on one particular detail or many scattered details and have difficulty noticing his or her environment, even when it is pointed out by another; problem solving not possible; person may be confused. ➢ Symptoms: headache, nausea, dizziness, and insomnia often increase, trembling, hyperventilation • Panic: most extreme level of anxiety, results in noticeably disturbed behaviour; lose touch with reality; hallucinations may occur ➢ Symptoms: pacing, running, shouting, screaming, or withdrawal, and actions may become erratic, uncoordinated, and impulsive DEFENSES AGAINST ANXIETY • Dysfunctional behaviour (e.g., compulsions, stress headaches, detachment) is a result of defence mechanisms. • Defence mechanisms: automatic coping styles that protect people from anxiety and maintain self-image by blocking feelings, conflicts, and memories. • Dec. anxiety = dec. dysfunctional behaviour. • Adaptive use of defense mechanism: helps people lower their anxiety to achieve goals in acceptable ways (healthy) • The excessive application of defence mechanisms, however, results in their maladaptive use and is particularly problematic when immature defences are called upon. • Use of defence mechanisms is adaptive or maladaptive is determined, for the most part, by their frequency, intensity, duration of use, and effect on relationships. • Types of Defense Mechanisms: ➢ Altruism: dedicating oneself to meeting the needs of others as a means of diffusing potentially anxious situations ➢ Compensation: make up for perceived deficiencies and to cover up shortcomings to protect the conscious mind from recognizing them ➢ Conversion: unconscious transformation of anxiety into a physical symptom with no organic cause ➢ Denial: escaping unpleasant, anxiety-causing thoughts by ignoring them ➢ Displacement: transference of emotions associated with a particular person, object, or situation to another nonthreatening person, object, or situation ➢ Dissociation: disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. ➢ Identification: attributing to oneself the characteristics of another person or group ➢ Intellectualization: process of analyzing events based on remote, cold facts w/o feelings ➢ Introjection: outside world is incorporated or absorbed into a person’s view of the self ➢ Projection: unconscious rejection of emotionally unacceptable features and the transfer of them onto other people, objects, or situations. ➢ Rationalization: justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations ➢ Reaction formation: unacceptable feelings or behaviours are controlled and kept outside of awareness by developing the opposite behaviour or emotion. ➢ Regression: reversion to an earlier, more primitive, and childlike pattern of behaviour. ➢ Repression: unconscious temporary or long-term exclusion of unpleasant or unwanted experiences ➢ Splitting: inability to integrate the positive and negative qualities of oneself or others into a cohesive image. ➢ Sublimation: unconscious process of substituting mature, constructive, and socially acceptable activity for immature, destructive, and unacceptable impulses ➢ Suppression: conscious denial of a disturbing situation or feeling SOMATIC SYMPTOM AND RELATED DISORDERS Somatic Symptom Disorder • Somatic symptom disorders: a complex spectrum of physical and emotional signs and symptoms. Individuals with these disorders will have physical symptoms and abnormal alterations in thoughts, feelings, and behaviours directly related to the physical symptoms experienced. • Somatization: the expression of psychological stress through physical symptoms, can affect women, men, and children • Often the patient has a comorbid psychiatric disorder such as depression, anxiety, or a personality disorder. • Young women, ages 16 to 25, are more likely to receive a somatic diagnosis than men or older individuals. Illness Anxiety Disorder • Illness anxiety disorder: results in the misinterpretation of physical sensations as evidence of a serious illness. • Illness anxiety can be quite obsessive as thoughts about illness may be intrusive and hard to dismiss even when patients realize that their fears are unrealistic. • Even normal body changes, such as a change in heart rate or abdominal cramps, can be seen as red flags for serious illness and imminent death. Conversion Disorder • Conversion disorder: manifests itself as neurological symptoms in the absence of a neurological diagnosis. • Patients with conversion disorder symptoms may be found to have “no neurological disorder” by the neurologist and “no psychiatric disorder” by the psychiatrist, thus adding to the complexity of treatment planning. OBSESSIVE-COMPULSIVE DISORDER (pp. 213) • Obsessions: thoughts, impulses, or images that persist and recur and cannot be dismissed from the mind. • Compulsions: ritualistic behaviours or thoughts an individual feels compelled to perform in an attempt to reduce anxiety. • ritualistic behaviours or thoughts an individual feels compelled to perform in an attempt to reduce anxiety. • Common types of obsessions include losing control, harm, contamination, perfectionism, sexual, and religious. • There are also common categories of compulsions: washing and cleaning, checking, repeating, and mental compulsions. • “Normal” individuals may experience mildly obsessive-compulsive behaviour. • Severe obsessive-compulsive disorder (OCD) consumes so much of the individual’s mental processes that the performance of cognitive tasks may be impaired. TRAUMATIC AND STRESS-RELATED DISORDERS Acute Stress Disorder • Acute stress disorder: occurs within 1 month of a highly traumatic event, such as those that precipitate post-traumatic stress disorder. • To be diagnosed with acute stress disorder, the individual must display at least three dissociative symptoms either during or after the traumatic event. • Symptoms: sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization (a sense of unreality related to the environment); depersonalization (a sense of unreality or self-estrangement) Post-Traumatic Stress Disorder • Post-traumatic stress disorder (PTSD): an acute emotional response to a traumatic event or situation involving severe environmental stress. • The individual with PTSD persistently re-experiences a traumatic event that involved threatened or actual death or serious injury to self or others, and to which the person responded with intense fear, helplessness, or horror. • PTSD symptoms often begin within 3 months of the trauma. • Features of PTSD: ➢ Flashbacks: dissociative experiences during which the event is relived (i.e., the person behaves as though he or she is experiencing the event in the present) ➢ Persistent avoidance of stimuli associated with the trauma, causing the individual to avoid talking about the trauma. ➢ Persistent numbing of general responsiveness, as evidenced by the individual’s feeling empty inside or feeling disconnected from others. ➢ Persistent symptoms of increased arousal, as evidenced by irritability, difficulty sleeping, difficulty concentrating, hypervigilance, or exaggerated startle response. DISSOCIATIVE DISORDERS • Dissociative disorders: group of disorders precipitated by significant adverse experiences or traumas and resulting in the unconscious altering of mind–body connections. • Dissociation is an unconscious defence mechanism that protects the individual against overwhelming anxiety and stress through an emotional separation; however, this separation results in disturbances in memory, consciousness, self-identity, and perception. • With pathological dissociation, pieces of a memory become fragmented. • Positive symptoms: unwanted additions to mental activity, such as flashbacks • Negative flashbacks: refer to deficits, such as memory problems or the inability to sense or control different parts of the body. Depersonalization and Derealization Disorder • Depersonalization/derealization disorder may cause a person to feel mechanical, dreamy, or detached from the body. • People with this disorder may experience episodes of depersonalization or derealization or both. • Depersonalization: individuals feel as though they are observers of their own body or mental processes. • Derealization: there is a recurring feeling that one’s surroundings are unreal or distant. Dissociative Amnesia • Dissociative amnesia: inability to recall important autobiographical information, often of a traumatic or stressful nature, that is too pervasive to be explained by ordinary forgetfulness. • While autobiographical memory is available (i.e., stored within the brain), the information is not accessible (i.e., the memory cannot be retrieved). • This additional information can be about the environment (smell, place, colour) or about a feeling (happy, sad, mad) or about an activity at the time (walking, crying, sitting, studying). Seeing or thinking about these retrieval cues helps us recall the memory. • Generalized amnesia: unable to recall information about his or her entire lifetime.; localised; selective. Dissociative Identity Disorder • DID: presence of two or more distinct personality states that alternately and recurrently take control of behaviour. • It is believed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to the development of DID. • The subpersonality has own pattern of perceiving, relating to, and thinking about the self and the environment. • Dissociative identity disorder appears to be associated with two dissociative identity states (alternate personalities): 1. a state in which the individual blocks access and responses to traumatic memories so as to be able to function daily and 2. a state fixated on traumatic memories. • The primary personality, or host, is usually not aware of the subpersonalities and is perplexed by lost time and unexplained events. BIOLOGICAL FACTORS Genetic • Twin studies demonstrate the existence of a genetic component to panic disorder, obsessive-compulsive disorder, and conversion disorder. • Although genetic variability is thought to play a role in stress reactivity, dissociation is thought to be largely due to extreme stress or environmental factors. Neurobiological • Unlike the patient who just needs a dressing changed several times a week, the patient with an anxiety-related disorder requires “emotional bandaging” much more often, and behavioural change is often accomplished slowly. • Such negative feelings are easily transmitted to the patient, who then feels increasingly anxious and may also withdraw. Therefore patience, the ability to provide clear structure, and empathy are important assets when working with patients with anxiety and related disorders. PLANNING • Planning for the delivery of specific nursing care is influenced by both the setting (community or inpatients) and the presenting problem. • Patients with anxiety disorders usually do not require admission to inpatient psychiatric units, so planning for their care may involve selecting interventions that can be implemented in a community setting. • Whenever possible, the patient should be encouraged to participate actively in planning. • Establishing a therapeutic relationship is the first step in delivering effective nursing care: 1. Provide continuity of care. 2. Avoid unnecessary tests and procedures. 3. Provide frequent, brief, and regular office visits. 4. Always conduct a physical examination. 5. Avoid making disparaging comments such as “Your symptoms are all in your head. 6. Set reasonable therapeutic goals such as maintaining function despite ongoing pain. IMPLEMENTATION (pp.225-226) • Determining Levels of Distress • Mild to moderate anxiety: ➢ Ability to concentrate decreases as anxiety increases. ➢ Reducing the patient’s anxiety level and preventing escalation to more distressing levels can be aided by providing a calm presence, recognizing the anxious person’s distress, and being willing to listen. ➢ Often you can help the patient consider alternatives to problematic situations and offer activities that may temporarily relieve feelings of inner tension. • Severe to panic: ➢ unable to solve problems and may have a poor grasp of what is happening in the environment. ➢ Appropriate nursing interventions are to provide for the safety of the patient and others and to meet physical needs (e.g., fluids, rest) to prevent exhaustion. ➢ Anxiety reduction measures may take the form of removing the person to a quiet environment (seclusion room) with minimal stimulation and providing gross motor activities to drain some of the tension. ➢ These patients are out of control, so they need to know they are safe from their own impulses. Firm, short, and simple statements are useful. • Nurses are in a position to assess and understand patients’ psychosocial stressors, identify needed coping skills, and teach stress-management techniques. • Effective coping skills that can be taught are many and varied (e.g., assertiveness training, cognitive reframing, problem-solving skills, social supports). • Consider referring the patient for instruction in relaxation techniques such as reiki, meditation, guided imagery, breathing exercises, and others, or teach the patient some techniques yourself. • Behavioural techniques, such as progressive muscle relaxation and biofeedback (which nurses can get special training to perform), are also useful. Relaxation techniques, stress- management skills, and supportive education should be part of patient care, regardless of the comorbid conditions. • Educate the patient about specific treatments. • Refer the patient to community support groups (or systems). • Teach patients more effective coping skills that take into consideration patients’ values, preferences, and lifestyle. • Focus on a patient’s strengths and reinforcing coping skills that work (e.g., prayerfulness, participation in hobbies, relaxation techniques). • The primary goal is to help patients identify ways to get their needs met without using harmful defence mechanisms or having pathological behaviour reinforced. • Psychiatric mental health nurses use counselling to reduce anxiety, enhance coping and communication skills, and intervene in crises. • Health teaching is a significant nursing intervention for patients with anxiety disorders. Patients may conceal symptoms for years before seeking treatment and often come to the attention of health care providers because of a co-occurring problem. Health teaching is a significant nursing intervention for patients with anxiety disorders. Patients may conceal symptoms for years before seeking treatment and often come to the attention of health care providers because of a co-occurring problem. • Antidepressants prescribed for anxiety have the secondary benefit of treating comorbid depressive disorders. ➢ Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for acute stress disorders and PTSD (can increase anxiety in some cases). Sertraline (Zoloft) and paroxetine (Paxil) seem to have a more calming effect than do other SSRIs. ➢ SSRIs are preferable to the tricyclic antidepressants (TCAs) because they have a more rapid onset of action and fewer problematic adverse effects. ➢ Monoamine oxidase inhibitors (MAOIs) are reserved for treatment-resistant conditions because of the risk for life-threatening hypertensive crisis in patients who do not follow dietary restrictions. • Antianxiety drugs (also called anxiolytics) are often used to treat the somatic and psychological symptoms of anxiety disorders. When moderate or severe anxiety is reduced, patients are better able to participate in treatment of any underlying problems. ➢ Benzodiazepines are most commonly used because they have a quick onset of action (can build dependence, which is why they are used for short time). ➢ Buspirone (BuSpar) is an alternative antianxiety medication that does not cause dependence, but 2 to 4 weeks are required for it to reach full effect. • Other classes of medications sometimes used to treat anxiety disorders include beta blockers, antihistamines, and anticonvulsants. • Beta blockers block the nerves that stimulate the heart to beat faster and have been used to treat social anxiety disorder (SAD). • Anticonvulsants have shown some benefit in the management of GAD, PD, PTSD, and SAD. • Antihistamines are a safe, nonaddictive alternative to benzodiazepines to lower anxiety levels, and again are helpful in treating patients with substance abuse problems. EVALUATION • Evaluation of patients with anxiety-related disorders is a simple process when measurable behavioural outcomes have been written clearly and realistically. • In general, evaluation of outcomes for patients with anxiety disorders deals with patient’s safety; decrease in anxiety levels; if patient recognizes symptoms; if patient still portrays symptoms; self-care activities done by the patient.