Contemporary Psychiatric-Mental Health Nursing Third Edition. Theories: Anxiety Disorders. Theories: Anxiety Disorders (cont'd) 10/2/2014
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1 Contemporary Psychiatric-Mental Health Nursing Third Edition CHAPTER 18 Anxiety Disorders Theories: Anxiety Disorders Biological changes in the brain Neurotransmitters are associated with anxiety. low levels of GABA (inhibits the reactivity of neurons) is assoc with anxiety. Dopamine system involved in pathophysiology of OCD. High levels of norepinephrine have been related to panic attacks. Theories: Anxiety Disorders (cont'd) Abnormal control of glutamate plays role in anxiety disorders. Hormonal changes in pregnant women affect certain anxiety disorders. Lactic acid may precipitate anxiety. **Caffeine and nicotine may trigger panic attacks. 1
2 Theories: Anxiety Disorders (cont'd) Genetic theories: strong evidence for familial or genetic predisposition for anxiety disorders Theories: Anxiety Disorders (cont'd) Psychosocial theories: in psychoanalytic theory, anxiety is viewed as sign of psychologic conflict; anxiety is the outcome of repressing forbidden impulses Theories: Anxiety Disorders (cont'd) Behavioral theory** Anxiety is a learned response that can be unlearned. Compulsive behavior is a maladaptive attempt to alleviate anxiety. Behavior modification teaches new ways to behave. 2
3 Theories: Anxiety Disorders (cont'd) Humanistic theories: Environmental stressors, biological factors, and intrapsychic fears cannot be dealt with separately but rather as they interact with one another. Treatment approaches are integrative. Anxiety** A universal experience A normal response that usually helps cope with threatening situations Anxiety disorders are characterized by anxiety so disabling as to adversely affect day-to-day functioning Affects all age groups Question #1 In assessing a client with panic disorder, the nurse determines that a predisposition to anxiety disorders likely exists in the family. This determination is related to: 3
4 Question #1 1.Genetic theories. 2.Biologic theories. 3.Psychosocial theories. 4.Behavioral theories. Anxiety (cont'd)** Anxiety disorders are the most common of mental illnesses All anxiety disorders have in common excessive, irrational fear and dread Anxiety is either a dominant disturbance or an avoidance behavior Free-floating anxiety is unrelated to a specific stimulus Anxiety (cont'd)** Panic disorder Phobia Agoraphobia Social phobia Specific phobia GAD-Generalized Anxiety DO 4
5 Anxiety (cont d)** OCD-Obsessive-Compulsive DO PTSD-Post-traumatic Stress DO ASD-Acute Stress DO Question #2 The nurse is assessing a client who exhibits great discomfort and anxiety and continually asks to go home, as he is certain he will lose bladder control if he does not leave soon. This behavior is consistent with a diagnosis of: Question #2 1.Acute stress disorder. 2.Obsessive-compulsive disorder. 3.Agoraphobia. 4.Acrophobia. 5
6 Question #6 The nurse is assessing a client who appears to be experiencing both anxiety and depression. Based on the dominant symptom reported, the nurse determines that the client likely has an anxiety disorder. Which of the following symptoms is characteristic of anxiety rather than depression? Question #6 1.Global negativism 2.Agitation 3.Hopelessness 4.Slowed motor activity Question #7 The client experiences feelings of extreme fear that occur for no apparent reason and are accompanied by intense physical symptoms. The priority nursing intervention would be to: 6
7 Question #7 1.Encourage the client to verbalize feelings. 2.Counsel the family on therapeutic responses. 3.Stay with the client. 4.Teach relaxation techniques. Anxiety* continued.. Obsessive-Compulsive Disorder Anxiety develops when indiv tries to resist an obsession or compulsion. Post-Traumatic Stress Disorder Re-experiencing a traumatic event. Acute Stress Disorder Development of anxiety and dissociative symptoms that occur within 1 month of an extremely traumatic event. Anxiety (cont'd)** Dissociation Emotional numbing Impaired social relationships Separates emotions from behaviors Consciousness, memory, identity, and/or perceptions of the environment are impaired. 7
8 Common Themes Anxiety disorders and dissociative identity disorder originate in childhood.** Major common theme = disabling anxiety** Other common features: personality and mood changes, distorted perceptions, inability to concentrate, memory impairment, defense mechanisms Common Themes (cont'd)** Both anxiety and dissociative disorders may have underlying comorbid illnesses like depression or substance abuse. Both disorders profoundly affect quality of life. Common Themes (cont'd) Psychotropic medications and teaching adaptive coping are mainstays of treatment. A holistic approach is best for caring for these clients. 8
9 Your Assessment Approach: The Client with an Anxiety Disorder Physiological Assessment How often do you experience palpitations? Psychological Assessment Do you feel sad and/or hopeless? Your Assessment Approach: The Client with an Anxiety Disorder Cognitive Assessment Do you think about the same things over and over? More at Your Assessment Approach: Anxiety Disorder page401* Your Assessment Approach: The Client with Panic Attack To determine the psychological effects of panic on your client, ask: How do you feel right now? When did you start feeling this way? 9
10 Your Assessment Approach: The Client with Panic Attack To determine the somatic effects of panic on your client, ask: Are you having chest pains or shortness of breath? Have you felt dizzy or faint? More at Your Assessment Approach: Panic Attack page 402* Your Assessment Approach: The Client with PTSD Questions to help assess PTSD When was the last time you struck out in anger? How would you describe your mood right now? Happy? Sad? Depressed? How much time do you spend thinking the same thing over and over? Your Assessment Approach: The Client with PTSD Questions to help assess PTSD How do you sleep at night? Any nightmares or repetitive dreams? More at Your Assessment Approach: PTSD page 402* 10
11 Comprehensive Assessment** (cont'd) Conduct a history and physical exam. Gather subjective and objective information. Interview family member(s) if possible. Comprehensive Assessment (cont'd)** Complete psychosocial assessment to discover source of anxiety. Differentiate between anxiety and depression. Evaluate sleep and sleep quality. Comprehensive Assessment (cont'd) Complete suicide and homicide assessment. Major focuses for a client with dissociative disorder are identity, memory, and consciousness. 11
12 Plan of Care for Anxiety** Mild to moderate anxiety Use a calm, quiet approach Observe client s verbal/nonverbal behavior Encourage client to verbalize feelings Videos jnvxxg5o psychology crash course ami82xkec OCD Nnz9SM4g Howie Mandel Plan of Care for Anxiety (cont'd)** Mild to moderate anxiety Teach relaxation techniques (meditation, guided imagery, etc.) when anxiety is mild Simple physical activities often help reduce anxiety Develop goal-oriented contract 12
13 Plan of Care for Anxiety (cont'd)** Severe to panic levels of anxiety: First priority is to reduce anxiety to tolerable levels. Stay with the client. Provide a safe and supportive milieu. Use a firm voice and short, simple sentences. Plan of Care for Anxiety (cont'd)** Severe to panic levels of anxiety: Place client in quieter, smaller, less stimulating environment; focus the client s diffuse energy on repetitive task or tiring task. Administer antianxiety medication if ordered. Client/Family Education Medications used to treat anxiety disorders include benzodiazepines, tricyclics, SSRIs and SNRIs, lithium, beta blockers, alpha-adrenergic antagonists, atypical antipsychotics, and neuroleptics. Teach about medication indications, side effects, and drug drug interactions. 13
14 Client/Family Education (cont'd)** Teaching about medications Drowsiness is a common side effect. Do not drink alcohol while taking. Drink decaffeinated beverages. Do not take other medications or adjust dosage in any way without consulting health care provider. Client/Family Education (cont'd)** Nonpharmacologic measures comprise effective coping skills: CBT techniques (desensitization, reciprocal inhibition, cognitive restructuring) Relaxation training Individual or group therapy Exercise and nutrition Personal Challenges** Anxiety is contagious. The nurse may be impatient and irritated by somatic complaints. It is important to identify the source of one s own anxiety and consistently role-model adaptive behavior. 14
15 Personal Challenges (cont'd) A client s avoidance mechanism can be challenging to staff. Some nurses feel overwhelmed and helpless in the face of clients pain and catharsis. Ready answers are more likely to interfere with client s communication. Question #10 The nurse is finding it difficult to listen to a client s expression of pain, fear, anger, and other feelings. The nurse must focus on: Question #10 1.Listening attentively and with concern. 2.Providing quick and ready answers. 3.Giving advice. 4.Changing the subject to a more positive one. 15
16 Resources Anxiety Disorders Association of America The Anxiety Disorders Association of America (ADAA) is a national nonprofit organization dedicated to the prevention, treatment, and cure of anxiety disorders and to improving the lives of all people who suffer from them. Resources (cont'd) National Center for Posttraumatic Stress Disorder The National Center for Posttraumatic Stress Disorder Information Center provides information to interested individuals, including veterans and their family members. Resources (cont'd) Social Phobia/Social Anxiety Association The Social Phobia/Social Anxiety Association site offers further links to topics such as current news, treatment, and local group availability. 16
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