NURSING 3125 WEEK 4 SEPT, 30 2019

THE NURSING PROCESS:

- Diathesis stress model: review

ANXIETY AND RELATED DISORDERS:

Anxiety: (most common mental illness) feeling of apprehension, uneasiness, uncertainty, or dread related to
an unspecified or unknown danger; fear is a reaction to a specific danger – normal anxiety: healthy and
necessary for survival
- Characterized by a mix of physiological, psychological behavioural, and cognitive symptoms; each has
distinctive characteristic, but all have an overarching theme of excessive irrational fear and dread
Levels of anxiety:
Mild: occurs in normal experience of everyday; ability to perceive is in sharp focus & problem solving becomes
effective. Slight discomfort, restlessness, or mild tension relieving behaviours may be observed
Moderate: perceptual field narrows; some details are excluded from observation. Selective inattention may be
experienced. Problem solving ability is reduced but may be improved in presence of supportive person;
physical symptoms: tension, pounding heart, increased pulse and resp rate, diaphoresis, and mild somatic
symptoms
Severe: perceptual field is greatly reduced; learning and problem solving are not possible, and person may
appear dazed and confused; experience a sense of doom, and have intensified somatic complaints
Panic: results in markedly disturbed behaviour, inability to process environmental stimuli; person might lose
touch with reality and experience hallucinations; physical behaviour may be erratic, uncoordinated, and
impulsive. Automatic behaviours are used to reduce and relieve anxiety
Defense mechanisms

Primitive Mid-level Mature

Denial Repression Sublimation

Regression Displacement Self-assertion
Acting out Intellectualization Suppression
Dissociation Rationalization Compensation
Compartmentalization Undoing Altruism
Projection Anticipation
Reaction formation Affiliation
Self-observation
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- Denial: ignore reality
- Regression: child-like behaviour women sucking thumb in public
- Acting out: projecting outward expression of anxiety; tantrums
- Dissociation: disconnect from thoughts; detached from reality but still understand reality
- Compartment: stored away in brain not actively dealing
- Projection: take feelings and project onto other
- Reaction Formation:
- Repression: keep thoughts in unconscious mind
- Displacement: placing negative feelings onto someone else who’s less threatening
- Intellectualization: hard cold facts
- Rationalisation: justifying illogical ideas; not taking responsibility
- Undoing: after women flirts with male assistant, she brings tickets for her husband favorite concert
- sublimation: don’t get job you want, don’t create own company
- Self-assertion: not think of unwanted thoughts or feelings
- Suppression:
- Compensation: poor family life so work well in school
- Self-assertion:
- Altruism:
- Anticipation:
- Affiliation:
- Self-observation
Limbic system and Anxiety:
- Hypothalamus: unconscious response to stress
- Flight or fight response; connect to RAS
o If stimulated: increase alertness and arousal; if inhibited: drowsiness and sleep induction
- RAS: Reticular Activating System: alerts cerebral cortex and transmits information to higher brain
centers
o If no signals decreased general brain activity
Responses to Anxiety:
Physiological: always first eliminate anything that is physical (can kill them: run physical tests first)
- Cardiovascular: palpitations,  or BP/HR, faintness, tightness/chest pain
- Respiratory: SOB, pressure, shallow breathing, gasping
- Neuromuscular: startle reaction, pacing, tremors, insomnia
- Gastrointestinal: nausea, appetite, abdominal pain, diarrhea
- Integumentary: flushed/pale, sweating, itching, hot/cold, numbness, tingling
- Urinary tract: frequency and urgency
Other responses:
- Cognitive
o poor concentration, forgetfulness, confusion, preoccupation, errors in judgment, fear of losing
control
- Behavioural
o Restlessness, inhibition, rapid speech, tension, tremors, avoidance, hyperventilation
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- Affective
o Impatience, fright, alarm, jittery, nervous, fearful

Defense mechanisms
 Adaptable: lower anxiety to achieve goals in acceptable ways
 Maladaptive: immature defense mechanisms are called upon
Neurotransmitters
 Norepinephrine
o Mediates mood and anxiety
o Stress response, attention/vigilance, arousal, ability to focus/learn, feeling of reward
o Fluctuates with sleep and wakefulness
 Gamma-aminobutyric acid (GABA)
o Most prevalent inhibitory neurotransmitter
o Decreased aggression, anxiety, excitation
o Sedative, anticonvulsant and muscle-relaxant properties
o Neuron is stimulated  GABA acts as a brake, decreased neuron excitability
o Benzodiazepines and barbiturates bind to GABA receptor  intensifies the effect of GABA
 Serotonin
 Modulator for specific brain functioning  affects temperature, sensory, sleep, and assertiveness
areas
Types of anxiety disorders:
- Generalized anxiety disorder: low grad anxiety; experience on daily basis; impairs functioning (“what
should I do today”); Cognitive therapy
- Acute stress disorder: within 4 weeks of occurring; driving on Deerfoot and see horrific accident then
for weeks you cannot sleep, and it is affecting you; therapy does help
- PTSD: 3 years later; another accident; anxiety triggered and occurs every time an accident occurs; no
timeline; CBT or EMBR therapy
- Panic disorder: the anticipatory of having one; limits ability to interact socially; decrease stimulation
(lower lights, stay with them, calm reassuring voice, breathe you are okay- comfort them, Ativan);
benzo
- OCD: may hold back urge to defecate since too engaged in their activities; obsessions= thoughts;
compulsions= actions; don’t interrupt them if they are in the middle of them; allows them to reduce
anxiety: “I must or else”- catastrophic reaction; therapy to understand actions
- Social anxiety (phobia): public speaking; afraid of doing something wrong therefore will avoid it,
people will see, avoidance where there is spotlighted to be criticized; therapy
- Specific phobia: fear of spiders; systematic desensitization; exposure therapy/flooding
- Separation anxiety: children separated from parents
Assessments
 Hamilton Rating Scale for Anxiety (HAM-A): high levels indicate GAD and PD
 Yale-Brown Obsessive-Compulsive Scale (YBOCS): OCD
 Obsessive Compulsive Inventory (OCI)
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 Panic Disorder Severity Scale (PDSS): extend of disorder and how well treatment plans are working
Interventions
 Establish open, trusting relationship
 Assist with management of anxiety
o Be aware of and control your own feelings
 Provide reassurance of safety
 Assist to identify anxiety triggers
 Assist to identify new adaptive coping strategies
 Promote physical health, well-being, relaxation response
Pharmacological treatments:
- Benzodiazepines: potentiates effects of GABA and other inhibitory neurotransmitters, decreasing
anxiety – good for panic attacks
- MAOIs: first line for general anxiety; increase concentrations of epinephrine, norepinephrine,
serotonin, dopamine
- Beta-adrenergic blocking agents: decrease blood pressure without reflex tachycardia or bradycardia;
control irregular pulse, reduce nervous tension, sweating, panic and shakiness
- SSRIs: inhibits serotonin reuptake and increase action of those neurotransmitters in nerve cells
- TCAs: block reuptake of norepinephrine and serotonin and increase action of those neurotransmitters
in nerve cells
- Non-benzodiazepines: rarely lead to dependence or tolerance, so safe to use on a daily basis (e.g.
generalized anxiety disorder)
Non-pharmacological treatment:
- Cognitive therapies: cognitive restructuring; CBT (cognitive-behavioural therapy)
- Behaviour therapies: relaxation, modelling, systemic desensitization, flooding, response prevention,
thought stopping
- Integrative therapy
o Meditation, guided imagery, yoga, nutritional and herbal supplements
- Milieu therapy: institutionalization; environment
- Health teaching
Somatoform disorders:
Somatic symptom disorders: (unintentional)
 Physical symptoms suggest physical disorder but no evidence to support it; no signs of disease: physical
manifestations of emotional states (instead of depression or anxiety they experience pain, paralysis,
skin rashes, etc.);
 Symptoms link to psychological factors; not intentional or under control of client
Types:
 Somatic symptom disorder: onset before age 30; impaired social, occupational or other func.
 Illness anxiety disorder: hypochondriasis; preoccupation with having serious disease; impaired
social or occupational func. --> use cognitive reframing
 Conversion disorder: function neurological disorder: cannot be explained by neuro, medical, or
culture bound syndrome; manifests itself as neurological symptoms but absence of
neurological disorder;
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o presence of deficits in voluntary motor or sensory functions including paralysis, blindness,
movement disorder gait disorder, numbness, paresthesia (tingling or burning), loss of hearing,
or seizures resembling epilepsy
o can display la belle indifference: lack of emotional concern about symptoms
Etiology:
 Biological factors (genetics)
 Psychological factors (psychodynamic theories: r/t to repression of conflict or unwelcomed
experiences), behavioural theory: learn methods of communicating helplessness to get their needs
met, cognitive theory)
 Primary gains: a decrease in anxiety (gain) from an unconscious defense that causes a physical
symptom
o E.g. A person strikes someone else; arm becomes (unconsciously) paralyzed because it was
used to harm someone, therefore the guilt is decreased
 Secondary gains: gain achieved from physical symptom which allows the person to get support
that they would not originally obtain find ways to help pt achieve same outcomes other ways
o E.g. avoiding difficult situations; getting attention, emotional support or sympathy
 Environmental factors
 Cultural factors
Factitious disorder: (intentional)
o Types:
 Munchausen syndrome: may have scars from exploratory surgeries, multiple tests and procedures
o go from one health care provider to another; fabricating exaggerated tales
o ex. To self: self-injection of e. coli
 Factitious disorder by proxy: deliberate feigning or causing illness in vulnerable dependent; attention,
sympathy, excitement
o ex. Harming others: puncturing amniotic sac with fingernail, putting pillow over child’s face
 Malingering: conscious act for primary or secondary gain; intentional production of false or
exaggerated symptoms
o ex. Commit fraud against insurance companies
APPLY TO BOTH DISORDERS:
Assessments:
 Patient health questionnaire symptom short form (PQH-SSS)
 Dissociative experiences scale (DES)
 Somatoform dissociation questionnaire (SDQ)
 Dissociative disorders interview schedule (DDIS)
 BATHE technique (background, affect, trouble, handling, empathy) – see slide 20/23
Diagnosis:
 Ineffective coping is frequently diagnosed
Interventions:
 Establish therapeutic relationship with client is first step in effective care: allows us to overcome
resistance that there is no physical cause
 Collect thorough history to clarify the course of past and current symptoms
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 Self-reflection/self-assessment
 Identify secondary gains
 Verbal and body psychotherapies
 Cognitive reframing (CBT therapy= most supported treatment)
 Sensorimotor psychotherapy
 Dance movement therapy
 Retribution therapy: specific treatment approach for somatization
 Accurately assess and interpret body’s responses to digestion, stress, fatigue, and excitement
Dissociative Disorders
 Precipitated by significant adverse effects or traumas resulting in unconscious altering of the mind
-body connections; dissociation is an unconscious defense mechanism that protects the individual
against overwhelming anxiety and stress through emotional separation;
 May result in disruptions in memory, consciousness, self-identity, and perception.
 Don’t have delusions or hallucinations but have flashbacks or see images that are triggered by current
events that are related to past trauma
 Pathological dissociation: involuntary and results in failure of control over one’s mental processes and
integration of conscious awareness; pieces of memory fragmented
 Not able to link specific sensations to event (smell, sound)
 Positive symptoms: unwanted additions to mental activity; flashbacks
 Negative symptoms: deficits; memory problems
Clinical picture:
1. Depersonalization/derealization: may cause person to feel mechanical, dreamy, or detached from the
body; depersonalize: feel as they are observers of their own body or mental processes: internal feeling
of disconnect; derealization: recurring feeling that one’s surroundings are unreal or distant: an external
or outside feeling of disconnect; feelings are not consciously controlled by the patients and very
distressing
2. Dissociative amnesia: marked by inability to recall important auto biological information, often of
traumatic or stressful nature, that is too pervasive to be explained by ordinary forgetfulness (while
autobiographical info is available the person is not accessible to the memory); Generalized: can’t recall
entire lifetime (can be localized or selective)
a. Dissociative fugue: characterized by sudden, unexpected travel away from customary locale (a
place where something happens) and an inability to recall one’s identity and information about
some or all of the past – move away to another place and have forgotten identity then slowly
remember later but time will be same for you
3. Dissociative identity disorder : presence of two or more distinct personality states that alternately and
recurrently take control of behaviour ; more physical, sexual, psychological trauma in childhood
predisposes to development; 2 states: (1) a state in which individual blocks access and responses to
traumatic memories so as to be able to function daily (2) a state fixated in traumatic memories
a. the primary personality is not aware of other ones, and is perplexed by lost time and unexplained
events – finding unfamiliar clothes in closet, not having childhood memories
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b. subpersonalities are often aware of the existence of each other to some degree; transition generally
occurs during times of stress and may range from a dramatic to a barely noticeable event
c. some patients experience transition when awakening; shifts may last minutes to months
d. impact physiological function; regional cerebral blood flow patterns and autonomic and subjective
reactions are displayed differently for each alternate personality when individual is exposed to
trauma related stimuli
e. dominant hand and voice may be different, and intelligence and ECG findings may be different
NURSING PROCESS:
Assessment: thorough history is very important
 Rule out other psychiatric disorders
 Assess identity and memory, comorbid conditions
 History of trauma or abuse as child
 Identify support systems
 Assess mood and anxiety
 Assess for safety of self and other
 Specific information regarding life events, mood, memory, consciousness, suicide risk, impact of disorder
on patient and family are important to assess
Interventions:
 Milieu management (safe, supportive environment)
 Provide simple and consistent routine
 Support process of disclosure of memories at patient’s own pace
 Health teaching and promotion: prevent dissociation if triggers can be identified
 Pharmacological: minimal effect: may use benzodiazepines or antidepressants for comorbid disorders