mental health nursing ii nurs 2310 unit 13 anxiety and somatoform disorders

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Mental Health Mental Health Nursing II Nursing II NURS 2310 NURS 2310 Unit 13 Unit 13 Anxiety and Anxiety and Somatoform Somatoform Disorders Disorders

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Mental Health Mental Health Nursing IINursing II

NURS 2310NURS 2310

Unit 13Unit 13

Anxiety and Anxiety and Somatoform DisordersSomatoform Disorders

Key TermsKey Terms Anxiety = Apprehension, tension, or

uneasiness from anticipation of unknown/unrecognized danger; considered pathological when social and/or occupational functioning is affected

Stress = Mental/emotional/physical strain experienced in response to stimuli from the external or internal environment

Somatization = the expression of psychological needs in the form of physical symptoms; possibly related to repressed anxiety

Panic = A sudden overwhelming feeling of terror or impending doom; usually accompanied by behavioral, cognitive, and physiological signs/symptoms considered to be outside the norm

Hysteria = Characterized by recurrent multiple somatic complaints that are unexplained by organic pathology, and is thought to be associated with repressed anxiety

Dissociation = The splitting off of clusters of mental contents from conscious awareness

Amnesia = A pathologic loss of memory of an experience or specific period of time; emotional, dissociative, or organic in nature

Phobia = An excessive or unreasonable fear cued by the presence or anticipation of a specific object or situation, exposure to which provokes an immediate anxiety response; the phobic stimulus is avoided or endured with marked distress

Types of Anxiety and Types of Anxiety and Anxiety-Related Anxiety-Related

DisordersDisorders

Panic DisorderPanic DisorderRecurrent panic attacks that cause intense apprehension, fear, or terrorAssociated w/feelings of impending doomAccompanied by intense physical discomfortPanic attacks usually last only minutes, but symptoms of depression are common due to unpredictable nature of occurrenceAverage age at onset is late 20sCharacterized by periods of remission and exacerbation

Diagnostic Criteria for Panic Disorder include the presence of at least 4 of the following:– palpitations, pounding heart, or accelerated

heart rate– sweating - parasthesias– trembling or shaking - chills or hot flashes– sensations of shortness of breath or smothering– feeling of choking– chest pain or discomfort– nausea or abdominal distress– feeling dizzy, unsteady, lightheaded, or faint– derealization or depersonalization– fear of losing control or going crazy– fear of dying

Generalized Anxiety DisorderGeneralized Anxiety DisorderChronic, unrealistic, and excessive worry that causes clinically significant distress or impairment in social/occupational functioningNumerous somatic complaints and symptoms of depression are common; exacerbations are stress-relatedOther symptoms include restlessness, fatigue, irritability, difficulty concentrating, muscle tension and sleep disturbancesMay begin in childhood/adolescenceDiagnosed after 6 months of symptoms

PhobiasPhobias Includes agoraphobia, social phobia (or

social anxiety disorder), and specific phobia

AgoraphobiaAgoraphobia Fear of being in places/situations from

which one can’t escape, or in which help might not be available if panic symptoms should occur

Onset in the 20s or 30s; persists for many years

Impairment can be severe and cause the individual to be confined to his/her home

Social PhobiaSocial PhobiaExcessive fear of situations in which a person might do something embarrassing or be evaluated negatively by othersExtreme concerns about being exposed to possible scrutiny by othersFear of social or performance situations in which embarrassment may occurOnset of symptoms often begins in late childhood or early adolescence and runs a chronic, sometimes lifelong, courseImpairment interferes with functioning

Specific PhobiaSpecific PhobiaA marked, persistent, and excessive or unreasonable fear when in the presence of, or when anticipating an encounter with, a specific object or situationFrequently occur concurrently with other anxiety disordersExposure to the phobic stimulus produces overwhelming symptoms of panic, including palpitations, sweating, dizziness, and difficulty breathingIndividual recognizes that fear is excessive, but powerless to change it

Obsessive-Compulsive DisorderObsessive-Compulsive DisorderObsessions = unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause marked anxiety or distressCompulsions = unwanted, repetitive behavior patterns or mental acts such as praying or counting that are intended to reduce anxietyObsessive-Compulsive Disorder = recurrent obsessions/compulsions severe enough to cause significant distress or impairment; individual recognizes behavior as excessive, but is compelled to continue due to the relief from discomfort that it provides; usually begins in adolescence or early adulthood

Body Dysmorphic DisorderBody Dysmorphic DisorderExaggerated belief that the body is deformed or defective in some specific wayMost common complaints involve imagined or slight flaws of the face or head

TrichotillomaniaTrichotillomania(Hair-Pulling Disorder)(Hair-Pulling Disorder)

The recurrent pulling out of one’s hair from the scalp, eyebrows, and eyelashesImpulse preceded by increasing tension; the act produces sense of release or gratification Usually begins in childhood

Trauma-Related DisordersTrauma-Related Disorders Includes post-traumatic stress disorder

(PTSD) and acute stress disorder

Post-Traumatic Stress DisorderPost-Traumatic Stress Disorder Develops following exposure to an

extreme traumatic stressor involving a threat to the physical integrity of self or others

Symptoms may begin within 3 months after the trauma or may be delayed; diagnosis occurs after symptoms that cause significant interference w/functioning have been present for at least 1 month

PTSD (cont’d)PTSD (cont’d)Individual re-experiences the traumatic event via intrusive recollections/nightmares; may not recall every aspect of the traumaInvolves either a sustained high level of anxiety/arousal or a general numbing of responsiveness; may lead to depression and/or substance abuse

Acute Stress DisorderAcute Stress DisorderSymptomology is the same as for PTSD, but symptoms resolve within 1 month of the precipitating trauma

Adjustment DisorderAdjustment DisorderA maladaptive reaction to an identifiable stressor that results in the development of clinically significant emotional or behavioral symptoms that impair social/occupational functioning or are in excess of expected reaction to the stressorOccurs within 3 months after onset of stressor and persists for no longer than 6 months after stressor or its consequences have endedManifested as depression, anxiety, acting-out behaviors or a combination thereof

Somatic Symptom DisordersSomatic Symptom Disorders Includes somatic symptom disorder,

illness anxiety disorder, conversion disorder, and factitious disorder (previously known as Munchausen syndrome)

May involve primary or secondary gains– In primary gain, the physical symptoms allow

the individual to avoid some unpleasant activity or difficult situation about which he or she is anxious

– Secondary gain involves the promotion of emotional support or attention the individual might not otherwise receive

Somatic Symptom DisorderSomatic Symptom DisorderCharacterized by multiple physical symptoms that have no medical explanationAssociated with psychological distress and long-term seeking of assistance from health-care professionalsSymptoms may be vague, dramatized, or exaggerated in their presentation

Illness Anxiety DisorderIllness Anxiety DisorderUnrealistic or inaccurate interpretation of physical symptoms that results in excessive preoccupation about having a serious illness

Illness Anxiety Disorder (cont’d)Illness Anxiety Disorder (cont’d)Fear becomes persistent and disabling in spite of reassurances that no organic pathology can be foundHistory of doctor-shopping due to presumed misdiagnosis

Conversion DisorderConversion DisorderEmotional distress expressed through loss of (or change in) body function for which there is no apparent physical causeSymptoms may occur suddenly following a stressful experience

Factitious DisorderFactitious DisorderThe conscious, intentional feigning of physical and/or psychological symptoms on oneself or another person (i.e. by proxy) in order to receive emotional care and supportMay involve self-infliction of painful injuries, injection or insertion of contaminated substances, manipulation of medical assessment instruments, and/or improper use of medication

Dissociative DisordersDissociative Disorders Includes dissociative amnesia,

dissociative identity disorder (or multiple personality disorder), and depersonalization-derealization disorder

Dissociative AmnesiaDissociative Amnesia Inability to recall important personal

information; may be specific to a trauma or series of traumatic experiences

Usually follows severe psychosocial stress, and recovery is often abrupt and complete

Dissociative Identity DisorderDissociative Identity DisorderCharacterized by the existence of two or more unique personalities in a single individualOnly one personality is evident at any given moment, and only one is dominant most of the time over the course of the disorderTransition from one personality to another may be sudden or gradual, and may be dramaticSymptomology causes clinically significant distress or functional impairment

Depersonalization-Derealization Depersonalization-Derealization DisorderDisorder

Depersonalization = a disturbance in the perception of oneselfDerealization = an alteration in the perception of the external environmentDepersonalization-Derealization Disorder = characterized by a temporary change in the quality of self-awareness

– Involves change in body image and feelings of unreality or detachment from the environment

– Diagnosis made upon functional impairment

Treatment ModalitiesTreatment Modalities

Individual psychotherapy– Eye movement desensitization and

reprocessing (EMDR)

Cognitive and/or behavioral therapy– Systematic desensitization– Implosion therapy (flooding)

Group/family therapy

Psychopharmacology

Medications used to Treat Medications used to Treat Anxiety DisordersAnxiety Disorders

Most commonly treated with anti-anxiety agents and sedative-hypnotics– Depress subcortical levels in the limbic system– CNS depression ranges from mild sedation to

coma Classes of anti-anxiety agents include

antihistamines, benzodiazepines, and miscellaneous agents– Buspirone (Buspar) does not depress the CNS

10-day to 2-week onset Does not build tolerance or dependence

Sedative-hypnotics include barbiturates, benzodiazepines, and miscellaneous agents

*Anti-anxiety agents: Antihistamines

– Hydroxyzine (Atarax, Vistaril) Benzodiazepines

– Alprazolam (Xanax)– Chlordiazepoxide (Librium)– Clonazepam (Klonopin)– Clorazepate (Tranxene)– Diazepam (Valium)– Lorazepam (Ativan)

Miscellaneous agents– Buspirone (Buspar)

Anti-Anxiety Agents (cont’d) Efficacy may vary

– Alcohol, narcotics, barbiturates, antipsychotics, and antidepressants increases effects

– Nicotine and caffeine decreases effects Common side effects include drowsiness,

confusion, and lethargy Abrupt withdrawal can be life-threatening

– Insomnia– Increased anxiety– Vomiting– Tremors, convulsions, and delirium

*Sedative-hypnotics: Barbiturates

– Secobarbital (Seconal) Benzodiazepines

– Flurazepam (Dalmane)– Temazepam (Restoril)– Triazolam (Halcion)

Miscellaneous Agents– Chloral Hydrate (Noctec)– Zaleplon (Sonata)– Zolpidem (Ambien)– Eczopiclone (Lunesta)

Sedative-Hypnotic Agents (cont’d) Short-term use Chronic use may induce tolerance and

physical/psychological dependence Additive effect on CNS depression with

alcohol, antihistamines, antidepressants, or other CNS depressants

Watch for decreased effectiveness of other medications metabolized by the liver

Nursing ProcessNursing Process

Assessment– Gather information about client’s mood

and level of anxiety, thoughts to harm self/others

Diagnosis– Risk for self-directed violence R/T anxiety-

related depression– Imbalanced nutrition, less than body

requirements R/T lack of interest in food– Disturbed sleep pattern R/T anxiety– Anxiety R/T panic disorder– Social isolation R/T agoraphobia

Planning– Care plan– Concept map

Implementation– Establish trust– Provide for safety– Perform risk assessment– Administer scheduled and PRN

medications Evaluation

– Mental health/psychiatric assessment tool– Review safety plan/contract– Assess for medication side effects