ANXIETY AND STRESS-RELATED ILLNESS

ELINOR B. MARCELINO, RN,MN

NCM 102 & 103, Instructor

Stress
- wear & tear on the body caused by life
Historically: Psychosomatic

physical problem caused by an emotional

state
Currently Psychological factors affecting
medical conditions
Used by the APA

Psychophysiological

Disorder must be present w/ a medical

condition

Stress
3 Reactions or Stage of Stress
Alarm Reaction Stage - stress stimulates the bodys
physiologic message from the hypothalamus to the glands
(i.e. adrenal gland to send out adrenalin & norepinephrine for
fuel) & organs ( for instance, the liver to reconvert glycogen
stores to glucose for food) to prepare for potential defense
needs.

Resistance Stage - stress stimulates the digestive

system reduces fxn to shunt blood to areas needed for
defense, the lungs take in more air, & the heart beats faster.

Exhaustion Stage - occurs when person has had a negative

response to anxiety & stress.

CAUSES: STRESS

Causative Factors: Stress

Psychodynamic

theories

Emotional rxn corresponds w/ biological changes

Alexanders Seven Psychosomatic Disorders

(1950):

Essential hypertension
Skin disorders
Rheumatoid arthritis
Hyperthyroidism
Ulcerative colitis
Peptic ulcer diseases
Asthma

Epidemiology: STRESS
Controversial
links

& difficult to discern

w/ medical & psychiatric disorders

Psychological

distress may represent chronic

conditions that influence immunology,
cardiovascular, respiratory, gastrointestinal, &
dermatological disorders

Causative Factors: Stress

Neurobiological

Theories

Stress

Complex neurobiological & psychosocial

processes are activated by stress

Autonomic nervous system (ANS) activated

Potential deleterious impact on psychological

& physical health may result from prolonged
activation of the ANS

Causative Factors: Stress

Psychodynamic

theories

Alexander (1950)
postulated physical dysfxn resulted from

unconscious personality traits or inadequate

coping behaviors

Causative Factors: Stress

Freud
Unreleased psychological tension was converted to

physical sxs
Conversion hysteria
Now called conversion disorder (APA) w/ specific
criteria

Neurobiological

theories

Stress activates complex neurobiological &

psychological response
Prolonged exposure to ANS activation results in
neurobiological changes that changes brain activity
9

Causative Factors: Stress

Seyle
Inability to manage stress vulnerability to

illness
General Adaptation Syndrome (Seyle)

Relationship bet. stress & neurobiological

changes
Adaptation
Effective mngt of stress
Maintaining homeostasis

10

Causative Factors: Stress

Cognitive
Coping

and Behavioral Factors:

styles

Relationship bet. coping & personality style

11

Contribute to predisposition toward certain

illnesses

Causative Factors: Stress

Traits

that enable the maintenance of

health & ability to cope w/ stressful
events
Hardiness
Self-efficacy
Hope
Optimism
Problem-solving skills
Constructive thinking
Internal locus of control

12

Causative Factors: Stress

Traits

that result in neurobiological

changes that vulnerability to stress
Negative affectivity
Anxiety
Hostility
Introversion
Type A behaviors

13

Causative Factors: Stress

Type

A personality traits:

Rapid speech
Rapid walking
Irritability
Time consciousness
Difficulty relaxing
Needs to stay busy
Attempts to do more than one thing at a time

14

Causative Factors: Stress

Type

B personality traits:

Less driven than Type A

More easy going
Laid back
Reposed
Lifestyles are relaxed & goal directed

15

Causative Factors: Stress

Cultural
Often

considerations

overlooked
psychophysiological disorders

Dramatic

concerning

demographic
changes
make
assessing role of culture, religion, & spirituality
critical

16

Specific
Psychobiological Disorders
Cardiovascular disorders
Coronary heart disease
Leading cause of death in U.S.
Linked w/ high-risk behaviors
Elevated cholesterol levels, smoking, uncontrolled blood
pressure

Type A personality traits of hostility

Hypertension
Caused by stress
Individuals at risk are those w/ family hx of heart dse,
maladaptive coping skills
17

Specific
Psychobiological Disorders
Cardiovascular disorders
Treatment modalities

Prevention is critical
Assess clients present stressors
Developing individualized treatment plans

18

Major interventions:
Smoking cessation, weight loss

Specific
Psychobiological Disorders
Pulmonary

or respiratory disorders

Asthma
Common respiratory disorder
Sxs are coughing, wheezing, SOB
Stress can exacerbate sxs
Treatment modalities
Require immediate medical attention
Approach client in nonjudgmental manner
Identify precipitants of the attacks
Stress management is key

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Specific
Psychobiological Disorders
Immunological

disorders

Stress alters immunological processes &

resistance to illness
Increased vulnerability to:
Immunodeficiency syndrome
Cancer
Common cold & flu
Herpes simplex Type I
Epstein-Barr virus
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Specific
Psychobiological Disorders
Gastrointestinal

disorders

Irritable Bowel Syndrome

Long-term effects potentially life threatening

Psychological
distress needs to be
assessed
Approach client in a caring manner to
reduce concerns & fears
Identify present stressors, coping styles, &
support systems

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Specific
Psychobiological Disorders
Dermatological

disorders

Skin responds to envt & various emotions

Condition of skin reflects health status
A rash suggests allergic rxn or intense emotional

response
Psychophysical disorders
Alopecia
Pruritis
Psoriasis
Urticaria

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Specific
Psychobiological Disorders
Chronic

pain disorders

Pain signals psychological & physiological pain

Psychosocial stress can exaggerate pain &

mask depression
Emotions generated by pain include: rage, fear,
& humiliation
Chronic pain can create feelings of guilt, low
self-esteem, & discouragement

23

Specific
Psychobiological Disorders
Chronic

pain disorders
Treatment modalities for pain
Hydrotherapy
Massages
Physiotherapy
Analgesics
Behavioral-cognitive techniques
Distraction
Biofeedback

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Psychobiological
Disorders Across the Life Span
Childhood
Linked w/ need for protection & attachment

3 factors of psychological disorders in

children:
Vulnerability
Specific family dynamics
Usefulness of the sick role

25

Psychobiological
Disorders Across the Life Span
Adolescence
Psychosocial stressors include:

Biological & psychosocial turmoil

Separation from primary caregivers
Academic demands
Interpersonal relationships

26

Psychobiological
Disorders Across the Life Span
Adolescence
Psychophysical responses

27

Recurrent abdominal pain, headaches,

chest pain, musculoskeletal pain,
chronic fatigue, dizziness

Psychobiological
Disorders Across the Life Span
Adulthood
Dse prone behaviors include:

Certain personality traits, chronic tension, &

internalized emotions

Psychophysiological disorders include all

previously discussed

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The Role of the Nurse

The

Generalist Nurse

Assesses clients current & past coping

29

behaviors
Helps clients resolve crisis situations
Psychoeducation
Crisis intervention
Promotes stress-reducing activities

The Role of the Nurse

The Advanced-Practice

Psychiatric Nurse

Identifies complex problems

Collaborates w/ clients to modify behavior
Prescribes psychotherapy
Prescribes medications
Assesses clients responses and participates in

comprehensive planning

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Anxiety
a vague feeling of dread that is unwarranted by
the situation.

A nonspecific, unpleasant feeling of apprehension

& discomfort that can be communicated
interpersonally & that prompts the person to take
some action to seek relief.
person feels uneasy or apprehensive
no identifiable object as the stimulus for anxiety
(Comer 1992)

internal warning device that issues an alarm to a

person.

Normal Anxiety
Protective response
Body uses it to mobilize coping resources
Accompanies devt,l changes & life span issues
Allows individuals to use behavior to reduce

helplessness or frustration

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Abnormal Anxiety
Some examples of anxiety disorder:

Panic disorder w/or w/o agoraphobia

Specific phobia & social phobia
Obsessive-compulsive
disorder(OCD)
Generalized Anxiety disorder(GAD)

33

Anxiety Disorder
A key feature is excessive anxiety
severe enough to interfere w/ the persons work,
family life & social relationship.
Not psychotic - they fxn w/ in the boundaries of
reality.
aware that these
experience are abn.

bizarre

episodes

they

dxd when anxiety becomes chronic, resulting in

maladaptive behaviors & emotional disability.

Anxiety Disorder
Oldest, most recognizable & prevalent mental

disorder
Affects approximately 15% of general population
most common reasons for seeking medical &

psychiatric tx

Fear
Persons experiences the same range of
emotional, physiologic & behavioral
response
- a knowledge that a threat exist;

Anxiety - is the emotion generated by the

fear.

DIFFERENCE FROM FEAR:

Fear-arises in response to
identifiable threatening object.

specific

Both

healthy & harmful facets: Depending

on the degree of anxiety, the amt. of time
the anxiety has been present, how well the
person copes w/ anxiety.
of Anxiety:
Excessive worry about real or potential
problem.

HARMFUL

&

NEGATIVE

S/E

4 Levels of anxiety
1.) Mild anxiety - sensation that something is
diff. & warrants special attention.
- sensory stimulation es & helps the
persons to focus attention to learn, solve
problems, think, act, feel, & protect
himself/herself.
2.) Moderate anxiety - disturbing feeling that
something is
definitely diff.; persons
becomes nervous or agitated.

4 Levels of anxiety
3.)

Severe anxiety - experienced when the

person is sure that something is diff. & a
threat exists; he/she demonstrates fear &
distress responses.

4.) Panic anxiety assoc. w/ red terror sense

of impending doom.
- rational, cannot communicate, cannot
concentrate.

4 levels of anxiety

To reduce anxiety w/c causes uncomfortable

feelings, person uses or implements new
adaptive behaviors or mechanism.

Adaptive behaviors can either be Positive , w/c

can help a person to learn, or it can be negative,
w/c can result to a maladaptive behavior thus
causing tension.

Levels Of Anxiety Responses

Anxiety level
Mild
(1+)

Physical Responses Cognitive Responses

Emotional Responses

Mild muscle tension

Aware perceptual field
Autonomic behaviors
Aware of milieu
Secure, confident
Some impatience
Relaxed or slight fidgeting
Low sense of failure
Solitary activities
Attentive
Alert, attends to many things Stimulated
Industrious
Abstracts information
Secure
Optimal learning level

Moderate Moderate muscle tension

Decreased perceptual field
Discomfort
(2+)
Increased vital signs
Selective inattention
Irritable
Pupils dilate, sweats starts
Increase focus on stimuli Mixed-self confidence
Some pacing, banging hands Decreased attention span
Impatient
Voice changes: tremor, pitch Problem solving decreased Excited
Increased alertness, tension
Learning occur w/ focusing
Urinary frequency, headache,
sleep changes, backache

Severe
(3+)

Severe muscle tension

Hyperventilation
Poor eye contact
Increased sweating
Speech rapid, high-pitch
Random, purposeless actions
Clench jaw gnash teeth
Spatial needs increase
Pacing, shouting
Wringing hands, trembling

Panic
(4+)

Flight, fight, or freeze

Extreme muscle weakness
Gross motor agitation
Dilated pupils
then vital signs
Sleepless
Depleted stress hormones
and neurotransmitters
Facial grimacing, agape

Limited perceptual field

Fragmented processing
Thinking is difficult
Poor problem solving
Unable to abstract info.
Attends only to threat
Preoccupied w/ thoughts
Egocentric

Tunnel vision perceptions

Illogical, distorted thoughts
Personality disorganized
Cannot solve problems
Focus on inner thoughts
Irrational
Inaccessible to external stimuli
Hallucinations, Delusions,

Frantic
Agitation
Dread
Confusion
Inadequacy
Withdrawal
Denial

Overwhelmed
Impotent, helpless
Out of control
Rageful, despair
Anger, terror
Expects bad outcome
Aghast, fearful
Depleted

Cultural Considerations
1)

Asian Cultural Response

- believe anxiety is somatized into expression of pain in the
body i.e. headache, backaches, and stomach problems.
- koro - fears that mans penis will retract into his abdomen
& he will die
- in women is fear that vulva & nipples will disappear.
- yin female - dark, empty, sleepy, cold sedentary, negative
chronic conditions.
- represents strength of life.
- yang is male - bright, warm, full & positive.
- symbolizes aggression of energy, fire & circulation, fever,
hypertension, & acute condition.

Cultural Considerations
2) Hispanic Cultural Response
- state of balance is a goal of health care

- cultures assigns hot, cool or cold values to

illnesses, medicines, food and liquids.

Cultural Factors
Beliefs
Mediate cognitive, biological, & behavioral

responses to danger and fear

Determine specific coping responses
Influence parenting & socialization
Basis of attachment
Separation
Sense of security
Perception of danger

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2 Major Kinds of Threats Causing Anxiety

THREATS TO BIOLOGIC INTEGRITY:
actual or impending interference w/ basic human
needs i.e. the need for food, drink or warmth.

2 Major Kinds of Threats Causing Anxiety

Threats to Physical Integrity
> suggest impending physiological disability or
ability to perform the ADL
External sources: exposure to viral & bacterial
infxn, envt,l pollutants, & safety hazards, lack of
adequate housing, food. Clothing & traumatic
injury
Internal
sources: failure of physiologic
mechanisms

2 Major Kinds of Threats Causing Anxiety

THREATS TO SECURITY OF THE SELF:
a. Unmet expectations impt to self-integrity
b. unmet needs to status & prestige
c. Anticipated disapproval by S.O.
d. Inability to gain or reinforce self-respect or gain
recognition from others.
e. Guilt or discrepancies bet. self-view & actual
behavior

Threats to Self-System

Imply harm to a persons identity, self-esteem &

integrated social fxng.

External sources: loss of a valued person, a

change in job status, an ethical dillema, social or
cultural group pressures.

Internal sources: interpersonal difficulties at home

or at work, assuming new role

CAUSES: ANXIETY

Biologic Theories
began after it became apparent that
benzodiazepine medications, discovered in the
1950s, reduced anxiety.
-

- Neurotransmitter & Neuroendocrinology theory

HPA axis
Vast neurotransmitters and their receptors
involved in the devt of anxiety
GABA
Norepinephrine (NE)
Serotonin (5-HT)

Neurochemical Theories
1. GABA SYSTEM
- dysfunctional in anxiety disorders.
GABA- inhibitory neurotransmitter, fxns as the body's
natural antianxiety agent by reducing cell
excitability, thus lessening the rate of neuronal
firing.

2. NOREPINEPHRINE SYSTEM
Mediates

the flight & fight response

Anxiety

is caused in part by inappropriate

activation of the norepinephrine system in
the locus ceruleus

Bec.

GABA
reduces
anxiety
&
norepinephrine increases anxiety, it is
thought that a problem w/ the regulation
of these neurotransmitters creates
anxiety disorders.

 Benzodiazepines,

an anxiolytic drugs, bind

at the same receptor sites as GABA. They
help the postsynaptic receptor to be even
more receptive to GABA's effects, further
reducing the firing rate of cells & ing
anxiety.

Anxiolytics-

reduce presurgical anxiety &

control acute anxiety rxns, but they must be
used judiciously bec. they are addictive.

3. SEROTONIN (5-HT) System

Anxiety

disorders may have hypersensitive 5HT receptors

Serotonin (5-HT), implicated in psychosis & mood
disorders, has many subtypes.
- plays a role in anxiety, as well as affecting
aggression & mood.
Serotonin - play a distinct role in OCD, panic
disorder, & generalized anxiety disorder.
A norepinephrine excess is suspected in panic
disorder, generalized anxiety disorder, & PTSD
(Sullivan & Coplan, 2000).

Neuroanatomical
Neuroimaging studies suggest
Abnormalities in glucose metabolism in the
frontal & prefrontal cortex (Panic Disorder,
OCD)
Abnormalities in the basal ganglia &
ventral prefrontal cortex (OCD)
blood flow in the anterior temporal lobes
(PTSD)

56

Genetic theories

- strong evidence of familial patterns of anxiety

disorders
- Anxiety- 1st-degree relatives have higher rates
of developing anxiety.
- Panic disorders - 25% in 1st-degree relatives, w/
women 2x the risk of men.
- Monozygotic twins 5X greater than dizygotic
twins (DSM-IV-TR, 2000).
-

Genetic theories
- Horwath & Weissman (2000) described a
possible "chromosome 13 syndrome."
- This chromosome is involved in the
genetic linkage of panic disorder, as
serious headaches, & problems w/ the
bladder, or thyroid (mostly hypothyroid)
valve prolapse.

possible
well as
kidneys,
or mitral

Existential

Major themes include impotence, fragility,

the threat of nothingness, and isolation

Cognitive-behavioral
Anxious persons exaggerate threat of danger
by using faulty cognitions

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Intrapsychic/ Psychoanalytic
-

Freud (1936) saw a person's innate anxiety as the

stimulus for behavior.

He described defense mechanisms as the

human's attempt to control awareness of anxiety.

Ex: if a person has inappropriate thoughts &

feelings that raise anxiety, he or she represses
them.

Psychodynamic Theories
Intrapsychic/ Psychoanalytic

Repression
- process of filing these inappropriate impulses into
the unconscious so they cannot be recalled.
- Because all behavior has meaning, anxiety sxs
signal incomplete repression.
-

> People w/ anxiety disorders were believed to

overuse one or a specific pattern of several
defense mechanisms, stranding them in one of
Freud's psychosexual devtl levels.

Psychodynamic Theories
Intrapsychic/ Psychoanalytic

> Anxiety is d/t conflict bet. ID & SUPEREGO;

described defense mechanisms as the human
attempt to control awareness of anxiety

 OTTO

RANK: believed that anxiety can be traced

back to birth trauma.

Superego

anxiety: the guilt felt by the person who

has socially & personally inappropriate impulses.

Castration

anxiety: R/T to the fantasy of genital &

body mutilation

Separation

Anxiety: anxiety about a potential loss

of significant others.

 Anxiety

- ego attempts to deal w/ the psychic

conflict or emotional tension.

Anxiety

is a rxn to danger: birth process is the

initial response to danger (Primary Anxiety)

Hunger

& Thirst not satisfied

Envt. is capable of threatening as well as satisfying
W/

increased age: anxiety is d/t the emotional

conflict bet. the ID & the SUPEREGO

Function

of anxiety: to warn the person that the

ego is in danger of being overtaken.

Anna Freud
Everyone

uses defense mechanisms to defend

against & reduce discomfort that arises from
internal & external demands.

Interpersonal Theory
Harry Stack Sullivan (1952) viewed anxiety as being
generated from problems in interpersonal
relationships.
- Caregivers communicate anxiety to an infant or child
by inadequate nurturing, agitation in holding or
handling the child, & distorted messages.
-

> communicating anxiety from one person to

another is called empathy.

> anxiety empathized by the infant or child can

result in dysfxn, i.e. failure to achieve age
appropriate devt,l tasks.

Interpersonal Theory
Harry Stack Sullivan (1952) viewed anxiety as being
generated from problems in interpersonal
relationships.
- In adults, anxiety arises from the person's need to
conform to the norms & values of his or her
cultural group.
- The higher the level of anxiety, the lower the ability
to communicate & solve problems & the greater
chance for anxiety disorders to develop.

 Anxiety

is 1st conveyed by mother to the infant

Devtl

traumas (separation & losses) can lead to

specific vulnerabilities

In

later life: anxiety arises when the person

perceives that he/she will be viewed
unfavorably or will lose the love of a valued
person

person who is easily threatened or has low selfesteem is more susceptible to anxiety

- humans existed in
interpersonal & physiologic realms;
Hildegard

Peplau

(1952)

as

empathized & guided the person to use the

energy that arose from anxiety to learn & change.
- therapeutic communication techniques develop &
nurture the nurse-client relationship & apply the
nursing process.

Behavioral Theory
-

view anxiety as being learned through one's

experiences.

> behaviors can be changed or "unlearned"

through new experiences.
-

believed one can modify maladaptive behaviors

w/o gaining insight into the causes of these
behaviors.

- disturbing behaviors that develop & interfere w/ a

person's life can be extinguished or unlearned by
repeated experiences guided by a trained
therapist.

 Lazarus

>Behavior
originates
from
lifelong
maladaptive learning experiences or
conditioning
Intense or disabling anxiety is a learned
maladaptive response to stress
Exposure

in early life to intense fears are

more likely to be anxious in later life.

Anxiety

- arise when a person experiences

2 completing drives & must choose between
them.

Developmental
Two

components:

Attachment theory
Separation anxiety

72

Developmental Theories
Bowlbys

attachment Theory
> Anxiety initially occurs w/ separation from early
primary caregivers (separation anxiety)
> childs ability to cope successfully w/ separation
anxiety depends on the quality attachment or
bonding during early infancy

> Failure to master these early devtl. milestones

will result in high-intensity-attachment seeking
behaviors-manifested
as
dependency
or
neediness of others or external means to
modulate anxiety & stress

Anxiety Across the Lifespan

Childhood & adolescent anxiety disorders
Separation anxiety disorder
Most common
Affects girls more than boys
Fears loss of primary caregiver
Social phobia
Fear of performance situations
Child fears embarrassment by others

Overanxious disorder
Unwarranted distress over appropriateness of
behavior
Inability to relax or settle down
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Anxiety Across the Lifespan

Childhood

and adolescent anxiety disorders

PTSD
Stems from inadequate tx ff traumatic event
Common in children who have been abused
Child internalizes depression and anxiety
OCD
Highly refractory
Presents with a chronic and episodic course
Repetitive, ritualistic behaviors and thoughts
May reflect a pediatric autoimmune neuropsychiatric
disorder

75

Anxiety Across the Lifespan

Adulthood

anxiety disorders

Generalized anxiety disorder (GAD)

Difficult to distinguish frm normal worrying or
apprehension
Prominent feature is frequent, uncontrollable worrying
Sxs: nervousness, irritability, & apprehension
Panic disorder (PD)
Sxs persist for at least 1 month
Attacks have sudden onset of intense anxiety
Profound fear or sense of imminent danger
Women -2-3X more likely to suffer from panic disorder
than men

76

Anxiety Across the Lifespan

Adulthood

anxiety disorders

Agoraphobia
Most cases arise from panic disorder
Global incapacitation stemming from avoidant behaviors
Clients find it difficult to seek help
Social phobia
Threatens clients social, interpersonal, and occupational
functioning
Fear of performance situations

77

Anxiety Across the Lifespan

Adulthood

anxiety disorders

Specific phobia
Parallels exposure to an anxiety-provoking situation or
stimulus
Most common objects that generate fear: animals,
storms, heights, illness, injury, and death
Obsessive-compulsive disorder
Obsessions: Intrusive, recurrent, and persistent
thoughts, impulses or images
Compulsions: repetitive behaviors used to alleviate
anxiety assoc. w/ obsessions
Common themes: contamination, washing, need for
symmetry or order
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Anxiety Across the Lifespan

Adulthood anxiety disorders
Acute stress disorder

Similar to PTSD
Results from exposure to a traumatic &
overwhelming event
Involves actual or threatened death, physical
injury or other threats to ones integrity
Occurs w//in 1 month of the traumatic event and
lasts a minimum of 2 days

79

Anxiety Across the Lifespan

Adulthood

anxiety disorders

PTSD

Sxs may occur immediately after the event or

later & endure for longer than 1 month
In survivors of traumatic or overwhelming
stressful events
Preexisting emotional problems risk
Specific treatment: Eye-movement
desensitization & reprocessing (EMDR)

80

Anxiety Across the Lifespan

Older adulthood

disorders

Anxiety disorders most common psychiatric

condition
Specific age-related issues
Considerations involving age-related factors
Quality of clients support system
Drug interactions (polypharmacy)
High risk of suicide

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Gen. Interventions for anxiety

Severe or Panic level of anxiety
a. Limit environmental stimuli
b. Establish a supportive & trusting relationship
c. keep demands at a level the pt can handle
d. Provide physical activities to release energy
e. administer prescribed tranquilizers.

Gen. Interventions for anxiety

Moderate anxiety
a. Teach about precipitating stressors, coping
strategies
b. Promote relaxation responses
c. Provide explanation/info. briefly & repeat if
necessary

Treatment Considerations
Nonpharmacologic

interventions

Psychoeducation
Continuous sxs monitoring
Breathing retraining
Cognitive restructuring
Cognitive-behavioral therapy
Adjunct txs:
Deep breathing, muscle relaxation techniques, guided
imagery, medication
Psychotherapy

84

Individual, group, family

Treatment Considerations
Pharmacologic

interventions
Anxiolytic agents
Antidepressants
Beta-blockers
Benzodiazepines
Non-benzodiazepine serotonin partial
agonists

85

Treatment Considerations
Complementary treatment of anxiety
disorders

86

Herbal

Exercise

supplements
Aromatherapy
Meditation
Massage therapy

Therapeutic Touch
Sleep manipulation
Balanced diet
Yoga

The Role of the Nurse

The

Generalist Nurse

Understands basis of anxiety disorders

Identifies clients mental health needs
Major interventions include:
Establishing rapport
Enhancing present coping skills
Assessing maladaptive responses
Promoting health maintenance

87

The Role of the Nurse

The Advanced-Practice

Psychiatric

Nurse
Major interventions
Psychotherapy
Prescribing medications
Case management
Evaluation of outcome measures

88

Interventions to Reduce Anxiety

Provide a calm & quite envt

Ask pt to identify what & how they feel

Encourage pt to describe & discuss the feelings

w/ you & identify possible causes of their feelings.

Ask pt if they feel suicidal or have a plan to hurt

themselves

Plan & involve pt in the activities.

Interventions in Problem Solving

1.
2.
3.
4.
5.

Discuss w/ pt their present & previous coping

mechanisms.
Assists pt w/ exploring alternative solutions &
behaviors.
Encourage pt to learn new adaptive coping
behaviors through role playing or implementation.
Teach pt relaxation exercises.
Promote the use of hobbies & recreational
activities.

Detrimental Interventions in Anxiety

1.
2.
3.
4.
5.
6.

Pressuring the pt to change permanently

Disapproving verbally a pt behavior.
Asking a pt a direct question that places him in
the defense.
Focusing in a critical way on the anxious feelings
of the pt w/ other pt
Lacking awareness of her(nurse) own behavior
Withdrawing from the pt

Categories Of Anxiety Disorders

1. Panic disorder with or without
agoraphobia
2. Phobic disorders: social or specific
3. Agoraphobia w/o panic disorder
4. OCD
5. Posttraumatic stress disorder (PTSD)
6. Acute stress disorder
7. Generalized anxiety disorder
8. Substance-induced anxiety disorder

PANIC DISORDER
1. PANIC DISORDER W/O AGORAPHOBIA
Recurrent

unexpected panic attacks & 1 mos. or

more (after an attack) of 1 of the ff:
Persistent concern about additional attacks
Worry about the implications of the attack or its
consequences
Significant change in behavior r/t the attacks

Absence
Not

of agoraphobia

a direct physiologic effect of a substance or

medical condition

1.a. Panic attack - a 15-30 mins. Episode of rapid,

intense anxiety in w/c the person experiences great

emotional fear & displays 4 or more of the following
symptoms:
. palpitations
. SOB
. nausea
. sweating
. sense of suffocation
abdominal distress tremors
.
chest pain
Dizziness

Derealization

(feeling of unreality) or depersonalization

being detached from oneself)

Fear

of dying

Chills

or hot flashes

1.a. Panic attack

>

dxd when the person is recurrent, unexpected panic attack

followed by at least I month of persistent concern/worry
about having future attacks & staying away from places
or people where or w/ whom the panic attacks occurred
Great apprehension about the outcome of routine activities &
experiences
Loss or disruption of impt. Interpersonal relationships
Demoralization & possible major depressive episode
Transient tachycardia
Moderate elevation of systolic B/P
Respiratory alkalosis
- onset- start on adolescent mid 30s (Keltner et al., 1998)

Assessment

Feels unreal and detached from the self

Fears losing control or going insane

Feels like he/she is dying & has a temporarily disorganized

thought process.

Attempts to free from severe emotions and frightening sxs:

judgment is suspended during panic attacks in an effort to
escape.

Bec. of fear to another attack-avoids people, places & events

assoc. w/ previous panic attack.

Panic disorder w/ Agoraphobia (fear of the marketplace or fear

of being outside)

Fear of stepping outside the front door or stays in limited area

near home

Assessment

Primary gain- relief of anxiety by performing

the specific anxiety-driven behavior (ex. staying
in the house)

Secondary gain- attention received from others

as a result of the persons behavior.

Treatment
Positive reframing - teaches the person to

create positive message to use during panic

attack.

(ex. I can slow my heart rate, this is just an

anxiety)
Assertiveness training - helps the person take
more control over life situations.

Medications
SSRI antidepressants - most effective, nonaddictive, given for 6-18 months.
Benzodiazepine anxiolytics - for a short period (4

wks or less), can cause dependence.

Ex: alprazolam (Xanax-short acting) and
clonazepam (klonopin-long-acting, ant seizure)
TCAs (tricyclic antidepressants or heterocyclic

antidepressants) - non-addictive, long-term tx

recommended

MAOI )- phenelzine (Nardil) inhibit sx of panic

disorder.

Data analysis: Panic disorder

Risk

for injury
Anxiety
Fear
Social Isolation
Situational Low self-esteem
Ineffective Role Performance
Ineffective coping
Disturbed sleep pattern

Outcome Identification: Panic

disorder
Client

will be;
-Free from injury
-Verbalize feelings
-Use effective coping techniques
- Manage own anxiety response
-Verbalize sense of personal control
-sleep at least 6 hrs. per night.

Nursing Interventions
1. Promoting Safety and Comfort
Provide a safe envt a quiet place to reduce
anxiety
Ensure clients safety
Stay w/ client use a soothing, calm voice &
give brief direction to assure client
that he is safe.

2. Therapeutic Relationship &Therapeutic

Communication

Establish trust & show unconditional positive regard &

genuineness.

Communication should be simple & calm

Tell the client that you recognize his behavior but calmly
explain that such behaviors are methods to release anxiety
.
Do not touch a person w/ high anxiety- interpreted as a
threat & full away abruptly

When anxiety has subsided, use open-ended questions to

discuss the experience to help client try to regain a sense of
control.

3. Client and Family Teaching

Relaxation techniques- guided imagery, progressive

muscle relaxation, rhythmic breathing.

Thought stopping - person forcefully orders himself to

stop the irrational fears or panicky thoughts.

Meditation - person ignores the panic thoughts & uses a

repeated word or sound to center his thoughts.

Stress-reduction techniques to allow the client gain a

sense of control - self-esteem & compliance w/ meds.

Encourage client to engage in regular exercise - panic

rxns & helps feelings of well-being.

PANIC DISORDER W/ AGORAPHOBIA

Meets

criteria for panic disorders, including

panic attacks

Experiences
Not

agoraphobia

better accounted for by another mental

disorder, i.e. phobia or social phobia

AGORAPHOBIA
Anxiety

about being in places & situations from

w/c escape might be difficult (or embarassing) or

in w/c help may not be available in the event of

having an unexpected or situationally predisposed
panic attack or panic-like symptoms.

AGORAPHOBIA
Fears

typically involve characteristic clusters of

situations that include being outside the home
alone;
being in the crowd or standing in a line;
being on a bridge &
traveling in a bus, train or automobile

Risk Factors: AGORAPHOBIA

Family

Hx
Substance or stimulant abuse
Severe stressors
Female gender
Those who experience separation anxiety during
childhood
Smoking tobacco products
Early life traumas

Management & Interventions:

AGORAPHOBIA
1. Breathing Control
- Abdominal breathing pt shld stop bet. each
cycle of 10 breaths & monitor normal breathing
for 30 secs (repeated for 3-5 mins.)

2. Nutritional Planning
- Maintain regular & balance diet
- Reduce & eliminate intake of food containing
caffeine, food coloring, MSG

3. Relaxation Techniques
- Isometric exercises & progressive relaxation
4. Increased Physical Activity
- Physical exercise can diminish the occurrence of
panic attacks by reducing muscle tension,
increasing metabolism, & relieving stress

5. Distractions
- Initiating a conversation w/ a nearby or engaging
in physical activity
-performing simple repetitive activities like counting
backward from 100 by 3s, counting objects along
the roadway
-Snapping a rubber band against the wrist
- To be tailored to the individual & shd be used
along w/ breathing exercise.

6. Positive Self-talk

- Positive coping statements w/c can give the

individual a focal point & reduce fear
- This is only anxiety & it will pass I can
handle these sxs, Ill get through this
7. Panic Control tx
- persons patterns of feared sensation are
assessed by inducing those sensations through
exercise-identified patterns become target for tx
-Pt are taught to use breathing training to manage
their responses & are instructed to practice these
techniques between sessions

8. Exposure Therapy
- Tx of choice for agoraphobia
- repeatedly exposed to anxiety-provoking
situations until he/she becomes desentized
through real or simulated situations through visual
or auditory imagery
9. Systemic Desentization
- Exposing the pt to hierachy of feared situations
that the pt has rated from least to most feared
- use muscle relaxation as levels of anxiety
increase

10. Implosive Therapy

- Therapist identifies phobic stimuli for the pt & then
presents highly anxiety provoking imagery to the pt
- Therapist describes the feared scene as
dramatically & as vividly as possible
- Flooding
11. Psychoeducation
- Teaching the client & family about anxiety disorders
-Breathing control & relaxation techniques
- maintaining prescribed medication regimen
- Nutrition & exercise
-Positive Coping strategies

12. Alternative & Complementary Therapies

- Taichi
- Meditation
-Yoga
- Hypnosis
- Acupuncture
- Herbal preparations

PHOBIAS
- is an illogical, irrational, intense, persistent fear of a
specific object or social situation that causes extreme
distress & interferes w/ normal life fxng.
Most phobic objects are usually not threatening
They understand that there fear is unusual & irrational

but they feel powerless to stop it.

2. PHOBIAS
-

Anticipatory anxiety- even when thinking about

encountering the dreaded object, they engage in
unusual ritualistic behaviors to attempt to avoid
it.
Performance of ritualistic behaviors reduce the

persons anxiety (primary gain)

The attention & assistance received from others

( secondary gain)

The phobic object or situation causes the person

extreme anxiety & panic response

Dx is made only when the behavior significantly

interferes w/ the persons life, creating marked
distress
or
difficulty
in
interpersonal
occupational fxng.

3.a. Simple/Specific Phobia: fear of specific things

animals, natural envt., blood-injection-injury,
situations, others)
- more in women.
3.b. Social Phobia: fear of potentially embarrassing
social situations
- Mostly in men
Agoraphobia (w/ or w/o panic): fear of being public
place from w/c escape might be difficult or help is
unavailable
> Equally Peak onsent: Childhood & mid 20s.

Categories of phobias:
Natural environmental phobias
- blood - injection phobias
- situational phobias
- animal phobia
- other types of specific phobia
Social phobia - become severely anxious to the
point of panic when confronted w/ situations
involving people - making a speech, attending
a social gathering alone
- d/t low self-esteem & concern about others
judgment about ones performance
- the person is afraid of being embarrassed

Etiology: Phobia
Biologic

(phobias run in families, hormonal

fxns, or neurotransmitter activity)

Psychodynamic

(faulty thinking, belief 1

doesnt control the envt., or learned by
modeling from parents)

Treatment: PHOBIAS

Medications: Benzodiazepine anxiolytics, SSRIs (Zoloft),

Propanolol HCL (Inderal)
Psychotherapy
Behavioral therapy: teaching relaxation techniques, setting
goals discussing methods to achieve goals.
Systematic desensitization - the client is progressively
exposed to the threatening object, in a safe setting, until his
anxiety is reduced.
Flooding - a form of rapid desensitization, in w/c the person
is confronted w/ the phobic object until it no longer produces
anxiety.

 Accept

pt anxiety & fears w/ a noncritical attitude

Provide

& involve pt w/ activities that do not

increase anxiety, but will increase involvement
rather than avoidance.

Help

pt w/ physical safety & comfort

Help

pt to recognize that their behavior is a

method of coping w/ anxiety

Systemic

desentisitization, Implosive therapy,

exposure therapy, social skills training &
relaxation techniques

OBSESSIVE-COMPULSIVE DISORDER
-

repeated ritualistic behavior that are

based on unrealistic fears & that
interfere w/ life activities.

OBSESSIVE-COMPULSIVE DISORDER

Obsessions

recurrent thoughts, ideas that are inappropriate, & anxiety

producing & that disturbed the persons social or
occupational fxng.
> The person attempts to ignore, suppress, or neutralize
obsessions w/ some other thought or action
.> The person recognizes that the obsessional thought,
impulses are a product of ones own mind

OBSESSIVE-COMPULSIVE DISORDER
>

Perfectionism & emotional constriction,

orderliness, rigidity & indecisiveness-stems from the
need to be perfect.
> Seems to be serious inflexible, & rigid about
their ideas
> Responds well to a structured, orderly & stable
envts.
> Comorbid conditions: MDD, alcohol disorders,
eating disorders

Ex.: fear of dirt or germs, fear of burglary or robbery,

worries about discarding something impt., concerns
about contracting a serious illness, worries that
things must be symmetrical or matching.

Compulsions
- behaviors or rituals continuously carried out to
get rid of the obsessive thoughts & reduce
anxiety.
- person feels driven to perform repititive
behaviors or mental acts in response to an
obsession or accdg to rules that one deems must
be applied rigidly
- Behaviors & mental acts are aimed at preventing
or reducing distress or preventing some dreaded
event or situation

Compulsions
Examples:
Checking rituals
Counting rituals
Repeating hand washing
Repeating the some words or tunes
Touching rituals
Symmetry rituals
Rigid performance rituals
Cleanliness
Somatic complaints
Sexual rituals
Aggressive impulses
> Person understands that these rituals are unusual &
unreasonable but feels forced to carry them out to alleviate
anxiety.

Recognition by a person that obsessions or

compulsions are excessive or unrealistic if not,
specify w/ poor insight)

Marked distress that is time-consuming

significantly interfering w/ normal routine & fxng

Not a direct physiologic effect of substance use or

medical condition

or

Associated Behavioral Findings

Avoidance

of situations involving the content of the

obsession or compulsion
Hypochondriacal concerns w/ frequent physician
visit
Guilt
Sleep disturbance
Excessive use of alcohol or sedative, hypnotic, or
anxiolytic medications
Compulsion performance a major life activity; may
lead to serious marital, occupational or social
disability.

Associated Physical Findings

Possible

dermatologic problems caused by excessive

washing w/ water or causatic cleansing agents

Etiology: OCD

Use of 4 types of defense mechanisms: regression,

isolation, rxn formation & undoing.

Regression & become fixated in the anal stage (analretentive or anal-explosive)

Treatment: OCD
Medications: SSRIs, TCA Clomipramine,
anxiolytics (Buspirone, Clonazepam)

Behavioral therapy exposure (confronting

anxiety-provoking stimuli)
Response Prevention- delaying or avoiding
ritual performance

NCP:OCD
Assessment:
Focuses on what behavior s or rituals are performed
& how often & how often a clients response & so
forth, to discover the pattern of behavior.
Data Analysis:
- Anxiety
- Ineffective Coping
- Fatigue
- Situational low sel;f-esteem
- Impaired Skin integrity (if scrubbing or washing
rituals)

NCP:OCD
Outcome

Identification:

Client will:
- Complete daily routine w/in realistic time
frame
- Demonstrate effective use of relaxation
techniques
- Discuss feelings w/ others
- Demonstrate effective use of behavior
therapy techniques
- Spend less time performing rituals

Nursing Interventions; OCD

Psychologic Int:
Therapeutic

relationship, offer support, compassion

and believe that the client can change - selfesteem & can help clients overcome feelings of
shame and doubt.

Therapeutic Comm., Interact w/ a client in a calm,

nonauthoritarian fashion

Thought stopping: pt is taught to interrupt

obsessional thoughts by saying STOP! either
loudly or subvocally

Nursing Interventions; OCD

Psychologic Int:

Relaxation techniques
Cognitive Restructuring :
pt is taught to monitor automatic thoughts, then to
recognize the connection between thoughts,
emotional response & behaviors
distorted thoughts are examined by the therapist
Therapist helps the pt to doubt the real likehood
that the feared event will happen even if the
compulsive behavior is performed.

Initially, it is impt. Not to prevent the pt from

engaging in rituals because of the increasing levels
of anxiety that will follow.
Gradually the amount of time for the client to
carry out ritualistic behaviors so that the persons
feels some sense of control - the clients
helplessness & anxiety.

Provide a schedule of daily activities, detailing all

events - help client focus on scheduled activities
and less time for rituals.

Allow some private time but also integrates the pt

into normal unit activities

Provide positive feedback

Convey acceptance of clients despite ritualistic behaviors

Allow client to perform rituals (anxiety will increase if the pt

perform compulsive behavior)

Encourage limit setting on ritualistic behaviors as part of the

established tx plan

Use active listening to encourage client to verbalize feelings

(best time for interaction is after client completes ritualistic
behaviors)

Direct need to conduct rituals into more socially useful

behaviors e.g. cleaning up after meals, folding laundry)

Explore w/ pt the purposes that the behavior fulfills

relaxation techniques & other coping measures to handle

anxiety

Teach information about medication used as part of tx plan.

Related Disorders
OTHER ANXIETY DISORDERS
1.

Generalized Anxiety Disorder

2.

worries excessively & feels highly anxious at least

half of the time for a period of 6 mos. or more.

S/S:

uneasiness
muscle tension
difficulty thinking

irritability
fatigue
sleep alterations

Related Disorders
OTHER ANXIETY DISORDERS
1.

Generalized Anxiety Disorder

- excessive anxiety & worry occurring for more days
than not for at least 6 mos involving a # of events or
activities
-Difficulty in controlling the worry
- Focus of anxiety & worry not confined to another
psychiatric disorder
-clinically significant distress or impairment of fxng
resulting from anxiety, worry or physical symptoms
- does not occur exclusively during a mood disorder,
psychotic disorder, or pervasive devtl disorder

Generalized Anxiety Disorder

Associated Behavioral Findings: Possible
depressive sxs
Associated Physical Examination Findings:
Muscle Tension w/ twitching,
trembling,
feeling shaby & muscle aches & soreness, clammy
cold hands, dry mouth, sweating, nausea or
diarrhea

2. Anxiety Disorder d/t a General

Medical Condition
- is a dx category in w/c anxiety disorders i.e.
OCD, GAD, or panic attacks are directly r/t the
persons gen. medical condition.
- affect the persons occupational, social, or
interpersonal fxn
- produced meds., toxins, or substance abuse.

3. PTSD
-

can occur in a person who has witnessed an extraordinarily

terrifying & potentially deadly event.
- after experience psychological trauma individual
experience event via dreams or nightmares & flashback.

natural disaster combat experience victims of rape

victims of accidents victims of accidents
victims/witness
victims of sexual or physical abus
to a crime
- recurrent experienced thoughts & feeling assoc. w/ severe,
specific trauma (eg.combat experience, rape, serious
accident, severe deprivation, torture)
-

3. PTSD
-

Not an inevitable consequence of exposure to a

traumatic event or disaster
consider:
- 1. Nature of the stressor
- 2. Available resources to assist debriefing
- 3. presence of premorbid hx of psychiatric
problem

Manifest:
sleep difficulties
hypervigilance
thinking difficulties
poor concentration

Characteristics of PTSD
Can be acute
Persistent

or delayed; can be chronic

re-experiencing
of
traumatic

events(recurrent & intrusive distressing recollection,

recurrent distressing dreams, acting or feeling like the
traumatic events was recurring, intense psychological
distress & physiologic reactions when exposed to cues or
resembling the event)

Persistent

trauma

Duration

avoidance of stimuli assoc. w/ the

of sxs greater than 1 mos(Acute:<3 mos.;

chronic: > 3 mos.;w/ delayed onset: if sxs appear 6
mos. or more after the event)

Characteristics of PTSD
Significant

distress or impairment of
occupational, or other impt. Areas of fxng

social,

Includes

sxs i.e. exaggerated startle response,

sleep disorders, guilt (survivors guilt), nightmares
& flashbacks, anger w/ numbing of other emotions

Alcohol

& drugs commonly used to self-treat &

relieve symptoms

Mngt./Int: PTSD

Validate w/ client that traumatic event was indeed highly

stressful.

Help client verbalize all aspects of traumatic events,

including own feelings.

Relaxation techniques & other coping measures to handle

anxiety

Systemic desensitization, prolonged exposure, implosive

therapy, anxiety mngt techniques (cognitive-behavioral
techniques)

Therapy: PTSD
gradual exposure to the event

support group - post somatic disorder

4. Acute Stress Disorder

-

similar to PTSD that a person has experienced

traumatic situation, but the response is more
dissociative in nature.
- sense the event is unreal, thinks he or she is
unreal, & forget some aspects of the event through
amnesia.
- must last a min. of 2 days; & a dx can only be
made up to 1 mos. after exposure to the stressor.
-Crisis intervention
-Stress debriefing

5. Somatoform disorder
- group of disorders charac. by complaints of physical sx that
cannot be explained by known physical mechanisms.
- Individuals experience a loss or change in physical fxn
- Sxs not under voluntary control of the individual
- Disorders charac. By primary gain (anxiety relief) & 2ndary
gain (special attention, relief from responsibilities)
- Significant impairment occurs in social or occupational fxng.
-form secondarily from love ones
- charac. by excessive boring or complain regarding physical
illness.
- increase when expose to anxiety & stress.

types: Somatoform
5-1. Somatization disorder hx of multiple physical
complaints involving multiple body system w/o
organic basis, occurring before age of 30 &
persisting several years.
5-2.Hypochondriasis unrealistic fear of having
serious illness or dse, no physical evidence.
- Individuals interpretation of body symptom is
w/o organic basis
-preoccupation
persist
despite
appropriate
medical evaluation
-Anxiety is real to the client who is not faking it.

5-3. Body Dysmorphic disorder

preoccupation w/ imagined physical defect in
normal person; if the individual has a defect,
expressed concern is excessive
-Leads to social isolation & unnecesary medical
(condition) procedures.

5-4. Pain disorder : Chronic pain in 1 or more

anatomic sites; a medical condition, if present,
plays a minor role in accounting pain.

5-5. Conversion disorder : Loss or

change of physical fxn suggesting:
1.

Nuerologic

2.

Involuntary

disorder

(blindness,
deafness, loss of tactile sense of pain)

motor

fxn

disorder

(aphasia, impaired coordination, paralysis,

seizures)
- likely to be seeing more than 1 health
provider at a time.

Etiology: Somatoform
Psychoanalytic

theory:
conflict
finds
expression by displacement of aqnxiety onto
physical symptom.

Behavioral

theory: child learns from parents to

express
anxiety
through
somatization;
secondary gains reinforces symptoms.

Mngt & Int.:Somatoform

Use

a matter of fact & be caring approach when

providing care for physical symptoms
Assist pt w/ developing more appropriate ways to
verbalize feelings & needs.
Use
positive
reinforcement
to
increase
noncomplaining behavior, & set limits by
withdrawing attention from pt when they focus on
physical complaints or make unreasonable
demands.
Use diversion by including pt in milieu activities &
recreational games.

NURSING CARE PLAN

Assessment Data
Objectives:
decreased attention span
restlessness, irritability
poor impulse control
feelings of discomfort, apprehension, or helplessness
perceptual field deficits
decreased ability to communicate verbally
Nursing Diagnosis
> Anxiety
A vague uneasy feeling, whose source is often nonspecific or unknown to the
individual
Goals and Objectives
The client will:
Be free of injury
Discuss feelings of dread, anxiety, and so forth
Respond to relaxation techniques with a decreased anxiety level
Reduce own anxiety level
Be free of anxiety attacks

Interventions

Rationale

Be aware of your own feelings &

level of discomfort or anxiety.

anxiety is communicated interpersonally. Being

w/ the anxious client can raise your own anxiety
level.

Encourage the clients participation

in relaxation exercises. These can
include deep breathing, progressive
muscle relaxation, medication,
guided imagery, and going (mentally) to quiet, peaceful place.

relaxation exercises are effective, nonchemical ways to reduce anxiety.

Teach the client to use relaxation

techniques independently.

Help the client see mild anxiety as

a positive catalyst for change.

independent use of the techniques can give

the client confidence in having some conscious control over his or her behavior.
A frequent misconception is that anxiety itself
is bad and not useful. The client does not
need to avoid anxiety per se.

Interventions and Rationale

Interventions

Rationale

Remain with the client at all times

when levels of anxiety are high
(severe or panic)

The clients safety is a priority, A highly anxious

client should not be left alone - his or her anxiety
will escalate.

Move the client to a quiet area w/

minimal or decreased stimuli. Using
small room or seclusion area may
be indicated.

The clients ability to deal w/ excessive stimuli is

impaired. Anxious behavior can be escalated by
external stimuli. A smaller room can enhance
the clients sense of security. The larger the area,
more lost and panicked the client can become.

Remain calm in your approach to

client.

the client will feel more secure if you are calm

and if the client feels you are in control of the
situation.

Use short, simple, and clear state-

the clients ability to deal with abstractions or

ments.
Avoid asking or forcing the client
to make choices.

complexity is impaired.
The clients ability to problem solve is impaired.
the client may not make sound decisions or may
be unable to make decisions at all.

Use of PRN medications may be

indicated if the clients level of
anxiety is high or if the client is
experiencing delusions, disorganized thoughts, and so forth.

medication may be necessary to decrease the

client anxiety to a level at which he or she can
listen to you and feel safe.

7. Disociative disorders
Dissociation: removal from conscious awareness of
painful feelings, memories, thoughts & aspects of
identity
- Occurs in extreme stress or trauma
- Identity, memory, consciousness are disturbed or
altered
- Dissociate the abuse experience as well as
feelings & needs assoc. w/ it in order to survive the
ordeal psychologically & physically.
ADULT: will be vulnerable to self-mutilation &
dissociation anytime she becomes angry.

Assessment:
- occupied physical fxng
- use home meds. and non prescriptive
drug

TYPES: Disociative disorder

1.

Multiple PD
disorder-

or Dissociative identity

2.

- 2 or more personalities develop distinct & unique

personalities w/ in the person, trigger by stress.
- 2 or more personalities that take control of the
persons behavior
- The person host is unaware of the other
personalities, but the other personalities may be
aware of each other in varying degrees
-

TYPES: Disociative disorder

1.
2.

Multiple PD
disorder-

or Dissociative identity

-Defense against extreme anxiety: splitting off

allows the child to survive the trauma but leaves

an impaired personality w/ disconnected parts or
alters
-Each personality alters has its own name,
behavior traits, memories, emotional characteristics
& social relations
- Most common personality: a fearful, terrified child &
the next most common is a persecutor modeled on
the abuser

 Child

abuse is almost always a part of the hx

of individuals w/ dissociative identity disorder

Trauma

is usually severe, sexual abuse that

overwhelms the child's nondissociative
defenses

The

abuse experience is dissociated &

aspects of the experience later appears in
the form of various personalities.

2. Dissociative amnesia charac. by inability to

recall impt. personal info. Bec. it is anxiety/stress
provoking
- loss of memory of impt. personal events that
were traumatic or stressful un nature.
3 types
1. Localized amnesia - clients blocks out all
memories about specific period
2. Selective amnesia - client recall some but not all
memories about specific period.
3. Generalized amnesia - loss of all memories
about past life.

3. Dissociative fugue sudden or unexpected

travel away from home or work w/ loss of memory
about the past; confusion about identity or
assumption of partial or completely new identity is
present
-last from few Hrs or several days & is usually
accompanied by amnesia
4. Depersonalization : experiences of feeling
detached from, or an outside observer of, ones
body or mental process.
- Sense of reality is changed but the person is
oriented to time, place & person
- Is often accompanied by sxs of derealization in
w/c the person.

Mngt/Int: Dissociative disorder

Establish trust & support

Discuss self-harm thoughts
Help client develop plan for going to safe place when having
destructive thoughts or impulses
grounding techniques to help client who is dissociating or
experiencing flashbacks
Validate clients feelings of fear, but try to increase contact w/ reality
During dissociative experience or flashback, help clieny change body
position but do not grab or force client to stand up or move
supportive touch if client responds well to it.
Teach deep breathing & relaxation techniques
Use distraction techniques i.e. physical exercise, listening to music,
talking w/ others, or engaging in a hobby or other enjoyable activity
Help to make a list of activities & keep materials on hand to client
when feelings are intense
Refer to client as survivor rather than victim
Establish social support system in community
Make a list of people & activities in the community for client ot contact
when help is needed.

8.Substance-induced anxiety disorder

Anxiety directly caused by drug abuse, a med., or
exposure to a toxin.
Symptoms:
- Prominent anxiety
- Panic attacks
- Phobias
- Obsessions
- compulsions

NCP: Anxiety-Stress Related

disorder
Assessment:

Objectives:
- ed attention span
-restlessness, irritability
-poor impulse control
-feelings of discomfort, apprehension, or
helplessness
-perceptual field deficits
- ed ability to communicate verbally

Nsg. Dx:
Anxiety vague uneasy feeling, whose source is
often nonspecific or unknown to the individual
Goal & Objectives: Client will:
-free from injury
-discuss feelings of dread, anxiety & so forth
Respond to relaxation techniques w/ a ed anxiety
level
-Reduce own anxiety level
-be free of anxiety attacks

Intervention
Intervent.

Rationale

1. Remain w/ the client at Pts safety is a priority, a highly anxious

all times when levels of client should not be left alone-his/her
anxiety are high (severe or anxiety will escalate
panic)
2. Move client to a quiet
area w/ minimal or ed
stimuli. Using small room
or seclusion area may be
indicated

Pts ability to deal w/ excessive stimuli is

impaired. Anxious behaviors can be
escalated by external stimuli. A smaller
room can enhance the clients sense of
security. The larger the area, more lost &
panicked the client can become.

3. Remain calm in your Pt will feel more secure if you are calm & if
approach to client
the cl,ient feels you are in control of the
situation

Intervention
Intervent.

Rationale

4. Use short, simple & Pts ability to deal w/ abstractions or

clear statements
complexity are impaired
5. Avoid asking or forcing Pts ability to problem solve is impaired.
the client to make choices The client may not make sound decisions or
may be unable to make decisions at all.
6. Use PRN meds. May be Meds. May be necessary to the client
indicated if the clients anxiety to a level at w/c he/she can
level of anxiety is high or listen to you & feel safe.
if the client is experiencing
delusions,
disorganized
thoughts, and so forth.
7. Be aware of your own Anxiety is aommunicated interpersonally.
feelings & level of Being w/ the anxious client can raise your
discomfort or anxiety
own anxiety level.

Intervention
Intervent.

Rationale

8. Encourage the clients Relaxation exercise are effective,

participation
in
relaxation non-chemical ways to reduce anxiety.
exercises. These can include
deep breathing, progressive
muscle relaxation, meds., guided
imagery, & going (mentally) to a
quiet, peaceful place
9. Teach the client to use Independence use of techniques can
relaxation
techniques give the client confidence in having
independently
some conscious control over his/her
behavior.
10. Help the client see mild A frequent misconception is that
anxiety as a positive catalyst for anxiety itself is bad & is not useful.
change
The client does not need to avoid
anxiety per se.

ANXIETY AND STRESSRELATED ILLNESS

END