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Stress and Anxiety o Stress Theories Conflict avoidance Biopsychosocial theory: SNS activation (fight/flight) Cannon, 1932 Cause of disease due to wear/tear on body General adaptation syndrome (GAS) Selye, 1956 Enlarged adrenal glands, shrinkage of thymus/spleen/lymph nodes, GI bleeding Life changes Holmes & Rahe, 1967 Social Readjustment Rating Scale: measures stress with life changes and categorized them (mild with 30% chance of physical manifestation; moderate 50%, high 80%) Stress as Transaction Lazarus, 1991 Stress includes life changes and everyday. Process of complex interplay among perceived demands of environment and perceived resources Phsychoneuroimmunology and stress o Anxiety Caused by threats (internal and external) Differs from fear: anxiety is unconscious emotion, fear is higher level processing cognitive response Mild to moderate enables effective functioning but increases alertness, narrows perspective and attention along the anxiety continuum Severe anxiety can lead to inability to problem solve, focus on small/irrelevant details Panic: debilitating Examples of physical conditions with morbid psychiatric symptoms: A fib, MI, angina, IBS, ulcers, NVD, hypoglycemia, metabolic syndrome, psoriasis, acne, alopecia, chronic pain, fibromyalgia, migraines, asthma, TB May be associated with withdrawal/intoxication from ETOH, sedatives, anxiolytics, amphetamines, hallucinogens, caffeine, cannabis Anxiety Disorders o Dx 6 months or greater Characterized by mixture of physiological, psychological, behavioral, and cognitive symptoms TO EXCESS o Assessment components Specific fears/phobias Sleep hygiene: Bed routine, where they sleep, napping, tv in bedroom, with kids or significant other, activity during the day o Neurobiological changes with prolonged anxiety Increased sensititivity to NE In PTSD, structural changes in hippocampus (can be improved with medication and therapies) In OCD and PTSD changes in amygdala Increase in lactic acid levels in some people before a panic attack Involves changes in 5HT, Gaba, Glutamate, Norepi, and Cortisol Cortisol balance: o Hypocortisolism: depression, motivation problems o Hypercortisolism: OCD, panic disorders, atrophy of the hippocampus Generalized Anxiety Disorder (GAD) and Panic Disorder o GAD’s prominent feature: frequent, uncontrollable worrying which can manifest as physical symptoms Restlessness, irritability, fatigue, muscle tension, difficulty concentrating, sleep disturbances o Panic Disorder Recurrent panic attacks with unpredictable onset Lasts minutes to hours May or may not be accompanied with agoraphobia S/sx: Sweating, trembling, shaking, SOB, chest pain/discomfort, nausea, dizziness, chills, hot flashes, derealization or depersonalization: surreal feeling of “not happening to me” (NOT PSYCHOSIS) Fear of losing control/going crazy Fear of dying o Theories Psycodynamic : ego is unable to intervene between id and superego, overuse of ineffective ego defense mechanisms Cognitive: faulty/distorted or counterproductive thinking patterns result in anxiety o Agoraphobia Fear of being in places or situations from which escape might be difficult Not wanting to leave home or having exact routine Typically not socializing/interacting May be accompanied by panic disorder o Pharmacologic txs Anxiolytics Antidepressants Antihypertensive agents Social Anxiety Disorder (Social Phobia) o Low self-concept and self-esteem contribute to excessive fear of doing something embarrassing Specific Phobia o Fear of objects or situations that could conceivable cause arm but the person’s rxn is excessive, unreasonable, inappropriate o Exposurepanic, palpitations, sweating, dizziness, difficulty breathing o Types: Animals Nautral environment type Blood-injection-injury-type Situational type (tunnels/bridges/elevators) Transportation and more o Theories: Psychoanalytical theory: unconscious fears may be expressed in a symbolic manner as phobia Learning theory: fears are conditioned responses and thus are learned by imposing reinforcements for certain behaviors (CONDITIONING) Cognitive theory: faulty cognitions, negative self-statements, irrational beliefs Temprament/Life experiences o Pharmacologic Txs Anxiolytics Antidepressants Antihypertensives OCD, Hoarding, Tichotillomania o Obsessive Compulsive Disorder (OCD) Recurrent obsessions ( recurrent thoughts/impulses experienced as intrusive) or compulsions (repetitive ritualistic behaviors) that is time consuming or marked distress/significant impairment Person recognize they are irrational o Body Dysmorphic Disorder (BDD) Exaggerated belief that body is deformed or defective in some specific way S/sx of depression and OCD are common o Trichotillomania Recurrent pulling out of one’s own hair Increasing tension release by pulling hair o Hoarding Disorder Can be classified as “with excessive acquisition” if continual addition of posessions Associated symptoms: perfectionism, indecisiveness, anxiety, depression, distractibility, difficulty planning/organizing tasks High relapse rate o Theories Psychoanalytic theory: clients with OCD have weak, underdeveloped egos Aggressive impulses are channeled into thoughts/behaviors that prevent feelings of aggression from surfacing. Biological perspectives: genetics, abnormalities in brain structure/ neurotransmitters (5HT0 o Pharmacologic txs for OCD and BDD Antidepressants o Pharmacologic tx for Trichotillomania Chlorpromazine (throazine) Amitriptiline Lithium Antidepressants: Paroxetine, Sertaline, Fluxoetine Psychopharmacology of Anxiety Disorders o Anxiolytics include: SSRIs, SNRIs Hydroxyzine (Vistaril) Benzodiazepenes Buspirone (BuSpar): 50/50 if effective o SE profile of benzos/buspirone: Drowsiness/confusion/lethargy Tolerance, dependence Potentiates CNS depression Orthostatic hypotension Pradoxical excitement Delayed onset of action (with BuSpar) Nursing care of Anxiety Disorders o Panic Attacks Stay with the person, maintain calm demeanor, use short simple sentences, move person away from stimulus, focus clients diffuse energy, administer anxiolytics Observe for increased psychomotor activity, anger, withdrawal, excessive demands, terafulness Connect with feelings that bring relief, triggers o OCD Acknowledge person’s rationality, allow time to complete rituals. This forms therapeutic alliance. Action takes place after ritual has taken place Affirming relationship is important before changing behaviors Gradually introduce possible new behaviors to substitute for damaging Do not use paraphrasing/reflecting. Why? Client understands their compulsions are irrational o Phobic Resistant to exposure/ insight oriented therapies o Behavioral techniques work better including desensitization and cognitive restructuring Safety Counsel to avoid dangerous activities when anxiety is severe Move more slowly and go over instructions before undertaking new tasks/skills o Coping skills Relaxation techniques (focused breating, progressive muscle relaxation) Sound therapy Boring book Warm liquids and warm bath o Promoting effective thought processes and sensory perception Use visual aids Practice problem solving Identify misperceptions Help clients explore opinions in light of validated experience Care Planning o Common nursing dx: Panic anxiety, powerlessness, fear, social isolation Ineffective coping, ineffective role performance, disturbed body image, ineffective impulse control o Outcomes Client is able to recognize signs of escalating anxiety and intervene before reaching panic level Is able to maintain anxiety at a manageable level and make independent decisions about life situations Functions adaptively in presence of phobic object or situation without experiencing panic anxiety Verbalizes a future plan of action for responding in the presence of the phobic object or situation without developing panic anxiety Is able to maintain anxiety at a manageable level without resorting to use of ritualistic behavior Demonstrates more adaptive coping strategies for dealing with anxiety than ritualistic behaviors Verbalizes realistic perception of his or her appearance and expresses feelings that reflect a positive body image Verbalizes and demonstrates more adaptive strategies for coping with stressful situations Adjustment Disorders o Difficulties with stress rxns to more normal events o Common PTSD o Rxn to extreme trauma which is likely to cause distress to anyone o o o o o o May begin within 3 months or be delayed Symptoms include: Re-experiencing trauma Sustained high level of anxiety/arousal General numbing of responsiveness Intrusive recollections/nightmares Amnesia Depression Survivor’s guilt Substance use Anger/aggression Relationship defecits Acute Stress Disorder Simmilar to PTSD, but time limited up to 1 month following trauma Neurobiology Excessive stimulation of amygdala->hyperarousal Neuroendocrine/autonomic responses Cortisol Kindling: phenomenon where high cortisol exposure over time leads to sensitivity of the thalamus (the stimulus processor) and EVEN GREATER stress response Glutamate Secreted during trauma to create strong vivid memories NE Similar to cortisol, amygdala tells brainstem to increase secretion 5HT Depletion Therapy Cognitive therapy Prolonged exposure Group/family EMDR Psychopharmacology Outcomes Pt will acknowledge the trauma and impact on life Demonstrate adaptive coping strategies Made realistic goals for the future Worked through feelings of survivor’s guilt Attends support group of individuals recovering from similar traumatic experiences Verbalizes desire to put trauma in the past and progress with his or her life Practice Problems: Lippincott: p. 844 1-22, 23-36 p. 815, 101-137 Saunders: p. 1054: 912, 913, 918. P. 1092: 950