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Psychiatric / Mental Health Nursing Anxiety Disorders and Dissociative Disorders West Coast University NURS 204 Learning Objectives Identify theories in understanding anxiety disorders and dissociative disorders Explain the concept of anxiety and how it relates to anxiety disorders and dissociative disorders Compare and contrast both the common themes and distinctive characteristics of anxiety disorders with dissociative disorders. Incorporate how dissociation serves as a defense mechanism for some individuals experiencing trauma into the care of clients with dissociative disorders Conduct a comprehensive assessment in the care of clients with anxiety and dissociative disorders. Learning Objectives Design a plan of care for intervening into mild, moderate, severe, and panic levels of anxiety. Educate clients and their families about pharmacologic and non-pharmacologic measures for anxiety disorders and dissociative disorders Identify the possible personal challenges in caring for clients with anxiety disorders and dissociative disorders. Theories: Anxiety Disorders Biological changes in the brain Noradrenergic system is sensitive to norepinephrine; locus ceruleus is involved in precipitating panic attacks. Dopamine system involved in pathophysiology of OCD. GABA dysfunction affects development of panic disorder. Locus Caeruleus Theories: Anxiety Disorders - continued Abnormal control of glutamate plays role in anxiety disorders. Hormonal changes in pregnant women affect certain anxiety disorders. Lactic acid may precipitate anxiety. Caffeine and nicotine may trigger panic attacks. Genetic theories: strong evidence for familial or genetic predisposition for anxiety disorders Psychosocial theories: in psychoanalytic theory, anxiety is viewed as sign of psychologic conflict; anxiety is the outcome of repressing forbidden impulses Theories: Anxiety Disorders - continued Behavioral theory Anxiety is a learned response that can be unlearned. Compulsive behavior is a maladaptive attempt to alleviate anxiety. Behavior modification teaches new ways to behave Humanistic theories: Environmental stressors, biological factors, and intrapsychic fears cannot be dealt with separately but rather as they interact with one another. Treatment approaches are integrative. Anxiety A universal experience A normal response that usually helps cope with threatening situations Anxiety disorders are characterized by anxiety so disabling as to adversely affect day-to-day functioning Affects all age groups Anxiety - continued Anxiety disorders are most common of mental illnesses All anxiety disorders have in common excessive, irrational fear and dread Anxiety is either a dominant disturbance or an avoidance behavior Free-floating anxiety is unrelated to a specific stimulus Anxiety - continued Panic disorder Phobia Social Phobia Agoraphobia Specific Phobia Generalized Anxiety Disorder (GAD) Obsessive Compulsive Disorder Post-Traumatic Stress Disorder Acute Stress Disorder Panic Disorder Recurrent attacks of severe anxiety lasting a few moments to an hour. No stimulus but occur suddenly and spontaneously. Experience physical symptoms Mimic symptoms of MI and mitral valve prolapse Phobias Agoraphobia: Fear of being alone or in public places from which escape might be difficult or help might not be available. Social Phobia: Fear of extreme embarrassment. Specific Phobia: Fear of specific objects and situations Generalized Anxiety Disorder (GAD) Pervasive, persistent anxiety of at least 6 months’ duration but without phobias, panic attacks, or obsessions and compulsions. Chronic feeling nervousness and apprehension for no apparent reason and is unable to control the worry. Unable to relax or stop worrying. Irritable, muscle tension, insomnia, SOB, and dizziness. Obsessive-Compulsive Disorder Obsession: recurring thought that cannot be dismissed from consciousness. Compulsion: uncontrollable, persistent urge to perform certain acts or behavior in order to relieve unwanted thoughts. Fear that they will harm someone. Trivial, ridiculous, morbid, violent or contamination. Common Obsessive-Compulsive Behaviors Repetitious hand washing – Urge to wash, scrub, or clean – Fear of disease or contamination. Returning home often to make sure appliances are turned off – Need to recheck related to self-doubt – Fear of disaster. Hoarding junk mail, receipts, and all types of papers – Need to keep everything – Fear of losing things. Ritualistic counting of number of stairs climbed – Urge to count repeatedly – belief that counting will yield control and thus prevent making mistakes. Post-Traumatic Stress Disorder Experience of a significant stressor or trauma Hyperarousal when reexperiencing the traumatic event: unable to relax, hypervigilance, always “on edge” Categories: Acute: symptoms last less that 3 months. Chronic: symptoms last 3 months or more. Delayed onset: at least 6 months have elapsed between trauma and the occurrence of symptoms. YOUR ASSESSMENT APPROACH: The Client with Anxiety Disorder YOUR ASSESSMENT APPROACH: The Client with Panic Attack Nursing Diagnosis: Fear Anxiety Ineffective coping Ineffective role performance Impaired verbal communication Risk for trauma Disturbed thought process Ineffective tissue perfusion Insomnia Nursing Outcome Identification: NOC Client will demonstrate absence of physical manifestation of anxiety. Client will identify indicators of own anxiety anxiety. Client will verbalize feelings of anxiety appropriately. Client will demonstrate the use new coping skills. Plan of Care for Anxiety Mild to moderate anxiety Use a calm, quiet approach Observe client’s verbal/nonverbal behavior Encourage client to verbalize feelings Teach relaxation techniques (meditation, guided imagery, etc.) when anxiety is mild Simple physical activities often help reduce anxiety Develop goal-oriented contract Plan of Care for Anxiety - continued Severe to panic levels of anxiety: First priority is to reduce anxiety to tolerable levels. Stay with the client. Provide a safe and supportive milieu. Use a firm voice and short, simple sentences. Place client in quieter, smaller, less stimulating environment; focus the client’s diffuse energy on repetitive task or tiring task. Administer antianxiety medication if ordered. Dissociative Disorder Theories: Dissociative Disorders Biological factors Serotonin Limbic system Physical illnesses and certain drugs Various personality states in dissociative identity disorder have different activity in frontal and temporal lobes. Genetic theories: Dissociative disorder occurs more often in first-degree biologic relatives Theories: Dissociative Disorders - continued Psychosocial theories: Current explanations are based on Freud’s dynamic concepts. Repression of ideas leads to amnesia, to protect oneself from emotional pain. Dissociative identity disorder is a result of childhood chronic trauma. Behavioral theories: Dissociative disorders are learned behaviors that provide protection from a painful experience. Humanistic theories: The person is a composite of life experiences, psychobiological factors, and interpersonal interactions. Distinctive Characteristics of Dissociative Disorder Consciousness, memory, identity, and perception of environment are impaired. Dissociation is a defense against trauma that separates emotions from behaviors. Dissociation is a response to extreme childhood trauma. Dissociation Emotional numbing Impaired social relationships Separates emotions from behaviors Dissociative Disorder Dissociative amnesia Dissociative fugue Dissociative identity disorder Depersonalization disorder Care of Clients with Dissociative Disorders Most clients with dissociative disorder seen in community rather than inpatient settings Obtain subjective and objective data Complete psychosocial and physical assessment Decide whether priority is to alleviate symptoms or reintegrate anxiety-producing conflict. Behavioral modification helps alleviate some problematic behaviors. Provide safe, supportive environment. Teach desensitization to conflict. Medication plays a key role in treatment. YOUR ASSESSMENT APPROACH: The Client with Dissociative Identity Disorder YOUR ASSESSMENT APPROACH: The Client with Depersonalization Disorder Common Themes Anxiety disorders and dissociative identity disorder originate in childhood. Major common theme = disabling anxiety Other common features: personality and mood changes, distorted perceptions, inability to concentrate, memory impairment, defense mechanisms Both anxiety and dissociative disorders may have underlying comorbid illnesses like depression or substance abuse. Both disorders profoundly affect quality of life. Psychotropic medications and teaching adaptive coping are mainstays of treatment. A holistic approach is best for caring for these clients. Comprehensive Assessment Conduct a history and physical exam. Gather subjective and objective information. Interview family member(s) if possible. Complete psychosocial assessment to discover source of anxiety. Differentiate between anxiety and depression. Evaluate sleep and sleep quality. Complete suicide and homicide assessment. Major focuses for a client with dissociative disorder are identity, memory, and consciousness. Client/Family Education Medications used to treat anxiety disorders include benzodiazepines, tricyclics, SSRIs and SNRIs, lithium, beta blockers, alpha-adrenergic antagonists, atypical antipsychotics, and neuroleptics. Teach about medication indications, side effects, and drug–drug interactions. Client/Family Education - continued Teaching about medications Drowsiness is a common side effect. Do not drink alcohol while taking. Drink decaffeinated beverages. Do not take other medications or adjust dosage in any way without consulting health care provider. Client/Family Education - continued Nonpharmacologic measures comprise effective coping skills: CBT techniques (desensitization, reciprocal inhibition, cognitive restructuring) Relaxation training Individual or group therapy Exercise and nutrition Personal Challenges Anxiety is contagious. The nurse may be impatient and irritated by somatic complaints. It is important to identify the source of one’s own anxiety and consistently role-model adaptive behavior. A client’s avoidance mechanism can be challenging to staff. Some nurses feel overwhelmed and helpless in the face of clients’ pain and catharsis. Ready answers are more likely to interfere with client’s communication. Psychopharmacology - Anxiolytics Anti-anxiety medication relieve insomnia, anti- convulsant, muscle relaxant, alcohol withdrawal Side effect: Sedation, mental confusion, amnesia, ataxia May cause withdrawal symptoms: anxiety, insomnia, seizure, muscle tension Important to taper dose by no more that 25% per week to prevent withdrawal symptoms Psychopharmacology - Anxiolytics Benzodiazepines Alprazolan - Xanax (0.25 - 4 mg/d) Chlordiazepoxide - Librium (50 - 300 mg/d) Clonazepam - Klonopin (0.25 - 4 mg/d) Clorazepate - Tranxene (15 - 10 mg/d Diazepam - Valium (15 - 40 mg/d) Lorazepam - Ativan (1 - 10 mg/d) Oxazepam - Serax (30 - 120 mg/d) Psychopharmacology - Anxiolytics Other Anxiolytics and Sleep Medication Buspiron - Buspar (10 - 60 mg/d) Zolpidem - Ambien (5 - 10 mg/d) Zaleplon - Sonata (10 mg/d) Eszopiclone -Lunesta (1-3 mg/d) Rameltoeon - Rozerem (8mg/d) Cholral Hydrate - Noctec (500 - 2000 mg/d) Diphenhydramine - Benadryl, Sominex, Nytol (25 - 100 mg/d) Review Questions The nurse is assessing a client who exhibits great discomfort and anxiety and continually asks to go home, as he is certain he will lose bladder control if he does not leave soon. This behavior is consistent with a diagnosis of: 1. Acute stress disorder. 2. Obsessive-compulsive disorder. 3. Agoraphobia. 4. Acrophobia. Review Question Which assessment question would indicate that the nurse understands the distinct characteristics of cognition in anxiety? 1. “Do you feel sad and/or hopeless? 2. “How often do you lose your temper?” 3. “How often do your criticize yourself?” 4. “How often do you worry about the past or future?” Review Question The development of an alternate personality, or alter, in the client with dissociative identity disorder usually arises as a response to: 1. Physical illness. 2. Substance abuse. 3. The demands of adulthood. 4. Chronic child abuse. Review Question The client experiences feelings of extreme fear that occur for no apparent reason and are accompanied by intense physical symptoms. The priority nursing intervention would be to: 1. Encourage the client to verbalize feelings. 2. Counsel the family on therapeutic responses. 3. Stay with the client. 4. Teach relaxation techniques. Review Question To evaluate the effectiveness of medications used to treat a client’s anxiety, the nurse should: 1. Monitor the client’s anxiety level. 2. Help the client understand the source of the anxiety. 3. Demonstrate patience and project a sense of calm. 4. Expect SSRIs to cause more side effects. Review Question To help a client reduce his/her anxiety level, the nursing priority would be to: 1. Teach relaxation exercises. 2. Involve the client in unit activities. 3. Encourage 1:1 interaction with peers. 4. Encourage the client to acknowledge and discuss feelings. Review Question The nurse is finding it difficult to listen to a client’s expression of pain, fear, anger, and other feelings. The nurse must focus on: 1. Listening attentively and with concern. 2. Providing quick and ready answers. 3. Giving advice. 4. Changing the subject to a more positive one. Resources http://www.adaa.org The Anxiety Disorders Association of America (ADAA) is a national nonprofit organization dedicated to the prevention, treatment, and cure of anxiety disorders and to improving the lives of all people who suffer from them. http://www.isst-d.org The International Society for the Study of Trauma and Dissociation is a professional association organized to develop and promote comprehensive, clinically effective, and empirically based resources and responses to trauma and dissociation. http://www.ncptsd.va.gov/ncmain/information The National Center for Posttraumatic Stress Disorder Information Center provides information to interested individuals, including veterans and their family members. Resources http://www.socialphobia.org The Social Phobia/Social Anxiety Association site offers further links to topics such as current news, treatment, and local group availability. Kneisl, C.R., Trigoboff, E. (2009). Contemporary psychiatric-mental health nursing. Anxiety and Dissociative Disorder (2nd ed.) (pp. 443-477). Upper Saddle River, NJ: Pearson Education.