Download Unit IV: Anxiety Disorders and Crises

Mental Health Nursing I
NURS1300
Lecture Notes
Unit IV: Anxiety Disorders and Crises
Objective 1: Define stress, stressors, and anxiety.
Stress is a state of bodily or mental tension resulting from factors that tend to alter an existent equilibrium
(Merriam-Webster, 2007). Stress is necessary for growth and development.
A stressor is anything that necessitates an adaptive response on the part of the individual.
Anxiety is a vague and sometimes intense sense of impending doom or apprehension that may appear
to have no clearly identifiable cause, and is often an early response to illness.
Objective 2: Describe the “fight-or-flight” syndrome.
The fight-or-flight response is the first stage of the general adaptation syndrome. It is the body’s
response to perceived threat or danger. During the fight-or-flight response, hormones are released which
increase heart rate, slow digestion, shunt blood flow to major muscle groups, and change various other
autonomic nervous functions. This gives the body a burst of energy and strength, enabling us to
physically fight or run away when faced with danger (About.com, 2007).
Objective 3: Define the four levels of anxiety.
Mild anxiety
 client able to focus attention
 motivates learning
 produces personal growth
Moderate anxiety
 considered the optimal level for learning
 client focused on immediate concerns or situation
Severe anxiety
 ability to think clearly is clouded
 solving problems becomes progressively impaired
Panic anxiety
 inability to communicate or function effectively
 misperceptions of surrounding events
 client may react impulsively by running or striking out
Objective 4: Describe various coping mechanisms used to deal with stress and anxiety.
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Imagery
Deep-breathing
Meditation
Yoga
Therapeutic touch
Music therapy
Biofeedback
Objective 5: Describe the major defense mechanisms.
Refer to Defense Mechanisms handout
Objective 6: Be able to discuss generalized anxiety disorder, panic disorder, phobias, obsessivecompulsive disorder, and post-traumatic stress disorder.
Generalized anxiety disorder (GAD) is an anxiety disorder characterized by chronic anxiety and
unrealistic, excessive worry and tension. Clients with GAD exhibit physical symptoms along with their
anxiety, such as fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling,
twitching, irritability, sweating, and hot flashes. Symptoms occur in the absence of organic conditions
(NIMH – National Institute of Mental Health, 2007).
Panic disorder is characterized by recurrent panic attacks, which are episodes of intense apprehension
of variable length, at times to the point of terror, and are often accompanied by feelings of doom. Panic
attacks often occur in familiar places, where there is seemingly nothing threatening to the individual.
Physical symptoms include:
 increased pulse
 elevated blood pressure
 trembling
 diaphoresis
 shortness of breath
 chest pain
 nausea
The panic attacks associated with panic disorder is the symptom that is most likely to motivate a person
to seek medical attention. The discomfort and sense of danger accompanying an attack is often so
intense that clients with panic disorder often believe they are having a heart attack or other lifethreatening illness (MedlinePlus, 2007).
A phobia is an irrational, persistent fear of certain situations, objects, activities, or persons. The main
symptom of this disorder is the excessive, unreasonable desire to avoid the feared subject. When the
fear is beyond one’s control, or if the fear is interfering with daily life, the phobia can be categorized as an
anxiety disorder (Wikipedia, 2007).
Obsessive-compulsive disorder (OCD) is an anxiety disorder that is characterized by recurrent,
unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Repetitive behaviors such as
hand washing, counting, checking, or cleaning are often performed with the hope of preventing obsessive
thoughts or making them go away. Performing these “rituals”, however, provides only temporary relief,
and not performing them markedly increases anxiety. Obsessions and/or compulsions that are
characterized as an anxiety disorder are severe enough to be time-consuming or to cause marked
distress or significant impairment. The client knows that thoughts or behaviors are irrational, but feels
powerless to stop.
Post-traumatic stress disorder (PTSD) is a cluster of symptoms experienced following a distressing
event that is outside the range of normal events and one in which the person experienced intense fear,
helplessness, and/or horror (National Center for PTSD, 2007).
Characteristic symptoms include:
 dissociative flashbacks (re-experiencing the traumatic event)
 sustained high level of anxiety or arousal or a general numbing of responsiveness
 intrusive recollections or nightmares of the event
(Wikipedia, 2007)
Objective 7: Be able to discuss somatoform disorders to include types, risk factors, signs and symptoms.
Somatoform disorders are physical ailments, such as pain, nausea, or dizziness, for which no adequate
medical explanation has been found. The complaints of physical symptoms are serious enough to cause
significant emotional distress and impairment of social and/or occupational functioning. These disorders
are associated with psychosocial distress and long-term seeking of assistance from healthcare
professionals. Somatoform disorders are not the result of conscious malingering (fabrication or
exaggeration of the symptoms of a mental or physical disorder for reward) or factitious disorders (mental
disorder in which the individual’s symptoms are either self-induced or falsified) (Wikipedia, 2007).
Types of somatoform disorders include conversion disorder, pain disorder, hypochondriasis, and body
dysmorphic disorder (PSYweb.com, 2007).
Conversion disorder is a psychiatric condition in which emotional distress or unconscious conflicts are
expressed through physical symptoms. The onset of symptoms is usually very sudden, and follows a
stressful experience. The disorder involves the involuntary loss of one or more bodily functions, such as
blindness, deafness, or paralysis. Diagnostic testing uncovers no physical cause for exhibition of these
symptoms, and most conversion symptoms resolve within a few days or weeks.
Risk factors for conversion disorder include:
 medical illness
 dissociative disorder
 personality disorder
(MedlinePlus, 2007)
Pain disorder is a condition in which a person experiences persistent or chronic pain at one or more
sites in which psychological factors, such as stress or unconscious conflict, are thought to play a role. In
this disorder, the suffering is so severe that it impairs the client’s ability to function. Individuals with this
illness may have other medical problems, but they fail to account fully for the pain. Characteristic
behaviors associated with this disorder include frequent visits to physicians in effort to obtain relief,
excessive use of analgesics, and requests for surgery. Dependence on addictive substances is a
common complication of the disorder (NIMH, 2007).
Common symptoms of pain disorder include:
 negative or distorted cognition, such as feeling helpless or hopeless with respect to pain and its
management
 inactivity, passivity, and/or disability
 increased pain requiring clinical intervention
 insomnia and fatigue
 disrupted social relationships at home, work, or school
 depression and/or anxiety
(MedlinePlus, 2007)
Associated risk factors are:
 underlying medical condition, such as fibromyalgia, migraines, or skeletal damage
 uncontrolled or inadequately managed pain
 depression and/or anxiety
(MedlinePlus, 2007)
Hypochondriasis is an excessive preoccupation or worry about having a serious illness. The disorder is
often characterized by fears that minor bodily symptoms may indicate a serious illness, constant selfexamination and self-diagnosis, and preoccupation with one’s body. The fear becomes disabling and
persists despite appropriate reassurances that no organic pathology can be detected. Individuals with
hypochondriasis often have a long history of “doctor shopping” and are convinced that they are not
receiving proper treatment. Concern about the feared illness often becomes a central part of people’s
lives and may impair social, occupational, or other important areas of functioning.
Body dysmorphic disorder is characterized by the exaggerated belief that the body is deformed or
defective in some specific way. The most common complaints involve imagined or slight flaws of the face
or head, such as thinning hair, acne, wrinkles, scars, vascular markings, facial swelling or asymmetry, or
excessive facial hair. Significance of the perceived defect is grossly excessive (APA – American
Psychiatric Association, 2000).
The etiology of body dysmorphic disorder is unknown, however, risk factors include:
 chemical imbalance in the brain
 obsessive-compulsive disorder (OCD)
 eating disorder
 generalized anxiety disorder
 psychological, behavioral, or cultural factors
o higher socioeconomic status
o strict cultural standards
(MayoClinic.com, 2007)
Objective 8: Describe the major types of crisis and what crisis intervention means.
Major types of psychiatric crisis include:
 suicidal thinking or behaviors
 homicidal thinking or behaviors
 acute psychotic symptoms
 sudden change in mental status
 violence resulting from a mental disorder
(HopkinsMedicine.org, 2007)
Crisis intervention is the provision of emergency psychological care to clients in order to restore their
level of functioning and to prevent or decrease potential negative effects of the crisis. Care includes
preventing clients in crisis from harming themselves or others, administering medications, and providing a
supportive, therapeutic environment (Crisis Intervention Network, 2007).
Objective 9: Identify medical treatment and nursing interventions for the client with an anxiety or
somatoform disorder.
Medical treatment for clients with anxiety or somatoform disorder –
 Therapies
o individual psychotherapy
o cognitive therapy
o behavior therapy
o group therapy
 Medications
o anxiolytics
o antidepressants
Nursing interventions for clients with anxiety or somatoform disorder –
 Anxiety R/T severe stress AEB patient’s self-report/agitation/appearance
 Ineffective coping R/T severe stress AEB development of somatic symptoms
 Disturbed body image R/T body dysmorphic disorder AEB expression of repugnance with
imagined defect or minor physical anomaly
Objective 10: Identify major drugs used, actions, side effects and nursing interventions for the client with
an anxiety disorder or somatoform disorder.
See Medications for Clients with Anxiety/Somatoform Disorder handout.