Anger, Hostility, and Aggression

Anger is a normal human emotion.

Hostility and aggression are inappropriate expressions of anger.

Anger is a strong, uncomfortable, emotional response to a provocation, either real or
perceived.
It results when one is frustrated, hurt, or afraid and energizes the body for defense
(fight or flight).
• Denying or suppressing angry feelings can lead to physical or emotional problems
• Anger that is expressed inappropriately can lead to hostility and aggression
• Appropriate expression of anger involves assertive communication skills that lead to
problem solving or conflict resolution
• Venting angry feelings by engaging in safe but aggressive activities (punching bag,
yelling) is called catharsis. However, research has shown that catharsis may increase
rather than alleviate angry feelings
• Clients with depression may have anger attacks when they feel emotionally trapped

Hostility and Aggression

Hostile and aggressive behavior may occur suddenly without warning, but often stages or
phases can be identified:
• Triggering
• Escalation
• Crisis
• Recovery
• Postcrisis
Hostility is an emotion expressed by:
• Verbal abuse
• Lack of cooperation
• Violation of rules or norms
• Threatening behavior (verbal aggression)

Related Disorders
Most psychiatric clients are not aggressive, but some exhibit angry, hostile, or aggressive
behavior caused by:
• Paranoid delusions
• Auditory (command) hallucinations
• Dementia, delirium
• Head injury
• Intoxication with alcohol or drugs
• Antisocial and borderline personality disorders
Intermittent Explosive Disorder:
 Rare psychiatric diagnosis involving discrete episodes of aggressive impulses resulting
in serious injury or property damage
Episodes are out of proportion to any provocation, and the person is remorseful and
embarrassed afterward.

Acting Out
An immature defense mechanism in which the person deals with emotional conflict or
stress by actions rather than reflection or feelings; the person is trying to feel less
powerless or helpless by acting out.

Etiology of Hostility and Aggression

• Neurobiologic theories: decreased serotonin, increased dopamine and norepinephrine;

structural damage to limbic system, damage to frontal or temporal lobes
• Psychosocial theories: failure to develop impulse control and ability to delay
gratification
Cultural Considerations
In certain cultures, expressing anger may be seen as rude or disrespectful; some
culture-bound syndromes involve aggressive, agitated, or violent behavior.
Treatments and Medications
Treatment often focuses on treating the underlying or comorbid psychiatric diagnosis
such as schizophrenia or bipolar disorder.

Aggressive Clients
• Lithium for bipolar disorder, conduct disorder, or mental retardation
• Carbamazepine (Tegretol) or valproate (Depakote) for dementia, psychosis, or
personality disorders
• Atypical antipsychotics such as clozapine (Clozaril), risperidone (Risperdal), and
olanzapine (Zyprexa) for dementia, brain injury, mental retardation, and personality
disorders
• Benzodiazepines for older adults with dementia
• Haloperidol (Haldol) and lorazepam (Ativan) for clients with psychoses

Application of the Nursing Process

Assessment
• Early assessment and intervention needed when clients are angry or hostile to avoid
physically aggressive episodes
• Nurse must assess both individual clients and the therapeutic milieu or environment
• Assessment and intervention are based on five phases of aggression
Data Analysis
Common nursing diagnoses:
• Risk for Other-Directed Violence
 • Ineffective Coping
Outcome Identification
The client will:
• Not harm self or threaten others
• Refrain from intimidating or frightening behaviors
• Describe feelings and concerns without aggression
• Comply with treatment
Intervention
Interventions are most effective and least restrictive when implemented early in the cycle
of aggression.
• Managing the milieu includes:
– Having planned activities; informal discussions
– Scheduled one-to-one interactions; letting clients know what to expect
– Helping clients with conflicts to solve their problems, including expression of
angry feelings
• Managing aggressive behavior includes:
– Triggering phase:
• Approach in nonthreatening, calm manner
• Convey empathy
• Listen
• Encourage verbal expression of feelings
• Suggest going to a quieter area, or use of PRN medications
• Physical activity such as walking
– Escalation phase:
• Take control
• Provide directions in firm, calm voice
• Direct client to room or quiet area for time out
• Offer medication again
• Let client know aggression is unacceptable and nurse or staff will help
maintain/regain control if needed
• If ineffective to that point, obtain assistance from other staff (show of
force) to get client to take time out or take medication
– Crisis phase:
• Staff must take control of situation as determined by facility or agency
policy (trained in techniques for behavioral management)
• Use restraint or seclusion only if necessary
– Recovery phase as client regains control:
• Talk about the situation or trigger
• Help client relax or sleep
• Explore alternatives to aggressive behavior
• Provide documentation of any injuries
• Staff debriefing
 – Postcrisis phase:
• Client is removed from any restraint or seclusion and rejoins the milieu
• Calm discussion of behavior; no lecturing or chastising; return to
activities, groups, and so forth
• Focus is on appropriate expression of feelings, resolution of problems or
conflicts in nonaggressive manner

Evaluation
• Was the client’s anger defused in an early stage?
• Did the angry, hostile, and potentially aggressive client learn to express feelings
verbally and safely without threats or harm to others or destruction of property?
• Was the client’s anger defused in an early stage?
• Did the angry, hostile, and potentially aggressive client learn to express feelings
verbally and safely without threats or harm to others or destruction of property?

Community-Based Care

• Regular follow-up appointments, compliance with prescribed medication, and

participation in community support programs help the client to achieve stability
• Anger management groups are available to help clients express their feelings and learn
problem-solving and conflict-resolution techniques

Self-Awareness Issues
• How nurse handles own angry feelings
• Comfort with expression of anger from others
• Ability to be calm, nonjudgmental
• Nurse must have assertive communication skills, conflict resolution skills, ability to see
that client’s behavior/anger is not personal or a sign of nurse’s failure, and ability to
deal with own fear when clients are aggressive or threatening
 Abuse and Violence

Abuse is the wrongful use and maltreatment of another person……can be child, spouse,
partner, or elder parent

Victims of abuse and trauma can have both physical and psychological injuries, including:
• Agitation anxiety, silence
• Suppressed anger or resentment
• Shame and guilt
• Feelings of being degraded or dehumanized; low self-esteem
• Relationship problems; mistrust of authority figures

Characteristics of Violent Families

• Social isolation
• Power and control by abusive person
• Alcohol and other drug abuse
• Intergenerational transmission process
• Domestic violence occurs in families of all ages and from all ethnic, racial, religious,
socioeconomic, and sexual orientation backgrounds
• Battered immigrant women face increased legal, social, and economic barriers

Spouse or Partner Abuse

• Involves the mistreatment of one person by another in the context of an intimate
relationship
• 90% to 95% of domestic violence victims are women
• Pregnancy escalates domestic violence
• Abuse can occur in same-sex relationships

Cycle of Abuse and Violence

• Initial episode of violence
• Honeymoon period: abuser promises it will never happen again, gives gifts and flowers,
is affectionate
• Tensions begins to build with arguments, silence, complaints
• Violence occurs again
• This cycle repeats over and over

Assessment
• It is necessary to identify victims of abuse in all settings, since they often do not seek
treatment directly
• SAFE questions can be used to assess:
 – Stress/Safety
– Afraid/Abused
– Friends/Family
– Emergency plan

Treatment and Intervention

• Domestic violence laws vary among states and are not always followed
• Women may stay in abusive relationships
for fear of violence to children, fear of increased violence or death, financial
dependence
• Identifying women in violent situations is a priority. More health care agencies are
beginning to ask routine screening questions of all women
• Providing women with information about shelters, services, and so forth is essential
• The nurse must never indicate that he or she thinks the woman should leave the
relationship; need to keep the door open for further communication

Child Abuse
Child abuse is intentional injury of a child, including:
– Physical abuse or injuries
– Sexual assault or intrusion
– Neglect or failure to prevent harm (failure to provide adequate physical or
emotional care or supervision; abandonment)
– Psychological abuse
All states have mandatory child abuse reporting laws that include nurses.
Parents who abuse children:
• Have minimal parenting knowledge and skills
• Are emotionally immature and needy
• Are incapable of meeting their own needs, much less those of a child
• Often raise their children the way they were raised, including corporal punishment and
abuse
• Expect the child to meet all their needs for love and affection

Assessment
Suspect child abuse when there are:
• Unusual injuries such as scalding and cigarette burns
• Delays in seeking treatment, inconsistent history, or illogical explanation for the
injuries
• Urinary tract infections; red, swollen, or bruised genitalia; tears of vagina or rectum
• Old injuries that were not treated
• Multiple, unexplained bruises
Treatment and Intervention
• Getting the child to a safe place once abuse is identified
 • Family therapy
• Individual therapy for the child
• Intensive involvement of social service agencies
• Treatment for parents for any substance abuse or psychiatric issues

Elder Abuse
Elder abuse is maltreatment of older adults by family members or caretakers, including:
– Physical, sexual, or psychological abuse or neglect
– Self-neglect
– Financial exploitation
– Denial of adequate medical treatment

• 60% of perpetrators are spouses, 20% adult children, 20% others

• People who abuse elders are almost always in a caretaker role
• Elders are reluctant to report abuse because they fear the alternative (nursing home)
• Not all states have mandatory elder abuse reporting laws

Assessment
Possible indicators of physical abuse:
• Malnourished, dehydrated
• Rashes, sores, lice
• Smell of urine, feces, dirt
• Failure to keep needed medical appointments
• Untreated medical condition

Possible indicators of emotional or psychological abuse:

• Reluctance to talk openly
• Helplessness
• Withdrawal or depression
• Anger or agitation

Possible indicators of self-neglect:

• Inability to manage own finances
• Inability to perform activities of daily living
• Inadequate clothing
• Signs of malnutrition or dehydration
• Rashes and sores

Possible indicators of financial exploitation:

• Inability to manage money
• Unusual activity in bank accounts
• Different signatures on checks
 • Recent changes in will that client could not make
• Missing valuables

Possible indicators of abuse by caregiver:

• Caregiver speaks for the elderly person
• Caregiver shows indifference or anger
• Caregiver blames elderly person for physical problems
• Caregiver shows defensiveness
• Caregiver and client give conflicting accounts

Treatment and Intervention

Treatment and intervention may involve:
• Providing adequate support and respite for the caregivers
• Changing caregiving arrangements
• Moving the elderly person to a safe environment

Rape

Rape is a crime of violence and aggression expressed through sexual means. The act is against
the victim’s will or against someone who cannot give consent.
• The victim can be any age
• Half of rapes are committed by someone known to the victim
• Rape is underreported to the police

Male rapists have been categorized as:

• Sexual sadists aroused by pain of victim
• Exploitative predators
• Inadequate men
• Those who rape as a displaced expression of anger and rage
• Same-sex rape can occur between partners but is most common in institutions

Physical and psychological trauma to rape victims is severe:

• Medical problems: victims are significantly less healthy; pregnancy, STDs, HIV are
concerns
• Victims may feel frightened, helpless, guilty, humiliated, and embarrassed; may avoid
previously pleasurable activities
• Relationship problems may occur

Treatment and Intervention

• Immediate support to ventilate fear and rage
• Care by persons who believe that the rape happened
• Coordination of all needed services in one location
 • Giving the victim control over choices whenever possible
• Prophylactic treatment for STDs
• Referral to therapy services; counseling; and groups for longer-term help

Community Violence
Of great concern are homicides and suicides associated with schools.
Solutions emphasize:
• Problem-solving skills, anger management, and social skills development
• Parenting programs that promote strong bonding between parents and children and
conflict management in the home
• Mentoring programs for young people
A history of violence, victimization, and witnessing of violence can lead to problems with
aggression, depression, relationships, achievement, and abuse of drugs and alcohol

Psychiatric Disorders Related to Abuse and Violence

Two psychiatric disorders are associated with histories of violence and abuse:
1. Posttraumatic stress disorder (PTSD)
2. Dissociative disorders

PTSD
Disturbing behavior resulting after a traumatic event at least 3 months after the trauma
occurred
Up to 60% of persons at risk (combat veterans, victims of violence and natural disasters)
develop PTSD.

Symptoms of PTSD include:

• Persistent nightmares
• Memories
• Flashbacks
• Emotional numbness
• Insomnia
• Irritability
• Hypervigilance
• Angry outbursts

Dissociative Disorders

Dissociation is a subconscious defense mechanism that helps a person protect the emotional
self from recognizing the full impact of some horrific or traumatic event by allowing the mind
to forget or remove itself from the painful situation or memory.
Dissociation can occur both during and after the event and becomes easier with repeated
use.
Dissociative disorders include:
• Amnesia
• Fugue
• Dissociative identity disorder (formerly multiple personality disorder)
• Depersonalization disorder

Treatment and Interventions

• Involvement in group and/or individual therapy in the community
• Clients with dissociative disorder or PTSD are seen in the acute setting for brief
periods when symptoms are severe or there is concern for their safety

Application of the Nursing Process

Assessment
• Includes history of trauma or abuse
• Client often appears hyperalert, anxious, or agitated
• Mood and affect: client is fearful and anxious; needs large personal space; has a wide
range of emotions
• Thought processes and content: nightmares, flashbacks, destructive thoughts or
impulses
• Sensorium and intellectual processes: disorientation (during flashbacks), memory gaps
• Judgment and insight: impaired decision-making and problem-solving abilities
• Self-concept: client has low self-esteem
• Roles and relationships: problems with relationships, work, authority figures
• Physiologic considerations: difficulty sleeping, under- or overeating, use of alcohol or
drugs for self-medication

Data Analysis
Nursing diagnoses include:
• Risk for Self-Mutilation
• Ineffective Coping
• Post-Trauma Response
• Chronic Low Self-Esteem
• Powerlessness

Outcome Identification
The client will:
• Be physically safe
• Distinguish between self-harm ideas and taking action on those ideas
• Learn healthy ways to deal with stress
• Express emotions nondestructively
 • Establish social support network in the community
Intervention
• Promoting the client’s safety
• Helping the client cope with stress and emotions using grounding techniques
• Helping to promote the client’s self-esteem
• Establishing social support
Evaluation
Is the patient:
• Learning to protecting him- or herself?
• Learning to manage stress and emotions?
• Able to function in their daily lives?
Self-Awareness Issues
• Becoming comfortable asking all women about abuse (SAFE questions)
• Listening to accounts of abuse from clients and families
• Recognizing client’s strengths, not just problems
• Working with perpetrators of abuse; dealing with own feelings about abuse and
violence
 Grief and Loss

Grief refers to the subjective emotions and affect that are a normal response to loss.

Grieving, also known as bereavement, is the process of experiencing grief.

Anticipatory grief is facing an imminent loss.

Mourning is the outward sign of grief.

Experiences of grief and loss are essential and normal in the course of life; letting go,
relinquishing, and moving on happen as we grow and develop.
Grief and loss are uncomfortable.

Types of Losses
Losses may be planned, expected, or sudden. Loss of a loved one is probably the most
devastating type of loss, but there are many other types of losses:
• Physiologic (loss of limb, ability to breathe)
• Safety (domestic violence, posttraumatic stress disorder, breach of confidentiality)
• Security/sense of belonging (relationship loss [death, divorce])
• Self-esteem (ability to work, children leaving home)
• Self-actualization (loss of personal goals, such as not going to college, never becoming
an artist or dancer)

The Grieving Process

Nurses must recognize the signs of grieving to understand and support the client through the
grieving process.

The therapeutic relationship and therapeutic communication skills are paramount when
assisting grieving clients. Using these skills, nurses may promote the expression and release
of emotional as well as physical pain during grieving.

Theories of the Grieving Process

Kubler-Ross’s stages of grieving:

• Denial (shock and disbelief)
• Anger (toward God, relatives, health care providers)
• Bargaining (trying to get more time, prolonging the inevitable loss)
• Depression (awareness of the loss becomes acute)
• Acceptance (person comes to terms with impending death or loss)

Bowlby’s phases of grieving:

 • Numbness and denial of the loss
• Emotional yearning for lost loved one and protesting permanence of loss
• Cognitive disorganization and emotional despair
• Reorganizing and reintegrating sense of self

John Harvey’s phases of grieving:

• Shock, outcry, and denial
• Intrusion of thoughts, distractions, and obsessive reviewing of loss
• Confiding in others to emote and cognitively restructure

Rodebaugh’s stages of grieving:

• Reeling
• Feelings
• Dealing
• Healing

There are many similarities among theorists about grief. Not all clients follow predictable
steps or make steady progress.

Tasks of the Grieving Process

• Undoing psychosocial bonds to loved one and eventually creating new ties
• Adding new roles, skills, and behaviors
• Pursuing a healthy lifestyle
• Integrating the loss into life

Dimensions of Grieving
• Cognitive responses to grief
– Questioning and trying to make sense of the loss
– Attempting to keep the lost one present
• Emotional responses to grief
• Spiritual responses to grief
• Behavioral responses to grief
• Physiologic responses to grief

Cultural Considerations
All cultures grieve for lost loved ones, but the rituals and habits surrounding death
vary among cultures, for instance, how shock and sadness are expressed, how long
mourning should last, and so forth. Many cultural bereavement rituals have their roots
in a major religion.
Nurses should be sensitive to cultural differences and ask how the mourners can be
assisted.
Nurse’s Role
The nurse must encourage clients to discover and use effective and meaningful grieving
behaviors:
• Praying
• Staying with the body
• Performing rituals
• Attending memorials and public services

Disenfranchised Grief or Complicated Grieving

Disenfranchised grief is grief over a loss that is not or cannot be openly acknowledged,
mourned publicly, or supported socially:
• A relationship has no legitimacy
• The loss itself is not recognized
• The griever is not recognized
Complicated grieving is a response that lies outside the norm of grieving in terms of
extended periods of grieving: responses that seem out of proportion or responses that are
void of emotion

People who are vulnerable to disenfranchised grieving:

• Relationships that may be viewed as having no legitimacy: lovers, friends, neighbors,
foster parents, colleagues, caregivers, same-sex relationships, cohabitation without
marriage, and extramarital affairs
• Losses that may not be recognized: prenatal death, abortion, relinquishing a child for
adoption, death of a pet, or other losses not involving death such as job loss,
separation, divorce, and children leaving home
• Grievers who may not be recognized: older adults, children, nurses

People who are vulnerable to complicated grieving include those with:

• Low self-esteem
• Low trust in others
• A previous psychiatric disorder
• Previous suicide threats or attempts
• Absent or unhelpful family members
• An ambivalent, dependent, or insecure attachment to the deceased person
Experiences increasing the risk for complicated grieving include:
• Death of a spouse or child
• Death of a parent (particularly in early childhood or adolescence)
• Sudden, unexpected, and untimely death
• Multiple deaths
• Death by suicide or murder
Complicated Grieving as a Unique and Varied Experience
• Physical reactions can include:
– Impaired immune system
– Increased adrenocortical activity
– Increased levels of serum prolactin and growth hormone
– Psychosomatic disorders
– Increased mortality from heart disease
• Emotional responses can include:
– Depression
– Anxiety or panic disorders
– Delayed or inhibited grief
– Chronic grief

Application of the Nursing Process

Assessment
• Does the client have adequate perception regarding the loss?
– What does the client think and feel about the loss?
– How is the loss going to affect the client’s life?
– What information does the nurse need to clarify or share with the client?
• Does the client have adequate support?
• Does the client have adequate coping behaviors?

Data Analysis and Planning

• Possible nursing diagnoses:
• Grieving
• Anticipatory Grieving
• Dysfunctional Grieving

Outcome Identification
Grieving
The client will:
• Identify the effects of his or her loss
• Seek adequate support
• Apply effective coping strategies while expressing and assimilating all dimensions of
human response to loss in his or her life

Anticipatory Grieving
The client will:
• Identify the meaning of the expected loss in his or her life
• Seek adequate support while expressing grief
• Develop a plan for coping with the loss as it becomes a reality
Dysfunctional Grieving
The client will:
• Identify the meaning of his or her loss
• Recognize the negative effects of the loss on his or her life
• Seek or accept professional assistance to promote the grieving process
Intervention
• Regarding perception of the loss
– Explore perception and meaning of the loss
• Regarding adequate support
– Help the client reach out and accept what others want to give
• Regarding adequate coping behaviors
– Shift from an unconscious defense mechanism to conscious coping
– Compare and contrast past coping
– Encourage the client to care for self
Essential communication and interpersonal skills to assist grieving:
• Use simple, nonjudgmental statements
• Refer to a loved one or object of loss by name (if acceptable in the client’s culture)
• Appropriate use of touch indicates caring
• Respect the client’s unique process of grieving
• Respect the client’s personal beliefs
• Be honest, dependable, consistent, and worthy of the client’s trust
• Offer a welcoming smile and eye contact

Evaluation
Evaluation of progress is based on the goals established for the client.
Make an evaluation of the client’s status based on the theoretical tasks and
phases of grieving.

Self-Awareness Issues
• Examining one’s own experiences with grief and loss
• Taking a self-awareness inventory and reflecting on the results may be helpful.
 Level Psychological Responses Physiological Responses
Mild Wide perceptual field Restlessness
Sharpened senses Fidgeting
Increased motivation GI butterflies
Effective problem solving Difficulty sleeping
Increased learning ability Hypersensitivity to noise
Irritability
Moderate Perceptual field narrowed to immediate task Muscle tension
Selectively attentive Diaphoresis
Cannot connect thoughts or events independently Pounding pulse
Increased use of automatisms Headache
Dry mouth
High pitch voice
Fast rate of speech
GI upset
Frequent urination
Severe Perceptual field reduced to one detail or Severe headache
scattered details Nausea, vomiting and diarrhea
Cannot complete tasks Trembling
Cannot solve problems or learn effectively Rigid stance
Behavior geared towards anxiety relief and is Vertigo
usually ineffective Pale
Doesn’t respond to redirection Tachycardia
Feels awe, dread or horror Chest pain
Cries
Ritualistic behavior
Panic Perceptual filed reduced to focus on self May bolt and run
Cannot process any environmental stimuli or
Distorted perceptions Totally immobile and mute
Loss of rational thought Dilated pupils
Doesn’t recognize potential danger Increased blood pressure and
Can’t communicate verbally pulse
Possible delusions and hallucination Fight, flight or freeze
May be suicidal
 Anxiety and Stress-Related Illness

Anxiety
 vague feeling of dread
 unwarranted by the situation
 with no identifiable stimulus
 accompanied by feelings of uneasiness and apprehension
o Fear
o there is an identifiable threatening object
 has healthy and harmful facets
 it is an internal warning device
 produces physiologic and emotional changes at each level
o mild
o moderate
o severe
o panic
WORKING WITH ANXIOUS CLIENTS

Mild anxiety Moderate anxiety Severe anxiety

o an asset o can cause client’s o causes impairment of many
attention to wander abilities
o client can learn and solve
problems effectively o nurse must redirect client o client cannot learn or
back to topic problem solve
o client is receptive to
teaching and suggestions o nurse must validate that o nurse must calm client and
client has heard and focus on lowering anxiety
understood level

CATEGORIES OF ANXIETY DISORDERS

Panic, with or without agoraphobia
Phobia (social or specific)
Obsessive-compulsive disorder (OCD)
Posttraumatic stress disorder
Acute stress disorder
Generalized anxiety disorder
Anxiety disorder due to a medical condition
Substance-induced anxiety disorder

This chapter focuses on panic disorder, phobic disorder, and OCD.

INCIDENCE
Anxiety disorders are the most common psychiatric disorders in the United
States, affecting 15% of adults
More prevalent in women
More common in divorced and separated persons
More common in persons of lower socioeconomic status
Onset and clinical course are variable

PHYSIOLOGIC AND PSYCHOSOCIAL RESPONSES TO ANXIETY

Anxiety can be communicated nonverbally from one person to another.
Defense mechanisms are used to reduce anxiety
 when overused, they preclude learning more adaptive coping skills.
Physiologic responses include:
 sympathetic stimulation (fight or flight)
 discomfort
 difficulty thinking clearly
 agitated motor activity
 tension headaches

ETIOLOGY
Stress: People handle stress in different ways. Stress is part of everyday
life. Selye identified responses to stress on the body in stages:
 alarm reaction
 resistance
 exhaustion
Biologic theories:
o Anxiety may have an inherited component
o neurotransmitter γ-aminobutyric acid (GABA)
o Serotonin plays a part in OCD
Psychodynamic theories:
o overuse of defense mechanisms
o results from problems in interpersonal relationships
o “learned” behavioral response

CULTURAL CONSIDERATIONS
People from Asian cultures often somatize anxiety into expressions of pain in
the body.
Hispanics may identify illnesses as “hot” or “cold” and eat either “hot” or
“cold” foods to counteract them.
TREATMENT
Effective treatment usually involves a combination of medication (anxiolytics
and antidepressants) and therapy.
Cognitive-behavioral therapy includes:
o positive reframing - turning negative messages into positive ones
o decatastrophizing - making a more realistic appraisal of the situation

Assertiveness training helps the client learn to negotiate interpersonal

situations more successfully.

PANIC DISORDER
o involves 15- to 30-minute episodes of intense, escalating anxiety with emotional fear
and physiologic discomfort
o 75% have spontaneous attacks of panic with no environmental trigger
o Onset peaks: late adolescence and in the mid-30s
o Treatment:
o Selective serotonin reuptake inhibitors (SSRIs)
o cyclic antidepressants
o benzodiazepines are used

Application of the Nursing Process for Panic Disorder

Assessment
 Client feels unreal and detached from self during attack.
 Fears losing control or going insane
 Has temporarily disorganized thought process; feels he or she is dying
 Judgment is poor during an attack.
 Anticipation of attacks causes the person to limit social activities and may interfere
with work, relationships, and family life
 Some develop agoraphobia and avoid public places altogether, not leaving their homes
 Clients experience:
o primary gain (relief of anxiety by staying at home)
o secondary gain (attention received from others due to the disorder; relief from
daily responsibilities).

Data Analysis
Nursing diagnoses include:
Risk for Injury
Anxiety
Fear
Social Isolation
Situational Low Self-Esteem
 Ineffective Coping
Powerlessness
Ineffective Role Performance
Disturbed Sleep Pattern

Outcome Identification
The client will:
Be free of injury
Verbalize feelings
Use effective coping techniques
Manage own anxiety response
Verbalize sense of personal control
Sleep at least 6 hours per night

Intervention
Promoting safety and comfort
Using therapeutic communication
Managing anxiety
Client and family teaching

PHOBIAS
o an illogical, intense, persistent fear of a specific object or social situation
o cause extreme distress and interferes with normal life functioning
o People with phobias understand that their fear is unusual and irrational but feel
powerless to control it.
o clients develop anticipatory anxiety when thinking about the possibility of encountering
the phobic object
o Types of phobia:

Specific phobia is irrational fear of an object or situation, such as fear of a

natural phenomenon (for instance, storms, heights), fear of seeing blood or
receiving an injection, fear of specific situations (for instance, being in an elevator),
or fear of animals

Social phobia involves severe anxiety, even panic, when confronted with
situations involving people, such as making a speech, having dinner with others, or
meeting new people; or fear of eating in public, using public bathrooms, or being the
center of attention

Specific phobias occur more often in women; social phobias occur in men and
women equally; peak onset is childhood and mid-20s.
Etiology
Biologic (phobias run in families, hormonal functions, or neurotransmitter
activity)
Psychodynamic (faulty thinking, belief one doesn’t control the environment, or
learned by modeling from parents)

Treatment and Prognosis

Psychopharmacology:
o anxiolytics
o SSRI antidepressants
o beta blockers to slow heart rate and lower blood pressure
Psychotherapy: There are useful approaches, although some people do not
seek treatment, especially for specific phobias that do not interfere with daily life.
Behavioral therapies include systematic desensitization and flooding.

OBSESSIVE-COMPULSIVE DISORDER
OCD involves:
Obsessions
o recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses that
cause marked anxiety and interfere with interpersonal, social, or occupational
functioning.
Compulsions
o ritualistic or repetitive behaviors or mental acts that a person carries out
continuously in an attempt to neutralize anxiety
o Examples:
o repeated checking or counting rituals
o excessive handwashing
o repeating words
o touching rituals
o symmetry rituals
o cleanliness
o The person knows the rituals are unreasonable but feels forced to continue
them in an attempt to relieve anxiety caused by obsessions.

Treatment and Prognosis

o behavior therapy
o exposure - confronting anxiety-provoking stimuli
o response prevention - delaying or avoiding ritual performance
o medication
o SSRI antidepressants
o fluvoxamine [Luvox]
 o clomipramine [Anafranil]
o buspirone [BuSpar]
o clonazepam [Klonopin])

Application of the Nursing Process for OCD

Assessment
Client assessment focuses on what behaviors or rituals are performed, when and how
often, client’s response, and so forth, to discover the pattern of behavior.

Data Analysis
Anxiety
Ineffective Coping
Fatigue
Situational Low Self-Esteem
Impaired Skin Integrity (if scrubbing or washing rituals)

Outcome Identification
The client will:
Complete daily routine within realistic time frame
Demonstrate effective use of relaxation techniques
Discuss feelings with others
Demonstrate effective use of behavior therapy techniques
Spend less time performing rituals

Intervention
Using therapeutic communication
Teaching relaxation and behavioral techniques
Completing a daily routine
Providing client and family education

Evaluation
• Based on established goals
• Integrating loss into life

GENERALIZED ANXIETY DISORDER

Excessive worry and anxiety that is unwarranted more days than not
Seen most often by family physicians
Treated with SSRI antidepressants and buspirone

SELF-AWARENESS ISSUES
Stress and anxiety are common experiences for all people.
 Persons with anxiety disorders often “look well enough” to control their
behavior.
Avoid trying to “fix” client’s problems.

ANTIANXIETY DRUGS
Indications:
anxiety disorders
insomnia
obsessive-compulsive disorder
depression
posttraumatic stress disorder
alcohol withdrawal

Benzodiazepines are the antianxiety agents used most frequently (buspirone [BuSpar] is the
only common nonbenzodiazepine in wide use). They moderate the actions of GABA.
A wide variety of benzodiazepines are used. They vary in half-life, how they
are metabolized, and effectiveness. Some are used primarily for insomnia, due to
sedation side effects.
Common side effects are drowsiness, sedation, poor coordination, memory
impairment, clouded sensorium, and hangover effect in the morning. The biggest
problem is psychological dependence: Long-term use can result in overuse or abuse.
Client teaching for anxiolytics: Avoid alcohol, and be aware of sedating side
effects when driving.
 Mood Disorders

Everyone has episodes of feeling sad, low, and tired, accompanied by anergia (lack of energy),
exhaustion, agitation, noise intolerance, and slowed thinking processes. Work, family, and
social responsibilities drive most people to go through their daily routines, knowing that this
mood and the feelings will pass. Mood disorders are diagnosed when these alterations in
emotions are pervasive and interfere with the person’s ability to live life.

CATEGORIES
Major depressive disorder: 2 or more weeks of sad mood, lack of interest in
life activities, and other symptoms
Bipolar disorder (formerly called “manic-depressive illness”): mood cycles of
mania and/or depression and normalcy

RELATED DISORDERS
Dysthymic disorder: sadness and low energy, but not severe enough to be
diagnosed as major depressive disorder
Cyclothymic disorder: mood swings not severe enough to be diagnosed as
bipolar disorder
Seasonal affective disorder (SAD)
Depressive personality disorder
Postpartum or “maternity” blues
Postpartum depression
Postpartum psychosis

ETIOLOGY
Biologic theories include genetics (mood disorders run in families) and
neurochemical theories (dysregulation of serotonin and norepinephrine, and
neuroendocrine or hormonal fluctuations).
Psychodynamic theories tend to “blame” clients and families for illness and
have little use today. The exception is Beck, who viewed depression as resulting
from specific cognitive distortions in susceptible people—cognitive therapy is used
in the treatment of depression.

CULTURAL CONSIDERATIONS
• Depression, often masked by other symptoms
• Somatic complaints may accompany depression.
MAJOR DEPRESSIVE DISORDER
Twice as common in women and more common in single or divorced people
Involves 2 or more weeks of sad mood, lack of interest in life activities, and
at least four other symptoms, such as anhedonia and changes in weight, sleep,
energy, concentration, decision making, self-esteem, and goal setting
Untreated, can last 6 to 24 months; recurs in 60% of people
Symptoms range from mild to moderate to severe.

Treatment and Prognosis

Antidepressants
Classification Indication Drugs Side Effects
insomnia
fluoxetine (Prozac)
Selective serotonin mild and weight gain
sertraline (Zoloft)
reuptake inhibitors moderate sedation
paroxetine (Paxil)
(SSRIs) depression constipation
citalopram (Celexa)
nausea
moderate and
severe
amitriptyline (Elavil)
depression
Tricyclic imipramine (Tofranil)
antidepressants desipramine (Norpramin)
(TCAs) nortriptyline (Pamelor)
*effectiveness
doxepin (Sinequan)
doesn’t begin
for 4-6 weeks
venlafaxine (Effexor) Headache
bupropion (Wellbutrin) Dizziness
Atypical
nefazodone (Serzone) Drowsiness
antidepressants
(trazodone used for Nausea
insomnia due to sedation). vomiting
Monoamine oxidase *Maximum isocarboxazid (Marplan) interaction with
inhibitors (MAOIs) effectiveness tranylcypromine (Parnate) tyramine causes
takes 6 weeks phenelzine (Nardil) hypertensive crisis

interact unfavorably
with a variety of
prescription and over-
the-counter drugs

lethal in overdose
 dry mouth
blurred near vision
constipation
urinary retention
sedation
weight gain
orthostatic
hypotension
nausea

Electroconvulsive Therapy (ECT)

 used when medications are ineffective or side effects are intolerable
 After anesthesia and muscle relaxants, a shock is administered via electrodes to
produce seizure activity in the brain
 administered in a series (for instance, three times a week for 6 weeks)
 Care of client before and after ECT is similar to that for any minor surgical procedure
 After ECT, there is short-term memory loss, confusion, headache, and drowsiness.

Psychotherapy
 Psychotherapy in conjunction with medication is considered the most effective
treatment
 Useful therapies include behavioral, cognitive, interpersonal, and family therapy,
depending on client needs.

Application of the Nursing Process: Major Depressive Disorder

Assessment
Must include determination of suicidal ideas, lethality, and client’s perception
of the problem
Psychomotor retardation or agitation;
 feelings of helplessness
 anxiety
 sadness
 guilt
 frustration
 negativism
 pessimism
 lack of pleasure
 social withdrawal
 reduced concentration and decision making
  fatigue and exhaustion
 low self-esteem and rumination about past bad deeds or failures
 loss of ability to function in life roles
 sleep disturbances
 overeating or undereating
 lack of attention to hygiene and grooming
Depression and rating scales may be used.

Data Analysis
Nursing diagnoses may include:
Risk for Suicide
Imbalanced Nutrition
Anxiety
Ineffective Coping
Hopelessness
Ineffective Role Performance
Chronic Low Self-Esteem
Disturbed Sleep Pattern
Impaired Social Interaction

Outcomes
The client will:
Not injure self or others
Carry out activities of daily living independently
Establish a balance of rest, sleep, and activity
Establish a balance of adequate nutrition, hydration, and elimination
Evaluate self-attributes realistically
Socialize with staff, peers, and family/friends
Return to occupation or school activities
Comply with medication regimen
Verbalize symptoms of recurrence

Intervention
Providing for the client’s safety and the safety of others
Promoting a therapeutic relationship
Promoting activities of daily living and physical care
Using therapeutic communication
Managing medications
Providing client and family teaching
BIPOLAR DISORDER
 Bipolar disorder involves mood swings of depression (same symptoms of major
depressive disorder) and mania
 Major symptoms of mania:
o grandiose mood
o Agitation
o exaggerated self-esteem
o sleeplessness
o pressured speech
o flight of ideas
o being easily distractible
o intrusive behavior with lack of personal boundaries
o high-risk activities with potentially severe consequences, and poor judgment.

Treatment and Prognosis

 Treatment may involve medication with lithium
 regular monitoring of serum lithium levels is needed
 Side effects of lithium therapy:
o mild nausea or diarrhea
o anorexia
o fine hand tremor
o fatigue
o metallic taste in the mouth
o polydipsia
o polyuria
 Signs of lithium toxicity:
o severe nausea
o vomiting and diarrhea
o severe mental confusion

Anticonvulsant drugs are used for their mood-stabilizing effects:

 Tegretol
 Depakote
 Lamictal
 Topamax
 Trileptal
 Neurontin
 Klonopin (a benzodiazepine)
 Side effects:
 Drowsiness
 Sedation
 dry mouth
 blurred near vision
 weight gain

Application of the Nursing Process: Bipolar Disorder

Assessment
General appearance and motor behavior:
 Assessing a client in the manic phase may be difficult and based more on observations
of the client than on the client’s responses to structured questions
 Client jumps from one subject to another
 cannot sit still
 may wear flamboyant clothing or makeup.
Mood and affect:
 psychomotor agitation
 racing thoughts
 pressured speech
 ignoring of directions or requests from others
 unusual speech patterns
Thought processes and content:
 starts many grandiose projects but finishes none
 careless spending sprees
Sensorium and intellectual processes:
 loud voice
 may be hypersexual
Judgment and insight: poor
Self-concept:
 false, grandiose sense of well-being that covers low self-esteem
Roles and relationships:
 may be charming and playful, then sarcastic and angry
 cannot take “no” for an answer
Physiologic and self-care considerations:
 inattention to hygiene and groominghunger, or fatigue

Data Analysis
Nursing diagnoses may include:
Risk for Other-Directed Violence
Risk for Injury
Imbalanced Nutrition
Ineffective Coping
 Noncompliance
Ineffective Role Performance
Chronic Low Self-Esteem
Disturbed Sleep Pattern
Fatigue
Self-Care Deficits

Outcomes
The client will:
Not injure self or others
Establish a balance of rest, sleep, and activity
Establish adequate nutrition, hydration, and elimination
Participate in self-care activities
Evaluate personal qualities realistically
Engage in socially appropriate, reality-based interaction
Verbalize knowledge of illness and treatment

Intervention
Providing for safety of client and others
Meeting physiologic needs
Providing therapeutic communication
Promoting appropriate behaviors
Managing medications
Client and family teaching

Evaluation
• Based on client’s mood at “normal” level
• Medication compliance is essential.

SUICIDE
Families need support when a member has committed suicide or is making attempts to do so.
They may feel guilty, angry, and ashamed, and they are at increased risk for suicide
themselves.

Assessment
Populations at risk
Warnings of suicidal intent
Risky behaviors
Lethality assessment

Outcomes
The client will:
 Be safe from harming self or others
Engage in a therapeutic relationship
Establish a no-suicide contract
Create a list of positive attributes
Generate, test, and evaluate realistic plans to address underlying issues

Intervention
Using an authoritative role
Providing a safe environment
Initiating a no-suicide contract
Creating a support system list
Supervision

SELF-AWARENESS ISSUES
Nurses and other staff members need to deal with their own feelings about
suicide.
Depressed or manic clients can be frustrating and require a lot of energy to
care for.
Keeping a journal may help deal with feelings; also, talking to colleagues is
often helpful.