Stress
- wear & tear on the body caused by life
Historically: Psychosomatic
Psychophysiological
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.
CAUSES: STRESS
theories
(1950):
Essential hypertension
Skin disorders
Rheumatoid arthritis
Hyperthyroidism
Ulcerative colitis
Peptic ulcer diseases
Asthma
Epidemiology: STRESS
Controversial
links
Psychological
Theories
Stress
theories
Alexander (1950)
postulated physical dysfxn resulted from
physical sxs
Conversion hysteria
Now called conversion disorder (APA) w/ specific
criteria
Neurobiological
theories
psychological response
Prolonged exposure to ANS activation results in
neurobiological changes that changes brain activity
9
illness
General Adaptation Syndrome (Seyle)
10
styles
11
12
13
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
B personality traits:
15
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
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
19
Specific
Psychobiological Disorders
Immunological
disorders
resistance to illness
Increased vulnerability to:
Immunodeficiency syndrome
Cancer
Common cold & flu
Herpes simplex Type I
Epstein-Barr virus
20
Specific
Psychobiological Disorders
Gastrointestinal
disorders
21
Specific
Psychobiological Disorders
Dermatological
disorders
response
Psychophysical disorders
Alopecia
Pruritis
Psoriasis
Urticaria
22
Specific
Psychobiological Disorders
Chronic
pain disorders
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
24
Psychobiological
Disorders Across the Life Span
Childhood
Linked w/ need for protection & attachment
children:
Vulnerability
Specific family dynamics
Usefulness of the sick role
25
Psychobiological
Disorders Across the Life Span
Adolescence
Psychosocial stressors include:
26
Psychobiological
Disorders Across the Life Span
Adolescence
Psychophysical responses
27
Psychobiological
Disorders Across the Life Span
Adulthood
Dse prone behaviors include:
previously discussed
28
Generalist Nurse
29
behaviors
Helps clients resolve crisis situations
Psychoeducation
Crisis intervention
Promotes stress-reducing activities
Psychiatric Nurse
comprehensive planning
30
Anxiety
a vague feeling of dread that is unwarranted by
the situation.
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
32
Abnormal Anxiety
Some examples of anxiety disorder:
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
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;
specific
Both
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.)
4 levels of anxiety
Emotional Responses
Severe
(3+)
Panic
(4+)
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)
Cultural Considerations
2) Hispanic Cultural Response
- state of balance is a goal of health care
Cultural Factors
Beliefs
Mediate cognitive, biological, & behavioral
45
Threats to Self-System
CAUSES: ANXIETY
Biologic Theories
began after it became apparent that
benzodiazepine medications, discovered in the
1950s, reduced anxiety.
-
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
Anxiety
Bec.
GABA
reduces
anxiety
&
norepinephrine increases anxiety, it is
thought that a problem w/ the regulation
of these neurotransmitters creates
anxiety disorders.
Benzodiazepines,
Anxiolytics-
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
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
Cognitive-behavioral
Anxious persons exaggerate threat of danger
by using faulty cognitions
59
Intrapsychic/ Psychoanalytic
-
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.
-
Psychodynamic Theories
Intrapsychic/ Psychoanalytic
OTTO
Superego
Castration
Separation
Anxiety
Anxiety
Hunger
Function
Anna Freud
Everyone
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.
-
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
Devtl
In
person who is easily threatened or has low selfesteem is more susceptible to anxiety
- humans existed in
interpersonal & physiologic realms;
Hildegard
Peplau
(1952)
as
Behavioral Theory
-
Lazarus
>Behavior
originates
from
lifelong
maladaptive learning experiences or
conditioning
Intense or disabling anxiety is a learned
maladaptive response to stress
Exposure
Anxiety
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
Overanxious disorder
Unwarranted distress over appropriateness of
behavior
Inability to relax or settle down
74
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
Adulthood
anxiety disorders
76
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 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
78
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 disorders
PTSD
80
disorders
condition
Specific age-related issues
Considerations involving age-related factors
Quality of clients support system
Drug interactions (polypharmacy)
High risk of suicide
81
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
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
Generalist Nurse
87
Psychiatric
Nurse
Major interventions
Psychotherapy
Prescribing medications
Case management
Evaluation of outcome measures
88
PANIC DISORDER
1. PANIC DISORDER W/O AGORAPHOBIA
Recurrent
Absence
Not
of agoraphobia
Derealization
Fear
of dying
Chills
or hot flashes
Assessment
Assessment
Treatment
Positive reframing - teaches the person to
Medications
SSRI antidepressants - most effective, nonaddictive, given for 6-18 months.
Benzodiazepine anxiolytics - for a short period (4
for injury
Anxiety
Fear
Social Isolation
Situational Low self-esteem
Ineffective Role Performance
Ineffective coping
Disturbed sleep pattern
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.
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
Experiences
Not
agoraphobia
AGORAPHOBIA
Anxiety
AGORAPHOBIA
Fears
Hx
Substance or stimulant abuse
Severe stressors
Female gender
Those who experience separation anxiety during
childhood
Smoking tobacco products
Early life traumas
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
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
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
2. PHOBIAS
-
( secondary gain)
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
Psychodynamic
Treatment: PHOBIAS
Accept
Provide
Help
Help
Systemic
OBSESSIVE-COMPULSIVE DISORDER
-
OBSESSIVE-COMPULSIVE DISORDER
Obsessions
OBSESSIVE-COMPULSIVE DISORDER
>
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.
or
Etiology: OCD
Treatment: OCD
Medications: SSRIs, TCA Clomipramine,
anxiolytics (Buspirone, Clonazepam)
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
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.
Related Disorders
OTHER ANXIETY DISORDERS
1.
2.
S/S:
uneasiness
muscle tension
difficulty thinking
irritability
fatigue
sleep alterations
Related Disorders
OTHER ANXIETY DISORDERS
1.
3. PTSD
-
3. PTSD
-
Manifest:
sleep difficulties
hypervigilance
thinking difficulties
poor concentration
Characteristics of PTSD
Can be acute
Persistent
Persistent
trauma
Duration
Characteristics of PTSD
Significant
distress or impairment of
occupational, or other impt. Areas of fxng
social,
Includes
Alcohol
Mngt./Int: PTSD
Therapy: PTSD
gradual exposure to the event
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.
Nuerologic
2.
Involuntary
disorder
(blindness,
deafness, loss of tactile sense of pain)
motor
fxn
disorder
Etiology: Somatoform
Psychoanalytic
theory:
conflict
finds
expression by displacement of aqnxiety onto
physical symptom.
Behavioral
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
Rationale
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.
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
Multiple PD
disorder-
or Dissociative identity
2.
Multiple PD
disorder-
or Dissociative identity
Child
Trauma
The
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
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
Intervention
Intervent.
Rationale
END