Mental Health Nursing II NURS 2310

1. Mental Health Nursing IINURS 2310 Unit 13 Anxiety and Somatoform Disorders

2. Key Terms • Anxiety = Apprehension, tension, or uneasiness from anticipation of unknown/unrecognized danger; considered pathological when social and/or occupational functioning is affected • Stress = Mental/emotional/physical strain experienced in response to stimuli from the external or internal environment • Somatization = the expression of psychological needs in the form of physical symptoms; possibly related to repressed anxiety

3. Panic = A sudden overwhelming feeling of terror or impending doom; usually accompanied by behavioral, cognitive, and physiological signs/symptoms considered to be outside the norm • Hysteria = Characterized by recurrent multiple somatic complaints that are unexplained by organic pathology, and is thought to be associated with repressed anxiety • Dissociation = The splitting off of clusters of mental contents from conscious awareness

4. Amnesia = A pathologic loss of memory of an experience or specific period of time; emotional, dissociative, or organic in nature • Phobia = An excessive or unreasonable fear cued by the presence or anticipation of a specific object or situation, exposure to which provokes an immediate anxiety response; the phobic stimulus is avoided or endured with marked distress

5. Types of Anxiety and Anxiety-Related Disorders

6. Panic Disorder • Recurrent panic attacks that cause intense apprehension, fear, or terror • Associated w/feelings of impending doom • Accompanied by intense physical discomfort • Panic attacks usually last only minutes, but symptoms of depression are common due to unpredictable nature of occurrence • Average age at onset is late 20s • Characterized by periods of remission and exacerbation

7. Diagnostic Criteria for Panic Disorder include the presence of at least 4 of the following: • palpitations, pounding heart, or accelerated heart rate • sweating - parasthesias • trembling or shaking - chills or hot flashes • sensations of shortness of breath or smothering • feeling of choking • chest pain or discomfort • nausea or abdominal distress • feeling dizzy, unsteady, lightheaded, or faint • derealization or depersonalization • fear of losing control or going crazy • fear of dying

8. Generalized Anxiety Disorder • Chronic, unrealistic, and excessive worry that causes clinically significant distress or impairment in social/occupational functioning • Numerous somatic complaints and symptoms of depression are common; exacerbations are stress-related • Other symptoms include restlessness, fatigue, irritability, difficulty concentrating, muscle tension and sleep disturbances • May begin in childhood/adolescence • Diagnosed after 6 months of symptoms

9. Phobias • Includes agoraphobia, social phobia (or social anxiety disorder), and specific phobia Agoraphobia • Fear of being in places/situations from which one can’t escape, or in which help might not be available if panic symptoms should occur • Onset in the 20s or 30s; persists for many years • Impairment can be severe and cause the individual to be confined to his/her home

10. Social Phobia • Excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others • Extreme concerns about being exposed to possible scrutiny by others • Fear of social or performance situations in which embarrassment may occur • Onset of symptoms often begins in late childhood or early adolescence and runs a chronic, sometimes lifelong, course • Impairment interferes with functioning

11. Specific Phobia • A marked, persistent, and excessive or unreasonable fear when in the presence of, or when anticipating an encounter with, a specific object or situation • Frequently occur concurrently with other anxiety disorders • Exposure to the phobic stimulus produces overwhelming symptoms of panic, including palpitations, sweating, dizziness, and difficulty breathing • Individual recognizes that fear is excessive, but powerless to change it

12. Obsessive-Compulsive Disorder • Obsessions = unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause marked anxiety or distress • Compulsions = unwanted, repetitive behavior patterns or mental acts such as praying or counting that are intended to reduce anxiety • Obsessive-Compulsive Disorder = recurrent obsessions/compulsions severe enough to cause significant distress or impairment; individual recognizes behavior as excessive, but is compelled to continue due to the relief from discomfort that it provides; usually begins in adolescence or early adulthood

13. Body Dysmorphic Disorder • Exaggerated belief that the body is deformed or defective in some specific way • Most common complaints involve imagined or slight flaws of the face or head Trichotillomania (Hair-Pulling Disorder) • The recurrent pulling out of one’s hair from the scalp, eyebrows, and eyelashes • Impulse preceded by increasing tension; the act produces sense of release or gratification • Usually begins in childhood

14. Trauma-Related Disorders • Includes post-traumatic stress disorder (PTSD) and acute stress disorder Post-Traumatic Stress Disorder • Develops following exposure to an extreme traumatic stressor involving a threat to the physical integrity of self or others • Symptoms may begin within 3 months after the trauma or may be delayed; diagnosis occurs after symptoms that cause significant interference w/functioning have been present for at least 1 month

15. PTSD (cont’d) • Individual re-experiences the traumatic event via intrusive recollections/nightmares; may not recall every aspect of the trauma • Involves either a sustained high level of anxiety/arousal or a general numbing of responsiveness; may lead to depression and/or substance abuse Acute Stress Disorder • Symptomology is the same as for PTSD, but symptoms resolve within 1 month of the precipitating trauma

16. Adjustment Disorder • A maladaptive reaction to an identifiable stressor that results in the development of clinically significant emotional or behavioral symptoms that impair social/occupational functioning or are in excess of expected reaction to the stressor • Occurs within 3 months after onset of stressor and persists for no longer than 6 months after stressor or its consequences have ended • Manifested as depression, anxiety, acting-out behaviors or a combination thereof

17. Somatic Symptom Disorders • Includes somatic symptom disorder, illness anxiety disorder, conversion disorder, and factitious disorder (previously known as Munchausen syndrome) • May involve primary or secondary gains • In primary gain, the physical symptoms allow the individual to avoid some unpleasant activity or difficult situation about which he or she is anxious • Secondary gain involves the promotion of emotional support or attention the individual might not otherwise receive

18. Somatic Symptom Disorder • Characterized by multiple physical symptoms that have no medical explanation • Associated with psychological distress and long-term seeking of assistance from health-care professionals • Symptoms may be vague, dramatized, or exaggerated in their presentation Illness Anxiety Disorder • Unrealistic or inaccurate interpretation of physical symptoms that results in excessive preoccupation about having a serious illness

19. Illness Anxiety Disorder (cont’d) • Fear becomes persistent and disabling in spite of reassurances that no organic pathology can be found • History of doctor-shopping due to presumed misdiagnosis Conversion Disorder • Emotional distress expressed through loss of (or change in) body function for which there is no apparent physical cause • Symptoms may occur suddenly following a stressful experience

20. Factitious Disorder • The conscious, intentional feigning of physical and/or psychological symptoms on oneself or another person (i.e. by proxy) in order to receive emotional care and support • May involve self-infliction of painful injuries, injection or insertion of contaminated substances, manipulation of medical assessment instruments, and/or improper use of medication

21. Dissociative Disorders • Includes dissociative amnesia, dissociative identity disorder (or multiple personality disorder), and depersonalization-derealization disorder Dissociative Amnesia • Inability to recall important personal information; may be specific to a trauma or series of traumatic experiences • Usually follows severe psychosocial stress, and recovery is often abrupt and complete

22. Dissociative Identity Disorder • Characterized by the existence of two or more unique personalities in a single individual • Only one personality is evident at any given moment, and only one is dominant most of the time over the course of the disorder • Transition from one personality to another may be sudden or gradual, and may be dramatic • Symptomology causes clinically significant distress or functional impairment

23. Depersonalization-Derealization Disorder • Depersonalization = a disturbance in the perception of oneself • Derealization = an alteration in the perception of the external environment • Depersonalization-Derealization Disorder = characterized by a temporary change in the quality of self-awareness • Involves change in body image and feelings of unreality or detachment from the environment • Diagnosis made upon functional impairment

24. Treatment Modalities

25. Individual psychotherapy • Eye movement desensitization and reprocessing (EMDR) • Cognitive and/or behavioral therapy • Systematic desensitization • Implosion therapy (flooding) • Group/family therapy • Psychopharmacology

26. Medications used to Treat Anxiety Disorders

27. Most commonly treated with anti-anxiety agents and sedative-hypnotics • Depress subcortical levels in the limbic system • CNS depression ranges from mild sedation to coma • Classes of anti-anxiety agents include antihistamines, benzodiazepines, and miscellaneous agents • Buspirone (Buspar) does not depress the CNS • 10-day to 2-week onset • Does not build tolerance or dependence • Sedative-hypnotics include barbiturates, benzodiazepines, and miscellaneous agents

28. *Anti-anxiety agents: • Antihistamines • Hydroxyzine (Atarax, Vistaril) • Benzodiazepines • Alprazolam (Xanax) • Chlordiazepoxide (Librium) • Clonazepam (Klonopin) • Clorazepate (Tranxene) • Diazepam (Valium) • Lorazepam (Ativan) • Miscellaneous agents • Buspirone (Buspar)

29. Anti-Anxiety Agents (cont’d) • Efficacy may vary • Alcohol, narcotics, barbiturates, antipsychotics, and antidepressants increases effects • Nicotine and caffeine decreases effects • Common side effects include drowsiness, confusion, and lethargy • Abrupt withdrawal can be life-threatening • Insomnia • Increased anxiety • Vomiting • Tremors, convulsions, and delirium

30. *Sedative-hypnotics: • Barbiturates • Secobarbital (Seconal) • Benzodiazepines • Flurazepam (Dalmane) • Temazepam (Restoril) • Triazolam (Halcion) • Miscellaneous Agents • Chloral Hydrate (Noctec) • Zaleplon (Sonata) • Zolpidem (Ambien) • Eczopiclone (Lunesta)

31. Sedative-Hypnotic Agents (cont’d) • Short-term use • Chronic use may induce tolerance and physical/psychological dependence • Additive effect on CNS depression with alcohol, antihistamines, antidepressants, or other CNS depressants • Watch for decreased effectiveness of other medications metabolized by the liver

32. Nursing Process

33. Assessment • Gather information about client’s mood and level of anxiety, thoughts to harm self/others • Diagnosis • Risk for self-directed violence R/T anxiety-related depression • Imbalanced nutrition, less than body requirements R/T lack of interest in food • Disturbed sleep pattern R/T anxiety • Anxiety R/T panic disorder • Social isolation R/T agoraphobia

34. Planning • Care plan • Concept map • Implementation • Establish trust • Provide for safety • Perform risk assessment • Administer scheduled and PRN medications • Evaluation • Mental health/psychiatric assessment tool • Review safety plan/contract • Assess for medication side effects