UNIT 4- ANXIETY & STRESS RELATED DISORDERS Flashcards
Anxiety & stress disorders are often comorbid with….
- Depression
- Eating disorders
- Bipolar disorder
- Substance abuse
Anxiety & stress disorders….
- Have low recovery rates and high recurrence rates
Anxiety and stress disorders interfers with…
- Personal
- academic
- occupational
- social functioning
What is eustress?
- Good stress (what motivates us)
What is distress?
Bad stress- can cause emotional, physiological issues
What are different types of stress
- Psychosocial- stress about the way they feel about themselves
- Psychological stress- anciety/guilt, even postive emotions can be stressful in certain events. Like a letter of acceptance to nursing school
- Phsycial- extreme temp, choatic environment, ex. scratchy tag in a tshirt..
- Spiritual- crisis of faith. Difficulty in the moment connecting with faith. “what is my purpose”
What are some healthy coping strategies/defense mechanisms?
- Altruism
- Sublimation-transfer something not acceptable into somethings acceptable.. instead of punching a wall… go to the gym.
- Humor
- Suppression-Short term can be useful. Sometimes we can’t fall apart in a certain time.
What are intermediate coping strategies/defense mechanisms?
- Repression
- Displacement
- Reaction formation
- Somatization
- Undoing
- Reationalization
What are immature/primitive coping strategies/defense mechanisms?
- Passive agression
- Acting out behavior
- Dissociation
- Devaluation
- Idealization
- Splitting
- Projection
Everyone has a threshhold… when it comes to coping strategies/defense mechanisms… once its crossed…
we eventually get to the point they cope with with immature primitive coping strategies.
Relaxation/calming techniques include…
- Reframing/decatastrophizing– reframing a situation to be more manageable.
- Sleep
- Phsycial exercise- increases endorphins that make you feel good it doesnt have to be super intense it can be a simple walk, yoga
- Reduced caffeine- increased anxiety which makes it harder to settle down
What is the patho of anxiety and stress
- Anxiety as an experience orignates in the amygdala
- Stress signal alerts hypothalamus which responds
- Engages the SNS resulting in
- Physiological/symptoms of anxiety
- Limbic system sends neural messages to
- Cerbral cortex, which generates
- Thought about anxiety
Serotonin in anxiety disorders is believed to be…
decreased which is why we give SSRs for anxiety disorders
Norepinephrine in anxiety is belived to be..
Increased- why we give noradrenegic drugs (porpanolol or clonidine for anxiety disorders)
GABA in anxiety adn stress disorders is belived to be….
altered- benzodiazepine receptors sensitivity is deminished which is why we give benzodiazepine for actue anxiety
What are the short-term effects of epi & norepi
- Elevated heart & resp rate
- Elevated FFAs, glucose and triglycerides
- increased platelet aggregation
- Increased kidney clearance
- Increased blood to skeletal muscles
- Increased muscular tension
What are long-term effects of epi & norepi?
- High resting heartrate
- Heart disease
- Platelet aggregation
- Reactive high BP
- Hypercholesteremia & hyperlipedmia
- Renal/hepatic problems
- Glucose intolerance
- Chronic muscle tension
- Hyperventalation
- Digestive problems
- Chronic anxiety/anger
What are short-term effects of cortisol/corticoids
- Decreased fluid loss
- Increase glucose/gluconeogenesis
- Less inflammation
- Less brain norepinephrine
What are long-term effects of cortisol/corticoids?
- Immune system compromise
- Athrosclerosis
- Depression
- Insulin insensitivity
- Obestiy
- Hyperlipidemia
- Protien breakdown in blood, bones (osteoprosis), Muscle (heart) immunoglobulins
What are some end results of chronic stress?
- Essential hypertension
- Heart disease/stokes
- Diabetes
- Cancer
- Ulcers/chronic GI problems
- Atherosclerosis
- Arthritis
- Autoimmune diseases/allergies/eczema
- Kidney and liver diseases
- Chornic GI problems
- Headaches
What is PTSD dignostic criteria?
- Exposure to actual or threatened death, injury, or sexual violence
- Presence of intrusion symptoms
- avoidance of associated stimuli
- Negative alt. in cogntions/mood
- Altered arousal & reactivity
- Symptoms lasting longer than one month
- Often presents with suicidal ideation & depression
Using TRAUMA for PTSD what should we remember?
T-Traumatic event
R- Re-experiencing the trauma
A-Avoiding things associated with the trauma
U-Unable to focus (can come off as irritability)
M- For 1 Month
A- Increased arousal (hyervigilance, startle response)
What are some treatment modalities for PTSD?
- Cogntive behavioral therapy
- Prolonged exposure therapy
- EMDR: eye movement and reporcessing
- Adaptive disclosure (specific to military)
- Meds SSRI
- Meds: other to treat target symptoms such as psychosis
Prozosin may be used to help with nightmares
What is acute stress disorder diagnostic criteria?
- Exposure to actual or threatened death, injury or sexual violecne
- Negative mood
- Dissociative & Avoidance behaviors
- Arousal symptoms
- Intrusion symptoms
- Hypervigilance
- Resolution of symptoms within 1 month
must last at least 3 days but less than 1 month
What is our treatment of acute stress disorder?
- May resolve without treatment
- Meds: Benzos PRN for severe symptoms
Long term anxiety meds are not ideal because of the timeframe of this disorder by the time those kick in there over it
Dissociative identiy disorder formaly known as
Multiple personality disorder
Dissociative amnesia is…
When patients are unable to recall information about self
Dissociative amnesia with fugue is when…
A patients amnesia for ones identiy may involve travel or wondering
What is depersonalization…
experiences of unreality or detachment from ones mind, self, or body
What is derealization?
- Experiences of unreality or detachment frome ones surroundings
What is normal anxiety?
Decribed as mild, jolt of energy that keeps pushing you through the day…
What is acute anxiety?
sense of change of security is changed
What is pathological anxiety
- Exisits in absence of an identifable source of threat. Must be intense enough and long eough to cause issues in academics and employment
What are different types of anxiety disorders?
- Generalized anxiety disorders (GAD)
- Obsessive/compulsive disorder (OCD)
- Phobic disorders
- Agoraphobia
- Social anxiety disorder (SAD)
- Specific phobic disorders
- Panic disorders
- W/agoraphobia
- or w/o agoraphobia
What are features of mild anxiety?
- Heightened awarness
- Still able to work, learn & solve problems
- Slight psychomotor agitation
Able to function… feel like they might even feel better at doing the things… might be slightless restless, tapping foot
What are nursing interventions for mild anxiety?
- Reframing
- Allow ventilation
- Activity to release energy
- Identify triggers
- Focus on communication
- Monitor levels of anxiety
What are features of moderate anxiety?
- Narrowed perceptual field
- Selective inattention
- Less able to problem solve
- HR & RR up
- Somatic complaints
Focus narrows, attention is limited,VITAL sign changes, tingling fingers, ringing in ears, more irriable
What are some nursing interventions for moderate anxiety?
- Reframing
- Allow ventilation
- Activity to release energy
- Identify triggers
- Focus on communication
- Monitor level of anxiety
- PRN anxiolytic– this is the level at which we are going to consider layering in this
What are features of severe anxiety?
- Perceptual field very limited
- Scattered attention,
- Distorted perceptions
- Diminished problem-solving ability
- Tunnel vision
- Sense of impending doom
- somatic symptoms
This is the level that most people describe as a panic attack. clinically though this is not.. the major key is that they are redirectable and within reality
More intense feelings- difficulty breathing, swallowing, unable to sit still or they freeze, GI stress, nausea.
What are nursing interventions for severe anxiety?
- Remain calm
- Stay with patient
- Low-pitched voice
- Slow down speech
- PRN anxiolytics
At this level we STAY with the patinet and do not leave alone. We need to stay clam, slow our speech down, lower tone, talk very simple
What are features of panic level anxiety?
- Unable to focus on environment
- Feeling of doom
- Disorganized thinking
- No problem solving
- EMotional paralysis
- Increased HR respirations
- Irrational
- Agitation
Significantly elevated vitals… agitation can lead to assult or violecne or self harm. at this point patient is NOT redirectable.
What are our nursing interventions for panic level anxiety?
- Stay with patient
- Remain clam
- Simple direct statements
- Assure safety
- PRN anxxiolytic
- Minimize environment stimulation
Not appropriate for groups, If they have completely loose control of reality we may have to use more emergent drugs but this is an absolute last choice. preventions is KEY
What is the panic disorder diagnostic criteria?
- Recurrent unexpected panic attack without a clear trigger which is why its different than PTSD no trauma associated
- Rapid onset from calm or anxious state
- Typically peaks within 10 mins
- Not attributable to
- Drug induced factors
- Medical condition
- Not better explained by another mental disorder
- Often comorbid with agoraphobia & depression
occurs with four more sysmptoms on differnt notecard followed by atleast 1 month of…. also on another note card
Panic disorder diagnostic critera occurs with four or more of the following symptoms which is followed by at least 1 month of…
Symptoms
1. Palpitations, pounding heart or accelerated heart rate
2. Seating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of chocking
6. Chest pain or discomfrot
7. Neusea or abdominal distress
8. feeling dizzy, unsteady, light-headed, or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling)
11. Derealization or depersonalization….
Follwoed by at least 1 one month of fear of reoccurance and maladaptive change in behavior
This person is going to feel like they are dying and they fear it happening again. Must r/o all causes
look at powerpoint missing some s/s
What are some treatments for panic disorder?
- CBT (reframing)
- Antidepressants (longer term)
- Benzos (short term)- not perferred long term just long enough for antidepressant to kick in
What is the diagnostic critera for phobic disorders?
- Marked fear or anxiety about a specific object or situation
- not better explained by the symptoms of another mental disorder
- Fear/anxiety/avoidance
- is out of proportion to the actual danger posed and to the sociocultural contect
- Causes clinically significant distress or impairment in social, occupational or other important areas of funcitoning
- Is PERSISTENT, typically lasting for 6 months or more
- Phobic object or situation
- Almost always provokes immediate fear or anxiety
- Is actively avoided or endured with instense fear or anxiety
Agoraphobia diagnostic criteria…
Marked fear of 2 or more of the 5 situations
1. Using public transportation
2. being in open spaces (eg. parking lot, marketplace)
3. Being in an enclosed place (shop, theater)
4. Standing in line or being in a crowd
5. Being alone outside the home home
Persistent
1. Must last longer than 6 months
Fear is disproprotionate to the risk of danger
Fear causes distress or impairment
What is the diagnostic criteria of social anxiety disorder (SAD)
- Marked persistent (more than 6months) fear of or axniety about- one or more social situations in which they may be scrutinized by others
- Fear must involve a negative evaluation by others (that patients will be humilated, emabarrassed or rejected or will offend others)
- Must be present-
- The same social situations nearly always trigger fear or anxiety
- Patients actively avoid the situation
- Fear/anxiety/avoidance- is out of proportion to the actural threat (taking into account sociocultureal norms)
- Causes significant distress or significantly impair social or occupational functioning
Specific phobias diagnositc criteria?
- Fear of one (or more) specific object or situation
examples:
- fear of heights/acrophobia
- fear of closed spaces/claustrophobia
- fear of spiders/ arachnophovbia
- fear of flying/ pteromechanophobia
What are our treatments of phobic disorders?
- CBT- layered into most phobic disorders
- Assertiveness training (agoraphobia)
- Systemic desensitization- gradual/support biggest factors
- SOcial skills training (SAD
- Medications
- SSRIs
- Beta blockers- specifically for social sititions and performances. can help them get them throug public speaking
- Benzodiazapines–helps in the moment but it is not a actual tx
What is the diagnostic criteria for generalized anxiety disorder (GAD)
- excessive worry/anxiety on more days than not for more than 6 months
- Cannot control worry
- Must be associated with more than three of the following
- Restlessness or keyed-up or on-edge feeling
- easily fatigability
- difficulty concentrating
- Muscle tension
- Distrubed sleep
R/O substance use or other medical disorders
important assessment questions… do you have difficulty controlling worry typically have underlying depressions
How do we treat GAD?
- CBT
- Stress management
- Phsyical activity
- Medication
- SSRIs
- SNRIs
- Benzo’s
- Buspar
Teach patient that it takes some time for the antidepressants to kick in. DOnt discontinue without talking to provider
Anxiety r/t other medical condition diagnostic criteria…
symptoms are a direct result of a medical condition
1. COPD
2. Parkinsons
3. MEetabolic disorders
4. Hyperthyroidism
What is the diagnostic criteria for obsessive compulsive disorder (OCD)
- Presence of obsessions, compulsions or both
- Unable to ignore or suppress thoughts or actions
- Obessions & compulsions are time consuming; 1 hour a day
Assessment questions
1. Do you do certain things repetitively
2. Do you have intrusive thoughts that are hard to shut out
3. Do you have to do things in a very specific way
What are obsessions?
- Recurrent & persistent thoughts, urgers or images which are unwanted and intrusive causeing distress to the individual
What are compulsions?
Repetitive behaviors that the individual is compelled to perform in response to related obsession
Aim is to alleviate anxiety
What are some treatments for OCD?
- Exposure/response prevention- focing a delay between the obsessive thoughts and progressing compulsions and overtime expanding the time between
- Medications: SSRI- long term
What are some OCD-related disorders?
- Body dysmorphic disorders- mirror checking, skin
- Hoarding disorder
- Trichotillomania- hair pulling
- Skin picking disorder
What might our assessment for anxiety disorders show?
- Level of anxiety
- Suicde risk
- Use of coping/defense mechanisms
- Use of standardized rating scalres
- The clinically useful anxiety outcome scale
- Generalized anxiety disorder screener
- Hamilton rating scale for anxiety
SSRI’s how does it work and examples of use…
Blocks reuptake of serotonin… paroxetine-helpful in GAD
SNRI’s (1st line) how does it work and examples of use
Blocks reuptake of serotonin and norepinephrine… venlafaxine– mixed anxiety/depression, anxiety, nerve pain
Noradrenergic drugs— how it works and example of use?
Propanolol–short-term relief of social anxiety and performance anxiety clonidine- anxiety disrorders, panic anxiety
Benzodiazapine how does it work, examples of use?
Binds to benzodiazapine receptors, facilitates GABA, slows neural transmission
Alprazolam-may be used short term to treat panic disorders and agoraphobia
Buspirone how does it work and exmaples of use
- Buspirone is a serotonin receptor partial agonist- treats the worry associate dwith GAD
What should we know about benzo’s
- Rapid onset
- Sedating
- Dependence & withdrawl
- tolerance varies with increased age
- May be used PRN
- Used for many anxiety disorders
What should we know about buspirone
- delayed onset
- Non-sedating
- No dependence or withdrawal
- No pharmacokinetic change w/age
- Not suitable for pRN use
- FDA for FAD only (effective in other anxiety disorders)
What should we know about hydroxyzine pamoate (vistaril)
- Rapid onset
- Sedating
- No dependence or withdrawal
- Maybe used PRN
- Used for many anxiety disorders
