Anxiety Treatment: Pharmacotherapy 1. Anti________ – SSRI, SNRI, TCA, MAOI, buproprion - SSRI and SNRI are ______ line b/c of safety risks - assess for suicide risk - monitor for 4-8 weeks after starting antidepressant for efficacy - can increase dose, switch drug or class, add 2nd drug 2. Anti _______ – benzodiazepines, buspirone 3. Beta blockers - short term physical symptoms of anxiety by bringing down HR and BP 4. Antihistamines – hydroxyzine - different mechanism of action that makes it effective for reducing anxiety symptoms 5. Anticonvulsants 6. Anti psychotics

Anxiety Treatment: Pharmacotherapy 1. Antidepressants – SSRI, SNRI, TCA, MAOI, buproprion - SSRI and SNRI are first line b/c of safety risks - assess for suicide risk - monitor for 4-8 weeks after starting antidepressant for efficacy - can increase dose, switch drug or class, add 2nd drug 2. Anti anxiety – benzodiazepines, buspirone 3. Beta blockers - short term physical symptoms of anxiety by bringing down HR and BP 4. Antihistamines – hydroxyzine - different mechanism of action that makes it effective for reducing anxiety symptoms 5. Anticonvulsants 6. Anti psychotics

w6 - 25 questions Flashcards by Garrett Anderson

________
- Universal huma experience
- Most basic emotion
- Feeling of apprehension, uneasiness, uncertainty or dread from a real or perceived threat
- Reponse to a threat that is unknown, vague, or conflictual
- Response to internal or external stimuli
- Symptoms are physical, emotional, cognitive, and behavioral
- Evolutionary response to impending doom – fight or flight response

Anxiety

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Reactive Attachment d/o vs Disinhibited social engagement d/o?

children with ______ are withdrawn and have trouble forming attachments

children with _______ are overly friendly with strangers, lacking normal boundaries

Social Interaction:
______: Socially withdrawn.
______: Overly social.

Response to Strangers:
______: Overly familiar and indiscriminate.
______: Avoidant and wary.

Attachment Behavior:
_____: Difficulty forming specific attachments.
_____: Diffuse attachments, lacking selectivity.

RAD
DSED

DSED
RAD

RAD
DSED

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Anxiety vs fear
- _______ - Feeling of apprehension, uneasiness, uncertainty or dread from a real or perceived threat (stress response from your thoughts)
- _______ – reaction to specific danger (stress response from immediate danger)
- Normal anxiety – necessary for survival

Anxiety vs fear
- Anxiety - Feeling of apprehension, uneasiness, uncertainty or dread from a real or perceived threat (stress response from your thoughts)
- Fear – reaction to specific danger (stress response from immediate danger)
- Normal anxiety – necessary for survival

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Theories of anxiety d/o
Biological factors
- Genetic
- Neurobiological
Psychological factors
Cultural factors
- Anxiety may be expressed through somatic symptoms or cognitive symptoms
Environmental factors

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Levels of anxiety
(4)

Mild
Moderate
Severe
Panic

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_______ anxiety
- Occurs in the normal experience of everyday living
- Adaptive
- Can provide motivation for survival

Perceptual field – heightened
- Sees and hears more information
- Sharper observations
- Focus is flexible
- Aware of anxiety

Ability to problem solve
- Able to work effectively toward a goal and examine alternatives

Characteristics
- Slight discomfort
- Attention seeking
- Restlessness
- Easily startled
- Irritable or impatience
- Mild tension relieving behavior – tapping, lip chewing, fidgeting

Mild

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_________ anxiety

Perceptual field - narrowed
- Sees and hears less information
- Some details excluded from observations
- Focus is on source of anxiety
- Less able to pay attention

Ability to problem solve
- Able to problem solve, not at optimal level
- Able to follow direction

Characteristics
Sympathetic nervous system symptoms begin:
- Tension
- Pounding heart
- Increased pulse and RR
- Perspiration
- Mild somatic symptoms – h/a, urinary frequency, backache, insomnia
- Voice tremors
- Poor concentration
- Shaking

Moderate

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_________ anxiety

Perceptual field – reduced and distorted
- Focuses on details or one specific detail
- Attention is scattered

Ability to problem solve
- Feels impossible
- Unable to connect events and details
- Dazed and confused

Characteristics
- Automatic behaviors aimed at reducing or relieving anxiety
- Feelings of dread, impending doom
- Confusion
- Purposeless activity
- More intense somatic symptoms – chest discomfort, dizzy, nausea, sleeplessness
- Diaphoresis
- Withdrawal
- Loud and rapid speech
- Threats and demands

Severe

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_________ anxiety

Perceptual field – non-existent
- Unable to process environment
- Focus is lost
- Depersonalization – person may feel unreal (themselves)
- Derealization – person may feel the world is unreal

Ability to problem solve
- Completely unable
- Disorganized and irrational reasoning

Characteristics
- Feelings of terror
- Immobility (freeze), severe hyperactivity (fight or flight)
- Speech – unable or unintelligible, amplified or muffled sounds
- Somatic symptoms increase – numbness, tingling, SOB, dizzy, chest pain, nausea, trembling, chills, overheating, palpitations
- Severe withdrawal
- Hallucinations or delusions
- Out of touch with reality

Panic - Most extreme level

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______________ against anxiety
- Automatic coping styles
- Protection from anxiety
- Enable individual to maintain self image by blocking feelings, conflicts, or memories
- Can be healthy or unhealthy
- Not always obvious to the individual using them

Defenses mechanisms

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Defense mechanisms against anxiety:
- Conversion
- Altruism
- Compensation
- Denial

_________: Deriving gratification from helping others, which serves to reduce feelings of guilt.

________: Counterbalancing perceived weaknesses by emphasizing strengths in another area.

________: Transforming anxiety into physical symptoms lacking an organic cause.

_________: Refusing to acknowledge painful subjective realities.

Altruism: Deriving gratification from helping others, which serves to reduce feelings of guilt.

Compensation: Counterbalancing perceived weaknesses by emphasizing strengths in another area.

Conversion: Transforming anxiety into physical symptoms lacking an organic cause.

Denial: Refusing to acknowledge painful subjective realities.

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Defense mechanisms against anxiety:
- Displacement
- Dissociation
- Identification
- Intellectualization

__________: Redirecting emotions from their source to a substitute target.

_________: Separating thoughts, emotions, or memories from conscious awareness.

_________: Adopting beliefs, values, or behaviors of another person or group.

__________: Avoiding emotions by focusing on facts and logic.

Displacement: Redirecting emotions from their source to a substitute target.

Dissociation: Separating thoughts, emotions, or memories from conscious awareness.

Identification: Adopting beliefs, values, or behaviors of another person or group.

Intellectualization: Avoiding emotions by focusing on facts and logic.

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Defense mechanisms against anxiety:
- Projection
- Rationalization
- Reaction formation
- Regression

__________: Attributing one’s unacceptable thoughts or impulses to others.

_________: Creating fictitious but credible justifications to make the irrational acceptable.

__________: Behaving in a manner directly opposite to one’s true feelings.

_______: Retreating to an earlier stage of development to avoid responsibility.

Projection: Attributing one’s unacceptable thoughts or impulses to others.

Rationalization: Creating fictitious but credible justifications to make the irrational acceptable.

Reaction Formation: Behaving in a manner directly opposite to one’s true feelings.

Regression: Retreating to an earlier stage of development to avoid responsibility.

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Defense mechanisms against anxiety:
- Repression
- Splitting
- Sublimation
- Suppression
- Undoing

_________: Unconsciously blocking unacceptable thoughts, feelings, or urges.

_________: Viewing people or situations as entirely good or entirely bad.

________: Channeling unacceptable impulses into socially acceptable behaviors.

_________: Consciously pushing away unwanted thoughts, emotions, or impulses.

______: Attempting to negate or cancel out unacceptable thoughts or behaviors.

Repression: Unconsciously blocking unacceptable thoughts, feelings, or urges.

Splitting: Viewing people or situations as entirely good or entirely bad.

Sublimation: Channeling unacceptable impulses into socially acceptable behaviors.

Suppression: Consciously pushing away unwanted thoughts, emotions, or impulses.

Undoing: Attempting to negate or cancel out unacceptable thoughts or behaviors.

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maladaptive vs adaptive

Use of ________ defense mechanisms:
- Problem solving
- Crying
- Talking
- Sleeping
- Exercising
- Deep breathing
- Imagery
- Relaxation

Use of _________ defense mechanisms:
- Blaming
- Negative self talk
- Obsessive compulsive behaviors
- Aggressive acting out behaviors
- Withdrawal
- Excessive eating, drinking, spending, gambling, drug use, sex

adaptive

maladaptive

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Process:
1. Anxiety occurs (acute or chronic)
2. Relief behavior – defense mechanisms, coping, support systems
3. Effective mediation = __creased anxiety
OR
4. Ineffective medication = __creased anxiety
- Difficulty coping
- Extreme use of defenses or coping
- Psychotic symptoms
- Unrelieved anxiety = chronic anxiety

decreased

increased

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Interventions

Mild to moderate anxiety
- Identify anxiety and triggers
- Nonverbal and verbal therapeutic communication
- Encourage pt to talk about feelings
- Clarify
- Identify feelings prior to onset of anxiety
- Problem solving, alternative solutions
- Outlets for working off excess energy

Mild to moderate anxiety: Reduce anxiety levels/prevent escalation
- Calm presence
- Recognize distress
- Listen
- Explore how anxiety was alleviated in the past
- Provide alternative coping strategies

Severe to panic anxiety
- Safety
- Always ____ with pt
- Calm
- Clear, simple statements, ____ pitched voice, speak slow
- _____ environment, minimal stimulation
- Reorient to reality if distortions
- Meds
- Risk for suicide

Severe to panic anxiety
- Safety
- Always stay with pt
- Calm
- Clear, simple statements, low pitched voice, speak slow
- Quiet environment, minimal stimulation
- Reorient to reality if distortions
- Meds
- Risk for suicide

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Anxiety disorders
- Most common mental health problem
- Affects all genders and ages
- Highly treatable
- Can be chronic and persistent
- Strong genetic predisposition
- S/s may begin in childhood/early adulthood
- Often recognizes thoughts/behaviors are ________ and emotion is an overreaction
- ________ used to reduce/manage the experience of overwhelming anxiety
- Allow continuation of behavior until other ________ strategies are in place

Anxiety disorders
- Most common mental health problem
- Affects all genders and ages
- Highly treatable
- Can be chronic and persistent
- Strong genetic predisposition
- S/s may begin in childhood/early adulthood
- Often recognizes thoughts/behaviors are irrational and emotion is an overreaction
- Behaviors used to reduce/manage the experience of overwhelming anxiety
- Allow continuation of behavior until other management strategies are in place

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_________ anxiety disorder
- Anxiety for more than 6 months
- Excessive and persistent worry
- Accompanied by muscle tension, autonomic hyperactivity, startle, difficulty concentrating

Risk factors
- Unresolved conflict
- Cognitive misinterpretations
- Life stressors
- Genetic predisposition
- Behavioral inhibition – shyness, fear, withdrawing in unfamiliar situations

Comorbidities
- MDD
- Other anxiety d/o
- Alcoholism

Generalized

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_________ anxiety disorder: Clinical course
- Chronic, fluctuating s/s
- s/s cause distress or impairment that interferes with daily life and relationships
- may have mild depressive s/s
- often present to PCP with somatic complaints like muscle aches, soreness, and GI complaints
- may have poor sleep, irritable, trembling, twitching, poor concentration, exaggerated startle, feels uneasy, fear of imminent disaster

Generalized

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Anxiety Treatment: Pharmacotherapy

Anti________ – SSRI, SNRI, TCA, MAOI, buproprion
- SSRI and SNRI are ______ line b/c of safety risks
- assess for suicide risk
- monitor for 4-8 weeks after starting antidepressant for efficacy
- can increase dose, switch drug or class, add 2nd drug
Anti _______ – benzodiazepines, buspirone
Beta blockers
- short term physical symptoms of anxiety by bringing down HR and BP
Antihistamines – hydroxyzine
- different mechanism of action that makes it effective for reducing anxiety symptoms
Anticonvulsants
Anti psychotics

Anxiety Treatment: Pharmacotherapy

Antidepressants – SSRI, SNRI, TCA, MAOI, buproprion
- SSRI and SNRI are first line b/c of safety risks
- assess for suicide risk
- monitor for 4-8 weeks after starting antidepressant for efficacy
- can increase dose, switch drug or class, add 2nd drug
Anti anxiety – benzodiazepines, buspirone
Beta blockers
- short term physical symptoms of anxiety by bringing down HR and BP
Antihistamines – hydroxyzine
- different mechanism of action that makes it effective for reducing anxiety symptoms
Anticonvulsants
Anti psychotics

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MAOIs – phenelzine, tranylcypromine, isocarboxazid
- Used less often
- Refractory depressant
- Atypical depression
- Complication – _____ crisis (when taken with ________)
- Food/drug interaction - Avoid tyramine rich foods (aged cheese, smoked meats, yeast, red wine)
- CNS stimulation
- Orthostatic hypotension
- Can lead to rapid ___crease in BP, stroke, coma
- Drug/drug interaction – antihypertensive, SSRI, indirect acting sympathomimetics (ephedrine), TCA, meperidine

MAOIs – phenelzine, tranylcypromine, isocarboxazid
- Used less often
- Refractory depressant
- Atypical depression
- Complication – HTN crisis (when taken with tyramine)
- Food/drug interaction - Avoid tyramine rich foods (aged cheese, smoked meats, yeast, red wine)
- CNS stimulation
- Orthostatic hypotension
- Can lead to rapid increase in BP, stroke, coma
- Drug/drug interaction – antihypertensive, SSRI, indirect acting sympathomimetics (ephedrine), TCA, meperidine

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Bupropion vs buspirone

_________ - antidepressant
- Atypical antidepressant
- Stimulant effect
- Decreased appetite
- 1-3 weeks for effect
- Doesn’t tend to affect sexual function – often given with other antidepressants to help counter sexual s/e
- s/e – seizure, agitation, h/a, dry mouth, constipation, weight loss, GI upset, dizzy, tremor

__________ - antianxiety
- antianxiety med
- sensitive to SSRI treatment
- several weeks for effect
- less drowsiness and abuse potential
- non-habit forming and low toxicity

Bupropion - antidepressant
- Atypical antidepressant
- Stimulant effect
- Decreased appetite
- 1-3 weeks for effect
- Doesn’t tend to affect sexual function – often given with other antidepressants to help counter sexual s/e
- s/e – seizure, agitation, h/a, dry mouth, constipation, weight loss, GI upset, dizzy, tremor

buspirone - antianxiety
- antianxiety med
- sensitive to SSRI treatment
- several weeks for effect
- less drowsiness and abuse potential
- non-habit forming and low toxicity

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benzodiazepines (antianxiety)
- quick onset, short term use only
- lowest dose necessary
- monitor ______ effects and risk for injury
- caution with machinery
- avoid caffeine, ________ (can be fatal), and other sedatives
- take with or without food?
- high or low addiction potential?
- tapper or d/c abruptly?
- enhances GABA action (calming, anti anxiety effect)
- promotes sleep?
- muscle relaxant
- promotes amnesia (flunitrazepam = date rape drug)
- teratogenic?
- antidote = flumazenil

benzodiazepines (antianxiety)
- quick onset, short term use only
- lowest dose necessary
- monitor sedative effects and risk for injury
- caution with machinery
- avoid caffeine, alcohol (can be fatal), and other sedatives
- take with food
- high addiction potential - use caution if hx of substance abuse
- tapper, do not d/c abruptly
- enhances GABA action (calming, anti anxiety effect)
- promotes sleep
- muscle relaxant
- promotes amnesia (flunitrazepam = date rape drug)
- teratogenic – avoid if pregnant
- antidote = flumazenil

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teaching for antianxiety pharmacotherapy treatment - don’t change dose/frequency w/o provider approval - caution with ________ - alcohol and other antianxiety meds may cause _________ effects - caffeine and nicotine __crease desired effect of antianxiety med - can be excreted in breast milk? - MAOIs – special _____ required - Withdrawal – benzo, SSRI - Take med _____ meals to avoid GI upset - Drug interactions can occur

teaching for antianxiety pharmacotherapy treatment - don’t change dose/frequency w/o provider approval - caution with machinery - alcohol and other antianxiety meds may cause depression effects - caffeine and nicotine decrease desired effect of antianxiety med - can be excreted in breast milk - MAOIs – special diet required - Withdrawal – benzo, SSRI - Take med after meals to avoid GI upset - Drug interactions can occur

Children/adolescents: ________ anxiety disorder - Excessive worry/fear with no real cause - Future events and past behaviors - Social acceptance - Family - Finances - Personal abilities - School Treatment: Children/adolescents - CBT - Antidepressants - Anti-anxiety

generalized

_________ anxiety disorder - Normal part of infant development - Begins – 8 months - Peaks – 18 months (should decline) - Not normal – developmentally inappropriate levels of concern over being away from a significant other - Fear something horrible happening, permanent separation - Intense anxiety interferes with normal activities, sleep disturbances, nightmares, physical symptoms

Separation

________ anxiety disorder - In adults – symptoms manifest as harm, avoidance, worry, shyness, uncertainty, lack of self-direction, impaired social and occupational functioning

Separation

__________ - Persistent irrational fear of a specific object, activity, or situation that leads to a desire for avoidance of that thing. - The specific object, activity, or situation provokes immediate fear or anxiety and is avoided – daily functioning is compromised - Fear/anxiety is out of proportion to the actual danger

Specific phobias - Common phobias – dogs, spiders, heights, storms, closed spaces, tunnels, bridges, birds, insects

Specific phobias - Medication not successful as singular treatment - 1st line treatment – med, therapy, desensitization or flooding __________ – individual is gradually introduced to feared object or experience through a series of steps (from least to most frightening) - Taught how to use relaxation techniques at each step when anxiety becomes overwhelming _________ – individual is exposed to large amounts of an undesirable stimulus to extinguish the anxiety response - Learns through prolonged exposure that survival is possible and anxiety diminishes

Systemic desensitization Flooding

- Most severe and persistent phobia d/o - Intense and excessive anxiety/fear about being in places/situations from which escape might be difficult/embarrassing or where help might not be available - Feared places are avoided - Causes impairment in areas of functioning - Common situations – alone outside or at home, traveling in car/bus/airplane, being on a bridge or in an elevator, being in a crowd - Treatment – SSRIs, benzo, CBT, desensitization or flooding

Agoraphobia

________ anxiety disorder or ______ phobia - Severe anxiety/fear provoked by exposure to a social situation that could be evaluated negatively by others - Common situations – being criticized by others, humiliation, fear of public speaking - Worry can occur days-weeks before dreaded situation - May interfere with life activities and difficult to keep friends - May have increased risk for MDD and SUD - Treatment – SSRI and benzo Risk factors - Childhood mistreatment - ACE - Shyness - Shy parents

Social anxiety disorder or social phobia

_______ disorder - Chronic with exacerbations - Sudden onset of extreme apprehension/fear usually associated with feeling impending doom - Occurs out of the blue - Lasts minutes - Feelings of terror during panic attack are so severe that functioning is suspended, perceptual field is severely limited, and reality may be misinterpreted - AUD or SUD common comorbidity Etiology - Genetics - Family hx - Early childhood stress Epidemiology - High associated with depression, HTN, cigarette and marijuana use

Panic disorder/attack

Panic disorder/attack: 2 key psychological symptoms - _______ anxiety – fearful expectation of panic anxiety onset - _______ anxiety – personal strategies used to increase feelings of control and decrease risk of panic anxiety

Anticipatory Avoidance

s/s ________ disorder - Chest pain or discomfort, palpitations, pounding heart, increased HR - Sweating, trembling - SOB - Feelings of choking - Nausea or GI distress - Dizzy, lightheaded, unsteady - Chills or hot flashes - Paresthesia - Derealization – feelings of unreality - Depersonalization – detached from oneself - Fear of losing control or dying

Panic disorder/attack

Panic disorder/attack Treatment - CBT - Distraction - Positive self talk - Flooding - Relaxation - Antidepressants ____ line – SSRI, SNRI, TCA, MAOI - Benzo ____ line Emergency care - Crisis - r/o life threatening events – cardiac event - stay with pt - reassurance - clear directions - quiet environment - walk with pt - admin prn meds

Treatment - CBT - Distraction - Positive self talk - Flooding - Relaxation - Antidepressants 1st line – SSRI, SNRI, TCA, MAOI - Benzo 2nd line Emergency care - Crisis - r/o life threatening events – cardiac event - stay with pt - reassurance - clear directions - quiet environment - walk with pt - admin prn meds

________ disorder - repetitive unwanted thoughts/obsessions - repeated activities/rituals compulsions - time consuming - distressing to individual, family, friends - s/s gradual onset - time consuming and causes impairment in functioning - stress increase = s/s increase - cyclical: obsessive thought = anxiety = compulsive behavior = temporary relief = obsessive thought = etc… - risk factors – childhood abuse or trauma, genetics - often occurs with anxiety d/o - humiliation or shame regarding behaviors - impaired cognition

OCD

compulsions vs Obsessions _________ – unwanted, intrusive, persistent thoughts, impulses, or images that persist and reoccur and can’t be dismissed from the mind - seem senseless to individual experiencing it - not consistent with individuals self perception or usual thought pattern - common – fear of contamination, symmetry, thoughts of hurting someone ___________ – behaviors that are performed repeatedly, ritualistic, goal is to prevent or relieve anxiety and distress caused by obsessions - performing act temporarily reduces anxiety, must be repeated for continued relief - common – hand washing, touching things in sequence, counting things, locking and unlocking doors

obsessions compulsions

OCD: treatment - very difficult to treat - SSRI – clomipramine, fluoxetine, fluvoxamine, paroxetine, sertraline - CBT - Exposure - DBS - TMS OCD in children/adolescents: Treatment - SSRI – clomipramine, fluoxetine, fluvoxamine, sertraline - Exposure - Response prevention therapy - CBT – adolescents only

__________ disorder - Preoccupation with perceived defects/flaws in physical appearance that is not observable or appears slightly to others - Most common – skin, hair ,nose, stomach, teeth, ,weight, breasts - Results in obsessional thinking and compulsive behaviors – check mirror, camouflaging, excessive grooming, skin picking, reassurance seeking - Results in mental acts – comparing appearance to others - Preoccupations are intrusive, unwanted, time consuming, difficult to control - May lead to embarrassment, shame, anxiety, disgust, depression - High suicide risk Treatment - Response to treatment is limited - Chronic - CBT - SSRI - Biofeedback - Meditation - Relaxation

Body dysmorphic

_________ disorder - Persistent difficulty discarding possessions, regardless of value - Causes distress or impairment in functioning - Condition worsens with age - Comorbidities - MDD, anxiety, OCD - Safety concern!!

Hoarding

__________ disorder - Recurrent hair pulling from any region of body - Most common areas – scalp, eyebrows, eyelashes - Pain may reduce anxiety - Many are unaware of pulling behavior until they notice a wad of hair - Causes distress or impairment in functioning - Treatment – SSRI and behavior therapy_

Trichotillomania

_________ disorder - Recurrent skin picking resulting in skin lesions – may include skin rubbing, squeezing, lancing, biting - Common areas – face, arms, hands - May relieve stress and anxiety - May not be aware of behavior - Causes distress or impairment in functioning - Comorbidities – OCD, trichotillomania - Treatment - SSRI, CBT

Excoriation

_______ abuse – physical pain or bodily harm ________ abuse – sexual contact or exposure without consent or if the victim is incapable of giving consent ________ abuse – undermining a persons self worth _______ – failure to provide for physical, emotional, educational, and medical needs _________ abuse – controlling persons access to economic resources making person financially dependent

Physical abuse – physical pain or bodily harm Sexual abuse – sexual contact or exposure without consent or if the victim is incapable of giving consent Emotional abuse – undermining a persons self worth Neglect – failure to provide for physical, emotional, educational, and medical needs Economic abuse – controlling persons access to economic resources making person financially dependent

_______ situation – situation puts stress on family with a violent member - Lack of effective impulse control - Lack of problem solving skills - Lack of healthy support system _______ – member of household that is violent toward another member _________ person – family member whom abuse is perpetrated ________ – recognizes the recovery and healing process that follows victimization and doesn’t have a connotation of passivity

Crisis situation – situation puts stress on family with a violent member - Lack of effective impulse control - Lack of problem solving skills - Lack of healthy support system Perpetrator – member of household that is violent toward another member Vulnerable person – family member whom abuse is perpetrated Survivor – recognizes the recovery and healing process that follows victimization and doesn’t have a connotation of passivity

_________ Physical violence, rape, stalking, psychological aggression by a current/former intimate partner

Intimate partner violence

Intimate partner violence: Risk factors - Perspective _______ - Pathological _______ - ________ abuse - Pregnancy

- Perspective dominance - Pathological jealousy - Substance abuse - Pregnancy

Cycle of violence (IPV) 1. _________ building – minor abusive events, victim ignores events out of fear, abuser rationalizes behavior 2. Acute _______ – tension peaks, triggered by events 3. _________ – tension reduces, abuser apologetic, victim abandons plans to leave

1. Tension building – minor abusive events, victim ignores events out of fear, abuser rationalizes behavior 2. Acute battering – tension peaks, triggered by events 3. Honeymoon – tension reduces, abuser apologetic, victim abandons plans to leave

________ abuse Intentional abuse that causes harm or creates a risk of harm to a vulnerable person - failure to provide basic needs - failure to protect them from harm

Older adult

Older adult abuse: risk factors - poor ______ health - poor _______ health - disruptive disorders – alzheimer’s - dependency - hx of violence - victim – female, 75+ years, living with relative, physical/mental impairment

risk factors - poor mental health - poor physical health - disruptive disorders – alzheimer’s - dependency - hx of violence - victim – female, 75+ years, living with relative, physical/mental impairment

caring for abused persons: assessment - screen all pts - vague symptoms – chronic pain, insomnia, hyperventilation, gynecological problems covert vs overt signs ________ signs – minor complaints - h/a - back trouble - dizzy - accidents (falls) _________ signs - bruises - scars - burns - wounds in various stages of healing - head, face, chest, arms, abdomen, back, butt, genitalia

covert overt

caring for abused persons: interview - privately - sit nearby - establish rapport - ask specifically about conflict resolution - inform pt if you must make a referral to protective services and explain process - do not use “abuse” or “violence” - do not interrupt - do not probe for answers pt is unwilling to give

indications of _________ abuse - sexualized behavior - sexualized knowledge - sexualized play - sexualized aggression - drawing sexualized material - sexual promiscuity in older children

sexual

indications of _______ abuse - low self esteem - feeling inadequate - anxiety - withdrawal - learning difficulties - poor impulse control

emotional abuse

indications of __________ - under nourished - dirty - poorly clothes - inadequate medical/dental care indications of ________ abuse - needs unmet with adequate finances - unpaid bills - d/c utilities - extreme dependency

neglect economic

implementation - nurses legally required to report abuse or suspected abuse - cultural considerations - counseling – safety plans, shelter, safe houses - case management roles - community support - education

abuse: prevention primary secondary tertiary _________ – early intervention in abusive situations - screening programs for individuals at risk - medical treatment for injuries - coordination of community services ________ – measures taken to prevent the occurrence of abuse - reduce stress and influence of risk factors - increase social support, coping skills, and self esteem _________ – occurs in mental health setting, nurse facilitates healing and rehabilitation - counseling individuals and families - providing support for groups of survivors - assisting survivors of violence to achieve their optimal level of safety, health, well being - legal advocacy for survivors - complementary therapies – mindfulness, stress reduction

secondary – early intervention in abusive situations - screening programs for individuals at risk - medical treatment for injuries - coordination of community services primary – measures taken to prevent the occurrence of abuse - reduce stress and influence of risk factors - increase social support, coping skills, and self esteem tertiary – occurs in mental health setting, nurse facilitates healing and rehabilitation - counseling individuals and families - providing support for groups of survivors - assisting survivors of violence to achieve their optimal level of safety, health, well being - legal advocacy for survivors - complementary therapies – mindfulness, stress reduction

______________ - unwanted sexual advances, harassment, rape - strangers - spousal/marital - statutory – minors - date/acquaintance - drug-facilitated - incest - human sex trafficking

sexual assault/violence

________ rape – threats or intention of rape that is unsuccessful __________ rape – penetration with any body part/object, or oral penetration by a sex organ of another person, without the consent of the victim

attempted rape – threats or intention of rape that is unsuccessful completed rape – penetration with any body part/object, or oral penetration by a sex organ of another person, without the consent of the victim

sexual assault/violence: male victims more likely to - suffer physical trauma - be victimized by multiple perpetrators - be raped in a locked institution sexual assault/violence: clinical picture - no typical presentation, emotional responses vary - long term effects – MDD, anxiety, fear, suicide - difficulties daily functioning - low self esteem - sexual dysfunction - somatic complaints

sexual assault/violence: acute stress disorder vs PTSD ____________ – symptoms less than 1 month - intrusive symptoms – memories, dreams, flashbacks - negative thoughts, moods, feelings - avoidance - arousal symptoms - disassociation _________ – symptoms greater than 1 month - depersonalization – feeling like they are living in a dream - derealization – feeling like the world is dreamlike, distant, or distorted

acute stress d/o PTSD

sexual assault/violence: assessment - consent required – pt has right to decline all or parts - anxiety level - coping mechanisms - support systems - s/s of physical and emotional trauma

Trauma and stress disorders: Traumatic events - war, military - crime related - natural disasters - mass violence - serious accident - interpersonal trauma – abuse, neglect - sudden and traumatic loss in any stage of life Trauma and stress disorders: intervention stages for children - provide safety and stabilization - reduce/regulate arousal, emotion, memories through symptom reduction - catch up on developmental and social skills, develop a value system

Acute stress disorder ____________ - diagnosed 3 days – 1 month following the traumatic event - person continually re-experiences the events - avoids situations that remind them of the event - has increased anxiety that negatively affects lifestyle - if the symptoms continue beyond 1 month = diagnosis changed to PTSD __________ - Persistent re-experiencing highly traumatic event - Intense fear, helplessness, horror - Trauma exposure: direct experience, witnessing in person, learning about traumatic event happening to a close friend/family, death violent or unexpected - Does not include exposure to tv, movies, pictures - Symptoms may begin 1 month – years after exposure

Acute stress disorder PTSD

Acute stress disorder: symptoms 1. intrusion - memories - recurrent dreams - dissociative reactions – flashbacks that seem real - psychological or physiological distress when reminded of event – location, sounds 2. avoidance - memories, thoughts, feelings - external reminders – people, places, conversation, activities, objects 3. arousal - sleep disturbances - irritable, angry outbursts - hypervigilance - difficulty concentrating - exaggerated startle 4. dissociative - altered send of reality - inability to remember event 5. negative mood - inability to experience positive emotions

acute stress disorder: treatment - CBT, EMDR – main treatment - Meds – minimal evidence to support effectiveness

Symptoms – 4 core - Reexperiencing – flashbacks, bad dreams, frightening thoughts - Avoidance – avoiding things or thoughts that remind them of event - Arousal and reactivity – easily startled, feeling tense/on edge, difficulty sleeping, angry outbursts - Cognitive and mood – trouble remembering, negative thoughts about self/world, distorted feelings of guilt, loss of interest in enjoyable activities - Symptoms must be present for longer than 1 month - Severe symptoms that interfere with daily life - Symptoms unrelated to meds, substances, illness

PTSD

PTSD: Risk factors - Not everyone that experiences a traumatic event will develop PTSD - Some factors are present before trauma - Previous exposure to traumatic events – childhood - Getting hurt, seeing others be hurt/killed - Feeling horror, helpless, fear - Little/no support after event - Extra stress after event – loss of loved one, pain, injury, loss of job or home - Hx of mental illness or substance abuse (self or family)

PTSD: Treatment Trauma focused psychotherapy - Exposure - Cognitive processing theraoy - EMDR Pharmacotherapy - SSRI – sertraline, paroxetine, fluoxetine (off label) - SNRI – venlaflaxine (off label) - MAOI – phenelizine (off label)

EMDR - For children and adults - 1st line for________ - Helps people process traumatic ________ - Person is encouraged to ______ about the traumatic event while also focusing on other ________ (eye movements, audio tones, tapping) - Works through neurological and physiological changes that help process and integrate traumatic memories

EMDR - For children and adults - 1st line for trauma - Helps people process traumatic memories - Person is encouraged to think about the traumatic event while also focusing on other stimulation (eye movements, audio tones, tapping) - Works through neurological and physiological changes that help process and integrate traumatic memories

Trauma informed care - Must have complete picture of pts life situation, past and present, to provide effective health care with healing orientation - Recognizing and responding to the effects of all types of trauma - Recognizing s/s of trauma - Actively avoiding re-traumatization - Focus on what happened to you (not whats wrong with you) - Can improve pt engagement, treatment adherence, health outcomes, staff wellness

PTSD: inpatient management - Trauma informed care - Provider recognition of pts who may have PTSD - Collaboration - Individualized care - Inpatient issues that may affect PTSD – sleep hygiene, pain, anxiety, anger

________ disorder Symptoms children - Blaming self for event - Reliving event in thought or play - Sleep problems, nightmares - Upset when memories are triggered - Lack of positive emotions - Hypervigilance, easy startle - Helpless, hopeless, withdrawn - Denying event, feeling numb - Irritable, aggressive, self destructive - Problems concentrating - Detachment – people or places related to event - Lack of interest in enjoyable activities - Somatic symptoms – h/a, stomachaches, pain, memory problems Preschool children symptoms - reduction in play - play that involves traumatic event - social withdrawal - negative emotions

PTSD

PTSD children: treatment - depends on age, symptoms, general health, severity psychotherapy - CBT - Play therapy - EMDR Pharmacotherapy - SSRIs

Depersonalization and derealization disorder - Persistent or recurrent episodes of depersonalization, derealization, or both - May last hours – months - Impacts life ____________ – extremely uncomfortable feeling of being an observer of one’s own body or mental process - Focus is on the body - Feelings of unreality, detachment, or unfamiliarity with self - Detachment from entire self, aspects of self, feelings, thoughts, body parts or sensations ___________ – recurring feelings that one’s surroundings are unreal or distant - Focus is on the outside world - Person may feel like they are walking around in a fog, bubble or dream - Person may feel like there is an invisible veil between them and the rest of the world - Visual distortions – blurriness, widened or narrowed visual field, altered size of objects - Auditory distortions – muting or heightening sounds

Depersonalization Derealization

Depersonalization and derealization disorder : Treatment - Often short lived, resolve on own - Hypnosis - CBT - rTMS - no meds effective

Attachment disorders (general): Treatment - include primary caregiver(s) - positive interactions with child/caregiver/staff - attachment through 5 senses – hold, hug, touch, feed, talk, story telling, eating meals together - safe and stable living situation, medical needs, safety - nurturing, responsive, caring - consistent caregivers - education about d/o

Reactive Attachment d/o vs Disinhibited social engagement disorder? _____________ Consistent pattern of inhibited, emotionally withdrawn behavior to adults caregivers s/s - withdrawal - fear - sadness - irritability - listless - not seeking comfort or not chowing a response when comfort is given - lack of smile - watching others but not engaging in social interactions - lack of asking for help - lack of reaching out when picked up - lack of interest in playing interactive games – peekaboo

Reactive Attachment d/o

Reactive Attachment d/o vs Disinhibited social engagement disorder? __________ occurs in 1st 2 years of life Child approaches/interacts with unfamiliar adults with: - reduced reservation - overly familiar and violates social/cultural boundaries - doesn’t check with caregiver - willing to go with unfamiliar person without reservation evidence of severe social neglect - caregiver neglects child’s basic needs - repeated changes of caregiver (foster, institutional care) – stable attachment can’t occur

Disinhibited social engagement disorder

___________ disorder Emotional/behavioral reaction within 3 moths of exposure to stressor - ex: death of loved one - distress affects ability to function - reaction is out of proportion to stressor severity - symptoms end by 6 months symptoms - anxiety - depression - mixed - regressive behaviors - fearful - acting out

Adjustment