Transcript your assessment approach - N204 & N214L Psychiatric / Mental

Psychiatric / Mental Health Nursing
Anxiety Disorders and Dissociative
Disorders
West Coast University
NURS 204
Learning Objectives
 Identify theories in understanding anxiety disorders and dissociative
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disorders
Explain the concept of anxiety and how it relates to anxiety
disorders and dissociative disorders
Compare and contrast both the common themes and distinctive
characteristics of anxiety disorders with dissociative disorders.
Incorporate how dissociation serves as a defense mechanism for
some individuals experiencing trauma into the care of clients with
dissociative disorders
Conduct a comprehensive assessment in the care of clients with
anxiety and dissociative disorders.
Learning Objectives
 Design a plan of care for intervening into mild, moderate,
severe, and panic levels of anxiety.
 Educate clients and their families about pharmacologic
and non-pharmacologic measures for anxiety disorders
and dissociative disorders
 Identify the possible personal challenges in caring for
clients with anxiety disorders and dissociative disorders.
Theories: Anxiety Disorders
Biological changes in the brain
 Noradrenergic system is sensitive to norepinephrine;
locus ceruleus is involved in precipitating panic
attacks.
 Dopamine system involved in pathophysiology of
OCD.
 GABA dysfunction affects development
of panic disorder.
Locus Caeruleus
Theories: Anxiety Disorders - continued
 Abnormal control of glutamate plays role in anxiety disorders.
 Hormonal changes in pregnant women affect certain anxiety
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disorders.
Lactic acid may precipitate anxiety.
Caffeine and nicotine may trigger panic attacks.
Genetic theories: strong evidence for familial or genetic
predisposition for anxiety disorders
Psychosocial theories: in psychoanalytic theory, anxiety is
viewed as sign of psychologic conflict; anxiety is the outcome
of repressing forbidden impulses
Theories: Anxiety Disorders - continued
 Behavioral theory
 Anxiety is a learned response that can be unlearned.
 Compulsive behavior is a maladaptive attempt to alleviate
anxiety.
 Behavior modification teaches new ways to behave
 Humanistic theories:
 Environmental stressors, biological factors, and intrapsychic
fears cannot be dealt with separately but rather as they interact
with one another.
 Treatment approaches are integrative.
Anxiety
 A universal experience
 A normal response that usually helps cope with
threatening situations
 Anxiety disorders are characterized by anxiety so
disabling as to adversely affect day-to-day
functioning
 Affects all age groups
Anxiety - continued
 Anxiety disorders are most common of mental
illnesses
 All anxiety disorders have in common excessive,
irrational fear and dread
 Anxiety is either a dominant disturbance or an
avoidance behavior
 Free-floating anxiety is unrelated to a specific
stimulus
Anxiety - continued
 Panic disorder
 Phobia
 Social Phobia
 Agoraphobia
 Specific Phobia
 Generalized Anxiety Disorder (GAD)
 Obsessive Compulsive Disorder
 Post-Traumatic Stress Disorder
 Acute Stress Disorder
Panic Disorder
 Recurrent attacks of severe anxiety lasting a few
moments to an hour.
 No stimulus but occur suddenly and spontaneously.
 Experience physical symptoms
 Mimic symptoms of MI and mitral valve prolapse
Phobias
 Agoraphobia: Fear of being alone or in public places
from which escape might be difficult or help might
not be available.
 Social Phobia: Fear of extreme embarrassment.
 Specific Phobia: Fear of specific objects and
situations
Generalized Anxiety Disorder (GAD)
 Pervasive, persistent anxiety of at least 6 months’
duration but without phobias, panic attacks, or
obsessions and compulsions.
 Chronic feeling nervousness and apprehension for
no apparent reason and is unable to control the
worry.
 Unable to relax or stop worrying.
 Irritable, muscle tension, insomnia, SOB, and
dizziness.
Obsessive-Compulsive Disorder
 Obsession: recurring thought that cannot be
dismissed from consciousness.
 Compulsion: uncontrollable, persistent urge to
perform certain acts or behavior in order to relieve
unwanted thoughts.
 Fear that they will harm someone.
 Trivial, ridiculous, morbid, violent or contamination.
Common Obsessive-Compulsive Behaviors
 Repetitious hand washing – Urge to wash, scrub, or
clean – Fear of disease or contamination.
 Returning home often to make sure appliances are
turned off – Need to recheck related to self-doubt –
Fear of disaster.
 Hoarding junk mail, receipts, and all types of papers
– Need to keep everything – Fear of losing things.
 Ritualistic counting of number of stairs climbed –
Urge to count repeatedly – belief that counting will
yield control and thus prevent making mistakes.
Post-Traumatic Stress Disorder
 Experience of a significant stressor or trauma
 Hyperarousal when reexperiencing the traumatic
event: unable to relax, hypervigilance, always “on
edge”
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Acute: symptoms last less that 3 months.
Chronic: symptoms last 3 months or more.
Delayed onset: at least 6 months have elapsed between
trauma and the occurrence of symptoms.
YOUR ASSESSMENT APPROACH:
The Client with Anxiety Disorder
YOUR ASSESSMENT APPROACH:
The Client with Panic Attack
Nursing Diagnosis:
 Fear
 Anxiety
 Ineffective coping
 Ineffective role performance
 Impaired verbal communication
 Risk for trauma
 Disturbed thought process
 Ineffective tissue perfusion
 Insomnia
Nursing Outcome Identification: NOC
 Client will demonstrate absence of physical
manifestation of anxiety.
 Client will identify indicators of own anxiety anxiety.
 Client will verbalize feelings of anxiety appropriately.
 Client will demonstrate the use new coping skills.
Plan of Care for Anxiety
 Mild to moderate anxiety
 Use a calm, quiet approach
 Observe client’s verbal/nonverbal behavior
 Encourage client to verbalize feelings
 Teach relaxation techniques (meditation, guided imagery, etc.)
when anxiety is mild
 Simple physical activities often help reduce anxiety
 Develop goal-oriented contract
Plan of Care for Anxiety - continued
Severe to panic levels of anxiety:
 First priority is to reduce anxiety to tolerable levels.
 Stay with the client.
 Provide a safe and supportive milieu.
 Use a firm voice and short, simple sentences.
 Place client in quieter, smaller, less stimulating
environment; focus the client’s diffuse energy on
repetitive task or tiring task.
 Administer antianxiety medication if ordered.
Dissociative Disorder
Theories: Dissociative Disorders
 Biological factors
 Serotonin
 Limbic system
 Physical illnesses and certain drugs
 Various personality states in dissociative identity disorder have
different activity in frontal and temporal lobes.
 Genetic theories:
 Dissociative disorder occurs more often in first-degree biologic
relatives
Theories: Dissociative Disorders - continued
 Psychosocial theories:
 Current explanations are based on Freud’s dynamic concepts.
 Repression of ideas leads to amnesia, to protect oneself from
emotional pain.
 Dissociative identity disorder is a result of childhood chronic
trauma.
 Behavioral theories:
 Dissociative disorders are learned behaviors that provide
protection from a painful experience.
 Humanistic theories:
 The person is a composite of life experiences, psychobiological
factors, and interpersonal interactions.
Distinctive Characteristics of Dissociative Disorder
 Consciousness, memory, identity, and perception of
environment are impaired.
 Dissociation is a defense against trauma that separates
emotions from behaviors.
 Dissociation is a response to extreme childhood trauma.
 Dissociation
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Emotional numbing
Impaired social relationships
Separates emotions from behaviors
Dissociative Disorder
 Dissociative amnesia
 Dissociative fugue
 Dissociative identity disorder
 Depersonalization disorder
Care of Clients with Dissociative Disorders
 Most clients with dissociative disorder seen in community
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rather than inpatient settings
Obtain subjective and objective data
Complete psychosocial and physical assessment
Decide whether priority is to alleviate symptoms or reintegrate
anxiety-producing conflict.
Behavioral modification helps alleviate some problematic
behaviors.
Provide safe, supportive environment.
Teach desensitization to conflict.
Medication plays a key role in treatment.
YOUR ASSESSMENT APPROACH:
The Client with Dissociative Identity Disorder
YOUR ASSESSMENT APPROACH:
The Client with Depersonalization Disorder
Common Themes
 Anxiety disorders and dissociative identity disorder originate
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in childhood.
Major common theme = disabling anxiety
Other common features: personality and mood changes,
distorted perceptions, inability to concentrate, memory
impairment, defense mechanisms
Both anxiety and dissociative disorders may have underlying
comorbid illnesses like depression or substance abuse.
Both disorders profoundly affect quality of life.
Psychotropic medications and teaching adaptive coping are
mainstays of treatment.
A holistic approach is best for caring for these clients.
Comprehensive Assessment
 Conduct a history and physical exam.
 Gather subjective and objective information.
 Interview family member(s) if possible.
 Complete psychosocial assessment to discover source of
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anxiety.
Differentiate between anxiety and depression.
Evaluate sleep and sleep quality.
Complete suicide and homicide assessment.
Major focuses for a client with dissociative disorder are
identity, memory, and consciousness.
Client/Family Education
 Medications used to treat anxiety disorders include
benzodiazepines, tricyclics, SSRIs and SNRIs,
lithium, beta blockers, alpha-adrenergic antagonists,
atypical antipsychotics, and neuroleptics.
 Teach about medication indications, side effects, and
drug–drug interactions.
Client/Family Education - continued
Teaching about medications
 Drowsiness is a common side effect.
 Do not drink alcohol while taking.
 Drink decaffeinated beverages.
 Do not take other medications or adjust dosage in
any way without consulting health care provider.
Client/Family Education - continued
Nonpharmacologic measures comprise effective coping
skills:
 CBT techniques (desensitization, reciprocal
inhibition, cognitive restructuring)
 Relaxation training
 Individual or group therapy
 Exercise and nutrition
Personal Challenges
 Anxiety is contagious.
 The nurse may be impatient and irritated by somatic
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complaints.
It is important to identify the source of one’s own anxiety and
consistently role-model adaptive behavior.
A client’s avoidance mechanism can be challenging to staff.
Some nurses feel overwhelmed and helpless in the face of
clients’ pain and catharsis.
Ready answers are more likely to interfere with client’s
communication.
Psychopharmacology - Anxiolytics
 Anti-anxiety medication relieve insomnia, anti-
convulsant, muscle relaxant, alcohol withdrawal
 Side effect: Sedation, mental confusion, amnesia,
ataxia
 May cause withdrawal symptoms: anxiety, insomnia,
seizure, muscle tension
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Important to taper dose by no more that 25% per week to
prevent withdrawal symptoms
Psychopharmacology - Anxiolytics
 Benzodiazepines
 Alprazolan - Xanax (0.25 - 4 mg/d)
 Chlordiazepoxide - Librium (50 - 300 mg/d)
 Clonazepam - Klonopin (0.25 - 4 mg/d)
 Clorazepate - Tranxene (15 - 10 mg/d
 Diazepam - Valium (15 - 40 mg/d)
 Lorazepam - Ativan (1 - 10 mg/d)
 Oxazepam - Serax (30 - 120 mg/d)
Psychopharmacology - Anxiolytics
 Other Anxiolytics and Sleep Medication
 Buspiron - Buspar (10 - 60 mg/d)
 Zolpidem - Ambien (5 - 10 mg/d)
 Zaleplon - Sonata (10 mg/d)
 Eszopiclone -Lunesta (1-3 mg/d)
 Rameltoeon - Rozerem (8mg/d)
 Cholral Hydrate - Noctec (500 - 2000 mg/d)
 Diphenhydramine - Benadryl, Sominex, Nytol (25 - 100 mg/d)
Review Questions
 The nurse is assessing a client who exhibits great
discomfort and anxiety and continually asks to go
home, as he is certain he will lose bladder control if
he does not leave soon. This behavior is consistent
with a diagnosis of:
1. Acute stress disorder.
2. Obsessive-compulsive disorder.
3. Agoraphobia.
4. Acrophobia.
Review Question
 Which assessment question would indicate that the
nurse understands the distinct characteristics of
cognition in anxiety?
1. “Do you feel sad and/or hopeless?
2. “How often do you lose your temper?”
3. “How often do your criticize yourself?”
4. “How often do you worry about the past or
future?”
Review Question
The development of an alternate personality, or alter,
in the client with dissociative identity disorder
usually arises as a response to:
1. Physical illness.
2. Substance abuse.
3. The demands of adulthood.
4. Chronic child abuse.
Review Question
 The client experiences feelings of extreme fear that
occur for no apparent reason and are accompanied
by intense physical symptoms. The priority nursing
intervention would be to:
1. Encourage the client to verbalize feelings.
2. Counsel the family on therapeutic responses.
3. Stay with the client.
4. Teach relaxation techniques.
Review Question
 To evaluate the effectiveness of medications used to
treat a client’s anxiety, the nurse should:
1. Monitor the client’s anxiety level.
2. Help the client understand the source of the
anxiety.
3. Demonstrate patience and project a sense of
calm.
4. Expect SSRIs to cause more side effects.
Review Question
 To help a client reduce his/her anxiety level, the
nursing priority would be to:
1. Teach relaxation exercises.
2. Involve the client in unit activities.
3. Encourage 1:1 interaction with peers.
4. Encourage the client to acknowledge and
discuss feelings.
Review Question
 The nurse is finding it difficult to listen to a client’s
expression of pain, fear, anger, and other feelings.
The nurse must focus on:
1. Listening attentively and with concern.
2. Providing quick and ready answers.
3. Giving advice.
4. Changing the subject to a more positive one.
Resources
 http://www.adaa.org
The Anxiety Disorders Association of America (ADAA) is a national
nonprofit organization dedicated to the prevention, treatment, and cure
of anxiety disorders and to improving the lives of all people who suffer
from them.
 http://www.isst-d.org
The International Society for the Study of Trauma and Dissociation is a
professional association organized to develop and promote
comprehensive, clinically effective, and empirically based resources and
responses to trauma and dissociation.
 http://www.ncptsd.va.gov/ncmain/information
The National Center for Posttraumatic Stress Disorder Information
Center provides information to interested individuals, including
veterans and their family members.
Resources
 http://www.socialphobia.org
The Social Phobia/Social Anxiety Association site offers
further links to topics such as current news, treatment, and
local group availability.
 Kneisl, C.R., Trigoboff, E. (2009). Contemporary
psychiatric-mental health nursing. Anxiety and
Dissociative Disorder (2nd ed.) (pp. 443-477). Upper
Saddle River, NJ: Pearson Education.