Transcript Anxiety related disorders

PSYCHIATRIC
NURSING
ANXIETY-RELATED DISORDER
Chapter 19
S
Objectives
S Discuss different types of psychophysiological,
somatoform and dissociative disorders
S Identify the etiology of these disorders and the
treatment modalities
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Anxiety-related disorders
•Psychophysiological responses to anxiety are those in which
it has been determined that psychological factors contribute to
the initiation or exacerbation of the physical condition.
•These responses have pathophysiological evidence or presence
of organic pathology.
•Certain psychological factors can influence the development
or exacerbation of, or delayed recovery from, different medical
conditions (p.368).
 Mental disorder (major depressive disorder)
 Psychological symptoms (depressed mood)
 Coping style (denial the need for care)
S
Introduction
 Maladaptive health behaviors (smoking, over eating)
 Stress-related physiological responses (tension headache)
S Somatoform disorders: physical symptoms suggesting
medical disease but without organic pathology or
pathophysiological mechanism.
S Are they classified as mental disorders???why??
S What is the difference between psychophysiological
responses and somatoform??
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What is the difference between psychosomatic
and somatoform disorders?
S Psychosomatic have a physical basis but are largely caused by
psychological factors such as stress and anxiety
S Somatoform have physical symptoms but can’t identify a
physical cause
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Anxiety-related disorders
S Somatization: all those mechanisms by which anxiety is
translated into physical illness or bodily complaints.
S Dissociative disorders/responses: disruption in integrated
functions of consciousness, memory, identity, or perception
of environment; they occur when anxiety becomes
overwhelming and personality becomes disorganized.
S Four general types of reaction to stress (Peplau, 1963):
Normal reaction (defense), Psychophysiological reaction
(somatic symptoms), Neurotic reaction (neurotic
symptoms), Psychotic reaction (misperception of the
environment) (p. 368).
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First: Psychophysiological disorders
S Asthma was found to be associated with those who have
fears and increased anxiety and depression.
S Cancer was found to be spreading with those having type C
personality (nice guy’s disease).
S Coronary heart disease: those with type A personality are at
risk of CHD
S Peptic ulcer: increased gastric secretion with feeling of
frustration
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Psychophysiological disorders
S Essential hypertension
S Migraine headache (migraine personality)
(perfectionists, inflexible)
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Second: Somatoform disorders (SD)
S SD are characterized by physical symptoms that suggest
medical disease, but that do not have demonstrable organic
pathology or known pathophysiological mechanism to
account for them.
S There is evidence or presumption that psychological factors
are the major cause of the symptoms of the SD.
S Somatization: those mechanisms by which anxiety is
translated into physical illnesses or body complaints.
S There are five types of SD
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1. Somatization disorder
S A syndrome of multiple somatic symptoms that cannot be
explained medically and that that are associated with
psychosocial distress and long-term seeking of assistance from health
care professionals.
S Symptoms are identified as recurring complain of pain (in at
least four different sites), GI symptoms ,sexual symptoms,
pseudo-neurological symptoms.
S Symptoms begins before 30 years old
S Other symptoms are: anxiety, depression, suicidal threats and
attempts, substance abuse and dependence.
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Somatization disorder
S Clients often receive medical care from several physicians.
S Seek relief through overmedicating with prescribed
analgesics or antianxiety agents. Therefore, drug abuse and
dependence are common.
S There is overlapping of personality characteristics and
features of histrionic PD: heightened emotionality,
impressionistic thought and speech, seductiveness and
strong dependency needs.
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Biopsychosocial
Biopsychosocial
Characteristics
Characteristics
of Somatoform
Disordersof
Somatoform Disorders
S Unconscious transformation of emotions into
physical symptoms to deal with stress
S Conversion disorder—impaired physical function
related to expression of a psychic conflict
S Pain disorder—pain experienced for no physiologic
basis and accompanied by psychological factors
Biopsychosocial
Characteristics
Biopsychosocial
- continued
Characteristics (cont'd)
S Hypochondriasis—preoccupation with fear/belief
of having a serious illness that is not present on
physical exam
S Body dysmorphic disorder—preoccupation with an
imagined defect in physical appearance that is
exaggerated and out of proportion
Biopsychosocial
Characteristics
Biopsychosocial
- continued
Characteristics (cont'd)
S Malingering—conscious falsification of illness, not
considered a psychiatric disorder
S Factitious disorder—psychological need to assume
the sick role
Theories
Theories
S Biologic, genetic, and psychosocial theories
S Biochemical brain imbalances that cause pain to
be experienced more intensely
Theories
continued
Theories (cont'd)
S Adoption and twin studies show both genetic and
environmental contributing factors.
S Communication theorists see symptoms as
nonverbal body language intended to
communicate a message to significant others.
Theories
continued
Theories (cont'd)
S Humanistic theorists view the client in context to
what is happening at the time.
S Life stressors like marital or work issues are
precipitants for somatic symptoms.
Somatoform
Disorders
Somatoform Disorders
S Not under voluntary control
S Have unconscious motivation
S Primary gain is reduction of anxiety
2. Pain disorder
S This disorder is characterized by severe and prolonged pain that
causes clinically significant distress or impairment in social,
occupational, and other important areas of functioning.
S Etiology of the pain may be evidenced by correlation of
stressful situations with the onset of the symptoms.
 Primary gain
 Secondary gain
S Characteristic behaviors include frequent visits to physicians in
an attempt to obtain relief, excessive analgesic use, and
requesting surgery.
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S Primary gain: produces positive internal motivations. For
example, a patient might feel guilty about being unable to
perform some task. If he has a medical condition justifying
his inability, he might not feel so bad. Alleviation of anxiety
that results from conversion of emotional conflict into
demonstrably organic illnesses.
S Secondary gain can also be a component of any disease, but
is an external motivator. If a patient's disease allows
him/her to miss work, avoid military duty, obtain financial
compensation, obtain drugs, or avoid a jail sentence, these
would be examples of secondary gain. Interpersonal or
social advantages gained indirectly from organic illness,
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such as an increase in attention
from others.
Question?
S What is the difference between somatization and pain
disorder?
 Somatization disorder is a multiple somatic syndrome
 Pain disorder is most commonly linked with patient’s
gain
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3. Hypochondriasis
S It is the person’s preoccupation with the fear/worry of
contracting, or the belief of having, a serious disease. The
preoccupation may be with specific organ or disease (e.g.
cardiac disease), or with bodily functions (e.g. heartbeat). Their
response to slight signs is usually unrealistic and exaggerated.
S Occasionally, medical disease may be present but in the
individual with this disorder, the symptoms are excessive
compared to the pathology.
S For example, those have hypochondriasis may become
convinced that a rapid heart rate indicate a serous heart disease,
a small sore on the skin is skin cancer, sounds in the intestine,
etc.
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Hypochondriasis
S Those people have a long history of ‘’doctor shopping’’.
S They are convinced they are not receiving proper treatment.
S Anxiety and depression are common and OCD frequently
accompany this disorder.
S Impaired social and occupational functioning.
S Even reading about a disease or hearing someone they know
has illness makes them distressed.
S Thought for the day: a little knowledge is a dangerous thing
(the nurse example).
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4. Conversion disorder
S Loss or change in body function (patient suffer from a
neurological symptoms) resulting from a psychological
conflict, the physical symptoms of which cannot be explained
by any known medical disorder or pathophysiological
mechanism.
S Affect voluntary motor or sensory functioning (called
“pseudo-neurological”).
S Examples of conversion disorders are: paralysis, aphonia,
difficulty swallowing, urinary retention, blindness, deafness,
anosmia, pseudocyesis (false pregnancy) and fits.
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Conversion disorder
S They are evidenced by presence of primary or secondary gain.
S Conversion symptoms serve to prevent internal conflicts or
painful issues from attaining awareness.
S Symptoms usually occur after a stressful situation, suddenly
appear, the individual expresses lack of concern to the impairment.
S Most of these symptoms resolve in days or weeks. Good
prognosis of blindness, aphonia, and paralysis; poorer
prognosis of seizures and tremor.
S E.g. in military.
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5. Body dysmorphic
disorder/Dysmorphophobia.
S Exaggerated belief that the body is deformed or defective in some specific
way. is preoccupation with an imagined or exaggerated defect in physical
appearance such as thinking one’s nose is too large or teeth are crooked and
unattractive.
S Examples: imagined or slight defects of the face or head (thinning hair,
acne, wrinkles, scars, facial swelling). Sometimes complaints include nose,
ears, eyes, mouth, lips, or teeth and may be other parts of the body.
S Concern the body image and physical features
S In some cases a true defect is present but the significance of the defect is
unrealistically exaggerated and the concern is excessive
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Body dysmorphic disorder
S Symptoms of depression and obsessive-compulsive personality
characteristics are common. Impairment in functioning is also
common due to excessive anxiety in relation to imagined
defect.
S Those people have history of visiting plastic surgeons and
dermatologists. They may undergo unnecessary surgeries to
correct imagined defect.
S Etiology is believed to be attributed to another pervasive
psychiatric disorder (schizophrenia, major mood disorder,
anxiety disorder) evidenced by improvement of the condition
by using serotonin-specific drugs.
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
Clinical Description
 Preoccupation With Appearance Imagined
Defect
 “Imagined” Ugliness
 Mirrors (Avoidance)
 Ideas of Reference
 Suicidal Ideation
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
Common Locations of Defects
 Hair
 Nose
 Skin
 Eyes
 Head / Face
 Lips
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Somatoform Disorders: True or
False?
S Discussion
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Nursing Diagnoses
S Ineffective coping
S Chronic pain
S Fear
S Disturbed sensory perception
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Third: Dissociative disorders (DS)
S DS is a disruption/breakdown in consciousness, memory,
identity, or perception of the environment.
S Dissociative responses occur when anxiety becomes
overwhelming (after a psychological trauma).
S In DS, defense mechanisms that usually govern
consciousness, identity, and memory break down, and
behavior occurs with little or no participation on the part of
the conscious personality (involuntary).
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Dissociation
S Dissociation is a continuum ranging from normal to
a disorder.
S Some people have the experience of driving a car
and suddenly realizing that they don’t remember
what happened during all or part of the trip.
S Some people find that sometimes they are listening
to someone talk and they suddenly realize that they
did not hear part or all of what was just said.
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Dissociation
S Some people find that they have no memory for some
important events in their lives (e.g. a wedding or
graduation).
S Some people sometimes have the experience of feeling
that other people, objects, and the world around them
are not real.
S There are four types of DS.
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1. Dissociative amnesia
S Inability to recall important personal information, usually of
traumatic or stressful nature, that is too extensive to be
explained by ordinary forgetfulness and is not related to
substance abuse or medical conditions or neurological or
other medical disorder.
S There are five types of recall disturbance: localized, selective,
continuous, generalized, systematized. Example (car
accident)
S Onset of amnesia usually follows a severe psychological
stress, termination is abrupt and followed by complete
recovery. Recurrences are unusual.
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2. Dissociative Fugue
S Sudden, unexpected travel away from home or place of daily
activities, with inability to recall some or all of one’s past.
(feels like they don’t belong)
S Confusion (they cannot recall personal identity and often
assume a new identity).
S They can provide details of their earlier life, but cannot recall
things after the fugue state.
S Duration is usually brief (hours, days, rarely months).
S Recovery is rapid and complete. Recurrences are unusual.
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3. Dissociative identity (Multiple
personality) disorder
S The existence of two or more personalities within a single
individual. Only one of the personalities is evident at any given
moment, and one of them is dominant most of the time over the
course of the disorder. each of them is amnesic of the other/s.
S Each personality is unique and responds to stress in a different
way.
S Personality IQ’s, components and transitions??
S Those people are misdiagnosed with borderline and antisocial
personality disorders, depression, schizophrenia, epilepsy, or
bipolar disorder before they are38diagnosed with DID.
4. Depersonalization disorder
S Occurrence of persistent feelings of unreality, detachment
from one’s self or one’s body.
S This disorder is more common in women and young people.
S It is common in all psychiatric disorders.
S It is estimated that half of the adults experience transient
episodes.
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Theories: Dissociative
Disorders
S Biological factors
S Serotonin
S Limbic system
S Physical illnesses and certain drugs
S Various personality states in dissociative identity
disorder have different activity in frontal and
temporal lobes.
Theories: Dissociative
Disorders (cont'd)
S Genetic theories:
S Dissociative disorder occurs more often in first-
degree biologic relatives
Theories: Dissociative
Disorders (cont'd)
S Psychosocial theories:
S Current explanations are based on Freud’s dynamic
concepts.
S Repression of ideas leads to amnesia, to protect
oneself from emotional pain.
S Dissociative identity disorder is a result of childhood
chronic trauma.
Theories: Dissociative
Disorders (cont'd)
S Behavioral theories:
S Dissociative disorders are learned behaviors that
provide protection from a painful experience.
Theories: Dissociative
Disorders (cont'd)
S Humanistic theories:
S The person is a composite of life experiences,
psychobiological factors, and interpersonal
interactions.
Care of Clients with
Dissociative Disorders
S Dissociation is a defense against trauma that
separates emotions from behaviors.
S Dissociation is a response to extreme childhood
trauma.
S Consciousness, memory, identity, or perception of
environment can be impaired.
Care of Clients with
Dissociative Disorders
(cont'd)
S Most clients with dissociative disorder seen in
community rather than inpatient settings
S Obtain subjective and objective data
S Complete psychosocial and physical assessment
Nursing Diagnoses
S Disturbed thought processes
S Ineffective coping
S Disturbed personal identity
S Disturbed sensory perception
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Etiological implications for SD
S Genetics: increased incidence in first degree relatives
(somatization and hypochondriasis)
S Biochemical: decreased levels of serotonin and endorphins
S Psychodynamic (ego defense mechanism, physical complains
are the expressions of low self-esteem and feeling of
worthlessness) AND (moral or ethical unacceptable emotions
are converted into physical symptoms)
S Learning theory (the sickness relieves the individual from the
need to deal with a stressful situation).
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Etiological implications for SD
S Family dynamics ( the child example, somatization by
the child brings stability to the family)
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Medical Treatment modalities
S Individual psychotherapy
S Group therapy
S Behavioral therapy
S Psychopharmacology
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Importance
of
Importance
of Comprehensive
Comprehensive
Assessment
Assessment
S Client will present with multiple complex
problems.
S Utilize nursing process to systematically assess
and deliver care.
S Remain cognizant of your own values, beliefs,
feelings, and nonverbal behaviors.
Importance
of
Importance
of Comprehensive
Comprehensive
Assessment
- continued
Assessment (cont'd)
S Clients will report physical symptoms for which
there is no evidence of physiologic cause.
S Always rule out physical causes for symptoms.
Comprehensive
Comprehensive
Assessment
Assessment
S Obtain subjective and objective data.
S Consider psychobiologic factors and utilize critical
thinking.
S Be alert to responses indicative of la belle
indifference and/or the client who is overly
dramatic and emotional when symptoms are
discussed.
Comprehensive
Assessment
Comprehensive
continued
Assessment (cont'd)
S Careful interviewing reveals a stressful life event
with which the client is not coping.
S Suggests that preoccupation with somatic
disorder is way of avoiding underlying conflict
Comprehensive
Assessment
Comprehensive
continued
Assessment (cont'd)
S Gathering objective data includes thorough
physical exam, lab work, and radiologic or other
studies
Personal
Challenges
to
Personal Challenges to
Professional
Practice
Professional Practice
S Focus on your feelings and be cognizant of your
reactions.
S Monitor your own feelings of defensiveness,
impatience, frustration, or anger toward the
client.
S Practice increased self-awareness.
Personal
Challenges
to
Personal
Challenges
to
Professional
Practice
Professional
Practice
- continued
(cont'd)
S Don’t judge, criticize, or make assumptions.
S Pain is determined and defined by the client.
S Pain of psychic origin is as hurtful as pain of
biologic origin.
Personal
Challenges
Personal
Challenges
- continued
(cont'd)
S Be alert for signs of secondary gain.
S Avoid reinforcing negative behaviors.
S Address client with a matter-of-fact approach.
S Reinforce adaptive vs. maladaptive behaviors.
THANK YOU
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