Anxiety, Trauma and Stressor Related Disorder.pptx

MHN, anxiety, stress, disorders

1. Sagun Lohala MN, Psychiatric Nursing Welcome

2. Anxiety Feelings experienced when one’s body responds to a frightening or threatening experience with ultimate purpose to protect an individual. Thus, can be considered as flight or fight response

3. Conceptual Model for Grief and Anxiety 2/1/2024 (Townsend,2010) 3

4. Generalized Anxiety Disorder (GAD) Anxiety is unvarying and persistent Not related to specific persons or situations Overly concerned about everyday matters such as health, finances, death, family, relationship concerns, or work difficulties Most common neurotic disorder Occurs most frequently in women Symptoms should last for at least 6 months in order to make a diagnosis

5. Incidence 4% of the global population currently experience an anxiety disorder Anxiety disorders are the world’s most common mental disorders, affecting 301 million people in 2019. Symptoms of anxiety often have onset during childhood or adolescence, younger people less than 45 years,

6. Cont’d… More prevalent in woman, Divorced Separated Lower socio-economic status There are highly effective treatments for anxiety disorders. Approximately 1 in 4 people with anxiety disorders receive treatment for this condition.

7. Causes Exact cause is not clear. Some of the reasons that are proposed are: Genetic: An anxious personality may be found to run in families Psychological Factor Childhood Trauma: Trauma in the form of abuse, death of a parent. Predisposes an individual for anxiety-related disorders Severe Stress: Stress in life may trigger anxiety-related symptoms in individuals undergoing the stress

8. Cont’d… Bio-chemical Factor: Disturbance in neurotransmitters especially nor-adrenaline, serotonin and gamma amino butyric acid may cause anxiety disorder Behavioral Theory: learned through one’s experience Environmental Factor: low socio-economic status may cause anxiety problem

9. Psychological Symptoms: Irritability Sensitivity to noise Restlessness, feeling of irritability, and muscle tension Poor concentration Worrying thoughts and fear Feels tired easily Poor sleep- initiation or terminal insomnia Physical Symptoms: Gastrointestinal changes Respiratory changes Cardiovascular changes Sleep disturbance Genitourinary changes Neuromuscular symptoms Clinical Features

10. Diagnosis History taking about the symptoms, causes or predisposing factors and any related stressful events, childhood experiences, parenting, environmental factors, etc. MSE of patient which helps to find out current features Baseline investigations

11. DSM V Criteria for GAD Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities. The individual finds it difficult to control the worry

12. Cont’d… The anxiety and worry are associated with at least 3 of the 6 symptoms (only 1 item is required in children) Blanking out Easily Fatigued Disturbed Sleep Keyed up, on edge, or restless Irritability Muscle tension Mnemonic B E S K I P

13. Cont’d… The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning The disturbances is not attributed to the physiological effects of substance use or another medical condition The disturbance is not better explained by other mental disorders

14. Treatment Anti-anxiety drugs: Benzodiazepines are found to be good to reduce anxiety but the drug can cause dependence. Thus, can be given for 2 to 4 weeks Antidepressant: are also good to treat anxiety disorder. Might take longer duration for treatment but can be continued for long term

15. Treatment Cognitive Behavior Therapy: are helpful to change the cognition towards self. It can be given with weekly session of 1 to 2 hours for about 4 months Distractive activities to focus away from the stressful factor, like engaging in demanding mental activity Self-help groups to relate to anxiety of others Anxiety management with progressive muscle relaxation therapy, guided imagery, biofeedback

16. Nursing Interventions Nursing management starts with the assessment Assess the nature of stress Assess the pattern of though that might be faulty Assess the type of defense mechanism used often or ineffectively Maintain safety for the client and the environment

17. Cont’d… Assess for presence of any medical condition, like Acute myocardial infraction Substance intoxication Complex partial seizure Pheochromocytoma Assess the level of anxiety and make a conscious effort to remain calm as anxiety is transferable from one person to another person

18. Cont’d… Assess for impairment in social, occupational, and other areas of functioning Assess for the level of knowledge, regarding effects of psychological problems on the body

19. Cont’d… Limit CNS stimulant , limiting stimulant prevents physical symptoms of anxiety, such as heart rate Provide a non-stimulating environment Help client to build positive coping strategies Instruct client to follow anxiety reducing strategies Identification of supportive person

20. Conversion Disorder

21. Introduction A psychological condition that causes symptoms that appear to be neurological, such as paralysis, speech impairment, or tremors, but with no obvious or known organic causes Previously known as Hysteria

22. Cont’d… Characterized by neurological symptoms which are not explained by any known neurological or medical condition Unaware so unable to control their symptoms Categorized as a type of somatic symptom disorder according to DSM-5

23. Cont’d… Lifetime prevalence rates of conversion disorder are between  11–300 per 100,000 people 5–14%  of general hospital patients are diagnosed with conversion disorder 1–3%  of outpatient referrals to psychiatrists are diagnosed with conversion disorder

24. Cont’d… 5–25 %  of psychiatric outpatients are diagnosed with conversion disorder An estimated  20–25%  of those in a hospital setting meet some of the criteria for conversion disorder diagnosis Conversion disorders are  more common  in adult women than men, with at least twice the number of women diagnosed with conversion disorder than men

25. Cont’d… Conversion disorders are more common in populations of individuals that have  less education  and lower socioeconomic status Compared to developed countries, third-world or developing countries can have up to a  31%  prevalence rate

26. Signs and symptoms Symptoms usually appear after a situation that produces stress all of sudden; symptoms might disappear as it appeared Symptoms promotes secondary gain as a way to obtain attention or support

27. Cont’d… Motor symptoms or deficits Impaired coordination or balance Weakness/ paralysis of a limb or the entire body Difficulty swallowing or a sensation of a lump in the throat Impairment or loss of speech Urinary retention Tremor Gait problems Fainting

28. Cont’d… Sensory symptoms Impaired vision Double vision Impaired hearing Loss or disturbance of touch or pain sensation Numbness

29. Diagnostic Measures History taking Physical examination CT and MRI scans: EEG

30. DSM V Criteria for Diagnosis There must be at least one symptom of sensory or motor impairment. Symptoms are not caused by a neurological condition, physical disease, or substance use. Symptoms are associated with significant distress. Symptoms are not better explained by another physical or psychological condition.

31. Management Pharmacological management Anxiolytic drugs Anti-depressant drugs Non-pharmacological management Psychotherapy Cognitive behavioral therapy Individual psychotherapy Group therapy Relaxation therapy Meditation ECT and TMS

32. Nursing Interventions Protect the patient from harm or injury during dissociative episodes Demonstrate to the client the importance of discussing stress situations and exploring associated feeling Structure the environment to reduce stimulation, such as loud noises, bright lights, or extraneous movements

33. Cont’d… Praise the client for using effective coping strategies Engage the client in appropriated therapies Approach the client in a clam, direct, non-authoritarian manner, using a soft tone of voice Assist the client to gain control of overwhelming feelings through verbal interactions

34. Cont’d.. Teach the client social skills, and encourage him or her to practice these skills with staff members and other client Provide feedback regarding social interactions Encourage to practice progressive muscle relaxation therapy

35. Cont’d.. Provide feedback regarding social interactions Encourage client to pursuer personal interests, hobbies, and recreational activities Encourage the client to identify supportive people outside the hospital and to develop these relationships

36. Thank you !!!

37. Phobias A type of anxiety disorder that causes an individual to experience extreme, irrational fear about a situation, living creature, place or object

38. Definition Phobia is a strong persistent fear of situation, objects, activities, or persons. The main symptom of this disorder is the excessive, unreasonable desire to avoid the feared subject

39. Causes Result of both internal predisposition of an individual along with external events. The external factors include the theory of classical conditioning Internal factor for phobia is because of the heredity, genetics and brain chemistry

40. Cont’d… Many phobias may be traced back to specific events that have happened mostly during the childhood and have been perceived a traumatic

41. Most Common Phobias Social phobia: An excessive fear of intimate social situations such as small groups of people, parties, etc. These people avoid people they do not know due to the fear that they may be overly critical of them

42. Most Common Phobias Specific phobia: These are fears which are experienced in terms of specific situations, or objects. The fears occur more in female and are more due to childhood experiences, eg , claustrophobia, fear of needles, fear of sight of blood

43. Agoraphobia: Fear of open places. Fear might be in conditions like crowded places Its onset is in adolescence and early adulthood People with this disorder may also experience anxiety, depression and panic .

44. Symptoms of Phobia

45. DSM V Criteria for Phobias Marked fear or anxiety about a specific object or situation. The phobic object or situation almost always provokes immediate fear or anxiety. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context .

46. Cont’d… The phobic object or situation is actively avoided or endured with intense fear or anxiety. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more .

47. Cont’d… The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms; objects or situations related to obsessions; reminders of traumatic events; separation from home or attachment figures; or social situations.

48. Treatment Pharmacotherapy Beta blockers are helpful for reduction of physical signs of anxiety that can accompany phobia Antidepressants SSRI group of drugs are commonly prescribed for people with phobias with better moods Tranquilizers are helpful for reduction of anxiety symptoms

49. Cont’d… Desensitization or Exposure therapy This can alter the response to the source of fear People are gradually exposed to the cause of phobia over a series of escalating steps First think about flying. The therapist will have them look at pictures of planes. The person will go to an airport. They will escalate further by sitting in a practice simulated airplane cabin. Finally, they will board a plane.

50. Cont’d… Cognitive Behavior Therapy: It is helpful for modification of thought pattern in order to handle the phobia Counselling: Supportive therapy where person is motivate to seek help and identify the best means of handling the phobia Relaxation Therapy are helpful for reduction of symptoms of anxiety.

51. Nursing Management Assessment Assess for the nature of the stress Assess for the pattern of thought that may be precipitated by a ‘conditioned’ response or may be modified Assess for the ego defense mechanisms used in excess or ineffectively

52. Assess for the impairment in social, occupational and other areas of functioning Assess for the level of knowledge regarding effects of psychological problems on the body Cont’d…

53. Interventions Reassure the patient of safety and security Maintain a calm and non-threatening approach Explore the patient’s perception of the threat to physical integrity of self-concept Discuss reality of the situation with the patient to recognize aspects that may be changed and those that cannot Cont’d…

54. Encourage decision making related to alternative coping strategies Encourage the patient to explore the underlying feelings that contribute to irrational fears Encourage the patient to face these fears rather than suppress it Reinforce the patient positively when adaptive methods are identified and used Cont’d…

55. Panic Disorder

56. Panic is derived from Greek word “Pan” which means god of the woods who produce mysterious sounds causing intense fear among both herbs and people A condition where the individual has a feeling of terror that strikes suddenly and repeatedly with no warning Cont’d…

57. Causes Specific cause: No specific causes of panic Genetic: Panic disorder has been found to run in families, and this may mean that inheritance has a role to play; more in first degree relatives Stress theory: The body’s normal “alarm system”, the set of mental and physical mechanisms that allows a person to respond to a threat, tends to be triggered unnecessarily when there is no danger

58. Bio-psycho-social model: It is because of the biological vulnerabilities, ways of thinking and the social stressors Nutritional Causes: It is proposed that deficiencies of zinc or magnesium deficiencies may also cause risk for development of panic disorder. Consumption of large amount of tea and coffee are also considered as causes for the panic Cont’d…

59. Psychodynamic theory: According to psychodynamic theory, anxiety is a result of loss of love and support from the mothering figure, resulting in an increased dependency need. Social Causes: An individual who has been abused sexually or emotionally is prone to panic disorders Cont’d…

60. Symptoms

61. Heart pounding Increased perspiration Tingling and numbness of extremities Feeling of flushed or chilled feeling Chest pain Sense of unreality-depersonalization and derealization Cont’d…

62. Fear of impending doom Loss of control Fear of a cardiac symptoms- due to palpitation Fear of losing one’s mind or fear of death Avoidance of situation where one fears the occurrence of the panic attack In some severe cases the patient may fail to carry out the activities of daily living Cont’d…

63. DSM V Criteria for Panic Attack The diagnostic criteria for panic disorder are defined in the DSM-5. It is an  anxiety disorder  based primarily on the occurrence of panic attacks, which are recurrent and often unexpected

64. In addition, at least one panic attack is followed by one month or more of the person fearing that they will have more attacks and causing them to change their behavior, which often includes avoiding situations that might induce an attack. It's important to note that a panic disorder diagnosis must rule out other potential causes for the panic attack (or the event that feels like one ). Cont’d…

65. The attacks must not be due to the direct physiological effects of a substance (such as drug use or a medication) or a general medical condition . The attacks must not be better accounted for by another mental disorder. These may include a social phobia or another  specific phobia ,  obsessive-compulsive disorder  (OCD),  post-traumatic stress disorder  (PTSD), or  separation anxiety disorder . Cont’d…

66. Management Drug Therapy Anxiolytic (benzodiazepines) SSRI group of antidepressant drugs Psychosocial Therapies Educating the patient about mind and body relationship It also involves educating patient about early identification of signs and symptoms

67. Cognitive Behavior therapy Educating the patient to recognize and control their reaction. Teach the patient to recognize the things that trigger panic attacks or worsen the symptoms. They are also taught to modify their behavior rather than avoiding the feared place and situation . Cont’d…

68. Behavioral therapy This involves gradually introducing the patient to the panic inducing situation. Because the patients with panic tend to have associated phobias which may be specific, social, or agoraphobia, this therapy is tailor-made for the specific experience of the people. Cont’d…

69. Group therapy This may be indicated for the purpose of learning and practicing newly learned skills. Psychoeducation are more fruitful for those patients Biofeedback Cont’d…

70. Nursing Management Assess for the unpredictable onset of symptoms Assess for the nature of stress Assess for the impairment in society, occupation, and other areas of functioning Assess for the level of knowledge regarding effects of psychological problems on the body

71. Possible Nursing Interventions Help the patient see the relationship between what he thinks, feels and behaves Reassure the patient of safety, security by recognizing the physical complaints as real for the patient Maintain a calm and non-threatening approach Speak in simple language using small sentences as the patient is unable to comprehend during periods of intense anxiety

72. Provide environment free of stimuli or minimum stimuli When the anxiety is lowered explore the cause for panic attack Administer anxiolytic as prescribed Teach the patient to evaluate the effectiveness of each of the interventions used to prevent escalation Cont’d…

73. Reinforce the patient positively when adaptive methods are identified and used Reinforce the patient when he views himself and his abilities realistically Encourage the patient to practice anxiety reducing techniques even before approaching the anxiety producing situation Cont’d…

74. Encourage to verbalize the feelings related to these aspects Assist the patient to anticipate the future problems that may provoke anxiety escalating to panic Role play to demonstrate management of stressors and problems commonly faced Cont’d…

75. Obsessive Compulsive Disorder A long-lasting disorder in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviors (compulsions), or both People with OCD have time-consuming symptoms that can cause significant distress or interfere with daily life.

76. Causes Genetics: People with first-degree relative (biological parent or sibling) with OCD are at a higher risk for developing the condition. The risk increases if the relative developed OCD as a child or teen.

77. Neurochemical Factor: Low serotonin levels, a brain chemical Brain Structure: Imaging studies have shown differences in the frontal cortex and subcortical structures of the brain in people who have OCD. Cont’d…

78. Life events: Childhood trauma, abuse or negligence Personality: Neat,   meticulous, methodical people with high personal standards may be more likely to develop OCD, also people who are generally quite anxious or have a very strong sense of responsibility for themselves and others Cont’d…

79. Signs and Symptoms of OCD Obsessions  are repeated thoughts, urges, or mental images that are intrusive, unwanted, and make most people anxious. Common  obsessions  include: Fear of germs or contamination Fear of forgetting, losing, or misplacing something Fear of losing control over one’s behavior

80. Aggressive thoughts toward others or oneself Unwanted, forbidden, or taboo thoughts involving sex, religion, or harm Desire to have things symmetrical or in perfect order Cont’d…

81. Compulsions  are repetitive behaviors a person feels the urge to do, often in response to an obsession. Common compulsions include: Excessive cleaning or handwashing Ordering or arranging items in a particular, precise way Repeatedly checking things, such as that the door is locked or the oven is off Compulsive counting Praying or repeating words silently Cont’d…

82. DSM 5 Criteria for OCD Presence of obsessions, compulsions, or both: Obsessions are the recurrent and persistent thoughts, urges, or images that are intrusive and cause distress or anxiety. Compulsions are the repetitive behaviors or mental acts that a person feels compelled to do to relieve the anxiety caused by the obsessions.

83. The individual attempts to ignore or suppress the obsessions or compulsions or to neutralize them with some other thought or action (i.e., by performing a compulsion). The obsessions or compulsions are time-consuming or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Cont’d…

84. The disturbance is not attributable to the physiological effects of a substance or another medical condition. The disturbance is not better explained by the presence of another mental disorder. Cont’d…

85. Treatment Pharmacotherapy Antidepressant Anti-anxiety drugs Antipsychotic drugs as per need

86. Cognitive Behavior Therapy: A type of therapy that focuses on changing the thoughts and behaviors that associate with obsessions as well as compulsions Thought stopping: say “Stop” loudly or tweaking a rubber band which is around their wrist whenever they have a thought Cont’d…

87. Exposure Therapy: Exposing the person to the thoughts, objects, or situations that trigger their OCD and then teaching them how to prevent themselves from engaging in compulsions Systemic desensitization and flooding Cont’d…

88. Nursing Management History taking for: Recurrent persistent thoughts, impulses or images that are experienced Unsuccessful attempts to suppress these thoughts Recognition of those repetitive thoughts Repetitive be haviors like handwashing History of distress Time consuming behaviors

89. Assess for: The nature of stress or traumatic event which predisposes the individual to the disorder The ego defense mechanism used in excess or ineffectively History of unsatisfactory parent-child relationship Cont’d…

90. Assess for: Impairment in social, occupational, and the other areas of functioning Level of knowledge regarding the psychological problem Cont’d…

91. Interventions Help the patient identify thoughts that produce anxiety Help to identify the association of the thought with the precipitating emotion of anxiety Help to associate the behavior with the behavior that brings some relief Cont’d…

92. Interventions Encourage to maintain daily journal regarding the repetitive thoughts, behavior and feelings Reinforce the cognitive techniques that can interrupt the dysfunctional thoughts Encourage methods of thought stopping Discuss the methods of interrupting increased anxiety Cont’d…

93. Interventions Encourage the patient to rate the anxiety levels after the use of the techniques with those before its use Encourage the family members to actively participate in formulating a plan in order to bring about a change, and also work to resolve the cause of the anxiety Cont’d…

94. Thank you !!!