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Crisis & Crisis

Interventions
LOURADEL ULBATA- ALFONSO, MAN, RN

CRISIS
• a situation or period in an individual’s life that
produces an overwhelming emotional response.
• This event occurs when an individual is confronted by
a certain life circumstance or stressor that he or she
cannot effectively manage by using his or her usual
coping skills.
• Crisis is an unexpected event that can create
uncertainty to an individual and has been viewed as a
threat to a person’s important goals

CRISIS

CRISIS

CRISIS . experience anxiety. and tries to cope in a customary fashion.CRISIS (Stages) 1) The person is exposed to a stressor.

CRISIS (Stages) 2) Anxiety increases when customary coping skills are ineffective. CRISIS .

CRISIS

(Stages)

3) The person makes all possible efforts to deal with the
stressors, including attempts at new methods of
coping.

CRISIS

CRISIS

(Stages)

4) When coping attempts fail, the person experiences
disequilibrium and significant distress.

CRISIS

CRISIS

(CATEGORIES- maturational

crises)
1) Sometimes called developmental crises, are
predictable events in the normal course of life, such as
leaving home for the first time, getting married,
having a baby, and beginning a career.

CRISIS

loss of a job.situational crises) 2) Unanticipated or sudden events that threaten the individual’s integrity. CRISIS . such as death of loved one. and physical or emotional illness in the individual or family member.CRISIS (CATEGORIES.

CRISIS (CATEGORIES. or hurricanes. riots. earthquakes. and violent crimes such as rape or murder. war. CRISIS . terrorist attacks.adventitious crises) 3) Also called social crises which include natural disaster like floods.

Characteristics of a Crisis state • Highly individualized • Lasts for 4-6 weeks • Self-limiting • Person affected becomes passive and submissive • Affects a person’s support system .

denial. psychosis . helplessness. inability to function socially • Crisis (may last a brief or prolonged period of time): Inability to cope.PHASES OF A CRISIS • Pre-crisis: State of equilibrium • Initial Impact (may last a few hours to a few days): High level of stress. rationalization • Resolution: attempts to use problem-solving skills • Post crisis: may have OLOF or may have symptoms of neurosis. projection.

CRISIS INTERVENTION .

physical. shortterm help to individuals who experience an event that produces emotional. mental. • Role of the nurse is to return the client to its pre-crisis state by assisting and guiding them until they achieved their OLOF. and behavioral distress or problems. • Goal: to enable patient to attain an OLOF • Nurse’s Primary Role: Active and Directive .CRISIS INTERVENTION • refers to the methods used to offer immediate.

CRISIS (intervention) 1) Supportive Interventions Aim at dealing with the person’s needs for empathetic understanding. such as encouraging the person to identify and discuss feelings. CRISIS . serving as sounding board for the person. and affirming the person's selfworth.

knowledge. raising the person’s self-awareness by providing feedback about behaviour. CRISIS . or meaning. such as offering the person new information. and directing the person’s behaviour by offering suggestions or courses of actions.CRISIS (intervention) 1) Directive Interventions Designed to assess the person’s health status and promote problem-solving.

Steps in Crisis Intervention • Identify the degree of disruption the client is experiencing • Assess the client’s perception of the event • Formulate nursing diagnoses • Involve the patient and family if applicable with planning • Implement interventions. reinforcement .new and old coping mechanisms • Evaluate-reassessment.

Guide for an effective crisis intervention: • Assist the person to view the event or issue in a different perspective. . • Assist the individual to use the existing support systems. It is vital to help the person find new sources of support that can help in decreasing the feelings of being alone or overwhelmed. • Assist the individual in learning new methods of coping that will help resolve the current crisis and give him or her new coping skills to be used in the future when dealing with another overwhelming situation.

ANXIETY DISORDERS .

result of threat to one’s Biologic. and physical symptoms.ANXIETY —Vague. subjective non specific feeling. Physiologic and Social Integrity.feeling of dread or impending doom • it is a response to external or internal stimuli that can have behavioral. cognitive. Causes. emotional.external influences . apprehension *tension. *uneasiness.

FEAR • Is feeling afraid or threatened by a clearly identifiable external stimulus that represents danger to the person .

Concept of Anxiety .Anxiety Disorder • Demonstrates unusual behavior and are experiencing significant distress overtime which significantly impairs their daily routines. and occupational functioning. social lives.

Anxiety Disorders Panic without reason!! Unwarranted fear!!! Objects life conditions Uncontrollable repetitive actions!!! Reexperience of traumatic events!!! Unexplainable or overwehelming worry!!! Concept of Anxiety .

and goals . problems.Stress • is the wear and tear that life causes on the body • It occurs when a person has difficulty dealing with life situations.

an endocrinologist.General Adaptation Syndrome • Hans Selye (1956. identified the physiologic aspects of stress • He determined three stages of reaction to stress . 1974).

STAGES .

g. release of adrenaline and norepinephrine • Activation of sympathetic nervous system . • During the 'alarm stage' the body responds to the distress signal sent to the hypothalamus with a burst of energy to help deal with the stressor. • E.ALARM STAGE • which provides a burst of energy.

the body is not able to fight off colds and flu during this time . • Deep energy reserves are used until the stressor is resolved or reserves are depleted.Resistance Stage • the body attempts to resist or adapt to the stressor • the body will continue to maintain a level or alertness to help fight or adapt to the stressor. • Because the body's energies are going to the stressor.

Exhaustion Stage • Energy is depleted • occurs when the person has responded negatively to anxiety and stress: body stores are depleted or the emotional components are not resolved. • resulting in continual arousal of the physiologic responses and little reserve capacity. .

LEVELS OF ANXIETY .

Levels of Anxiety (Mild Anxiety) • Sensation that something is different and warrants special attention. feel. Sensory stimulation increases and helps the person focus attention to learn. solve problems. act. and protect himself or herself. Concept of Anxiety . think.

the person becomes nervous or agitated. solve problems. • Person has difficulty concentrating independently but can be redirected to the topic. Concept of Anxiety .Levels of Anxiety (Moderate Anxiety) • A disturbing feeling that something is definitely wrong. learn new things with assistance from others. • Can still process information.

and angry. Concept of Anxiety . and vital signs increase.Levels of Anxiety (Severe Anxiety) • Person has trouble thinking and reasoning. • Restless. Muscles tighten. or uses similar emotional – psychomotor means to release tension. irritable.

or freeze responses. flight. Concept of Anxiety .Levels of Anxiety (Panic Anxiety) • Emotional-psychomotor realm predominates with accompanying fight. • Pupils enlarge to let in more light. and the only cognitive process focuses on the person’s defence. adrenaline surge greatly increases vial signs.

Levels of Anxiety (MANIFESTATIONS) MILD ANXIETY PSYCHOLOGICAL RESPONSE PHYSIOLOGIC RESPONSE Wide perceptual field Restlessness Sharpened senses Fidgeting Increased motivation GI “butterflies” Effective problem-solving Difficulty Sleeping Increased learning ability Hypersensitive to noise Concept of Anxiety .

Levels of Anxiety (MANIFESTATIONS) MODERATE ANXIETY PSYCHOLOGICAL RESPONSE  Perceptual field narrowed to immediate task PHYSIOLOGIC RESPONSE Muscle tension Diaphoresis  Selectively attentive Pounding pulse  Can not connect thoughts or Headache events independently  Increased use of automatisms Dry mouth High voice pitch Faster rate of speech GI upset Concept of Anxiety Frequent urination .

 Cannot complete tasks  Cannot solve problems or learn effectively  Behaviour geared toward anxiety relief and is usually ineffective. vomiting.Levels of Anxiety (MANIFESTATIONS) SEVERE ANXIETY PSYCHOLOGICAL RESPONSE PHYSIOLOGIC RESPONSE  Perceptual field reduced to one detail scattered details. and diarrhea Trembling Rigid stance Vertigo Pale Tachycardia Chest pain Concept of Anxiety . dread.  Doesn’t respond to redirection  Feels awe. or horror  Cries  Ritualistic Behaviour Severe headache Nausea.

Levels of Anxiety (MANIFESTATIONS) PANIC ANXIETY PSYCHOLOGICAL RESPONSE  Perceptual field reduced to focus on self  Cannot process any environmental stimuli  Distorted perceptions  Loss of rational thought  Doesn’t recognize potential danger  Cant communicate verbally  Possible delusions and hallucinations  May be suicidal Concept of Anxiety PHYSIOLOGIC RESPONSE May bolt and run Totally immobile and mute Dilated pupils Increased blood pressure and pulse Fight. or freeze . flight.

Reinforce reality. Physical limits may need to be set. Assess the person’s need for medication or seclusion. Minimize environmental stimuli. . Listen for themes in communication. Remain with the person. Attend to physical safety and medical needs first. Provide opportunities for exercising.Interventions for Severe and Panic Levels of Anxiety • • • • • • • • • Maintain a calm manner.

Etiological Theories of Anxiety .

Etiological Theories of Anxiety • Biologic Model • Hans Selye.& y-amino-butyric acid(GABA) .expanded the idea that endocrine system and CNS (hypothalamus and Pituitary gland ) have reciprocal relationships • Studies of the neuropharmacology of the Autonomic Nervous System (ANS) re: regulation of Cardiovascular/GI/Motor systems –was shown responsive to stimuli • RX’s target serotonin. noradrenergic.

Psychodynamic Model • Concept views Anxiety as a warning to the ego • Three types Anxiety identified • REALITY Anxiety(painful emotional experience resulting from perception of danger in external world) • MORAL Anxiety (THE Ego’s experience of Guilt and Shame) • NEUROTIC Anxiety (perception of threat according to one’s instincts) • Neurotic sx’s develop to defend against anxiety .

Interpersonal /Social Psychology Models/Anxiety • Anxiety is the response to external environment • Sullivan:”Anxiety is the first great educative experience in living” • Symptoms were response to expectations/insecurities/frustrations/conflicts between person and Primary Groups i.. • Emphasis on early development .e.family. social associates. colleagues.

etiology of sx’s based on generalization of an earlier traumatic experience to a benign setting or object.Behavioral Model/Anxiety • Based on Learning theory. • Links past experiences with present responses – anxiety occurs when a “signal” predicts a painful or feared event • May be linked to PTSD .

DEFENSE MECHANISM .

DEFENSE MECHANISM • describe the unconscious attempt to obtain relief from emotional conflict or anxiety. • a coping technique that reduces anxiety arising from unacceptable or potentially harmful impulses. .

DEFENSE MECHANISM • Purposes: • 1. Protect one’s sense of security . To reduce anxiety or fear • 3. To resolve a mental conflict. • 2. Protect one’s self-esteem • 4.

 Four Levels of Defense • The psychiatrist George Eman Vaillant introduced a four-level classification of defence mechanisms: • Level I .neurotic defences (intellectualization.pathological defences (psychotic denial. delusional projection) • Level II . anticipation) . passive aggression. projection.immature defences (fantasy. reaction formation. sublimation. altruism. displacement. suppression. dissociation. repression) • Level IV .mature defences (humour. acting out) • Level III .

common in overt psychosis. when predominating. almost always are severely pathological. they are normally found in dreams and throughout childhood as well. . • These are the "psychotic" defences. However. • The pathological users of these mechanisms frequently appear irrational or insane to others. • These permit one to effectively rearrange external experiences to eliminate the need to cope with reality.Level 1: Pathological • The mechanisms on this level.

Level 1: Pathological • Conversion: -The transferring of mental conflict into a physical symptom to release tension or anxiety. wishes. • Ex: an elderly woman experiences sudden blindness after witnessing a robbery • Ex: a middle-aged man develops paralysis of his lower extremities after he learns that his wife has terminal cancer • Denial: The unconscious refusal to face thoughts. or reality factors that are intolerable. feelings. Also defined as blocking the awareness of reality by refusing to acknowledge its existence. • Ex: A person who is told he has terminal cancer denies the diagnosis by telling his family he had a little tumor on his lung and his doctor “removed all of it. .” • Distortion: A gross reshaping of external reality to meet internal needs. needs.

• These defences are often seen in major . in that they are immature. difficult to deal with and seriously out of touch with reality. • Excessive use of such defences is seen as socially undesirable.Level 2: Immature • These mechanisms are often present in adults. • These are the so-called "immature" defences and overuse almost always leads to serious problems in a person's ability to cope effectively. • These mechanisms lessen distress and anxiety produced by threatening people or by an uncomfortable reality.

rationality. • Fantasy: Tendency to retreat into fantasy in order to resolve inner and outer conflicts. often through procrastination. without conscious awareness of the emotion that drives that expressive behavior.Level 2: Immature • Acting out: Direct expression of an unconscious wish or impulse in action. • Wishful thinking: Making decisions according to what might be pleasing to imagine instead of by appealing to evidence. or reality • Idealization: Tending to perceive another individual as having more desirable qualities than he or she may actually have • Passive aggression: Aggression towards others expressed indirectly or passively. .

” • 2. or shortcomings that are unacceptable to self. The person rejects unwanted characteristics of self and assigns them to others. “My wife forgot to set the alarm last night so I overslept. A student who fails in an exam blames his teacher for not discussing the topic properly . • Ex: 1. He may blame others for faults.Level 2: Immature • PROJECTION: Often termed as “scapegoat” defense mechanism. A man who is late for work states. feelings.

Level 2: Immature • Somatization: The transformation of uncomfortable feelings towards others into uncomfortable feelings toward oneself: pain. . and anxiety. illness.

• Such defences have short-term advantages in coping. but can often cause long-term problems in relationships. work and in enjoying life when used as one's primary style of coping with the world. .Level 3: Neurotic • These mechanisms are considered neurotic. but fairly common in adults.

• Ex: Slamming the door when you are angry • Or yelling at one person when you are angry at another . • Ex: A woman who was raped was found wandering a busy highway in torn clothing. or anxiety from one idea. the woman was exhibiting symptoms of traumatic amnesia. emotionally charged conflict from one’s consciousness. or object to another.Level 3: Neurotic • DISSOCIATION: The act of separating and detaching a strong. When examined by the ER physician. person. hostility. • DISPLACEMENT • -A mechanism that serves to transfer feelings such as frustration.

• Ex: A young man shows no emotional response to the “dear John” letter he received from his fiancée. instead. The person uses reasoning as a means of avoiding confrontation with unconscious conflicts and their stressful emotions. he tells his roommate he is trying to figure out why she changed her mind about the upcoming wedding. . • INTELLECTUALIZATION • -The act of transferring emotional concerns into the intellectual sphere.Level 3: Neurotic • Hypochondriasis: An excessive preoccupation or worry about having a serious illness.

idea. or impulse from one’s thoughts (also referred to as emotional isolation) • Ex: An oncologist is able to care for a terminally ill cancer patient by separating or isolating his feelings or emotional reaction to the patient’s inevitable death. He focuses on the treatment.Level 3: Neurotic • ISOLATION • -The process of separating an unacceptable feeling. . not the prognosis.

Level 3: Neurotic • RATIONALIZATION • -The most common ego defense mechanism. • “John really wanted to date me but felt sorry for Ann and took her the prom. Referred to as self-deception at its subtle best. actions. or feelings with good. • Ex: A teenaged girl who was not asked to the junior prom tells her friend. acceptable reasons or explanations.” . It is used to justify ideas.

• Ex: 1.Level 3: Neurotic • REACTION-FORMATION • . A young man who dislikes his mother-in-law may act very polite and courteous toward her.Also referred to as overcompensation. or feeling from what he normally would show in a given situation. . attitude. The person exaggerates or overdevelops certain actions by displaying exactly the opposite behavior.

A 5 year. . • 2. A 27 year old woman acts like a 17 year old on her first date with a fellow employee. • Ex: 1. allow one to feel comfortable.Level 3: Neurotic • REGRESSION • -Retreating to past levels of behavior that reduce anxiety. The person has regressed to earlier developmental levels to reduce feelings of anxiety. and permit dependency.old boy who is toilet trained becomes incontinent during his father’s hospitalization.

Level 3: Neurotic • REPRESSION • -One of the most common defense mechanisms. • Ex: A young man sends flowers to his fiancée after he embarrassed her at a cocktail party. referred to as the “burying alive mechanism. . • RESTITUTION OR UNDOING • -The negation of a previous consciously intolerable action or experience to reduce or alleviate feelings of guilt.” The person is unable to recall painful or unpleasant thoughts or feelings because they are automatically and involuntarily pushed into one’s unconsciousness. • A young man who feels guilty of having another love affair with a female regularly sends flowers to his girlfriend.

. It entails removing oneself from events.Level 3: Neurotic • Withdrawal: • Withdrawal is a more severe form of defence. and interactions under the threat of being reminded of painful thoughts and feelings. stimuli.

• . • The use of these defences enhances pleasure and feelings of control. even though many have their origins in an immature stage of development.Level 4: Mature • These are commonly found among emotionally healthy adults and are considered mature. • They have been adapted through the years in order to optimise success in human society and relationships. • These defences help to integrate conflicting emotions and thoughts. whilst still remaining effective.

Level 4: Mature • Respect: Willingness to show consideration or appreciation. • Moderation: The process of eliminating or lessening extremes and staying within reasonable limits. It necessitates self-restraint which is imposed by oneself on one's own feelings. attack etc. The lack of respect is at the very heart of most conflict in families. desires etc.) one can take before negativity. communities. Respect can be a specific feeling of regard for the actual qualities of a person or feeling being and also specific actions and conduct representative of that esteem. and nations. provocation. Patience is a recognized virtue in many religions. . • Patience: The level of endurance under difficult circumstances (delay. Relationships and contacts that are built without the presence of respect are seldom long term or sustainable. criticism.

Religions and psychological treatments often suggest the path of acceptance when a situation is both disliked and unchangeable. protest. recognizing a process or condition (often a difficult or uncomfortable situation) without attempting to change it. pain. Physical courage often extends lives. considering their own defects. fear. vicissitudes or intimidation. . uncertainty. while moral courage preserves the ideals of justice and fairness. danger. despair. obstacles. • Humility: A mechanism by which a person. • Acceptance: A person's assent to the reality of a situation. or when change may be possible only at great cost or risk.Level 4: Mature • Courage: The mental ability and willingness to confront conflicts. Humility is intelligent self-respect which keeps one from thinking too highly or too meanly of oneself. has a humble self-opinion. or exit.

. • Mercy: Compassionate behavior on the part of those in power. • Tolerance: The practice of deliberately allowing or permitting a thing of which one disapproves. Gratitude is likely to bring higher levels of happiness. and lower levels of depression and stress. gratitude has been given a central position in religious and philosophical theories. Throughout history. • Altruism: Constructive service to others that brings pleasure and personal satisfaction.Level 4: Mature • Gratitude: A feeling of thankfulness or appreciation involving appreciation of a wide range of people and events.

disagreement. indignation or anger as a result of a perceived offence. • Humour: Overt expression of ideas and feelings (especially those that are unpleasant to focus on or too terrible to talk about directly) that gives pleasure to others. • Identification: The unconscious modelling of one's self upon another person's character and behaviour.Level 4: Mature • Forgiveness: Cessation of resentment. but they are "skirted around" by witticism. . or mistake. The thoughts retain a portion of their innate distress. or ceasing to demand retribution or restitution. for example self-deprecation. • Anticipation: Realistic planning for future discomfort.

• Emotional self-regulation: The ability to respond to the ongoing demands of experience with the range of emotions in a manner that is socially tolerable. duration. behaviours. or emotions. • Emotional self-sufficiency: Not being dependent on the validation (approval or disapproval) of others. • Suppression: The conscious decision to delay paying attention to an emotion or need in order to cope with the present reality.Level 4: Mature • Introjection: Identifying with some idea or object so deeply that it becomes a part of that person. making it possible to later access uncomfortable or distressing emotions whilst accepting them. • Sublimation: Transformation of unhelpful emotions or instincts into healthy actions. for example. . or expression of various emotions. Emotional self-regulation refers to the processes people use to modify the type. intensity. playing a heavy contact sport such as football or rugby can transform aggression into a game.

PANIC DISORDER .

without any cause or precipitation • The Attacks occur in 50%-75% of cases during non REM sleep ( night panic) in addition to day occurrence 7/14/15 .:DEFINITION OF PANIC ATTACK • Periodic short bouts of panic • Sudden feelings of terror that occur suddenly and without warning .

time.Panic attacks • Onset Most can recall the precise date . 7/14/15 .  Daily attacks for months .  Few attacks in a life time. nature and circumstances of the first panic attack • Course • Frequency of attacks vary considerably between.then disappear and reappear.

rarely it persists for hours followed by exhaustion or headaches and sometimes long sleep.Panic attacks • Duration From seconds to minutes in most cases. 7/14/15 .

which peaks in approximately 10 minutes.Panic Attack criteria • The abrupt onset of an episode of intense fear or discomfort. and includes at least four of the following symptoms: • A feeling of imminent danger or doom The need to escape Palpitations Sweating Trembling Shortness of breath or a smothering feeling • A feeling of choking • Chest pain or discomfort • • • • • 7/14/15 • Nausea or abdominal discomfort • Dizziness or lightheadedness • A sense of things being unreal. depersonalization • A fear of losing control or "going crazy" • A fear of dying • Tingling sensations • Chills or hot flushes .

situations in which an individual is likely to have a Panic Attack. upon entering a tunnel. Unexpected . 7/14/15 . 3. 2. An example of this would be an individual who sometimes has attacks while driving. for example. Situationally Predisposed .the attack "comes out of the blue" without warning and for no discernable reason. Situational .There are three types of Panic Attacks 1. but does not always have one.situations in which an individual always has an attack.

– Worry about the implications or cause of attack.Diagnostic Criteria: Panic Disorder DSM-IV criteria • Recurrent unexpected panic attacks • A month or more of at least one of the following after an attack: – Persistent concern about having more attacks. 7/14/15 . – Significant change in behavior related to attack.

Diagnostic Criteria:
Panic Disorder
• Absence or presence of agoraphobia
• Panic attacks not due to substance or another mental
disorder
• Various symptoms present with attacks

7/14/15

Agoraphobia
Fear of the marketplace (agora)” = fear of public areas (stores, theater, public
transport), fear of being away from safe places (home)
• Hypothesis: almost exclusively a complication
of panic
– Patient afraid of being caught somewhere
having a panic attack, where escape would be
difficult/impossible

7/14/15

DIFERENTIAL DIAGNOSIS

MEDICAL CONDITIONS
1. Acute myocardial infarction
- in pure panic attacks patient doesn't
experience crushing chest pain

7/14/15

palms and forehead  Splitting headache 7/14/15 . Catecholamine secreting tumors ( pheochromcytoma)  Severe Abdominal or Back pain  Hypertensive response to smoking  Malignant hypertensive episodes  Sweating in the chest and back while in panic in soles .DIFERENTIAL DIAGNOSIS 2.

DIFERENTIAL DIAGNOSIS 3.     Substance Abuse : Cocaine. Marijuana Alcohol Opiates 7/14/15 .

Caffeine:More than 700mg may cause panic attacks .DIFERENTIAL DIAGNOSIS 4. 7/14/15 .Hypoglycemia:Extremely rarely cause panic attacks 5. also patient with panic disorder may aggravate with one cup of coffee.

What You Can Do • Assessment • Intervention 7/14/15 .

including sexual dysfunction 7/14/15 .Assessment Physical exam and baseline lab investigations should be performed before initiation of pharmacological treatment • • Regularly monitor weight changes and adverse effects of medication.

Assessment Explore the possibility of physical causes for emotional symptoms 􀂄 A physical exam should be part of the assessment when new symptoms are present 􀂄 Look for a history that does not fit 􀂄 Review personal and family history carefully 􀂄 Be suspicious if the onset of the disorder is late in life 7/14/15 .

drugs. 7/14/15 . or hallucinations.especially visual. drugs. loss of function. or tactile) 􀂄 Drugs. dissociation. olfactory. visual disturbances. unusual perceptions (tingling.Assessment Be suspicious if there is a history of recent onset of headaches.

Baseline Lab Investigations • Urinanalysis • Complete blood count (CBC) • Fasting glucose • Electrolytes • Liver enzymes • Serum bilirubin • Serum creatinine 7/14/15 • Urine toxicology for substance use • 24-hour creatinine clearance (if history of renal disease) • Thyroid stimulating hormone • Electrocardiogram (>40 years or if indicated) • Pregnancy test (if relevant) • Prolactin .

TREATMENT IN Emergency Department Most cases the attack exhausts itself within minutes but if it persists An injectable form of benzodiazepines can be used 7/14/15 .

An immediate treatment is to rebreathe expired air from bag in order to increase the concentration of CO2 in alveolar air 7/14/15 . • Rebreathing .Treatment of hyperventilation …..

Cognitive therapy • The two major foci of cognitive therapy for panic disorder are : Instruction regarding the patient's false beliefs ( patient's tendency to misinterpret mild bodily sensations as indicative of impending panic attack. doom or death)  Information regarding panic attacks ( when they occur . are time – limited and not life-threatening) 7/14/15 .

after awhile patients learned to cope with the negative feelings associated with them and replace them with positive ones 7/14/15 . writing down list of top fears and doing one of them once a week. spinning in a chair until dizzy.Behavioral and Cognitive Therapy • Teaches patient to react differently to situations and bodily sensations that trigger anxiety • Teaches patient to understand how thinking patterns that contribute to symptoms • Patients learn that by changing how they perceive feelings of anxiety. the less likely they are to have them • Examples: Hyperventilating.

Strategies to reduce anxiety 7/14/15 .

Breathing exercises • Produce slow deep breathing • Prevent hyperventilation • Prevent excessive blowing off of CO2 7/14/15 .

next choose a calming phrase (such as “om” or that with great significance to you). silently repeat the word or phrase for 20 minutes 7/14/15 .Meditation • Cultivates calmness to create a sense of control over life • Practice: Sit quietly in a position comfortable to you and take a few deep breaths to relax your muscles.

PHOBIA .

from all walks of life. • affect people of all ages. and go about a daily routine . socialize.activities. and in every part of the country • can interfere with your ability to work.Phobia… • refers to a group of symptoms brought on by feared objects or situations • People can develop phobic reactions to animals . or social situations.

trembling.all the physical reactions associated with extreme fear • Extreme measures taken to avoid the feared object or situation . shortness of breath. dread. horror. or terror • Recognition that the fear goes beyond normal boundaries and the actual threat of danger • Reactions that are automatic and uncontrollable. practically taking over the person's thoughts • Rapid heartbeat. and an overwhelming desire to flee the situation .Symptoms… • Feelings of panic.

fear of being alone in any place or situation from which it seems escape would be difficult or help unavailable should the need arise 2. Agoraphobia .Categories of Phobias… 1. fears being watched or humiliated while doing something in front of others . Social .

Categories of Phobias… 3. Specific people with a specific phobia generally have an irrational fear of specific objects or situations .

AGORAPHOBIA .

1996 • Agoraphobics are often extremely sensitized to their own bodily sensations.. subconsciously overreacting to perfectly normal events .AGORAPHOBIA… • fear of experiencing a difficult or embarrassing situation from which the sufferer cannot escape • Agoraphobia occurs about twice as commonly among women than men (Magee et al.

Symptoms… • Fear of being alone • Fear of losing control in a public place • Fear of being in places where escape might be difficult • Becoming housebound for prolonged periods of time • Feelings of detachment or estrangement from others • Feelings of helplessness • Dependence on others • Feeling that the body is unreal • Feeling that the environment is unreal • Anxiety or panic attack (acute severe anxiety) • Unusual temper or agitation with trembling or twitching .

near fainting • Dizziness • Excessive sweating • Skin flushing • Breathing difficulty • Chest pain • Heartbeat sensations • Nausea and vomiting • Numbness and tingling • Confused or disordered thoughts • Intense fear of going crazy • Intense fear of dying .Symptoms… • Lightheadedness.

Combination of therapy and medications . Therapy • Behavior and cognitive therapy are the treatments of choice for agoraphobia 2.Treatment… There are three main types of treatment for agoraphobia: 1. 3. Medications • antianxiety medication.

SOCIAL PHOBIA .

Social Phobia… • an experience of fear. apprehension or worry regarding social situations and being evaluated by others • excessive long-lasting social anxiety causing relatively extreme distress and impaired ability to function in at least some areas of daily life .

Signs and Symptoms… • Blushing • sweating (hyperhidrosis) • Trembling • Nausea • Stammering • Palpitations • shaking .

Signs & Symptoms… • dread over how they will be presented to others • overly self-conscious • have high performance standards • excessive social avoidance • substantial social or occupational impairment .

Causes… • Genetic and family factors • Social experiences • Social/cultural influences • Evolutionary context • Neurochemical and neurocognitive influences • Psychological factors .

Treatment… • Pharmacological treatments • • • • • Selective serotonin reuptake inhibitors (SSRIs) monoamine oxidase inhibitors (MAOIs) Reversible inhibitors of monoamine oxidase subtype A (RIMAs) Benzodiazepines beta-blockers .

Treatments… • Psychotherapy • cognitive-behavioral therapy • social skills training • Interpersonal Therapy .

SPECIFIC PHOBIA .

Definition… • extreme fear of a specific object or situation that is out of proportion to the actual danger or threat • generic term for any kind of anxiet disorder that amounts to an unreasonable or irrational fear related to exposure to specific objects or situations .

Signs & Symptoms… • feelings of anxiety • Fear • panic • Tachycardia • Tachypnea • Hyperhydrosis • palpitations .

Causes… • Learning History • Direct Learning Experiences • Observational Learning Experiences • Informational Learning • Psychological Factors • Attention and Memory • Beliefs and Interpretations about Feared Objects and Situations • Avoidance and other Anxious Behaviors • Biological Factors .

Categories of Specific
Phobias
• Animal Type
• Natural Environment Type
• Situational Type
• Blood injection or Injury Type
• Other

SPECIFIC PHOBIAS
• Animal phobias: Examples include the fear of dogs, snakes, insects, or
mice. Animal phobias are the most common specific phobias.
• Situational phobias: These involve a fear of specific situations, such as
flying, riding in a car or on public transportation, driving, going over
bridges or in tunnels, or of being in a closed-in place, like an elevator.
• Natural environment phobias: Examples include the fear of storms,
heights, or water.
• Blood-injection-injury phobias: These involve a fear of being injured, of
seeing blood or of invasive medical procedures, such as blood tests or
injections
• Other phobias: These include a fear of falling down, a fear of loud sounds,
and a fear of costumed characters, such as clowns.

Examples”
• Ablutophobia- Fear of washing or bathing.
• Acarophobia- Fear of itching or of the insects
that cause itching.
• Acerophobia- Fear of sourness.
• Achluophobia- Fear of darkness.
• Acousticophobia- Fear of noise.
• Acrophobia- Fear of heights.
• Aerophobia- Fear of drafts, air swallowing, or
airbourne noxious substances.
• Aeroacrophobia- Fear of open high places.
• Aeronausiphobia- Fear of vomiting secondary
to airsickness.
• Agateophobia- Fear of insanity.
• Agliophobia- Fear of pain.
• Agoraphobia- Fear of open spaces or of being
in crowded, public places like markets. Fear of
leaving a safe place.
• Agraphobia- Fear of sexual abuse.
• Agrizoophobia- Fear of wild animals.

• Aichmophobia- Fear of needles or
pointed objects.
• Ailurophobia- Fear of cats.
• Albuminurophobia- Fear of kidney
disease.
• Alektorophobia- Fear of chickens.
• Algophobia- Fear of pain.
• Alliumphobia- Fear of garlic.
• Allodoxaphobia- Fear of opinions.
• Altophobia- Fear of heights.
• Amathophobia- Fear of dust.
• Amaxophobia- Fear of riding in a car.

Treatment… • Psychological Treatments • Exposure to Feared Situation/Systemic desensitization • Applied Muscle Tension • Cognitive Therapy • Biological treatments .

PTSD POST-TRAUMATIC STRESS DISORDER .

long after any physical danger involved has passed. .POST-TRAUMATIC STRESS DISORDER (PTSD) • is an anxiety disorder characterized by reliving a psychologically traumatic situation. through flashbacks and nightmares.

CAUSES • Genes • Brain Areas • Traumatic events • Other risk factors .

CAUSES • War • Natural disasters • Car or plane crashes • Terrorist attacks • Sudden death of a loved one • Rape • Kidnapping • Assault • Sexual or physical abuse • Childhood neglect .

CAUSES
• Previous traumatic experiences, especially in early life
• History of substance abuse
• History of depression, anxiety, or another mental illness
• Witnessing violent deaths

• Being held hostage
• High level of stress in everyday life
• Lack of support after the trauma
• Lack of coping skills

SIGNS & SYMPTOMS
• Re-experiencing symptoms
• Avoidance symptoms
• Hyperarousal symptoms

SIGNS & SYMPTOMS
• Re-experiencing symptoms
– may cause problems in a person’s everyday routine. They
can start from the person’s own thoughts and feelings.
Words, objects, or situations that are reminders of the event
can also trigger re-experiencing.

after a bad car accident.SIGNS & SYMPTOMS • Avoidance symptoms – Things that remind a person of the traumatic event can trigger avoidance symptoms. For example. a person who usually drives may avoid driving or riding in a car. These symptoms may cause a person to change his or her personal routine. .

They can make the person feel stressed and angry. eating. These symptoms may make it hard to do daily tasks. or concentrating. such as sleeping. instead of being triggered by things that remind one of the traumatic event. .SIGNS & SYMPTOMS • Hyperarousal symptoms – Hyperarousal symptoms are usually constant.

and many other serious events. Women are more likely to develop PTSD than men. • Anyone can get PTSD at any age. • Not everyone with PTSD has been through a dangerous event. and there is some evidence that susceptibility to the disorder may run in families. abuse. including childhood.WHO IS AT RISK? • It can occur at any age. . Some people get PTSD after a friend or family member experiences danger or is harmed. This includes war veterans and survivors of physical and sexual assault. accidents. disasters. unexpected death of a loved one can also cause PTSD. The sudden.

a person must have all of the following for at least 1 month: • At least one re-experiencing symptom • At least three avoidance symptoms • At least two hyperarousal symptoms • Symptoms that make it hard to go about daily life. and take care of important tasks. go to school or work.DIAGNOSIS • To be diagnosed with PTSD. • PTSD is often accompanied by depression. be with friends. substance abuse. or one or more of the other anxiety disorders. .

TREATMENTS PSYCHOTHERAPY MEDICATIONS OTHER MEDICATIONS • Exposure therapy • Sertraline (Zoloft) • Benzodiazepines • Cognitive restructuring • Paroxetine (Paxil) • Antipsychotics • Stress inoculation training • Family therapy • Other antidepressants .

Acute Stress Disorder .

helplessness. or horror. death. • Traumatic events include: witnessing or experiencing rape or other violent assaults. . • The person's response involves intense fear. or a severe transport accidents.What is Acute Stress Disorder (ASD)? • ASD is an anxiety disorder characterized by a group of dissociative and anxiety symptoms that occur within a month of a traumatic event. suffered a severe injury or natural disaster. guiltiness.

where PTSD can only be diagnosed after 4 weeks have passed.What are the differences between ASD and Post-Traumatic Stress Disorder? • ASD and PTSD are both disorders that can occur following a traumatic event. • ASD can be diagnosed between 2 days and 4 weeks after exposure. • If left untreated. ASD is likely to advance into PTSD. • In addition to the symptoms experienced in PTSD. . ASD includes symptoms of dissociation.

Symptoms: • Dissociative symptoms • • • • Less aware of surroundings Feeling numb or detached Derealization Depersonalization • Dissociative amnesia • Re-experiencing symptoms • • • • Dreams Illusions Flashback Intense distress .

Other symptoms that indicate ASD • • • • • • • Sleeping problems Difficulty concentrating Irritability Inability to do necessary tasks including seeking help Feeling detached from others Motor restlessness Avoiding people or places that remind him/her about the event .

Diagnosis ASD is diagnosed by: • comparing the patient's symptoms to the DSM-IV and DSM-IV-TR criteria • using the Acute Stress Disorder Scale .

Treatment of Acute Stress Disorder • Medications • Psychotherapy • Alternative and complementary treatments .

Medications • Prescribed antidepressants: • Sertraline • Paroxetine • Fluvoxamine • Citalopram • Clomipramine • For avoidance symptoms • Fluoxetine .

Medications • To reduce anxiety and panic • Alprazolam • Diazepam • Clonazepam • Lorazepam • Propanol • For insomnia and nightmares • Trazodone • Topiramate .

Psychotherapy • Cognitive-behavioral therapy • Gestalt Therapy • Psychoanalityc • Rational-Emotive Therapy • Behavior Therapy • Group and Family Therapies • Therapeutic Writing .

Alternative and complementary treatments • Yoga • Meditation • Music Therapy • Hypnosis • Hydrotherapy • Traditional Chinese Medicine • Critical Incident Stress Management Program .

Prognosis • 80% of people diagnosed with ASD have PTSD six months later. 75% will develop symptoms of PTSD two years from the traumatic event. .

Treatment for children with ASD • Antidepressants: • Imipramine • Chloral hydrate • Cognitive Behavioral Therapy • Adjunctive Therapies • Family-Based Treatments • Group Therapy .

OCD .

Obsessive-Compulsive Disorder • affects almost 3% of world’s population • Start anytime from preschool to adulthood • Typically between 20-24y • many different forms of OCD – differ from person to person • cause of OCD is still unknown • Better when diagnosed early .

Definition • Anxiety disorder with presence of obsessions or compulsions • Must take up more than 1 hour a day • Must disrupt daily routine • Symptoms can’t result from effects of other medical conditions or substances .

images. or impulses that cause anxiety or distress • thoughts. images. or impulses . or impulses not about real-life problems • Try to ignore or counter act thoughts.Obsessions • repetitive and constants thoughts. images.

radiation) • Household chemicals (examples: cleaners. HIV) • Environmental contaminants (examples: asbestos. feces) • Germs/disease (examples: herpes. solvents) • Dirt • Unwanted Sexual Thoughts: • Forbidden or perverse sexual thoughts or images • Forbidden or perverse sexual impulses about others • Obsessions about homosexuality • Sexual obsessions that involve children or incest • Obsessions about aggressive sexual behavior towards others .Common Obsessions in OCD • Contamination: • Body fluids (examples: urine.

Compulsions • Repetitive behaviors or mental acts person does in reaction to obsessions • behaviors or mental acts done to avoid or decrease distress • behaviors or mental acts are clearly excessive or not realistic .

bathing. tooth brushing. grooming or toilet routines • Cleaning household items or other objects excessively • Doing other things to prevent or remove contact with contaminants • Checking: • Checking that you did not/will not harm others • Checking that you did not/will not harm yourself • Checking that nothing terrible happened • Checking that you did not make a mistake • Checking some parts of your physical condition or body .Common Compulsions in OCD • Washing and Cleaning: • Washing hands excessively or in a certain way • Excessive showering.

History • 14th & 15th century thought people were possessed by the devil and treated by exorcism • 17th century thought people were cleansing their guilt • 18th century finally considered medical issue • 20th century began treating with behavioral techniques .

Theories • Scientist split into 2 groups • Psychological disorder were people are responsible for feelings they have • Abnormalities in the brain .

Causes • Serotonin is involved in regulating anxiety • Abnormality in the neurotransmitter serotonin • OCD suffers may have blocked or damaged receptor sites preventing serotonin from functioning to full potential • Possible genetic mutation • Some people suffering have mutation in the human serotonin transporter gene .

Comorbidity • Has excessive comorbidity with other diseases • Common diseases: Depression. Tourette Syndrome • Depression is the most common • Many people with OCD suffered from depression first • 2/3 of OCD patients develop depression  makes OCD symptoms worse and more difficult to treat • People with OCD common diagnosed as Schizophrenic  hard to separate obsessions from delusions . Schizophrenia.

Treatment • Only completely curable in rare cases • Most people have some symptom relief with treatment • Treatment choices depend on the problem and patients preferences • Most common treatments: • Behavioral Therapy • Cognitive Therapy • Medication .

Cognitive-Behavioral Therapy • Cognitive: change the way they think to deal with their fears • Behavioral: change the way they react to “anxietyprovoking” situations • Exposure and Response Prevention • Slowly learning to tolerate anxiety associated with not performing ritual behavior • Psychotherapy • Talking with therapist to discover what causes the anxiety and how to deal with symptoms • Systematic Desensitization • Learning cognitive strategies to deal with anxiety then gradual exposure to feared object .

Cognitive-Behavioral Therapy • Should be done when people are ready for it • Must be customized for each person’s specific form of OCD and their needs • No side affects except increased anxiety with exposure to fear • Often lasts about 12 weeks • If OCD returns can successfully treat again with same therapy • Best treatment approach for most is CBT combined with medication .

Zoloft. Lexapro. Paxil .Medication • Anxiolytic benzodiazepine such as chloradiazepoxide or diazepam  give temporary relief from anxiety but not really effective on obsessions and compulsions • Antidepressants because of common depression • Selective Serotonin Reuptake Inhibitors (SSRIs): alter the levels of neurotransmitter serotonin in the brain which helps brain cells communicate with one another • Prevents excess serotonin from being pumped back into original neuron that released it • Then can bind to receptor sites of nearby neurons and send chemical message that can help regulate anxiety and obsessive compulsive thoughts • Most effective drug treatment helping about 60% of patients • Ex: Prozac.

Conclusion • OCD is a complicated issue • Most cases are incurable • Best form of treatment is CBT in combination with medication .

Chronic Anxiety Disorder or Generalized Anxiety Disorder .

Chronic Anxiety Disorder or Generalized Anxiety Disorder • Excessive worry and anxiety for days but not more than 6 months • Difficulty in controlling the worry • Anxiety and worry are evident by 3 or more of the following : • • • • • Restlessness. Keyed up Fatigue and irritability Decreased ability to concentrate Muscle tension Disturbed sleep • Anxiety or worry causes significant impairment in interpersonal relationship or activities of daily living .

Review Anxiolytic Drugs!!!! .

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