Review Levels of Anxiety



• • • • • • • • • Used only in a short time (1-2 weeks) Tolerance (after 7 days) and dependence (after 1 month) Hepatotoxic: LFTs Monitor for side effects. Avoid machines, activities needing concentration Z track if given parenterally Avoid mixing with alcohol, antacids Don’t stop abruptly but gradually for 2-6 weeks Avoid caffeine

Anxiety Disorders

Basic Anxiety Disorder


Dissociative Disorders


Basic anxiety disorders
• Generalized Anxiety Disorder • Panic • Phobia • PTSD • Obsessive Compulsive

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

Post Traumatic Stress Disorders

Post Traumatic Stress Disorders
• Disturbing pattern of behavior occurring after a traumatic event that is outside the range of usual experience. • Characteristics – Persistent re-experiencing of the trauma through recurrent intrusive recollections of the event, through dreams or flashbacks – Persistent avoidance of the stimuli – Feeling of detachment of estrangement from others – Chemical abuse to relieve anxiety

• Definition


• Treatment: Systematic Desensitization • Defense mechanisms
– Repression and displacement

– Persistent, irrational fear of a specific object, activity or situation that leads to a desire for avoidance or actual avoidance of the object of fear

Major Types of Phobias

Major Types of Phobias
• Agoraphobia – Comes from the Greek word “Agora” – Meaning “market place” – Fear of being alone in open or public spaces • Social Phobia – Fear of situations where one might be seen and embarrassed or criticized • Specific Phobias – Fear of a single object, situation or activity that cannot be avoided

Obsessive Compulsive Disorder
Obsessions  Preoccupation with persistent intrusive thoughts, impulses or images Compulsions > Repetitive behaviors or mental acts that the person feels driven to perform in order t reduce distress or prevent a dreaded event or situation Cues: • Ritualistic behavior • Constant doubting if he/she has performed the activity


“Wash away my sins”. Thought appeared after sexual encounter with a married man “Everything must be in place”. “Everything is contaminated”

Young woman repeatedly washes hands

Washing or cleaning

Need for order

Arranges and rearranges items

Germs or dirt


Avoids touching all objects. Scrubs hands if she is forced to touch any object “Secretaries who practice Secretary lines up neatness never gets fired’ objects in rows on her desk, then realigns them repeatedly during

Care Strategies
• Be nonjudgmental and honest; offer empathy and support • Help patient to recognize the connections between the trauma experience and their current feelings, behaviors and problems. • Encourage verbalizations of feelings, especially anger. • Encourage adaptive coping strategies and techniques • Encourage patients to establish or reestablish relationships • Explore shattered assumptions. “I’m a good person. This is a safe world”. • Promote discussion of possible meaning of the events.


Somatoform Disorders
• Body Dysmorphic Disorder • Somatization • Conversion Disorders • Hypochondriasis • Psychogenic pain

Body Dysmorphic Disorder
• Preoccupation with an imagined defect in his or her appearance
– Ex. Michele, a young, attractive woman, is preoccupied that her nose is too long and “ugly”. She is preoccupied and quite distressed over her perception. Two plastic surgeons she consulted are hesitant to reshape her nose but have not altered her thinking that her nose makes her ugly.

• A client expresses emotional turmoil or conflict through a physical system, usually with a loss or alteration of physical functioning • Hx of pain in at least 4 sites • Hx of at least 2 GIT symptoms other than pain • Hx of at least one sexual/reproductive symptom • Hx of at least one neurologic disorder

• Ex. Deanna, 27, presents at the doctor’s office with excessive heavy menstruation. She tells the nurse that recently she experienced pain “first in my back and then going to every part of my body”. She states that she is often bothered with constipation and frequent vomiting when she “eats the wrong food.” She states she had been “unwell” and had suffered from seizures and still has them occasionally. The nurse becomes confused, not knowing what symptoms she wants the doctor to evaluate. Deanna tells the nurse she lives at home with her parents because her poor health makes it hard for her to hold a job.

Conversion Disorders
• A psychological condition in which an anxiety-provoking impulse is converted unconsciously into functional symptoms • Development of a symptom suggesting neurologic disorder (blindness, deafness etc.) or involuntary motor function (paralysis, seizures)

• Ex. Jan, a 28 year old former secretary, awakes one morning to find that she has a tingling in both hands and cannot move her fingers. Two days earlier, her husband had told her that he wanted a separation and that she would have to go back to work to support herself.

• Presentation of unrealistic or exaggerated physical complaints – Ex. Julio, 52 lost his wife to colon cancer 5 months ago, which he “took very well”. Recently he saw the sixth physician with the same complaint. He believes that he has liver cancer, despite repeated and extensive diagnostic tests, which are all negative. He has ceased seeing his friends, has dropped his hobbies and spends much of his time checking his sclera and “resting his liver”.


• Offer explanations and support during diagnostic testing-reduces anxiety while ruling out organic illness • After physical complaints have been investigated, avoid further reinforcement-directs focus away from physical symptoms • Spend time with client at all times other than when client summons nurse to offer physical complaintrewards non-illness related behaviors and encourages repetition of desired behavior • Observe and record frequency and intensity of somatic symptoms-establishes a baseline and later evaluation of effectiveness of interventions

• Do not imply that symptoms are not real-psychogenic symptoms are real to the client even though causation is not organic • Shift focus from somatic complaints to feelings or to neutral topics-conveys interest in client as a person rather than in client’s symptoms • Assess secondary gains that “physical illness” provides for client-nurse can work with the client to meet these needs in healthier ways and thus minimize secondary gains • Use matter-of-fact approach to clients exhibiting resistance or covert anger-avoids power struggles, demonstrates acceptance of anger and permits discussion of angry feelings

• Set limits on manipulative behavior that violates rights of others-protects other clients and significant others • Help client look at result of manipulative behavior on others-encourages insight and can help improve intrafamily relationships • Show concern for client while avoiding fostering dependency needs-shows respect for client’s feelings while minimizing secondary gains • Reinforce client’s strengths and problem-solving abilities-contributes to positive self-esteem


Dissociative Disorders
• Dissociative amnesia • Dissociative fugue • Depersonalization • Dissociative Identity Disorder / Multiple Identity Disorder

Dissociative amnesia
• Characterized by the inability to recall an extensive amount of important personal information because of physical or psychological trauma
– Ex. A young woman was partly dressed and poorly nourished when found by a police road patrol. She had no knowledge of who she was. Her parents identified her when she appeared on a morning news television program. Hospital examination revealed the probability of recent rape. She was able to remember going to a party off-campus but had no recall of the party or the events after.

Dissociative fugue
• The person suddenly and unexpectedly leaves home or work and is unable to recall the past

• Person experiences a strange alteration in the perception or experience of the self, often associated with a sense of unreality
– Ex. Mrs. Terry became highly distressed when she perceived changes in her appearance when she looked in a mirror. She thought her image looked wavy and indistinct. Soon after, she described feeling as though she was floating in a fog with her feet not actually touching the ground. During therapy, it was learned that Mrs. Terry’s son had revealed to her his HIV-positive status

Dissociative Identity Disorder / Multiple Identity Disorder
• A person is dominated by at least one of two or more definitive personalities at one time
– Ex. Gertrude, a passive, conservative woman alternated personalities with Diana, who was sexy and flirtatious. During therapy, Jane and Evelyn revealed themselves as other distinct personalities.


Psychosomatic Disorder
- True (but unconscious) because of hormonal and bodily changes - Increase anxiety may result to asthma, stress ulcers or migraine

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