psychiatric nursing

I. STRESS, ANXIETY, and ANXIETY- RELATED DISORDERS
1.Generalized Anxiety Disorder (GAD)
2. Panic Disorder
3. Obsessive-Compulsive Disorder (OCD)
4. Phobic Disorder
5. Post-Traumatic Stress Disorder (PTSD)
6. Dissociative Disorders
STRESS : ANXIETY
nStress is a stimulus or situation that produces distress and creates physical and psychological demands on an individual, requiring coping and adapting.

nANXIETY is the subjective response to stress.

Psychobiological aspects of stress and anxiety
nGABA : researchers believe that a relative deficiency or imbalance is directly related to anxiety; Associated with the relaxation response.
nSEROTONIN : deficits or imbalance in the amygdala are thought to be significant in anxiety and anxiety related disorders.
nNOREPINEPHRINE : either overactive or underactive in areas of the brain associated with anxiety; responsible for cardiovascular changes in stress and anxiety.
General Adaptation Syndrome (GAS)
nHANS SELYE Describes stress as wear and tear on the body occurring regardless of whether the stressor is positive or negative.
nJEROME KAGAN (1996) Hypothesis: Biological differences can lead to an overly active stress response ( such as overproduction of hormones and neurotransmitters involved in the stress response).

Stages of STRESS
1. Alarm reaction/”fight or flight response occurs when the SNS and Endocrine system react to stress.
> epinephrine and norepi are released
> pupils dilate
> tear secretion increases
> bronchioles and pulmo blood vessels dilate
> INCREASES RR; CO; HR; BP; ureter motility; sweat secretions
> DECREASES GI secretions; gastric motility
> Lipolysis is initiated
> bladder sphincter relaxes
> Glycogenolysis and Gluconeogenesis increase
2. Stage of Resistance are adaptive responses that attempt to limit the damage to stress.
3. Stage of Exhaustion occurs when physiologic and psychologic
resources are depleted and the immune system becomes depressed.

Coping Strategies for Stress Reduction Promotive / Preventive
nSeek out a supportive person
nStrive for self-discipline and perseverance
nVent strong emotions
nThink through options and use problem-solving techniques
nPerform physical activities and exercise to release energy
nUse relaxation technique, such as:
> listening to music
> taking a warm shower or bath
> meditating
> performing imagery or visualization exercises
> using progressive muscle-relaxation techniques
ANXIETY
nSubjective response to stress
nIt is characterized by feelings of apprehension, uneasiness, uncertainty, resulting from a real or perceived threat.
nRanging from mild anxiety to panic, which can affect an individual’s ability to function.
MILD – increased alertness : stress management education; problem solving approach.
MODERATE – ability to focus on central concerns : relaxation technique; teach coping strategies; encourage verbalization of feelings.
SEVERE – inability to focus or solve problems; SNS activated : encourage physical activity; structured tasks and exercise are helpful.
PANIC – complete inability to focus : decreased environmental stimuli; stay with the client; using a quiet voice, assist with relaxation breathing.

Generalized Anxiety Disorder (GAD)> excessive anxiety and worry occurring more days than not for at least 6 months.> restlessness; feeling “on edge”; easy fatigue; difficulty concentrating; irritability and muscle tension; sleep disturbances
nWomen are affected twice as often as men
nIs associated with low self-esteem, decreased tolerance for stress, and tendency to believe in an external locus of control.

Panic Disorder> panic attacks that recur at unpredictable times with intense apprehension, fear, and terror
nHallmark : racing heart; chest pains; dizziness and nausea; dyspnea; choking sensations; numbness and tingling sensations; trembling and diaphoresis; feeling that one is having heart attack;feeling that one is “going crazy”; fear of loss of control; decreased perceptual ability; decreased cognitive abilities.

AGORAPHOBIA - anxiety about being in places or situations from which escape might be difficult or embarrassing, or in which help may not be available in the event of having panic-like symptoms.
nPanic disorder without agoraphobia : recurrent, unexpected panic attacks followed by at least 1 month of persistent concern about having another attack, worry about the possible implications or consequences of the attack, or a significant behavioral change related to attack.
nPanic disorder with agoraphobia : recurrent, unexpected panic attacks along with agoraphobia.
Nursing Implementation for GAD and Panic disorder
Independent:
nHelp the client identify precipitating stressors and teaches her to monitor physical and physiological responses to stress.
nStay with the client and provide support.
nKeep demands on the client to a minimum.
nLimit environmental stimuli.
nEncourage physical activity ( walking ) to release energy.
nHelp the client to perform relaxation-breathing techniques.
nEncourage to limit caffeine and nicotine intake.
nPromote sleep with comfort measures ( warm bath, music, bach rub ).
nOne-to-one supervision.
nLet client express feelings.

Dependent:
1. Administer prescribed Anxiolytic medications
OCD> recurrent obsessions or compulsions that are severe enough to be time-consuming, caused marked distress, or lead to significant impairment in functioning.
nOften begins in childhood and adolescence.
nIndividuals with OCD may be performing repetitive rituals to “self-medicate” for their serotonin deficiency ( brain STRIATUM that controls voluntary movement ).
nThe obsessions and compulsions commonly occur together.
nThe individual is aware of the unrealistic, inappropriate nature of obsessions and compulsions ( describe as ego- dystonic symptoms).
nAttempt to resist behavior causes increased anxiety.
nIndulgence causes temporary anxiety relief ( termed primary gain )
OCD
Obsessions – persistent ideas
> repeated thoughts about contamination
> repeated doubts
> a need to have things in particular order
> aggressive or horrific impulses
> sexual imagery

OCD
Compulsions – uncontrollable urges to perform an act repetitively.
> washing and cleaning
> counting
> checking
> requesting or demanding assurances
> repeating actions
> ordering
Nursing Implementation for OCD
nCONVEY ACCEPTANCE DESPITE HIS RITUALISTIC BEHAVIORS.
nALLOW THE CLIENT TIME TO PERFORM RITUALS; HIS ANXIETY LEVEL WILL INCREASE IF HE CANNOT PERFORM COMPULSIVE BEHAVIORS.
nENCOURAGE TO SET LIMITS ON REALISTIC BEHAVIORS.
nUSE ACTIVE LISTENING TO VERBALIZE FEELINGS; BEST TIME FOR INTERACTION IS AFTER HE COMPLETES A RITUALISTIC BEHAVIOR.
nHELP THE CLIENT TO LIST ALL OF THE OBJECTS AND PLACES THAT TRIGGER ANXIETY.
nTEACH THE CLIENT ABOUT COPING MEASURES AND THE MEDICATIONS.
nENCOURAGE THE CLIENT TO USE COMMUNITY SUPPORT SYSTEMS.

Phobic Disorder> irrational fear of specific object, activity, or event accompanied by persistent avoidance; individuals may have panic attacks or severe anxiety when exposed to these situations or objects.
nHave genetic factor.
nIndividual recognizes the fear as irrational and inappropriate ( ego-dystonic ), but he feels powerless to control it.
nSimple phobia is the fear of specific things : elevators, airplanes, heights, insects.
nSocial phobia is the fear of potentially embarrassing situations : fear of eating or speaking in public or of using public restrooms.
Nursing Implementation for Phobic Disorder
nDo not force the client to be in contact with a phobic object or situation.
nhelp client describe feelings prior to response to a phobic object.
nUse cognitive strategies, such as reframing, to help the client put thoughts and feelings into a different perspective.
nPractice relaxation techniques with the client.

PTSD> recurrent thoughts and feelings associated with a severe, specific trauma ( combat experiences, rape, serious accident, severe deprivation or abuse ).Sleep disorders; guilt (survivors guilt); nightmares and flashback; anger and numbing of other emotions.
nMay be an acute or delayed response or a chronic condition.
nAffected individuals often use drugs, alcohol, or both to self-medicate for relief of distressful symptoms.
nSeparation from parents during childhood can increase vulnerability to PTSD.
n31 OUT OF 100 war veterans have suffered severe trauma will develop PTSD at some point in their life.
Nursing Implementation for PTSD
n Use appropriate interventions to reduce anxiety (relaxation techniques, encouraging expression of feelings, limiting caffeine and nicotine).
nValidate for the client that the traumatic event he experienced was highly stressful.
nHelp the client verbalize all aspects of the traumatic event, including his thoughts and feelings.
nTeach the client coping strategies to manage anxiety symptoms that accompany memories of his trauma.
Dissociative Disorder> has an altered conscious awareness that may include periods of forgetfulness, memory loss of past stressful events, feeling disconnected from daily events, or an emergence of distinctly different personalities
nAn individual reacts to trauma by “splitting off”’, or dissociating himself, from the memory of trauma.
nGenerally thought to result from severe, traumatic abuse in early childhood.
nSexual and physical abuse in early childhood.
n3 to 9 times more common in women than in men.
nHighly hipnotizable.
Nursing Implementation for Dissociative Disorder
nEstablish a trusting relationship.
nEncourage disclosure
nTeach the client anxiety-binding techniques, which provide the client with a mechanism that can be used to reduce anxiety. For example: instruct the client to imagine that the memory is a story in a book and when anxiety gets too high, to close the book and put it on the shelf.
TREATMENT for STRESS, ANXIETY, and ANXIETY-RELATED DISORDERS
BENZODIAZEPINES (short term) : increase levels of GABA, thereby decreasing anxiety; treatment of GAD, panic disorder and social phobia.
> alprazolam (Xanax)
> chlordiazepoxide (Librium)
> clonazepam (Klonopin)
> lorazepam (Ativan)

AZAPIRONES (nonbenzodiazepine) long term : decreases SEROTONIN secretions in synapse lead to decrease anxiety; treatment of GAD, panic disorder and social phobia.
> buspirone (Buspar)

TREATMENT for STRESS, ANXIETY, and ANXIETY-RELATED DISORDERS
TRICYCLIC antidepressants : increasing levels of serotonin and norepinephrine at synapse; used for GAD, panic disorder, social phobia, and OCD.
> clomipramine ( Anafranil )
> imipramine ( Tofranil )

Selective Serotonin Reuptake Inhibitors (SSRI) : selectively block serotonin reuptake at synapse, thereby increasing serotonin levels; used for GAD, panic disorder, and OCD.
> fluoxetine (Prozac)
> fluvoxamine (Luvox)
> paroxetine (Paxil)
> sertraline (Zoloft)

TREATMENT for STRESS, ANXIETY, and ANXIETY-RELATED DISORDERS
Other Antidepressant : used for GAD
> venlafaxine (Effexor)

Monoamine Oxidase Inhibitors ( MAOIs) : inhibits action of enzyme oxidase, which breaks down serotonin, thereby increasing serotonin levels; used for panic disorders and Agoraphobia.
> phenelzine (Nardil)

BETA BLOCKERS : induced peripheral beta-adrenergic blockade, thereby reducing physiologic effects of anxiety; used for social phobia and PTSD.
> atenolol (Tenormin)
> propranolol (Inderal)

II. The Mind-Body Continuum CommonDisorders
A. Somatoform Disorders
1. Somatization Disorder
2. Hypochondrias
3. Body Dysmorphic Disorder
4. Pain Disorder
5. Conversion Disorder
B. Sexual Disorders
1. Sexual dysfunctions
1.1 sexual desire disorders
1.4 sexual pain disorders
1.2 sexual arousal disorders
1.5 sexual dysfunction due to general
1.3 orgasmic disorders medical condition
2. Paraphilias
3. Gender Identity Disturbance
C. Eating Disorders
1. Anorexia Nervosa
2. Bulimia Nervosa
•Somatoform Disorders> complaints of physical symptoms that cannot be explained by known physical mechanisms.> anxiety relief (primary gain)> special attention, relief from responsibilities (secondary gains)> ego-syntonic ( congruent with the individual’s view of self)
nSomatization – history of multiple physical complaints without organic basis; persisting for several years.
nHypochondrias – is the unrealistic fear of having a serious illness without organic basis.
nBody Dysmorphic Disorder – preoccupation with an imagined defect in a normal-appearing client. If the client actually has a defect, expressed concern is excessive.
nPain Disorder – chronic pain in one or more anatomic sites; a medical condition, if present, plays a minor role in accounting for pain.

5. Conversion Disorder – is a loss, or change in, physical functioning that cannot be associated with any organic cause and that seems to be associated with psychosocial stressors, such as disorder is generally characterized by:
. Sensory dysfunction : blindness; deafness; or loss of tactile sense.
. Motor system Dysfunction : aphasia; impaired coordination; paralysis or seizure.
. La belle indifference : seeing unconcern with a fairly dramatic symptom, such as being unable to walk or move a limb.
B. Sexual Disorders> destruction in part of limbic system or involving the temporal lobe
2. Paraphilias – sexual fantasies, urges, or behaviors involving nonhuman objects, suffering or humiliation, children, or other non- consenting individuals.
. Sexual sadism and masochism
. Fetishism
. Transvestic fetishism
. Pedophilia
. Voyerism
. Froteurism
. Exhibitionism
. Zoophilia
. Necrophilia
3. Gender Identity Disorder
nStatistics indicate that about 1:2000 children are born with ambiguous looking genitalia (transgenderism) each year.
nContributing causes include the influence of social learning on gender development in childhood and parental dynamics that encourage the child’s identity with a non gender-based sex role.
C. Eating Disorders> both not a disease, but syndromes
nAnorexia Nervosa – refusal to maintain minimally normal weight, intense fear of gaining weight, a significant disturbance in perception of shape or body size.

> body weight is <85% of normal for age and height; hypotension; bradycardia; arrythmias; hypokalemia;hypocalcemia; dehydration; amenorrhea; lanugo; hypothermia; dry skin; hair loss; osteoporosis; constipation
> although underweight, the client has an intense fear of becoming fat.
> has a disturbed body image
> exercises strenuously and has peculiar food-handling patterns.
> feels lack of control or competence in any area of life other than weight control.

2. Bulimia Nervosa> repeated episodes of binge eating, followed by purging behaviors; it also includes inappropriate use of laxatives, fasting, or exercise to control weight.
Binge eating : consuming enormous quantities of food in a discrete time period; anxiety often triggers the binge.

Purging : is using compensatory behaviors to rid the body of food and prevent weight gain; behaviors include self-induced vomiting or misuse of laxatives, diuretics, enemas, or other medications or substances (syrup of ipecac)
> the client fasts or exercises excessively.
> Binges commonly lead to feelings of loss of control, guilt, and humiliation.
> esophagitis, hoarseness, enlarged parotid glands, hypokalemia, hypocalcemia, bradycardia, arrythmias, hypotension, all related to vomiting.
Treatment for Eating Disorders
nTricyclic Antidepressants ( TCA’s )
> reduces anxiety and depression
> more effective in treating bulimia than anorexia
. Desipramine (Norpramin)
. Imipramine (Tofranil)
nSelective Serotonin Reuptake Inhibitors (SSRI)
> restores serotonin levels
> use to treat concurrent depression
. Fluoxetine (Prozac)
. Sertraline (Zoloft)
III. Personality Disorders> inflexible, pervasive pattern of self-perception and behavior that deviates markedly from one’s usual culture.
nOdd, Eccentric Disorders
1. Paranoid PD
2. Schizoid PD
3. Schizotypal PD
nDramatic, Emotional, Erratic Disorders
1. Antisocial PD
2. Borderline PD
3. Histrionic PD
4. Narcissistic PD
nAnxious, Fearful Disorders
1. Avoidant PD
2. Dependent PD
3. Obsessive-Compulsive PD
Odd, eccentric disorders
nParanoid PD – distrusrt and suspiciousness; interprets other people’s motives as threatening.
nSchizoid PD – lacks personal and social relationships; he is detached from others and withdraws from interactions.
nSchizotypal PD – may have behaviors similar to schizophrenia, but psychotic episodes are infrequent; he may also be acutely uncomfortable in relationships.
Dramatic, emotional, erratic Disorders
nAntisocial PD – disregard for and violation of the rights of others.
> unable to follow rules
> is grossly selfish and irresponsible
> generally manipulative in relationships with others

2. Borderline PD
nImpulsive and unpredictable
nHaving unstable moods
nDisturbed relationships with others
nIntolerance to being alone
nA chronic sense of boredom
nMay use Splitting (“all or none” mentality) defense mechanism and Projection unable to recognize negative feelings or undesirable characteristics in himself instead believes these feelings or characteristics belong to another person).

3. Histrionic PD – excessive emotionality and attention seeking behaviors that are dramatic and egocentric.

4. Narcissistic PD – typically demonstrates grandiosity and the need for constant admiration by others; such a person exaggerates his importance and accomplishments.
Anxious, fearful Disorders
Avoidant PD
> social inhibition
> feelings of inadequacy
> sensitivity to potential rejection or critism

Dependent PD
> submissive and clinging behavior associated with an excessive need to be cared for by others

Obsessive-Compulsive PD
> preoccupation with orderliness, perfectionism, and the need to be in control of situations, objects, and people.