NUR 131 Stress and Coping

What traumatic components relate to/effect emotional disorders? [McKinney]

Growing evidence points to the secondary development of mood disorders in children and adolescents who have sustained traumatic brain injury (TBI), including concussion.

Physical Signs of stress

Headaches •Back/neck pain •Nausea/upset stomach •High blood pressure / palpitations •Fatigue/low energy •Insomnia •Frequent colds/infections

Define coping

to face and deal with responsibilities, problems, or difficulties, especially successfully or in a calm or adequate manner. •Synonyms: wrestle, strive, persevere.

Comorbidity with stress

75% of the general population experience at least some stress every 2 weeks •Anxiety disorders are the most prevalent psychiatric disorders in the US (28.8%). •Of those with an anxiety disorder, 90% develop another psychiatric disorder. •Patients frequently seek relief of physical symptoms. •Women are more frequently affected than men. •These disorders usually begin in childhood, adolescence, and early adulthood. 4 Prevalence and Co-Morbidity of Anxiety Disorders and Stress Loading... The concept of "mental health" is partially culturally defined; it includes the ability to engage in activities of daily living, manage normal levels of stress, and have meaningful interpersonal relationships. Psychosocial or mental illness refers to disorders that affect personal and social functioning, or cause acute distress. These disorders are characterized by disruption or alteration in thinking, mood, or behavior. (McKinney) 5 Across the Lifespan

Phobias Symptoms

A feeling of uncontrollable panic, terror or dread when you're exposed to the source of your fear The feeling that you must do everything possible to avoid what you fear The inability to function normally because of your anxiety Physical as well as psychological reactions, including sweating, rapid heartbeat, difficulty breathing, a feeling of panic and intense anxiety Often, the knowledge that your fears are unreasonable or exaggerated but feeling powerless to control them In some cases, anxiety just thinking about what you fear In children, possibly tantrums, clinging or crying

Normal anxiety

A healthy life force Necessary for survival Provides energy needed to carry out tasks Motivates to make and survive change. Prompts constructive behaviors •Studying for an examination •Being on time for a job interview •Preparing for a presentation •Working toward a promotion

Define stress

A pattern of physiologic and psychologic responses determined through cognitive appraisal. •World: hardship, adversity, or affliction

Phobias

A phobia is an overwhelming and unreasonable fear of an object or situation that poses little real danger but provokes anxiety and avoidance. Unlike the brief anxiety most people feel when they give a speech or take a test, a phobia is long lasting, causes intense physical and psychological reactions, and can affect your ability to function normally at w

Distress

Distress seen as "bad" Can cause many kinds of negative outcomes •Physical •Emotional •Spiritual •Relational •Educational •Vocational

Dysfunctional behavior and stress

Dysfunctional behavior is often a defense against anxiety. ●When behavior is recognized as dysfunctional, interventions can be initiated by the nurse to reduce anxiety. ●As anxiety decreases, dysfunctional behavior will frequently decrease.

Types of stress

Eustress Distress

Levels of Anxiety

Mild anxiety •Moderate anxiety •Severe anxiety •Panic level of anxiety

Panic

Panic disorder (panic attacks) is distinguished from other anxiety disorders by the rapid onset of physical, cognitive, and emotional symptoms.

What is stress? [Giddens]

Stress refers to an event or demand made on the individual or family that •causes the individual or family to appraise the event •determine whether resources for its management are exceeded •and whether the event or demand is neutral (no stress), challenging, or threatening. The appraisal determines the end result (outcome) of health, disability, or dysfunction.

If somebody said they wanted to learn to cope better and said they had so many stressful events a nurse would say

Tell me about what is causing the stress. Let's them talk about it and also they may be able to come to a conclusion themselves about what they need to do.

Resilience

The ability to spring back into shape Recover quickly from hardships

Panic Age-related factors

The diagnosis of panic disorder is more frequently seen in adolescents than in children

What role does the immune system play in emotional disorders? [McKinney and Lewis]

The psychosocial state of a person can have direct impacts on the immune system. For instance, stress has many different effects on the endocrine systems, including the well known fight or flight activation which is activations of the sympathetic adrenal-medullary (SAM) system, the hypothalamic-pituitary-adrenocortical (HPAC) system, and other endocrine systems.

Obsessive-Compulsive Disorder (Children and Adults) Age-related factors

The thoughts and behaviors associated with obsessive-compulsive disorder are often perplexing to parents, teachers and peers. Recognizing the symptoms of obsessive-compulsive disorder may be challenging, as the symptoms can easily be misinterpreted as willful disregard, oppositionality, or meaningless worry. In addition, children and adolescents may try to hide their symptoms or may not know how to express their underlying worries. Often, a parent or teacher only sees the end result of the symptom (hours in the bathroom, extended time alone in the bedroom, or tantrums when the child cannot do something his or her way). Symptoms may vary over time and may change in the way they appear, which can further complicate diagnosis. Children may be able to resist the obsessions and compulsions at school but not at home. The symptoms may fluctuate, with more symptoms at stressful periods and fewer symptoms at other times. Other medical conditions can mimic the disorder, and other conditions may co-occur with the disorder.

Documenting stress

You would make a nursing note documenting what the patient is stressed about

Panic Symptoms/ behaviors

cardiovascular (palpitations, chest pain) and respiratory (shortness of breath) distress, and psychological symptoms characterized by a strong feeling of impending doom or fear that the child is dying

Differentiate for Separation Anxiety (children) Behavior

children with separation anxiety stay home or attempt to remain with their parents. The child may complain of physical symptoms, cry, bargain, plead, or even exhibit panic symptoms as school time approaches.

Obsessive-Compulsive Disorder (Children and Adults) Symptoms and behaviors

manifests as repetitive unwanted thoughts (obsessions) or ritualistic actions (compulsions), or both. Obsessions are recurrent intrusive thoughts, feelings, and ideas. Compulsions are behaviors or actions that are repetitive and recurrent. Compulsions are designed to relieve the anxiety that the child usually realizes is irrational. Because young children cannot adequately describe their uncomfortable thoughts or concerns, severe temper tantrums, particularly when a ritual has been interrupted, may be the predominant sympto

Situational Crisis Characteristics

situational crisis arises from an external rather than an internal source. Often the crisis is unanticipated. Examples of external situations that can precipitate a crisis include loss of a job, death of a loved one, unwanted pregnancy, a move, change of job, change in financial status, divorce, and severe physical or mental illness.

Key Points about Crises Is struggle a pathological state? How long until these crisis usually resolved? How many types of crisis and what are they? What is crisis intervention usually aimed against? What are the basic goals of outcomes from crisis?

A crisis is not a pathological state but a struggle for emotional balance. •Crises offer opportunities for emotional growth but can also lead to personality disorganization. •There are three types of crisis: maturational, situational, and adventitious. •Situational and maturational crises are usually resolved within 4 to 6 weeks. •The patient is an active participant in setting goals and planning possible solutions. •Crisis intervention is usually aimed at the mentally healthy person who generally is functioning well but is temporarily overwhelmed and unable to function. •The basic goals of crisis intervention are to reduce the individual's anxiety level and to support the effort to return to the person's pre-crisis level of functioning.

Guided Imagery What is it? What symptoms does it reduce? What senses are involved? How is it done?

A mind-body therapy that involves voluntary thinking about specific mental images, usually in combination with progressive muscle relaxation and deep breathing. •Known to reduces stress, anxiety and pain. •Not just a visual exercise, but ALL senses (hearing, taste, smell, touch, and sight) are used to produce the greatest benefit. •In a relaxed state, recall the image and accompanying sensations to assist in the process of improving your health.

Motivational Interviewing

A style of conversation designed to help a person realize his or her true goals and act in line with those aspirations. •Four basic principles:

Acute anxiety

Acute anxiety is precipitated by an imminent loss or change that threatens an individual's sense of security.

Internal Factors Affecting One's Response To Stress

Age •Health status •Personality characteristics •Previous experience with stressors •Genetic background Hardiness Resilience Attitude Nutritional status

Agoraphobia

Agoraphobia Is an intense and excessive level of anxiety and a fear of being in places and situations from which escape is impossible. •Feared places are avoided to control anxiety. •Avoidance behaviors can be debilitating and life constricting.

Exemplars of Maladaptive Coping Behaviors

Alcohol and Drug abuse •Anxiety •Bullying •Denial •Dependency •Developmental delay •Emotional outbursts •Excessive eating •Impaired functional status •Nonadherence to treatment plan •Social isolation or withdrawal •Violence

the 'Tend and Befriend' Response

Almost all the studies of the stress response have been conducted in males and so, therefore, uphold fight-or-flight as the main response to stress. Although fight-or-flight may characterize the primary physiological responses to stress for both males and females, behaviorally, females' responses are more marked by a pattern of "tend-and-befriend." Researchers propose that females respond to stressful situations by protecting themselves and their young through nurturing behaviors--the "tend" part of the model--and forming alliances with a larger social group, particularly among women--the "befriend" part of the model.

Coping Mechanisms [Varcarolis]

Altruism Sublimation Humor Suppression Repression Displacement Reaction formation Somatization Undoing Rationalization Passive aggression Acting out Dissociation Devaluation Idealization Splitting Projection Denial

Ocd quote

An individual with OCD can't turn a thought off or stop an image from recurring. Moreover, this person will give increasing attention to these thoughts or images, and spend increasing energy to avoid them. One way to describe an obsession is an inability of the brain to apply the brakes and change course. Current research on OCD describes it as a brain disorder that occurs when the brain overvalues thoughts and images, and can't inhibit them (Sharp, 2013).

Relationship between mind and body

An intricate relationship exists between the mind, emotions, and the physical processes of the body. Thoughts and thought habits can positively or negatively affect our physical well-being. Similarly, the choices we make regarding our physical bodies, such as diet, exercise, and rest, among other things, can also positively or negatively affect our mental states. The mind and body are inseparable; they share a common chemical language that constantly communicates back and forth (Hart, 2008 in ANA Mindfulness and You). Fortunately, there are a number of practices that we can utilize to enhance the mind's positive impact on the body as well as the body's positive impact on the mind. These self-care practices have been shown to increase awareness of mental states, regulate emotions, and enhance overall health and well-being.

Anxiety vs fear

Anxiety and fear are indistinguishable except for the cause. •FEAR is a reaction to a specific danger. •ANXIETY is a feeling resulting from a real or perceived threat ●Is the most basic emotion.

Situational Crisis

Arises from an external rather than an internal source. •Often unanticipated. •Examples of external situations that can precipitate a crisis include loss of a job, death of a loved one, unwanted pregnancy, a move, change of job, change in financial status, divorce, and severe physical or mental illness. •Are encountered by most people during the course of their lives.

Situational Crisis Symptoms/ behaviors

As in all crises or potential crisis situations, the stressful event involves a loss or change that threatens a person's self-concept and self-esteem. To varying degrees, successful resolution of a crisis depends on resolution of the grief associated with the loss.

Teaching Points (geared towards parents)

Be consistent in how you handle problems and administer discipline. •Remember that anxiety is not willful misbehavior, but reflects an inability to control it. Therefore, be patient and be prepared to listen. •Maintain realistic, attainable goals and expectations for the child. Do not communicate that perfection is expected or acceptable. •Maintain a consistent, but flexible, routine for homework, chores, and activities. •Accept mistakes as a normal part of growing up, and that no one is expected to do everything equally well. Praise and reinforce effort, even if success is less than expected. •If the child is worried about an upcoming event, such as giving a speech in class, practice it so that confidence increases and discomfort decreases. •Teach the child simple strategies, such as organizing materials and time, developing small scripts of what to do and say, either externally or internally, when anxiety increases, and learning how to relax under stressful conditions. •Listen to and talk with the child on a regular basis and avoid being critical. Do not treat emotions, questions, and statements about feeling anxious as silly or unimportant. •Do not assume that the child is being difficult or that the problem will go away. Seek help if the problem persists and continues to interfere with daily activities.

Sympathetic vs. Parasympathetic

Because most of the stressors found in modern life are chronic in nature, they continually impede proper regulation of the two parts of the autonomic nervous system: sympathetic (fight or flight) and parasympathetic (rest and restoration). While the fight or flight response may assure survival in the short term, it has deleterious effects on every system of the body after it becomes chronic and overwhelming because individuals are unable to engage in the important relaxation response (Benson, 1975 in ANA Mindfulness and You).

Cognitive Behavioral Therapy Is anxiety learned? How to unlearn it with using behavioral therapy

Behavioral psychologists conceptualize anxiety as a learned response that can be unlearned. Some individuals may learn to be anxious from the modeling provided by parents or peers. For example, a mother who is fearful of thunder and lightning and who hides in closets during storms may transmit her anxiety to her children, who continue to adopt her behavior even into adult life. Such individuals can unlearn this behavior by observing others who react normally to a storm. For example, behavioral therapy in the form of gradually exposing a highly anxious person to a feared object or situation (such as that in agoraphobia) over time with support can help the person overcome his or her fear of the object or situation.

Generalized Anxiety Disorder Age-related factors

Binary logistic regression analyses revealed that four distinct sets of symptoms were associated with GAD in each age group, and that numerically fewer symptoms were associated with GAD in older adults. Moreover, there were graduated changes in the type and number of symptoms associated with GAD in each successive age group.

What biologic components relate to/effect emotional disorders? [McKinney]

Biologic factors that contribute to mental disorders include genetic determinants, genetic predispositions (risk factors), traumatic brain injury, and disease states that affect brain function (Fay, Yeates, Drotar, et al., 2009).

Coping (Defense) mechanisms Relationship from one another What makes them maladaptive or adaptive

Can be used in healthy or unhealthy ways. •Most people use a variety of them. •Discrete from one another. •Are adaptive or maladaptive based on their frequency, intensity, and duration of use.

More severe symptoms:

Center on dirtiness, contamination, and germs and occur with corresponding compulsions such as cleaning and hand washing.

Differentiate for Separation Anxiety (children) Symptoms

Children with separation anxiety frequently fear that if they are apart from their parents, harm will come to the parent or themselves.

Obsessive-Compulsive Disorder (Children and Adults) Therapeutic management

Cognitive Behavior Therapy (CBT) Individual psychotherapy Parent guidance sessions Group psychotherapy

Panic Therapeutic management

Cognitive-behavioral therapy Pharmacologic management All patients with panic disorder should be referred to a psychiatrist, psychologist, or other mental health professional.

What do compulsions do? Symptoms without a disease? When is the onset?

Compulsions are designed to relieve the anxiety that a person (child or adult) usually realizes is irrational (McKinney, p. 1453). •Children often go through transient stages of obsessive thinking or compulsive behavior, usually at times of anxiety or stress, and these transient symptoms do not warrant the diagnosis (McKinney, p. 1453). •Routines and rituals may develop around age 2 and wane by age 5 or 6. With childhood onset of OCD, routines or rituals develop and intensify, without subsequently declining (Sharp, 2013).

What cultural considerations play into stress and coping? [Varcarolis]

Culture is one of the fundamental aspects of society that influence both the per- son and the environment. Although culture is part of the environmental system, it should be distinguished from the more proximal social climate of Panel I, which con- sists of specific settings (e.g., family, work, and neighborhood) and ongoing stressors and resources. Culture would be better conceptualized as a macro-social or ecological system that permeates the entire stress and coping process.

Key points How common? Etiology Shame?

Defenses against anxiety can be adaptive or maladaptive. •Anxiety disorders are the most common psychiatric disorders in the United States and frequently co-occur with depression or substance abuse. •Research has identified genetic and biological factors in the etiology of anxiety disorders. •People with anxiety disorders are often too embarrassed or ashamed to seek psychiatric help. Instead, they consult their primary care providers about multiple somatic complaints.

Motivational Interviewing Developing discrepancies

Developing discrepancy: acknowledge any gaps between what you are currently doing and what you want to be doing. Listen for resistance talk

Separation Anxiety

Developmental milestones that are typical anxiety responses in children: stranger anxiety at 7-9 months and separation anxiety at 12-18 months. Both usually resolve by 2 years of age. This is expected and an important indicators of progressive cognitive development (Huberty, n.d.) •Essential hallmark of disabling separation anxiety is disabling anxiety about being apart from one's parents or another significant person to whom the child is attached, or anxiety about being away from home. •It may develop spontaneously or under stress (e.g., in temporary relation to a move or a death in the family) and may last for several years, with symptoms developing and remitting in a cyclical pattern. •Children with separation anxiety frequently fear that if they are apart from their parents, harm will come to the parent or themselves. •Separation anxiety disorders in childhood are associated with increased risk for the subsequent development of panic disorders and depression (Rosenberg et al., 2011).

Pathological anxiety

Differs in terms of duration, intensity, and disturbance in a person's ability to function (e.g., the person exhibits dysfunctional behaviors or extreme withdrawal). •Usually more chronic in nature (a person has experienced this anxiety for a long time).

General guidelines of a problem with a child

Disrupt normal functioning for the child and the family. •Children may lose interest in play and school activities. •Relationships with family and friends are usually impaired. •May exhibit learning deficits related to behavior in school or inability to concentrate on learning. •Some disorders manifest through somatic complaints, such as recurrent abdominal pain, or headaches with no physical cause. •Recurrent thoughts of death or suicide are sometimes reported.

Fight or flight response pic

Dry mouth Liver releases glucose Increased HR lungs relax Cortisol is released

Interventions

Education •Developing an Action Plan •Identifying and Accessing Resources •Cognitive Restructuring

How do I know (or what will I see) in a person who has a disturbance between stress levels and coping abilities? [McKinney]

Emotional and behavioral disorders may be manifested as disturbances in feeling (e.g., depression, anxiety), in body function (e.g., constipation, encopresis, enuresis), in somatic symptoms (e.g., headaches, stomachaches), in behavior (e.g., conduct disturbance, school avoidance, passive-aggressive behaviors), or in performance (concentration problems, test-taking difficulties).

Motivational Interviewing Empathy

Empathy: Become and remain your own ally (as we are often our own worst enemy, listening to our inner conversations with a harsh inner critic).

What environmental components relate to/effect emotional disorders? [McKinney]

Environmental stressors, such as inconsistent or contradictory child-rearing practices, marital conflict, neglect, or traumatic events may also precipitate the development of a psychosocial disorder. A family history of depression (particularly parental) is a significant risk factor for depression in children or adolescents, which increases the risk for suicide (NIMH, 2010e). Emotional and behavioral theories emphasize the importance of the interaction within the family system and quality of relationships with siblings (Waldinger, Vaillant, & Orav, 2007).There is evidence that children with a history of verbal, physical, or sexual abuse; frequent separation from or loss of loved ones; drug use; incarceration; lower socioeconomic status; homosexuality; chronic illness; behavioral disorders; and dysfunctional families are more likely than peers with healthy family patterns to have anxiety or depressive disorders (NIMH, 2010b).

Maturational Crisis

Erikson declared that each of these stages constitutes a crisis in personal growth and development. Each developmental stage can thus be referred to as a maturational crisis.

Evidence of adequate coping

Evidence of adequate coping behavior includes insight and engagement with the primary appraisal and the development of a coping plan.

Evidence of poor coping

Evidence of poor coping behaviors includes anger, anxiousness, sadness, or hopelessness. If somebody had PTSD and said "it shouldn't have been them it should have been me" you need to follow up on that statement and ask them if they are having suicidal thoughts

Clinical Management: Primary Prevention

Exercise •Nutrition •Positive relationships •Social supports •Relaxation techniques

Stress training

Few people receive formal training on how to manage stress, which may explain why many of us turn to destructive ways of coping. If you can't do something about the cause, you need to find a successful strategy for coping w

Anxiety and Neurotransmitters GABA

GABA is an inhibitory neurotransmitter in the brain. The release of GABA slows neural transmission, which has a calming effect. A number of drugs including antianxiety agents, sedative-hypnotics, general anesthetics, and anticonvulsant drugs are the targets of the GABA receptor system (Howland, 2010).

Guided Imagery Example

Go to your happy place: the beach. Visuals. Sounds. Smells. Touch. Tastes. •Starting an exercise program. Imagine a time when you were in better shape: physical feelings. Emotional feelings. What sort of clothes were you wearing? What types of fun things did you do? Who did you do them with? Imagine yourself doing some sort of physical activity you want to be able to do ...and tell yourself you can start to do this now. •Triangle of awareness: our thoughts, feelings, and physical sensations. Giving your goal a "face."

Mindfulness What does it do What symptoms can it relieve What reaction does it reduce

Helps us look at real or perceived threats in a more objective manner and can be useful at every stage of the emotional process (Rosenberg, 2013 in ANA Mindfulness and You). Mindfulness is the antithesis of suppression. •Demonstrated to reduce the frequency and intensity of chronic pain, lower anxiety, improve mood disturbances associated with depression, and to improve the duration and quality of sleep (Grossman, Niemann, Schmidt, & Walach, 2004; McCarney, Schulz, & Grey, 2012). •Softens our fight-or-flight response to stress: Engages the relaxation response and lowers stress and the harmful effects of chronic stress. Helps to lower inflammation and boost the immune response— both of which are compromised in the face of prolonged stress (Davidson et al., 2003 in ANA Mindfulness and You).

Oxytocin

In a double-blind experiment, 100 students were administered either oxytocin or a placebo via a nasal spray, then subjected to social rejection. In a conversation that was staged to simulate real life, researchers posing as students disagreed with, interrupted and ignored the unsuspecting participants. Using mood and personality questionnaires, the data showed that participants who were particularly distressed after being snubbed by the researchers reported greater trust in other people if they sniffed oxytocin prior to the event, but not if they sniffed the placebo. In contrast, oxytocin had no effect on trust in those who were not emotionally affected by social rejection.

Cognitive behavioral therapy How does it work? Evidence that it works? Is it the best technique?

Individuals, by consciously becoming aware of stressful thoughts and feelings associated with various events or situations, can learn to analyze behaviors related to these thoughts or feelings and begin to think and behave in more positive ways. Brain scans taken before and after cognitive therapy treatment support the hypothesis that learning to reframe one's thinking can literally change the chemistry and function of the brain. Cognitive behavioral therapy seems to have the best evidence not only for effective psychotherapeutic treatment of anxiety disorders but also for more lasting results in other disorders and problematic situations.

Is Professional Help Needed?

Is the anxiety typical for a child this age? •Is the anxiety shown in specific situations or is it more pervasive? •Is the problem long term or is it recent? •What events may be contributing to the problems? •How are personal, social, and academic development affected?

Psychosocial Disorders in Children Risk factors

Is there a familial or genetic predisposition toward the disease? •Physical or emotional stressors may create a vulnerability •Physical problems, such as head injuries, sleep disorders, birth defects, physical injuries, and chronic illness may precipitate/aggravate disorders •Environmental stressors, such as inconsistent or contradictory child-rearing practices, marital conflict, neglect, or traumatic events increase potential •Some cognitive, emotional, and behavioral manifestations are associated with genetic syndromes, such as fragile X syndrome •Other disorders, such as fetal alcohol syndrome (FAS), are associated with prenatal or infancy deficiencies or substance abuse by pregnant women •Still other disorders are related primarily to an inaccurate or inappropriate relationship between the child and significant others in the social environment.

What happens during the four levels of anxiety pic

Key: things: Mild- things that cause mild anxiety- job interview. Moderate- will experience physical symptoms- restless, headache, feel "undone", You can give them choices, they may be unclear about instructions so slow down and repeat what you said and repeat it to make sure they understand. Also have them do the teaching again later. Severe- nausea, vomiting, dizzy, hyperventilation, defensive, fearful Panic- highest priority is patient safety, never leave them alone, severely distraught, cannot make decisions for themselves, WILL BE ON TEST

Resistance talk

Listen for resistance talk •Resistance talk is whatever your mind comes up with in defense of the status quo

Male aggression vs female aggression and why

Male aggression appears to be regulated by androgen hormones, such as testosterone, and linked to sympathetic reactivity. Female aggression appears to be more cerebral in nature (social exclusion, gossiping). Oxytocin promotes caregiving behavior and underlies attachment between mothers and their infants. Some studies have found that mothers tend to be more nurturing and caring toward their children when they are most stressed. And it may help explain why women are less vulnerable than men to stress-related illnesses like hypertension and alcohol and drug abuse.

Maturational Crisis Therapeutic management

Maturational crises are predictable and can be prepared for and prevented. Proactively identifying actual or possible changes that the event will cause and then taking steps to become more prepared for those changes can minimize the disruption. For example, a young couple can take parenting classes to help prevent pediatric head trauma that could result from shaking their infant out of frustration during a period of uncontrollable crying.

May be manifested as disturbances in

May be manifested as disturbances in •Feeling (depression, anxiety) •Body function (constipation, encopresis, enuresis) •Somatic symptoms (headaches, stomachaches) •Behavior (conduct disturbance, school avoidance, passive-aggressive behaviors) •Performance (concentration problems, test-taking difficulties) The manner in which a child responds to stress depends on multiple factors within these interactions.

ABC example

Most people's initial automatic thought are negative; grossly distorted versions of what actually took place. Psychologists call the cognitive distortions. The ABC exercise helps to recognize these cognitive distortions for what they are and then actively replace them with more functional thoughts. Cognitive distortions can take the form of jumping to conclusions (the person dissed you), personalization (because they are angry with you), overgeneralization (therefore it is true that you cannot maintain relationships), and filtering (not allowing positive thoughts in because of such a strong negative focus).

Adventitious crisis

National disaster, crime or violence, assault, rape or murder, floods etc

Qualities of Mindfulness and Their Implications

Non-judging Becoming more aware of the prevalent habit of categorizing people and events as good, bad, or indifferent. Patience Gaining the wisdom to know and accept the fact that some things must unfold in their own time. Beginner's Mind (Openness) Seeing things as if for the first time, allowing oneself to be receptive to all possibilities. Trust Trusting in one's own wisdom, enabling the cultivation of trust in others. Non-striving Enhancing the ability to deeply experience the present without the tension of goal or achievement orientation. Acceptance Seeing things as they actually are rather than how one wishes them to be. Letting Go (Non-attachment) Allowing thoughts, feelings, and experiences to come and go without getting entangled.

Anxiety and Neurotransmitters Norepinephrine

Norepinephrine is known to mediate arousal. When a person feels threatened (real or perceived) the level of norepinephrine (adrenaline) increases and can cause hyperarousal and increased anxiety. Noradrenergic drugs such as propranolol (which blocks adrenergic receptor activity) and clonidine (which stimulates α-adrenergic receptors) are used to help lower anxiety.

So when is Anxiety a mental disorder? Normal vs abnormal anxiety

Normal anxiety disappears when the danger or stressor is gone. •Abnormal anxiety remains when the stressor is no longer present, causing a disruption in the person's daily functions, such as job performance, relationships, or other areas of importance.

Obsessive-Compulsive Disorder Continuum What is considered normal?

OCD behavior exists along a continuum. •"Normal" individuals may experience mild obsessive-compulsive behaviors. •Mild compulsions are valued traits in U.S. society. Obsessions Compulsions

Obsessive-Compulsive Disorder (Children and Adults) Characteristics

OCD is considered when obsessions and compulsions are intractable, disturbing to the child, and interfere with activities and relationships.

Obsessive-Compulsive Disorder (Children and Adults)

Obsessive-compulsive disorder (OCD), formerly considered a type of anxiety disorder, is now regarded as a unique condition. It is a potentially disabling illness that traps people in endless cycles of repetitive thoughts and behaviors. People with OCD are plagued by recurring and distressing thoughts, fears, or images (obsessions) they cannot control. The anxiety (nervousness) produced by these thoughts leads to an urgent need to perform certain rituals or routines (compulsions). The compulsive rituals are performed in an attempt to prevent the obsessive thoughts or make them go away.

Generalized Anxiety Disorder Symptoms

Persistent worrying or obsession about small or large concerns that's out of proportion to the impact of the event Inability to set aside or let go of a worry Inability to relax, restlessness, and feeling keyed up or on edge Difficulty concentrating, or the feeling that your mind "goes blank" Worrying about excessively worrying Distress about making decisions for fear of making the wrong decision Carrying every option in a situation all the way out to its possible negative conclusion Difficulty handling uncertainty or indecisiveness Physical signs and symptoms may include: Fatigue Irritability Muscle tension or muscle aches Trembling, feeling twitchy Being easily startled Trouble sleeping Sweating Nausea, diarrhea or irritable bowel syndrome Headaches

Differentiate for Separation Anxiety (children) Therapeutic management

Practice separation. Leave your child with a caregiver for brief periods and short distances at first. Schedule separations after naps or feedings. Babies are more susceptible to separation anxiety when they're tired or hungry. Develop a "goodbye" ritual. Rituals are reassuring and can be as simple as a special wave through the window or a goodbye kiss. Keep familiar surroundings when possible and make new surroundings familiar. Have the sitter come to your house. When your child is away from home, let him or her bring a familiar object. Have a consistent primary caregiver. If you hire a caregiver, try to keep him or her on the job. Leave without fanfare. Tell your child you are leaving and that you will return, then go —don't stall. Minimize scary television. Your child is less likely to be fearful if the shows you watch are not frightening. Try not to give in. Reassure your child that he or she will be just fine—setting limits will help the adjustment to separation.

Maturational Crisis

Process of maturation occurs throughout life. •Erikson's eight stages of growth and development. •The path (stages) to adulthood is stressful and at times can be overwhelming. •With a new stage, the person is without effective defenses. This often leads to increased anxiety, which may manifest as variations in the person's normal behavior. •If a person lacks support systems and adequate role models, successful resolution may be difficult or may not occur. •Marriage, the birth of a child, and retirement are examples of maturational crises.

General pathophysiology of consequences of long term stress

Research is ongoing about the exact mechanisms of disease causation in chronic stress. There are theories proposing that disease results from the harmful effects of prolonged inflammatory responses, inhibitory effects on the immune system, and specific effects on target organs including the cardiovascular system. If left untreated, chronic stress can result in exhaustion, adrenal cortex depletion, and even death. (Giddens)

Separation anxiety behaviors or symptoms

School refusal is related to separation anxiety disorder (AACAP, 2007a) and may also be related to a social anxiety disorder. •Persistent reluctance or refusal to go to school or elsewhere may be the primary reason families seek intervention. •This is not truancy, where the child is relatively fearless and avoids school to pursue other interests. •The child may complain of physical symptoms, cry, bargain, plead, or even exhibit panic symptoms as school time approaches. Symptoms resolve quickly if the child is allowed to stay home, but will reappear the next morning. •Consideration of this diagnosis should rule out precipitating factors such as fear of bullying, fatigue, boredom, learning challenges, upsetting incidents that occur in the school setting, or upsets that are occurring in the home.

Self efficacy

Self-efficacy is your belief in your ability to succeed, regardless of how small or large the success may be. •Become your own cheerleader:

Anxiety and Neurotransmitters seratonin

Serotonin level is thought to be decreased in anxiety disorders. The selective serotonin reuptake inhibitors (SSRIs), which increase serotonin levels in the brain, are often first-line medications for the treatment of many anxiety disorders.

Differentiate for Social Anxiety (children) Behaviors

Social anxiety can be misinterpreted as shyness; the child may seem aloof from groups of children or uninvolved in social situations, where children avoid social or performance situations to such a degree that their daily routine is affected (e.g., by refusing to participate in physical education exercises or by failing to raise their hands to ask a question in class).

Differentiate for Social Anxiety (children)

Social anxiety disorder (social phobia) is the most common of the anxiety disorders, and usually shows its first symptoms in childhood or early adolescence but is evident into adulthood. •If untreated, it has wide-reaching effects on the child's ability to make friends, successfully transition to school, play sports, be part of a peer group during adolescence, and make the transition to college and to dating. •Social anxiety disorder generally responds well to treatment, and several different treatment approaches have been shown to be effective, although it is generally considered to be a chronic disorder (Schneier, 2006).

Interventions for Children with Psychosocial Disorders

Social skills training or group therapy may be most helpful for social anxiety. Children will often try to avoid anxiety by limiting social interactions. •Controversy has surrounded the use of antidepressants. Children may not metabolize these substances in the same manner as adults. There is a potential for increased risk of suicidal ideation and behavior in children, adolescents, and young adults. •Children, parents, and clinicians may prefer to initiate psychotherapy before, and perhaps in lieu of, medications; however, the most effective treatment combines medication and the child and family's exploration of situations and environmental factors that are related to the child's symptoms. •Hospital and day treatment settings use cognitive-behavioral therapies (CBTs) to increase coping skills and social skills and to provide tools that can be used to manage stress.

Differentiate for Social Anxiety (children) Therapeutic Management

Social skills training or group therapy may be most helpful for social anxiety. Children will often try to avoid anxiety by limiting social interactions. This creates a cycle of avoidance and associated shame.

Automatic memory of stress

Some experts hypothesize that once a particular stimulus causes this cascade of events, the memory is hardwired into the amygdala so that the next time the threat's encountered, the response can be even quicker (Murphy, 2005). KNOW ABOUT CORTISOL AND WHAT HAPPENS TO THE BODY WHEN IN FIGHT OR FLIGHT.

Situational Crisis Age related factors

Some refer to these events as "critical life problems" because they are encountered by most people during the course of their lives.

Phobias Therapeutic Management

Specific phobias usually are treated with exposure therapy. Social phobias may be treated with exposure therapy or with antidepressants or beta blockers. Agoraphobia, especially when it's accompanied by a panic disorder, is usually treated with exposure therapy or with SSRIs.

Resiliency in Children

Studies have shown that a resilient child/adolescent has the following characteristics: •A temperament that can adapt to changes in the environment •The ability to form nurturing relationships with other adults when a parent is not available •The ability to distance himself or herself from the emotional chaos of the parent or family •Social intelligence •The ability to use problem-solving skills

Differentiate for Separation Anxiety (children) Characteristics

Such anxiety is characterized by excessive fear, even panic, of being away from the parent or home.

Is it really a problem or is it normal behavior

Symptoms and displays of anxiety are expected and normal in children at specific times in development. For example, infants and children up to preschool age often show intense distress at times of separation from their parents or family members (see Chapter 35). •In addition, it is common for young children to have short-lived fears related to darkness, storms, animals, and imaginary situations (see Chapters 6 and 7). •Predispositions to anxiety result from genetic factors, neurochemical and hormonal imbalances, parental patterns of coping with stress, and societal influences.

Generalized anxiety disorder

Symptoms include restlessness, fatigue, poor concentration, irritability, and sleep disturbances.

Social anxiety Symptoms and behaviors

Symptoms of social anxiety may be generalized, or may be focused on specific triggers. •Social anxiety can be misinterpreted as shyness; the child may seem aloof from groups of children or uninvolved in social situations, where children avoid social or performance situations to such a degree that their daily routine is affected (e.g., by refusing to participate in physical education exercises or by failing to raise their hands to ask a question in class). •Social phobia can result in social isolation for the child who has difficulty establishing and maintaining peer relationships (Stafford, Boris, & Dalton, 2004).

Review of Stress Response

The amygdala is the control center for the instinct to survive. It coordinates the often unthinking reactions that lead to the "Fight or Flight" response (Murphy, 2005).

Expected Outcomes for Children with Psychosocial Disorders

The child will display adaptive ability, as evidenced by participation in and enjoyment of regular activities. •The parent will describe expected or unexpected side effects from prescribed med. •The child will display increased self-esteem, as evidenced by verbalization of an increase in self-confidence and an increase in positive feelings about self. •The child will demonstrate more positive moods and reduced anxiety levels and will talk to a responsible family member or professional about any thoughts of self-directed violence. •The child will exhibit appropriate sleep patterns, as evidenced by expressing feelings of being well rested, showing no signs of sleep deprivation (e.g., irritability, lethargy, restlessness), and showing no signs of excessive sleeping. •The child will engage in appropriate play for developmental level, attend school, maintain educational progress, and continue positive relationship with peers.

Across the lifespan

The concept of "mental health" is partially culturally defined; it includes the ability to engage in activities of daily living, manage normal levels of stress, and have meaningful interpersonal relationships. Psychosocial or mental illness refers to disorders that affect personal and social functioning, or cause acute distress. These disorders are characterized by disruption or alteration in thinking, mood, or behavior.

Why this difference between males and females?

The difference between the fight-or-flight response in males and this ''tend and befriend'' response in females, is based in hormonal differences between the sexes, the researchers suggest.

Differentiate for Separation Anxiety (children)

The essential hallmark of separation anxiety is disabling anxiety about being apart from one's parents or another significant person to whom the child is attached, or anxiety about being away from home.

CBT D

The fourth step of this ABC exercise in CBT is to create an alternate way of looking at the situation (correcting the cognitive distortion). D = do-over or devise a new plan Check in with the person and ask directly about the situation. If negative thoughts become persistent (crossing your mind more than 5 or 6 times in one day), take some time to slow down the inner conversation and look closely at the situation.

What role does the nervous system play in emotional disorders? [McKinney and Lewis]

The hypothalamus responds to signals of stress by engaging the autonomic nervous system. The autonomic nervous system is comprised of the sympathetic (fight-or-flight response) and parasympathetic nervous systems (relaxation response). In times of stress the sympathetic nervous system assumes control (fight-or-flight response) and sends signals to the adrenal glands, releasing epinephrine (or adrenaline). The circulating adrenaline increases heart rate, elevates blood pressure, increases blood flow to the skeletal muscles, and increases muscle tension. Respirations also increase, bringing more oxygen to the lungs, which is then sent to the brain, increasing alertness.

Generalized Anxiety Disorder Therapeutic Management

The two main treatments for generalized anxiety disorder are psychotherapy and medications. You may benefit most from a combination of the two. I

Fluoxetine (Prozac) action, uses, side effects, and adverse effects

Therapeutic Effects/Uses To treat depression with or without melancholia; bulimia disorder; obsessive-compulsive disorder; panic disorder; and premenstrual dysphoric disorder Mode of Action: Serotonin is increased in nerve cells because of blockage from nerve fibers. Side Effects Adverse Reactions Headache, nervousness, restlessness, insomnia, blurred vision, mydriasis, tremors, dry mouth, anorexia, nausea, diarrhea, weight loss, menstrual irregularities, sexual dysfunction

Maturational Crisis Symptoms / behaviors

This often leads to increased anxiety, which may manifest as variations in the person's normal behavior. Marriage, the birth of a child, and retirement are examples of maturational crises.

Lorazepam (Ativan) action, uses, side effects, and adverse effects

To control anxiety and to treat status epilepticus; for preoperative sedation; for substance withdrawal Mode of Action: Potentiate gamma-aminobutyric (GABA) effects by binding to specific benzodiazepine receptors and inhibiting GABA neurotransmission Side Effects Drowsiness, dizziness, weakness, confusion, blurred vision, nausea, vomiting, anorexia, restlessness, hallucinations, anterograde amnesia, sleep-related behavior Adverse Reactions Hypertension, hypotension, bradycardia, respiratory depression

Obsessions

Unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause significant anxiety or distress

Compulsions

Unwanted, repetitive behavior patterns or mental acts intended to reduce anxiety but not to provide pleasure or gratification

What happens to the body with stress

When a person undergoes a stressful event or situation, changes will occur within the body. These physiological changes may have some positive effects in the short term, such as boosting the immune system, but the long term effects can lead to impaired immune functions and changes in hormone secretion (Romeo et al., 2008).

What role does the endocrine system play in emotional disorders? [McKinney and Lewis]

When an individual is (or feels) threatened physically or emotionally, the hypothalamus readies the body to "fight" or "take flight" by sending impulses to the adrenal medulla. In response, the medulla secretes norepinephrine (in small amounts) and epinephrine (in larger amounts). Norepinephrine causes blood vessels in the skin and skeletal muscles to constrict, raising blood pressure. Epinephrine causes an increase in heart rate and contraction, stimulates the liver to change glycogen to glucose for use as energy by the cells, and stimulates fatty tissue to break down and release stored fats for use as energy by the cells as well. The actions of both hormones bring about increased levels of oxygen and glucose in the blood and a faster circulation of blood to the body organs, especially the brain, muscles, and heart. Reflexes and body movements quicken and the body is better able to handle a short-term emergency situation.

Ability to handle situational crisis (4)

Whether these events precipitate a full blown crisis depends on ➢The degree of support available from caring friends and family members ➢A person's general emotional and physical status ➢Social supports available in the community ➢A person's ability to understand and cope with the meaning of the stressful event.

Generalized Anxiety Disorder

a psychological disorder characterized by excessive or disproportionate anxiety about several aspects of life, such as work, social relationships, or financial matters.

Differentiate for Social Anxiety (children) Symptoms

fearfulness or discomfort in many social situations. Nongeneralized social disorder (also called performance anxiety) is characterized by severe anxiety about discrete situations or tasks, such as public speaking and socializing at parties, that people without social anxiety disorder can manage

Most severe symptoms:

• Include persistent thoughts of sexuality, violence, illness, and death.

Panic Disorders Is panic disorder commonly easily diagnosed? What do symptoms do People with panic disorder usually exhibit.

•70% of patients with panic disorder had seen at least 10 medical practitioners without receiving a diagnosis or adequate treatment (Pollock et al., 2010) •Others had developed symptoms of generalized anxiety disorder shortly before exhibiting somatic symptoms. (Varcarolis, page 174)

The consequences of poor coping can be physical, psychosocial, or both. Examples:

•A decline in physical health status •Development of mental health problems •Reduction in functional ability •Change in social status, financial status, or relationships •Alterations in family dynamics.

Phobias

•A persistent, intense irrational fear of a specific object, activity, or situation that leads to a desire for avoidance, or actual avoidance, of the object, activity, or situation. •Specific phobias are characterized by the experience of high levels of anxiety or fear •Usually in response to specific objects or situations such as dogs, spiders, heights, storms, water, blood, and closed spaces, among others. •Are common, but do not usually cause much difficulty.

Mindfulness

•According to Kabat-Zinn (2009), mindfulness is purposefully paying attention in the present moment, with a stance of acceptance and non-judgment. By definition, mindful awareness means being awake and aware, even aware of one's awareness. Contrasting awareness is the notion of operating on "autopilot" by being lost in thoughts of the past or the future (Smalley & Winston, 2010 in ANA Mindfulness and You). •Mindfulness does not involve an attempt to change the content of the experience, so you are not trying to resolve cognitive distortions. This is an attempt to experience your thoughts, feelings, physical sensations as they are in the here and now, without judging them and without trying to change them. When we are mindful, it is easier to recognize when our automatic thoughts are tending in a dangerous direction. Remain alert. Read the signs signaling entry into dangerous territory. Turn around.

Obsessive-Compulsive Disorder (Children) Why are children at risk? When is OCD Considered?

•Affects approximately 1% of children (Massachusetts General Hospital, 2010). •Because young children cannot adequately describe their uncomfortable thoughts or concerns, severe temper tantrums, particularly when a ritual has been interrupted, may be the predominant symptom. Sharp (2013) states the child may not recognize the thoughts or behaviors as excessive or unrealistic. •OCD is considered when obsessions and compulsions are intractable, disturbing to the child, and interfere with activities and relationships. To a casual observer, the ability to be successful at school and in extracurricular activities indicates "normal" behavior.

Ethnic and Cultural Differences What race has increased phobias? Anxiety and culture relationship

•African Americans experience phobias at a higher rate than Caucasians. •Different cultures respond to anxiety according to their beliefs, customs, and health practices. •For example, what a person living in New York considers normal anxiety is different from what a person in South Africa does. Remember, it's important to include cultural differences in the assessment and diagnosis of anxiety disorders. Murphy, 2010

Antidepressants action, uses, side effects, and adverse effects

•Antidepressants are used for depressive episodes that are accompanied by feelings of hopelessness and helplessness. •orthostatic hypotension, sedation, anticholinergic effects, cardiotoxicity, and seizures.dry mouth, blurred vision, insomnia, headache, nervousness, anorexia, nausea, diarrhea, and suicidal ideation. •They affect one or two of the three neurotransmitters: serotonin, norepinephrine, and dopamine.

Anti-psychotics action, uses, side effects, and adverse effects

•Antipsychotics block the actions of dopamine and thus may be classified as dopaminergic antagonists. •Pseudoparkinsonism, which resembles symptoms of Parkinson's disease, is a major side effect of typical antipsychotic drugs. •The most common side effect for all antipsychotics is drowsiness. Many of the antipsychotics have some anticholinergic effects: dry mouth, increased heart rate, urinary retention,

Psychological Signs of stress

•Anxiety •Depression •Irritability •Lack of focus/concentration •Forgetfulness •Disengagement •Feeling overwhelmed

Anxiolytics action, uses, side effects, and adverse effects

•Anxiolytics, or antianxiety drugs, are primarily used to treat anxiety and insomnia. The major anxiolytic group is benzodiazepines (a minor tranquilizer group). •enhance the action of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter within the CNS. •sedation, dizziness, headaches, dry mouth, blurred vision, rare urinary incontinence, and constipation. Adverse reactions include leukopenia (decreased WBC count) with symptoms of fever, malaise, and sore throat; tolerance to the drug dosage with continuous use; and physical dependency.

Assessment of Coping

•Background and Culture •Appraisal stage (threat and then resources) •Perception of threat •Past coping patterns •Medical and Social History (context) •How the individual functions in the presence of the stressor and how the individual reacts when speaking of the stressor

Coming Face-to-Face with our Internal Dialogue

•Cognitive Behavioral Therapy •Mindfulness •Guided Imagery •Motivational Interviewing Most people have good insight about their deep-seated longings, fears, desires and beliefs. This insight can lead to taking steps to change lives.

What is coping? [Giddens]

•Cognitive means and behavioral actions to manage internal or external situations perceived as difficult and/or beyond the individual's current resources (Lazarus and Folkman) •Being action oriented toward a goal of changing a situation (Ray) (Giddens)

Diseases linked with untreated or prolonged stress are

•Coronary heart disease, Hypertension, Stroke •Dysrhythmia disorders •Obesity •Tension headache, backache •Autoimmune disease •Infection •Ulcers, bowel problems, urinary problems •Eczema, acne •Diabetes •Menstrual cycle disorders •Fatigue, depression, and insomnia

External Factors Affecting One's Response To Stress

•Cultural and ethnic influences •Socioeconomic status •Social support •Religious/spiritual influences •Timing of stressors •Number of stressors already experiencing

Eustress

•Eustress seen as "good" Motivates one to take action to solve problems or reach goals.

Four basic principles:

•Expressing empathy •Developing discrepancy •Rolling with resistance •Supporting self-efficacy

Risk Factors for Stress

•Impaired Cognition •Developmental Level •Age (extremes) •Socioeconomic status (e.g., low income, homeless) → Limited Resources •Individual in a foreign country—especially with language/cultural barrier •Chronic health conditions •Multiple significant life changes •Caregiver

Risk Factors for Stress [McKinney, Lewis]

•Impaired Cognition •Developmental Level •Age (extremes) •Socioeconomic status (e.g., low income, homeless) → Limited Resources •Individual in a foreign country—especially with language/cultural barrier •Chronic health conditions •Multiple significant life changes •Caregiver

Risk Factors for Maladaptive Coping

•Inability to accurately assess stressor •Denial or avoidance •Actual or perceived lack of control •Actual or perceived lack of support •No experience or poor (negative) past experiences in managing stressful situations

Risk Factors for Maladaptive Coping [Giddens]

•Inability to accurately assess stressor •Denial or avoidance •Actual or perceived lack of control •Actual or perceived lack of support •No experience or poor (negative) past experiences in managing stressful situations

Generalized Anxiety Disorder

•Is a chronic disorder associated with severe distress. •Degree of anxiety is so high that it interferes with function at work, social, and family events. •Is characterized by excessive anxiety or worry. •Lasts 6 months or longer. •Self medication may lead to substance disorders. •Is different from other anxiety disorders: •Cognitive dysfunction •Poor health-related outcomes •No fear of external object or situation

Become your own cheerleader

•Look back to find examples from your past when you were able to accomplish change. Remember the details (practice guided imagery.) •Learn where things may have gone wrong and figure out how to avoid those pitfalls in the future. •Look forward and imagine your success. Again, embellish by recruiting all your senses.

Describe the four levels of anxiety. (What are the signs, responses to, and functional abilities of each level?)

•Mild anxiety •Moderate anxiety •Severe anxiety •Panic level of anxiety

What types of stress are there? (Give examples of each.)

•Physical •Emotional •Spiritual •Relational •Educational •Vocational

Social Anxiety

•Social anxiety disorder (social phobia) is the most common of the anxiety disorders, and usually shows its first symptoms in childhood or early adolescence but is evident into adulthood. •If untreated, it has wide-reaching effects on the child's ability to make friends, successfully transition to school, play sports, be part of a peer group during adolescence, and make the transition to college and to dating. •Social anxiety disorder generally responds well to treatment, and several different treatment approaches have been shown to be effective, although it is generally considered to be a chronic disorder (Schneier, 2006). (McKinney, page 1452)

Cognitive Behavioral Therapy (CBT) ABC method

•Turn the spotlight on thoughts, feelings and physical sensations. •Identify where they may be inaccurate or exaggerated •Devise and implement a plan to correct distortions Most basic exercise •A = antecedent event or trigger •B = belief •C = consequences

Consequences of poor coping are Highly variable, depending on the:

•Type and number of stressors involved •Way the stressors are perceived •Length of time the stressor occurs •Type of coping mechanism (if any) implemented (and degree of effectiveness) •Resilience of the individual.

Strategies for Heart Disease

•Using positive self-talk •Employing emergency stress stoppers •Finding sources of pleasure •Performing daily relaxation training