psych test #2

In the assessment of a client with a Conversion Disorder what would the nurse anticipate that the health assessment would reveal?

a. High serum calcium levels b. Sensory loss along affected nerve tracks c. No organic cause to the problem displayed d. Motor loss to body parts along the nerves

What does the nurse want to focus on to help a client with somatic S &S ?

a.The physical symptoms b.Suppression of thoughts of inferiority c.The client's feelings d.Use of medications

What group has the highest incidence of suicide? What are some contributing factors for suicide? What are some protective factors?

contributing factors: 90% of people who attempt suicide have a psychiatric condition. Alcohol and drugs are contributing factors, along with being a veteran, T.B.I. and physical illness. Can you name others?

Compare and contrast the essential characteristics of Somatic Symptom Disorder versus those of Dissociative Disorders.

The individual with a somatic sympton disorder usually has a long history of physician visits for complaints of multiple somatic symptoms. Much time and energy is spent on preoccupation with this health concern. The most frequent symptoms are pain (head, chest, back, joints, pelvis), dysphagia, nausea, bloating, constipation, palpitations, dizziness, and shortness of breath, although vague symptoms such as fatigue may also be prominent. Sexual symptoms, such as lack of libido or erectile dysfunction, or pseudoneurological symptoms, such as fainting or colorblindness, may also be present. Usually the disorder appears before the age of 30 years. One or more somatic symptoms is distressing or causes significant functional impairment. When describing their symptoms, individuals may describe their symptoms in very exaggerated and colorful ways or have symptoms that do not generally co-occur with a serious disease (e.g., a strange taste in one's mouth). Patients report significant distress and seek multiple providers for medical care—a process that alleviates the patient's concerns. Individuals with somatization disorders often have histories of repeated surgeries, alcohol or drug abuse, marital instability, and suicide attempts. Because somatic symptom disorder often co-occurs with a mood or anxiety disorder, when diagnosed, these co-occurring symptoms must be treated. Physical symptoms that are caused by an anxiety or depressive disorder often resolve dramatically with treatment (Yates, 2010). Unfortunately, these individuals refuse referral to a psychiatrist because they believe their symptoms are physical. Even though negative test findings persist, people with somatic symptom disorder experience severe distress, and their ability to function in personal, social, and occupational roles is often impaired. The hallmark of the dissociative disorders is disturbances in the normally well-integrated continuum of consciousness, memory, identity, and perception. Dissociative disorders include amnesiac states (dissociative amnesia and dissociative fugue) and dissociative identity disorder (DID), formerly known as multiple personality disorder. Dissociation is an unconscious defense mechanism to protect the individual against overwhelming anxiety. Patients with dissociative disorders have intact reality testing; that is, they are not delusional or hallucinating. When the ability to integrate memories is impaired, the individual has dissociative amnesia. When the ability to maintain one's identity is affected, the individual may develop a dissociative fugue or dissociative identity disorder. When there is a persistent or recurrent disruption in perception, the individual has depersonalization disorder, with a feeling of detachment from the mind or body. Dissociative disorders are characterized by altered mind-body connections and possibly brain alterations related to traumatic stress or anxiety (e.g., from early child abuse). For people who use extreme dissociation as a defense against overwhelming anxiety, consciousness itself can be altered in a dramatic way, whereas thinking, feeling, and perceptions are less impaired. These disorders can be quite severe.

1. Anxiolytics (Anti-Anxiety Drugs) 2. Antidepressants 3. Buspirone (Buspar) 4. CAM (Kava-Kava and Valerian)

1. Anxiolytics (Anti-Anxiety Drugs): Anxiolytic effects result from depressing neurotransmission in the limbic system and cortical areas. Useful for short-term treatment of anxiety; dependence and tolerance develop. These drugs are NOT indicated as a primary treatment for OCD or PTSD. Benzodiazepines : Short term use only. Prescribed for short-term treatment only; not recommended for use by patients with substance dependence problems Alleviates anxiety, but works best before benzodiazepines have been tried. Less sedating than benzodiazepines. Does not appear to produce physical or psychological dependence. Requires 3 or more weeks to be effective. Anxiolytic drugs (also called antianxiety drugs) are often used to treat the somatic and psychological symptoms of anxiety disorders. When moderate or severe anxiety is reduced, patients are better able to participate in treatment directed at their underlying problems. Benzodiazepines are most commonly prescribed because they have a quick onset of action. Because of the potential for dependence, however, these medications should ideally be used for short periods only until other medications or treatments reduce symptoms. It is important for the nurse to monitor for side effects of the benzodiazepines, including sedation, ataxia, and decreased cognitive function. Benzodiazepines are not recommended for patients with a known substance use problem and should not be given to women who are pregnant or breast-feeding. Box 11-1 lists important information on patient and family medication teaching. 3. Buspirone (BuSpar): is an alternative anxiolytic medication that does not cause dependence; however, 2 to 4 weeks are required for it to become fully effective. Its usefulness in anxiety disorders is probably limited to the treatment of GAD. Management of anxiety disorders or short-term relief of anxiety symptoms, especially GAD Why can MAOI'S be dangerous? * TCA'S: Second- or third-line use in people with PD, GAD, and SAD; clomipramine is effective in obsessive-compulsive disorder (OCD) Inhibit the reuptake of norepinephrine and serotonin. Take 7-28 days to work. May cause drowsiness, dizziness and hypotension. Anticholinergic effects Do not use in clients with cardiac disease and older adults. Do not stop suddenly. Second- or third-line use in people with PD, GAD, and SAD; clomipramine is effective in obsessive-compulsive disorder (OCD) *SSRI'S and SNRI'S: SNRIs: Examples include venlafaxine, milnacipran, and duloxetine; only venlafaxine is currently approved for panic disorder (PD), generalized anxiety disorder (GAD), and social affective disorder (SAD First-line treatment for all anxiety disorders Blocks serotonin reuptake. Less anticholinergic SE's and less cardiotoxicity. May cause sexual dysfunction. Faster onset of action than TCA's. Monitor for Serotonin Syndrome. *ATYPICAL antidepressants Lithium: is used for long-term control. The normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L. SECOND LINE *MAOI'S: Recently being used in people with social anxiety disorder (SAD) and rejection sensitivity Prevent the breakdown of norepinephrine, serotonin and dopamine. Useful in Atypical Depression. Tyramine free diet.

Describe three key components in the assessment of a patient with a dissociative disorder.

1. Assess for a history of a similar episode in the past with benign outcomes. 2. Establish whether the person suffered abuse, trauma, or loss as a child. 3. Identify relevant psychosocial distress issues by performing a basic psychosocial assessment. (See Chapter 7 for information on the basic psychosocial assessment.) 1. Medical illnesses, substance abuse and co-existing psychiatric disorders must be ruled out. 2. Assess identity, memory and mood. 3. Use of alcohol or drugs. 4. Effect on the family. 5. Most importantly, assess for Suicide.

therapies for bipolar disorder

1. ECT 2. Psychotherapy 3. Interpersonal and Social Rhythm Therapy 4. Family Focused Therapy 5. Support Groups

Identify evidence-based interventions for providing care to clients with mental illness (SLO 1.2), specifically mood disorders.

1. When a patient is mute, use the technique of making observations: "There are many new pictures on the wall" or "You are wearing your new shoes." 1. When a patient is not ready to talk, direct questions can raise the patient's anxiety level and frustrate the nurse. Pointing to commonalities in the environment draws the patient into, and reinforces, reality. 2. Use simple, concrete words. 2. Slowed thinking and difficulty concentrating impair comprehension 3. Allow time for the patient to respond. 3. Slowed thinking necessitates time to formulate a response. 4. Listen for covert messages and ask about suicide plans: "Have you had thoughts of harming yourself in any way?" 4. People often experience relief and decrease in feelings of isolation when they share thoughts of suicide. 5. Avoid platitudes such as, "Things will look up" or "Everyone gets down once in a while." 5. Platitudes tend to minimize the patient's feelings and can increase feelings of guilt and worthlessness because the patient cannot "look up" or "snap out of it."

Discuss three classes of medications that have demonstrated evidenced-based effectiveness in treating anxiety disorders

1.Benzodiazepines: Prescribed for short-term treatment only; not recommended for use by patients with substance dependence problems 2.Buspirone: Management of anxiety disorders or short-term relief of anxiety symptoms, especially GAD 3.SSRIs: First-line treatment for all anxiety disorders 4.SNRIs: Examples include venlafaxine, milnacipran, and duloxetine; only venlafaxine is currently approved for panic disorder (PD), generalized anxiety disorder (GAD), and social affective disorder (SAD) 5.Tricyclic antidepressants: Second- or third-line use in people with PD, GAD, and SAD; clomipramine is effective in obsessive-compulsive disorder (OCD) 6.MAOIs: Recently being used in people with social anxiety disorder (SAD) and rejection sensitivity Antidepressants As stated previously, selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for anxiety disorders. They are preferable to the tricyclic antidepressants (TCAs) because they have more rapid onset of action, have fewer problematic side effects, and are more effective. Monoamine oxidase inhibitors (MAOIs) are reserved for treatment-resistant conditions because of the risk of life-threatening hypertensive crisis if the patient does not follow dietary restrictions. (Patients cannot eat foods containing tyramine and must be given specific dietary instructions.) Venlafaxine (Effexor) and duloxetine (Cymbalta) are serotonin-norepinephrine reuptake inhibitors (SNRIs) used to treat anxiety disorders.Antidepressants have the secondary benefit of treating co-occurring depressive disorders in patients. Because anxiety and depression frequently occur together, these agents may bring welcome benefits to patients. However, there are three notes of caution. First, when treatment is started, low doses of SSRIs must be used because of the activating effect, which temporarily increases anxiety symptoms. Second, in patients with co-occurring bipolar disorder, use of an antidepressant may cause a manic episode, which requires the addition of mood stabilizers or even antipsychotic agents. Third, use of MAOIs is contraindicated in patients with comorbid substance abuse because of the risk of hypertensive crisis with use of stimulant drugs. Anxiolytic drugs (also called antianxiety drugs) are often used to treat the somatic and psychological symptoms of anxiety disorders. When moderate or severe anxiety is reduced, patients are better able to participate in treatment directed at their underlying problems. Benzodiazepines are most commonly prescribed because they have a quick onset of action. Because of the potential for dependence, however, these medications should ideally be used for short periods only until other medications or treatments reduce symptoms. It is important for the nurse to monitor for side effects of the benzodiazepines, including sedation, ataxia, and decreased cognitive function. Benzodiazepines are not recommended for patients with a known substance use problem and should not be given to women who are pregnant or breast-feeding. Box 11-1 lists important information on patient and family medication teaching. Buspirone (BuSpar) is an alternative anxiolytic medication that does not cause dependence; however, 2 to 4 weeks are required for it to become fully effective. Its usefulness in anxiety disorders is probably limited to the treatment of GAD. Other classes of medication sometimes used to treat anxiety disorders include beta-blockers, antihistamines, and anticonvulsants. These agents are often added if the first course of treatment is ineffective. Beta-blockers have been used to treat panic disorder and social anxiety disorder (SAD). Anticonvulsants have shown some benefit in the management of GAD, SAD, and co-occurring depression with SAD or panic disorder. See page 188 varc.

A nurse is teaching abut how benzodiazepines work. What brain chemical is targeted?

A. Acetylcholine B. Gamma aminobutyric acid (GABA) C. Norepinephrine D. Dopamine

What would the nurse do when caring for a client with PTSD?

A. Avoid discussion of the traumatic event B. Encourage verbalization of thoughts C. Help the client use distraction to cope D. Advise the client to forget the past

What is the best intervention for a client who is having a panic attack?

A. Teach the client S & S of a panic attack. B. Provide the client with privacy and leave for 30-60 seconds. C. Distract the client with involvement in fine motor activities. D. Remain with the client.

What is an advantage of using benzodiazepines other than efficacy?

A. There is no abuse potential. B. It is useful for treating anxiety long-term. C. Its onset of action is rapid. D. There are no agonist reactions with other CNS depressants.

What is true about GAD symptoms?

A. They are usually so severe that the client will refuse to leave the house. B. They are always associated with depression or phobic symptoms. C. They include excessive tearfulness, guilt, and suicidal thoughts. D. They can cause considerable distress and impair the client's ability to function.

What category of antidepressant medication is used most commonly for these disorders?

A. Tricyclics B. SSRIs C. MAOIs D. SSNRIs

Medications for anxiety disorders

ABLE 11-10 ACCEPTED TREATMENTS FOR SELECTED ANXIETY DISORDERS page 188 varcarolis

Develop an intervention plan for the nursing diagnosis, Risk for Suicide.

Assessment: 1. Always evaluate the patient's risk of harm to self or others. Overt hostility is highly correlated with suicide (see Chapter 23). 2. A thorough medical and neurological examination helps determine if the depression is primary or secondary to another disorder. Depression can be secondary to a host of medical or other psychiatric disorders, as well as medications. Essentially, evaluate the following: • If the patient is psychotic • If the patient has used drugs or alcohol • If comorbid medical conditions are present • If the patient has a history of a comorbid psychiatric disorder (e.g., eating disorder, borderline personality disorder, anxiety disorder) 3. Assess history of depression. If the patient has a history, determine therapies used previously that were effective. Some of the following questions can be asked: •"Have you ever gone through or felt anything like this before?" •"What seemed to help you at that time?" 4. Assess support systems, family, and significant others and the need for information and referrals. •"With whom do you live?" •"Whom do you trust?" •"To whom do you talk when you are upset?" 5. Assess for any events that might have "triggered" a depressive episode. • "Has anything happened recently to upset you?" • "Have you had any major changes in your life?" • "Have you had any recent losses: job, divorce, loss of partner, child moving away, deaths?" 6. Include a psychosocial assessment that includes cultural beliefs and spiritual practices related to mental health and treatment. Determine if the depression is affecting the patient's beliefs and practice. •"How do you view depression?" •"Have you tried taking any over-the-counter remedies (e.g., herbs) to help with your depression?" •"Do you find solace in spiritual activities or a place of worship (e.g., church, temple, mosque)?" Communication interventions: 1. Help the patient question underlying assumptions and beliefs and consider alternate explanations to problems. 1. Reconstructing a healthier and more hopeful attitude about the future can alter depressed mood. 2. Work with the patient to identify cognitive distortions that encourage negative self-appraisal. For example: a.Overgeneralizations b.Self-blame c.Mind reading d.Discounting of positive attributes 2. Cognitive distortions reinforce a negative, inaccurate perception of self and world. a.The patient takes one fact or event and makes a general rule out of it ("He always..."; "I never..."). b.The patient consistently blames self for everything perceived as negative. c.The patient assumes others do not like him or her, and so forth, without any real evidence that assumptions are correct. d.The patient focuses on the negative. 3. Encourage activities that can raise self-esteem. Identify need for (a) problem-solving skills, (b) coping skills, and (c) assertiveness skills. 3. Many depressed people, especially women, are not taught a range of problem-solving and coping skills. Increasing social, family, and job skills can change negative self-assessment. 4. Encourage exercise, such as running and/or weightlifting. Initially walking 10 to 15 minutes a day 3 or 4 times a week has short-term benefits. 4. Exercise can help alleviate depression and anxiety, improve self-concept, and shift neurochemical balance. 5. Encourage formation of supportive relationships, such as through support groups, therapy, and peer support. 5. Such relationships reduce social isolation and enable the patient to work on personal goals and relationship needs. 6. Provide information referrals, when needed, for spiritual/religious information (e.g., readings, programs, tapes, community resources). 6. Spiritual and existential issues may be heightened during depressive episodes—many people find strength and comfort in spirituality or religion. Interventions to address Physical needs of a depressed patient: Nutrition: 1. Offer small, high-calorie and high-protein snacks frequently throughout the day and evening. 1. Low weight and poor nutrition render the patient susceptible to illness. Small, frequent snacks are more easily tolerated than large plates of food when the patient is anorectic. 2. Offer high-protein and high-calorie fluids frequently throughout the day and evening. 2. These fluids prevent dehydration and can minimize constipation. 3. When possible, encourage family or friends to remain with the patient during meals. 3. This strategy reinforces the idea that someone cares, can raise the patient's self-esteem, and can serve as an incentive to eat. 4. Ask the patient which foods or drinks he or she likes. Offer choices. Involve the dietitian. 4. The patient is more likely to eat the foods provided. 5. Weigh the patient weekly and observe the patient's eating patterns. 5. Monitoring the patient's status gives the information needed for revision of the intervention. Sleep: 1. Provide periods of rest after activities. 1. Fatigue can intensify feelings of depression. 2. Encourage the patient to get up and dress and to stay out of bed during the day. 2. Minimizing sleep during the day increases the likelihood of sleep at night. 3. Encourage the use of relaxation measures in the evening (e.g., tepid bath, warm milk). 3. These measures induce relaxation and sleep. 4. Reduce environmental and physical stimulants in the evening—provide decaffeinated coffee, soft lights, soft music, quiet activities. 4. Decreasing caffeine and epinephrine levels increases the possibility of sleep. Playing relaxing music can help the patient sleep. Self care: 1. Encourage the use of toothbrush, washcloth, soap, makeup, shaving equipment, and so forth. 1. Being clean and well groomed can temporarily increase self-esteem. 2. When appropriate, give step-by-step reminders such as, "Wash the right side of your face, now the left." 2. Slowed thinking and difficulty concentrating make organizing simple tasks difficult. Elimination: 1. Monitor intake and output, especially bowel movements. 1. Many depressed patients are constipated. If the condition is not checked, fecal impaction can occur. 2. Offer foods high in fiber and provide periods of exercise. 2. Roughage and exercise stimulate peristalsis and help evacuation of fecal material. 3. Encourage the intake of fluids. 3. Fluids help prevent constipation. 4. Evaluate the need for laxatives and enemas. 4. These measures prevent fecal impaction.

Identify internal and external factors that contribute to mood disorders.

BOX 15-1 PRIMARY RISK FACTORS FOR DEPRESSION • History of prior episodes of depression • Family history of depressive disorder, especially in first-degree relatives • History of suicide attempts or family history of suicide • Female gender • Age 40 years or younger • Postpartum period • Chronic medical illness • Absence of social support • Negative, stressful life events • Active alcohol or substance abuse • History of sexual abuse Internal: The primary neurotransmitters involved with depression are serotonin ( Serotonin is an important regulator of sleep, appetite, and libido. A serotonin circuit dysfunction can result in poor impulse control, low sex drive, decreased appetite, disturbed regulation of body temperature, and irritability.) and norepinephrine, although dopamine (The dopamine (DA), acetylcholine, and γ-aminobutyric acid (GABA) systems are believed to be involved in the pathophysiology of a major depressive episode. Dopamine neurons in the mesolimbic system are thought to play a role in the reward and incentive behavior processes, emotional expression, and learning processes that are disrupted in depression. This is particularly true in melancholic states (severe MDD).)is also related to depression. These neurotransmitter abnormalities may be the result of inherited or environmental factors, or even of other medical conditions, such as cerebral infarction, hypothyroidism, acquired immunodeficiency syndrome, or drug use. Whatever the etiological contribution, depression is ultimately mediated through changes in the brain's neurochemistry and the circuitry involved in emotional regulations. It is becoming evident that depression is a heterogeneous, systemic illness involving an array of different neurotransmitters, neuronal pathways, hereditary processes, and/or traumatic life events. It is commonly accepted that genetic predisposition to the illness combined with childhood stress may lead to significant changes in the central nervous system (CNS) that result in depression. However, there are common risk factors for depression that may signal the presence of this common and serious psychiatric illness

Bipolar I Bipolar II Cyclothymia Bipolar D.O. Unspecified

Bipolar I: at least one episode of mania Bipolar II: major depressive and hypomanic episodes Cyclothymia: less severe form of bipolar Bipolar D.O. Unspecified: only hypomania Lithium used to treat

Describe the clinical manifestations of each anxiety disorder.

Clinical manifestations of anxiety: Dry mouth Sweating Irritable Fearful Urinary frequency Nausea ("butterflies") Suspicious Forgetful Short attention span Pacing, figiting Sad Withdrawal OCD: At the more severe end of the continuum are obsessive-compulsive symptoms that typically center on dirtiness, contamination, and germs and occur with corresponding compulsions, such as cleaning and hand washing. A smaller number focus on safety issues and engage in repetitive checking rituals. At the most severe levels are persistent thoughts of sexuality, violence, illness, or death. These obsessions or compulsions cause marked distress to the individual. People often feel humiliation and shame regarding these behaviors. The rituals are time-consuming and interfere with normal routine, social activities, and relationships with others. Severe OCD consumes so much of the individual's mental processes that the performance of cognitive tasks may be impaired. Suicide can be a risk for these individuals, especially in the presence of a co-occurring depression. Panic: The panic level of anxiety is the most extreme form and results in markedly disturbed behavior. An individual is not able to process events in the environment and may lose touch with reality. The resulting behavior may be confusion, shouting, screaming, or withdrawal. Hallucinations, or false sensory perceptions such as seeing people or objects that are not present, may be experienced by people at panic levels of anxiety. Physical behavior may be erratic, uncoordinated, and impulsive. Automatic behaviors are used to reduce and relieve anxiety, although such efforts may be ineffective. Acute panic may lead to exhaustion. Review Table 11-1 to identify the levels of anxiety and review how the level affects (1) perceptual field, (2) ability to learn, and (3) physical manifestations and other defining characteristics. Phobia:A phobia is 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 in response to specific objects or situations, such as dogs, spiders, heights, storms, water, blood, closed spaces, tunnels, and bridges. Specific phobias are common and usually do not cause much difficulty because people can contrive ways to avoid the feared object, such as cats or spiders, flying, or heights. However, the fear, anxiety, or avoidance in some cases may cause impairment in social, occupational, or other areas of functioning when faced Generalized: is a chronic psychiatric disorder associated with severe distress different from other anxiety disorders in that there is pervasive cognitive dysfunction, impaired functioning, and poor health-related outcomes (Allgulander, 2009; Taylor et al., 2008). Up to two thirds of people with generalized anxiety disorder have comorbid major depression, and up to 25% present with panic disorder. Self-medication may lead to alcohol or substance use disorder. GAD also differs from other anxiety disorders in that patients do not fear a specific external object or situation, and there is no distinct symptomatic reaction pattern. Basically, GAD is characterized by excessive, persistent, and uncontrollable anxiety, and by excessive worrying. It is sometimes referred to as the "worry disease." A diagnosis of GAD is made if at least three of the following symptoms are present: restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance Body Dismorphic: Patients with BDD usually have a normal appearance, although a small number do show minor defects. The average age of onset is younger than 20 years. A DSM-5 diagnosis includes preoccupation with an imagined "defective body part"; obsessional thinking (e.g., thinking they are ugly or deformed) and compulsive behaviors (e.g., such as mirror checking, skin picking, or excessive grooming); and impairment of normal social activities related to academic or occupational functioning. Individuals with BDD are frequently concerned with the face, skin, genitalia, thighs, hips, and hair. Usually the person feels great shame and hides or withdraws from others. Many will alter their appearance through plastic surgeries, wrongly perceiving themselves as being ugly or having "hideous physical flaws." (People with BDD may have multiple plastic surgeries.) Unfortunately, cosmetic surgery often does not relieve the symptoms.

What are common compulsive behaviors and what purpose do they serve? What defense mechanisms are used? What pharmacological treatment is best?

Clomipramine (tca)

Compare and contrast dissociative amnesia and dissociative fugue.

Dissociative Amnesia: Psychologically induced memory loss of an autobiographical nature is called dissociative amnesia and is marked by the inability to recall important personal information. The amnesia is reported to occur after a severe physical or psychological stressor. These symptoms can cause marked distress; social, occupational, and other important areas of functioning; localized amnesia (inability to recall specific events during a specific period of time); and generalized amnesia (the person experiences loss of memory of who they are and all autobiographical data, and often general knowledge about the world). Black and Andreasen (2011) report estimations that between 5% and 20% of combat veterans were amnesic for their combat experience. Dissociative Fugue: Dissociative amnesia with a specifier of fugue is characterized by sudden, unexpected travel away from the customary locale and inability to recall one's identity and information about some or all of the past. In rare cases, an individual with dissociative fugue assumes a whole new identity. During a fugue state, individuals tend to lead rather simple lives, rarely calling attention to themselves. After a few weeks to a few months, they may remember their former identities and become amnesic of the time spent in the fugue state. Usually a dissociative fugue is precipitated by a traumatic event.

EPINEPHRINE (INCREASED NOREPINEPHRINE (INCREASED) SEROTONIN (DECREASED) GABA ( DECREASED)

During a manic episode, patients with bipolar disorder demonstrate significantly higher plasma levels of norepinephrine and epinephrine, and people with depression have decreased levels of epinephrine and norepinephrine.

2. Antidepressants

First-line agents: • Cyclic antidepressants (e.g., TCAs): The tricyclic antidepressants (TCAs) inhibit the reuptake of norepinephrine and serotonin by the presynaptic neurons in the CNS. Therefore the amount of time that norepinephrine and serotonin are available to the postsynaptic receptors is increased. This increase in norepinephrine and serotonin levels in the brain is believed to be responsible for mood elevations when TCAs are given to depressed people. The sedative effects of TCAs are attributed to antihistamine (H1 receptor) actions and somewhat to anticholinergic actions. Patients must take therapeutic doses of TCAs for 10 to 14 days or longer before they become effective. The full effects may not be evident for 4 to 8 weeks. An effect on some symptoms of depression, such as insomnia and anorexia, may be noted sooner. A person who has shown a positive response to TCA therapy would probably be maintained on that medication for 6 to 12 months to prevent an early relapse. Choice of TCA is based on the following: •The drug that has proven effective for the patient or a family member in the past •The drug's adverse effects • SSRIs and SNRIs • Atypical antidepressants Second-line agents: • Monoamine oxidase inhibitors (MAOIs)

Identify nursing interventions for each anxiety disorder.

General interventions for severe/Panic level of anxiety: 1. Maintain a calm manner. 1. Anxiety is communicated interpersonally. The quiet calm of the nurse can serve to calm the patient. The presence of anxiety can escalate anxiety in the patient. 2. Always remain with the person experiencing an acute severe to panic level of anxiety. 2. Alone with immense anxiety, a person feels abandoned. A caring face may be the patient's only contact with reality when confusion becomes overwhelming. 3. Minimize environmental stimuli. Move to a quieter setting and stay with the patient. 3. Helps minimize further escalation of patient's anxiety. 4. Use clear and simple statements and repetition. 4. A person experiencing a severe to panic level of anxiety has difficulty concentrating and processing information. 5. Use a low-pitched voice; speak slowly. 5. A high-pitched voice can convey anxiety. Low pitch can decrease anxiety. 6. Reinforce reality if distortions occur (e.g., seeing objects that are not there or hearing voices when no one is present). 6. Anxiety can be reduced by focusing on and validating what is happening in the environment. 7. Listen for themes in communication. 7. In severe to panic levels of anxiety, verbal communication themes may be the only indication of the patient's thoughts or feelings. 8. Attend to physical and safety needs when necessary (e.g., need for warmth, fluids, elimination, pain relief, family contact). 8. High levels of anxiety may obscure the patient's awareness of physical needs. 9. Because safety is an overall goal, physical limits may need to be set. Speak in a firm, authoritative voice: "You may not hit anyone here. If you can't control yourself, we will help you." 9. A person who is out of control is often terrorized. Staff must offer the patient and others protection from destructive and self-destructive impulses. 10. Provide opportunities for exercise (e.g., walk with nurse, use a punching bag, play Ping-Pong). 10. Physical activity helps channel and dissipate tension and may temporarily lower anxiety. 11. When a person is constantly moving or pacing, offer high-calorie fluids. 11. Dehydration and exhaustion must be prevented. 12. Assess need for medication or seclusion after other interventions have been tried and been unsuccessful. 12. Exhaustion and physical harm to self and others must be prevented. Family therapy: This type of therapy assists the family who is living with a person with anxiety disorder; learning coping mechanisms and suggesting ways to improve quality of life are part of this therapy. Family counseling facilitates communication and maintenance of healthy relationships, and provides for psychoeducation regarding the disease process and pharmacologic therapy. Group therapy: This type of therapy provides a trusting environment whereby patients who have anxiety disorders can express emotions and feelings, receive validation and feedback, and obtain reinforcement of coping skills. Examples of types of group therapy include art, exercise, humor, spirituality, psychoeducation, and life skills learning. Play therapy is useful in treating children with anxiety disorders. Cognitive and behavioral therapy (CBT): This therapy is a tested and effective form of psychotherapy used across the lifespan. Research has shown CBT to successfully treat children/adolescents with separation anxiety disorder, OCD, phobias, and PTSD. In adults it is an effective treatment for panic disorder, agoraphobia, social phobia, OCD, and PTSD. Prolonged exposure therapy: This specific therapy includes psychoeducation (i.e., common trauma responses, symptomatology), instruction on breathing exercises to decrease anxiety and other techniques to manage short-term distress, and counseling that encourages repeated purging of trauma-related feelings. The expected outcome of exposure therapy is decreased fears related to untoward memories Mindfulness: This treatment modality is a way to facilitate persons inflicted with PTSD to think and focus on the present versus past experiences. Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings related to these experiences. Inclusive in this treatment is the need to practice acceptance of one's thoughts without self-judgment Eye movement desensitization and reprocessing (EMDR): This treatment is successful in treating PTSD in pediatric and adult populations. This method includes expression of feelings and memories while focusing on other stimuli such as sounds, hand taps, and/or eye movements. It is still unclear how EMDR precisely works; recent studies report it is the cognitive treatment, rather than the accompanied stimuli, that results in positive outcomes Peer support: This type of group is led by persons inflicted with mental illness themselves. The intent of peer support is that persons who experience the challenges of mental illness share their own effective wellness tools. Examples of specific peer groups for anxiety disorders include PTSD, agoraphobia, and social phobic support groups. Complementary and Alternative Medicine: These treatments can prevent and/or alleviate anxiety symptomatology. Examples include meditating, exercising, performing abdominal breathing exercises, listening to music, spending time with a pet, reducing/stopping the intake of caffeine, and/or implementing sleep hygiene measures. The substances kava kava, valerian root, and St. John's wort are natural remedies to reduce anxiety, but must be used cautiously with certain prescriptions. Scientific evidence is still needed to validate the effectiveness of herbal treatments.

GAD Diagnostic criteria Screening tools - Compare the GAD-7 scale to the diagnostic criteria

Generalized Anxiety Disorder 7 (GAD-7) is a self-reported questionnaire for screening and severity measuring of generalized anxiety disorder (GAD).[1] GAD-7 has seven items, which measure severity of various signs of GAD according to reported response categories with assigned points (see below). Assessment is indicated by the total score, which made up by adding together the scores for the scale all seven items.[2] GAD-7 is a sensitive self-administrated test to assess generalized anxiety disorder,[3] normally used in outpatient and primary care settings for referral to psychiatrist pending outcome.[4] However, it cannot be used as replacement for clinical assessment and additional evaluation should be used to confirm a diagnosis of GAD. The scale uses a normative system of scoring as shown below - [bullet points of answer options and points assigned] - with question at the end qualitatively describing severity of the patient's anxiety over the past 2 weeks. [4] Over the last 2 weeks, how often have you been bothered by the following problems? Not at all sure Several days Over half the days Nearly every day 1. Feeling nervous, anxious, or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Worrying too much about different things 0 1 2 3 4. Trouble relaxing 0 1 2 3 5. Being so restless that it's hard to sit stil l 0 1 2 3 6. Becoming easily annoyed or irritable 0 1 2 3 7. Feeling afraid as if something awful might happen 0 1 2 3 Not at all (0 points) Several days (1 point) More than half the days (2 points) Nearly every day (3 points) DSM 5 diagnostic criteria: The anxiety and worry is associated with at least 3 of the following physical or cognitive symptoms (In children, only 1 symptom is necessary for a diagnosis of GAD.): Edginess or restlessness. Tiring easily; more fatigued than usual. Impaired concentration or feeling as though the mind goes blank. Irritability (which may or may not be observable to others). Increased muscle aches or soreness. Difficulty sleeping (due to trouble falling asleep or staying asleep, restlessness at night, or unsatisfying sleep).

defense mechanisms

Healthy defense mechanisms: Altruism: emotional conflicts and stressors are addressed by meeting the needs of others. Unlike in self-sacrificing behavior, in altruism the person receives gratification either vicariously or from the response of others--Six months after losing her husband in a car accident, Jeanette began to spend 1 day a week doing grief counseling with families who had lost a loved one. She found that she was effective in helping others in their grief, and she obtained a great deal of satisfaction and pleasure from helping others work through their pain. Sublimation: is an unconscious process of substituting constructive and socially acceptable activity for strong impulses that are not acceptable in their original form. Often these impulses are sexual or aggressive.--- A man with strong hostile feelings may choose to become a butcher, or he may participate in rough contact sports. A person who is unable to experience sexual activity may channel this energy into something creative, such as painting or gardening. Humor: Humor makes life easier. An individual may deal with emotional conflicts or stressors by emphasizing the amusing or ironic aspects of the conflict or stressor through humor.----A man goes to an interview that means a great deal to him. He is being interviewed by the top executives of the company. He has recently had foot surgery and, on entering the interview room, he stumbles and loses his balance. There is a stunned silence, and then the man states calmly, "I was hoping I could put my best foot forward." With everyone laughing, the interview continues in a relaxed manner. Suppression: Suppression is the conscious denial of a disturbing situation or feeling. For example, a student who has been studying for the state board examinations says, "I can't worry about paying my rent until after my exam tomorrow." Intermediate Defenses: Repression: Repression is the exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness.---- Examples include forgetting the name of a former boyfriend or girlfriend or forgetting an appointment to discuss poor grades. Repression is considered the cornerstone of the defense mechanisms, and it is the first line of psychological defense against anxiety. Displacement: Transfer of emotions associated with a particular person, object, or situation to another person, object, or situation that is nonthreatening is called displacement.--- The frequently cited example in which the boss yells at the man, the man yells at his wife, the wife yells at the child, and the child kicks the cat demonstrates the successive use of displaced hostility. The use of displacement is common but not always adaptive. Spousal, child, and elder abuse are often cases of displaced hostility. Reaction Formation: In reaction formation (also termed overcompensation), unacceptable feelings or behaviors are kept out of awareness by developing the opposite behavior or emotion. ---For example, a person who harbors hostility toward children becomes a Boy Scout leader. Somatization: Transforming anxiety on an unconscious level into a physical symptom that has no organic cause is a form of somatization. Often the symptom functions as an attention seeker or as an excuse.---A professor develops laryngitis on the day he is scheduled to defend a research proposal to a group of peers. A woman who does not want to go out with the brother of her boss calls to say "her back went out," and she cannot make the date (and, in fact, her back is sore). Undoing: Undoing compensates for an act or communication (e.g., giving a gift to undo an argument). ----A common behavioral example of undoing is compulsive hand washing. This can be viewed as cleansing oneself of an act or thought perceived as unacceptable. Rationalization: Rationalization consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener.--- Common examples are, "If I had Lynn's brains, I'd get good grades, too," or "Everybody cheats, so why shouldn't I?" Rationalization is a form of self-deception. Immature Defenses: Passive Aggression: A passive-aggressive individual deals with emotional conflict or stressors by indirectly and unassertively expressing aggression toward others. On the surface, there is an appearance of compliance that masks covert resistance, resentment, and hostility. In passive aggression, aggression toward others is expressed through procrastination, failure, inefficiency, passivity, and illnesses that affect others more than oneself. Such passive-aggressive behaviors occur especially in response to assigned tasks or demands for independent action, responsibilities, or obligations.---Sam promises his boss that he is working on the presentation for important patients, even though he constantly "forgets" to bring in samples of the presentation. The day of the presentation, Sam calls in sick with the flu. Acting-Out Behaviors: In acting out, an individual addresses emotional conflicts or stressors by actions rather than by reflections or feelings (APA, 2000). ---For example, a person may lash out in anger verbally or physically to distract the self from threatening thoughts or feelings. The verbal or physical expression of anger can make a person feel temporarily less helpless or vulnerable. By lashing out at others, an individual can transfer the focus from personal doubts and insecurities to some other person or object. Acting-out behaviors are a destructive coping style.----When Harry was turned down a third time for a promotion, he went to his office and tore apart every patient file in his file cabinet. His initial feelings of worthlessness and lowered self-esteem related to the situation were interpreted by Harry to mean "I am no good." This thinking resulted in Harry's quickly transforming these painful feelings into actions of anger and destruction. Temporarily, Harry felt more powerful and less vulnerable. Dissociation: A disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment is known as dissociation.---A young mother who saw her son struck by a car was taken to a neighbor's house while the police dealt with the accident. Later she told the policeman, "I really don't remember what happened. The last thing I remember is going out the door to check on Johnny." At that moment, to protect herself from an unbearable situation, she separated the threatening event from awareness until she could begin to deal with her feelings of devastation. Devaluation: Devaluation occurs when emotional conflicts or stressors are handled by attributing negative qualities to self or others (APA, 2000). When devaluing another, the individual then appears good by contrast.--A woman who is very jealous of a coworker says, "Oh, yes, she won the award. Those awards don't mean anything anyway, and I wonder what she had to do to be chosen." In this way she minimizes the other woman's accomplishments and keeps her own fragile self-esteem intact. Idealization: In idealization, emotional conflicts or stressors are addressed by attributing exaggerated positive qualities to others. Idealization is an important aspect of the development of the self. Children who grow up with parents they can respect and idealize develop healthy standards of conduct and morality. When people idealize and overvalue a person in a new relationship, they are sure to be disappointed when the object of the idealization turns out to be human. This leads to a great deal of disappointment and painful lowering of self-esteem. Such individuals may then devalue and reject the object of their affection to protect their own self-esteem. This pattern can be repeated over and over on a job, in friendships, in intimate relationships, and in marriage.----Mary met the most "wonderful and perfect" man. No one could tell Mary that Jim was nice but had some quirks, like everyone else. Mary would not listen. When Jim failed to live up to Mary's expectations of giving her constant attention, adoration, and gifts, Mary was devastated. Shortly thereafter, she started saying that Jim was, like all men, a brute, and that she wanted no more to do with such an insensitive person. Splitting: Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. Aspects of the self and of others tend to alternate between opposite poles; for example, either good, loving, worthy, and nurturing, or bad, hateful, destructive, rejecting, and worthless. Use of this defense mechanism is prevalent in personality disorders, especially in people who have borderline components.---Alice viewed her therapist as the most wonderful, loving, and insightful therapist she had ever seen. When her therapist refused to write her a prescription for Valium, Alice shouted at her that she was the "stupidest, most uncaring, and thickheaded person," and she demanded another therapist "right away." Projection: A person unconsciously rejects emotionally unacceptable personal features and attributes them to other people, objects, or situations through projection. Projection is the hallmark of blaming, scapegoating, prejudicial thinking, and stigmatization. People who always feel that others are out to deceive or cheat them may be projecting onto others those characteristics in themselves that they find distasteful and cannot consciously accept. Projection of anxiety can often be seen in systems (family, hospital, school, business, politics). In a family in which there are problems, the child is often scapegoated, and the pain and anxiety within the family are projected onto the child: "The problem is Tommy." In a larger system in which anxiety and conflict are present, the weakest members are scapegoated: "The problem is the nurses' aides...the students...the new salesman...the Democrats /Republicans who are to blame for the mess we're in today." When pain and anxiety exist within a system, projection can be an automatic relief behavior. Once the cause of the anxiety is identified, changes in relief behavior can ensue, and the system can become more functional and productive. Denial: Denial involves escaping unpleasant realities by ignoring their existence. ---For example, a man believes that physical limitations reflect negatively on one's manhood. Thus he may deny chest pains, even though his family has a history of heart attacks, because of a threat to his self-image as a man. A woman whose health has deteriorated because of alcohol abuse denies she has a problem with alcohol by saying she can stop drinking whenever she wants. Table 11-4 gives examples of adaptive and maladaptive uses of some common defense mechanisms. Introjection: After his wife's death, husband has transient complaints of chest pains and difficulty breathing—the symptoms his wife had before she died. Young child whose parents were overcritical and belittling grows up thinking that she is inferior. She has taken on her parent's evaluation of her as part of her self-image. Identification: Five-year-old girl dresses in her mother's shoes and dress and meets her father at the door. Young boy thinks a neighborhood pimp with money and drugs is someone to emulate. Conversion: Student is unable to take a final examination because of a terrible headache. Man becomes blind after seeing his wife flirt with other men.

Recognize unstable affective states in clients and the need for further assessment in emergency situations.

In particular, nurses must be able to recognize unstable affective states known as affective instability. Signs of affective instability, such as crying, rage, euphoria, and blunting(absence/ diminished reactions to stimuli), indicate the need for further assessment because such individuals may have a mood disorder;3 this important nurse responsibility will be discussed in more detail in the Assessment section of this concept analysis. The term euthymia is used to describe normal, healthy fluctuations in mood. Conceptually, depression is characterized by such overwhelming sadness and despair that one feels drained of energy. An individual suffering from depression may feel so sad and empty that he or she becomes incapacitated by a loss of the will to live and suicidal thoughts may prevail. For clarity in this concept the undiagnosed mood state characterized by sadness, despair, and loss of functional status will be referred to as melancholy. The term mania is used as a defining characteristic of some medical/psychiatric bipolar diagnoses that nurses are not qualified to make; however, like recognizing affective instability, nurses are qualified and expected to recognize mania. Individuals with mania are recognizable in the nursing paradigm by the presence of euphoric or agitated affective states, and they often suffer from varying degrees of perceptual disturbances (hallucinations) as well. Racing thoughts, grandiose delusions, difficulty concentrating, impulsivity, and lack of insight are not uncommon. Consequently, individuals with mania experience impaired functional status, and behavior associated with mania may be reckless and dangerous. Hypomanic affective states are expansive or agitated and possibly euphoric, but to a less severe degree than in mania and with less impairment. Although the individual with hypomania experiences racing thoughts and agitation or euphoria, perceptual disturbances are much less likely in hypomania. To facilitate the assessment of affective instability in the generalist nurse conceptual paradigm, the presence of perceptual disturbances will be used to distinguish mania from hypomania in this analysis.

What is Serotonin Syndrome?

One rare and life-threatening event associated with the SSRIs is serotonin syndrome. This is thought to be related to overactivation of the central serotonin receptors, caused either by too high a dose or by interaction with other drugs. Symptoms include abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure, altered mental state (delirium), myoclonus (muscle spasms), increased motor activity, irritability, hostility, and mood change. Severe manifestation can induce hyperpyrexia (excessively high fever), cardiovascular shock, or death. The risk of this syndrome seems to be the greatest when an SSRI is administered in combination with a second serotonin-enhancing agent, such as an MAOI. For example, a person taking fluoxetine would have to discontinue this medication for a full 5 weeks before starting an MAOI (5 weeks is the half-life for fluoxetine). If a person is already taking an MAOI, the person should wait at least 2 weeks before starting fluoxetine therapy. Other SSRIs have shorter periods of activity; for example, sertraline and paroxetine have half-lives of 2 weeks, so there would need to be a 2-week gap between the administration of different medications. Symptoms • Hyperactivity or restlessness • Tachycardia → cardiovascular shock • Fever → hyperpyrexia • Elevated blood pressure • Altered mental status (e.g., delirium) • Irrationality, mood swings, hostility • Seizures → status epilepticus • Myoclonus, incoordination, tonic rigidity • Abdominal pain, diarrhea, bloating • Apnea → death Emergency Measures 1. Discontinue offending agent(s) 2. Initiate symptomatic treatment: •Serotonin receptor blockade: cyproheptadine, methysergide, propranolol •Cooling blankets, chlorpromazine for hyperthermia •Dantrolene, diazepam for muscle rigidity or rigors •Anticonvulsants •Artificial ventilation •Paralysis

Propose realistic outcomes for patients with each anxiety disorder.

PTSD: Patient and others (e.g., family, friends) will remain safe. •Patient will receive treatment for co-occurring conditions, which is always part of active treatment (e.g., alcohol/drug addiction, depression, anxiety disorders, specifically panic attacks). •Patient will attend support group meetings. •Patient will expand social support network. •Patient will exhibit an increase in restful sleep periods. •Patient will have fewer nightmares and flashbacks. •Patient will express decreased irritability. •Patient will be able to demonstrate effective anxiety reduction techniques (cognitive or behavioral). Phobia: Patients will: •Develop skills at reframing anxiety-provoking situation (date). •Work with nurse/clinician to desensitize self to feared object or situation (date). •Demonstrate one new relaxation skill that works well for them (date). Generalized anxiety disorder: Patients will: •State increased ability to make decisions and problem solve. •Demonstrate ability to perform usual tasks even though still moderately anxious by (date). •Demonstrate one cognitive or behavioral coping skill that helps reduce anxious feelings by (date). Obsessive-compulsive disorder: Patients will: •Demonstrate techniques that can distract and distance self from thoughts that are anxiety producing by (date). •Decrease time spent in ritualistic behaviors. •Demonstrate increased amount of time spent with family and friends and on pleasurable activities. •State they have more control over intrusive thoughts and rituals by (date).

Develop a holistic plan of care in accordance with the Psychiatric-Mental Health Nursing Scope and Standards of Practice

Planning: Outcomes should include goals for safety. Even if the patient is not having self-destructive thoughts, one goal should be to name a person who the patient will contact if such thoughts arise. Goals for the outcomes of vegetative or physical signs of depression (e.g., reports adequate sleep) are formulated to show, for example, evidence of weight gain, return to normal bowel activity, sleep of 6 to 8 hours per night, or return of sexual desire. The planning of care for patients with depression is geared toward the phase of depression the person is in and the particular symptoms the person is exhibiting. At all times the nurse and members of the health care team are cognizant of the potential for suicide, and assessment of risk for self-harm (or harm to others) is ongoing during the care of the depressed person. There is evidence that a combination of therapeutic (cognitive, behavioral, interpersonal [IP]) and psychopharmacological interventions can be an effective approach in treating depression. Nurses and clinicians need to assess and plan for any vegetative signs of depression, as well as changes in concentration, activity level, social interaction, or personal appearance, for example. Therefore the planning of care for a patient who is depressed is based on the individual's symptoms and attempts to encompass a variety of areas in the person's life. Safety is always the highest priority. Communication Guidelines A person who is depressed may speak and comprehend very slowly. The lack of an immediate response by the patient to a remark does not mean that the patient has not heard or chooses not to reply; rather, the patient just needs a little more time to compose a reply. In extreme depression, however, a person may be mute. Some depressed patients are so withdrawn that they are unwilling or unable to speak. Nurses may feel uncomfortable with silence and not being able to "do anything" to effect immediate change. However, just sitting with a patient in silence may be a valuable intervention. It is important to be aware that this time spent together can be meaningful to the depressed person, especially if the nurse has a genuine interest in learning about the depressed individual.

What Medication used for performance anxiety?

Propranolol (Inderal) & Atenolol(Tenormin) Used to relieve physical symptoms of anxiety, as in performance anxiety (stage fright). Act by attaching to sensors that direct arousal messages.

Identify psychosocial interventions for a patient with somatic complaints that have no medical cause.

Psychotherapy and psychodynamic techniques such as psychoeducation, "talking through", traumatic re-enactment, safety planning, and journaling. Communication Guidelines Generally for patients with somatic symptom disorders, nursing interventions take place in the home or clinic setting. The nurse attempts to help the patient improve overall functioning through the development of effective coping and communication strategies. Remember, when patients complain of physical symptoms, take the symptoms seriously, because even if a medical explanation is not found the symptoms are real and troublesome to the patient. Table 12-2 lists several possible interventions for patients with somatic symptom disorders Health Teaching and Health Promotion When somatization is present, the patient's ability to perform self-care activities may be impaired and nursing or caregiving intervention is necessary. In general, interventions involve the use of a straightforward approach to support the highest level of self-care of which the patient is capable. For patients manifesting paralysis, blindness, or severe fatigue, an effective nursing approach is to support patients while expecting them to feed, bathe, or groom themselves. For example, the patient who demonstrates arm paralysis can be expected to eat using the other arm. The patient who is experiencing blindness can be told where foods are located on his or her plate by comparing the plate to a clock face. These strategies are effective in reducing secondary gain. Assertiveness training is often appropriate to teach patients with somatic symptom disorders. Use of assertiveness techniques gives patients a direct means of meeting needs and thereby decreases the need for somatic symptoms. Teaching an exercise regimen, such as doing range-of-motion exercises for 15 to 20 minutes daily, can help the patient feel in control, increase endorphin levels, and may help decrease anxiety. Case Management "Doctor shopping" is common among patients with these disorders. The patient constantly changes physicians, clinics, or hospitals, hoping to establish a physical basis for distress. Repeated computed tomography scans, magnetic resonance images, and other diagnostic tests are often documented in the medical record. Case management can help limit health care costs associated with such visits. The case manager can recommend to the physician that the patient be scheduled for brief appointments every 4 to 6 weeks at set times rather than on demand and that laboratory tests be avoided unless they are absolutely necessary. The patient who establishes a relationship with the case manager often feels less anxiety because the patient has someone to contact and knows that someone is "in charge." Psychotherapy Cognitive and behavioral approaches can be effective and may prove to be the therapy of choice for patients with somatic symptom disorders (Braun et al., 2010). Behavior modification can provide incentives, motivation, and rewards to help patients control their symptoms. Family and group therapy can increase awareness of communication and interaction patterns and help patients improve interpersonal communication and learn strategies to improve social skills (Cely-Serrano & Floet, 2006). Nurses and other clinicians may be 3. Spend time with patient at times other than when summoned by patient to voice physical complaint. 3. Rewards non-illness-related behaviors and encourages repetition of desired behavior.involved with teaching patients alternative coping skills (relaxation techniques, cognitive restructuring, and refocusing) to aid in controlling anxiety and reappraising thinking in an effort to better mediate symptoms. 1. Offer explanations and support during diagnostic testing. 1. Reduces anxiety while ruling out organic illness. 2. After physical complaints have been investigated, avoid further reinforcement (e.g., do not take vital signs each time patient complains of palpitations). 2. Directs focus away from physical symptoms. 3. Spend time with patient at times other than when summoned by patient to voice physical complaint. 3. Rewards non-illness-related behaviors and encourages repetition of desired behavior. 4. Observe and record frequency and intensity of somatic symptoms. (Patient or family can give information.) 4. Establishes a baseline and later enables evaluation of effectiveness of interventions. 5. Do not imply that symptoms are not real. 5. Acknowledges that psychogenic symptoms are real to the patient. 6. Shift focus from somatic complaints to feelings or to neutral topics. 6. Conveys interest in patient as a person rather than in patient's symptoms; reduces need to gain attention via symptoms 7. Assess secondary gains that "physical illness" provides for patient (e.g., attention, increased dependency, and distraction from another problem). 7. Allows these needs to be met in healthier ways and thus minimizes secondary gains. 8. Use straightforward approach to patient exhibiting resistance or covert anger. 8. Avoids power struggles, demonstrates acceptance of anger, and permits discussion of angry feelings. 9. Have patient direct all requests to case manager. 9. Reduces manipulation. 10. Show concern for patient, but avoid fostering dependency needs. 10. Shows respect for patient's feelings while minimizing secondary gains from "illness." 11. Reinforce patient's strengths and problem-solving abilities. 11. Contributes to positive self-esteem; helps patient realize that needs can be met without resorting to somatic symptoms. 12. Teach assertive communication. 12. Provides patient with a positive way of meeting needs; reduces feelings of helplessness and need for manipulation. 13. Teach patient stress reduction techniques, such as meditation, relaxation, and mild physical exercise. 13. Provides alternate coping strategies; reduces need for medication. Pharmacological Therapies Currently antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs), show the greatest promise for helping patients suffering from somatic symptom disorders (Black & Andreasen, 2011). Patients may also benefit from short-term use of antianxiety medication, which must be monitored carefully because of the risk of dependence. The nurse may administer these medications in certain settings, but teaching about the medication to patients and families should be done in all settings.

What is a barrier for some cultural groups seeking health care for an anxiety disorder?

Reliable data on the incidence of anxiety disorders among cultures are sparse, but sociocultural variation in symptoms of anxiety disorders has been noted. In some cultures, individuals express anxiety through somatic symptoms, whereas in other cultures cognitive symptoms predominate. Panic attacks in Latin Americans and Northern Europeans often involve sensations of choking, smothering, numbness, or tingling, as well as fear of dying. In other cultural groups, panic attacks involve fear of magic or witchcraft. Social phobias in Japanese and Korean cultures may relate to a belief that the individual's blushing, eye contact, or body odor is offensive to others. One of the barriers for some cultural groups seeking health care for anxiety disorders is the stigma that various cultures are associated with mental disorders. For example, African Americans are much less likely to seek mental health services than the majority of the population, and Asian Americans even more so (Satcher et al., 2005). Interestingly, the incidence of anxiety disorders seems to vary among culture and countries. Anxiety disorders also vary among immigrants from generation to generation. One must be aware of the cultural norm before hastily making a diagnosis (e.g., labeling ritualistic behavior as obsessive-compulsive disorder).

Suicide: High risk populations What and how do we assess? What do we know when energy levels increase as a result of treatment? Interventions for Risk for Suicide

Risk populations: 16.5% OF ADULTS. WOMEN ARE 70% MORE LIKELY TO EXPERIENCE A DEPRESSIVE EPISODE THAN MEN. OFTEN SECONDARY TO A MEDICAL CONDITION. OFTEN UNDIAGNOSED IN TEENS. ASSOCIATED WITH SUBSTANCE ABUSE AND ANTISOCIAL BEHAVIOR. DEPRESSION IN OLDER ADULTS IS APPROX. 6-9% Assessment: THE STRESS-DIATHESIS MODEL - Life events trigger certain neuro-physical and neurochemical changes in the brain. COGNITIVE THEORY - Person has a negative view of self, a pessimistic view of the world and the belief that negative reinforcement will continue. LEARNED HELPLESSNESS Several assessment tools are available. Such as the Geriatric Depression Scale, the Beck Depression Inventory, etc. The nurse must assess mood, physical changes and cognition. What else should the nurse look for? Interventions: 1. Milieu Therapy 2. Psychotherapy 3. Mindfulness-Based Cognitive Therapy 4. Group Therapy 5. Brain Stimulation Therapies 6. Complementary Therapies 7. Pharmacological Therapies

SSRIs

Selective serotonin reuptake inhibitors (SSRIs) may cause sexual dysfunction or lack of sex drive. Inform nurse or physician. • SSRIs may cause insomnia, anxiety, and nervousness. Inform nurse or physician. • SSRIs may interact with other medications. Be sure physician knows other medications patient is taking (e.g., digoxin, warfarin). SSRIs should not be taken within 14 days of the last dose of a monoamine oxidase inhibitor (MAOI). • No over-the-counter drug should be taken without first notifying physician. • Common side effects include fatigue, nausea, diarrhea, dry mouth, dizziness, tremor, and sexual dysfunction or lack of sex drive. • Because of the potential for drowsiness and dizziness, patient should not drive or operate machinery until these side effects are ruled out. • Alcohol should be avoided. SSRIs may act synergistically, and people report increased effects of alcohol (e.g., one drink can seem like two). Alcohol is also a central nervous system (CNS) depressant that may work against the desired effect of the SSRI. • Liver and renal function tests should be performed and blood counts checked periodically. • Medication should not be discontinued abruptly. People report such effects as dizziness, nausea, diarrhea, muscle jerkiness, and tremors. If side effects from the SSRIs become bothersome, patient should ask physician about changing to a different drug. Abrupt cessation can lead to serotonin withdrawal. • SSRIs should be used with caution in the elderly and in pregnant women. The physician should take into account the benefits versus the risk in these populations, as well as all patients taking SSRIs or any kind of antidepressant. • Any of the following symptoms should be reported to a physician immediately: •Increase in depression or suicidal thoughts •Rash or hives •Rapid heartbeat •Sore throat •Difficulty urinating •Fever, malaise •Anorexia and weight loss •Unusual bleeding •Initiation of hyperactive behavior •Severe headache

Assess personal feelings, values, and attitudes towards clients with mood disorders that may provide challenges to professional practice.

Self-awareness is a positive trait and a competent and effective interviewer needs to possess a high degree of psychological, emotional, and social/cultural self-awareness to perform optimally We all have personal biases and "off days" (i.e., days we feel sad or upset, for example), and we all hold our own expectations of the outcome of the interview. In addition, we all come from a specific culture/subculture with inherent expectations, traditions, and well-ingrained social beliefs. Being consciously aware of our personal biases and emotional states can help us become cognizant of how these traits can influence and distort our understanding of the patient (Sommers-Flanagan & Sommers-Flanagan, 2009) as well as our patient's experience of us as a safe and empathetic health care provider.It is a good idea to be aware of cultural and social beliefs that may influence your interactions with a person from another background with inherently different cultural, social, and spiritual/religious beliefs. Also examine how you are feeling at the moment before an interview. We are not always aware of personal feelings or how they are affecting us when we first begin an interview, with the exceptions of students who will always feel anxious in the beginning, a very healthy sign. How do we obtain a good picture of ourselves in relationship to our interviewing skills? One way is clinical supervision from a seasoned and effective psychiatric nurse or clinician. Another effective way is by the use of videotapes of ourselves during an interview (usually a very painful experience, initially). Even seasoned interviewers can be shocked and surprised by their videotapes. With a confident colleague or supervisor, although these insights may be painful they are enormously helpful in becoming more self-aware and they increase our awareness of our patient as well. Taking notes shortly after an interview of what the patient said and what you said (process recordings) is a useful exercise because these "verbatim" notes provides an overall evaluation of your interaction, which may help you reevaluate and review not only what you missed but also what you could has done differently to be more effective. Process recordings are also useful for reviewing alternatives to what the patient has meant. Although these assessment methods are not as popular as they were in the past in nursing education, they offer the opportunity for important learning experiences in improving communication skills (refer to Applying the Art features throughout the clinical chapters).

What is the hallmark feature of panic disorder?

Severe and panic levels prevent problem solving and discovery of effective solutions. Unproductive relief behaviors are implemented, thus perpetuating a vicious cycle. The panic attack is the key feature of panic disorders (PDs). A panic attack is the sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom: "I am going to die." The feelings of terror present during a panic attack are so severe that normal function is suspended, the perceptual field is severely limited, and misinterpretation of reality may occur. Severe personality disorganization is evident. People experiencing panic attacks may believe that they are losing their minds or are having a heart attack; the attacks are often accompanied by highly uncomfortable physical symptoms. Some of the symptoms a person may experience are 175 176 palpitations, chest pain, diaphoresis, muscle tension, urinary frequency, hyperventilation, breathing difficulties, nausea, feelings of choking, chills, hot flashes, and gastrointestinal symptoms. Typically, panic attacks occur suddenly (not necessarily in response to stress), are extremely intense, last 1 or 2 minutes (occasionally lasting up to 30 minutes), and then subside. Panic attacks can happen at any time during the day or can occur while sleeping at night, causing the person to wake up terrified. During the intervals between panic attacks, the person may experience low-level constant anxiousness and anticipatory anxiety. It is not uncommon for someone rushed to the emergency department (ED) with all the signs and symptoms of a heart attack (chest pain, difficulty breathing, dizziness, excessive fatigue) to have an extensive medical workup that proves negative for cardiac problems. At that point the person needs to be referred to a counselor for potential diagnosis and treatment of an anxiety disorder. Major depression occurs in up to two thirds of the cases of people with PD and complicates the course of the disorder considerably ( Unable to focus on the environment Experiences the utmost state of terror and emotional paralysis; feels he or she "ceases to exist" In panic, may have hallucinations or delusions that take the place of reality May be mute or have extreme psychomotor agitation leading to exhaustion Shows disorganized or irrational reasoning Experience of terror Immobility or severe hyperactivity or flight Dilated pupils Unintelligible communication or inability to speak Severe shakiness Sleeplessness Severe withdrawal Hallucinations or delusions; likely out of touch with reality Table on page 167 varc.

Secondary prevention

The Revised Children's Manifest Anxiety Scale (RCMAS) is a 73-item yes and no answer tool used to evaluate anxiety in children in grades 1 through 12. There are several tools used to screen various types of anxiety in adults. The Acute Panic Inventory (API) is primarily a symptom assessment tool to assess a person's characteristics during a panic attack. The Covi Anxiety Scale (COVI) is a simple tool to measure the severity of anxiety in three areas: patient's subjective experience, somatic symptoms, and behavior. The Social Phobia and Anxiety Inventory (SPAI) assesses the severity of dimensions of somatic symptoms, avoidance, and cognition in persons with agoraphobia and social phobia. The State-Trait Anxiety Inventory (STAI) is a self-report tool used to differentiate between acute versus chronic anxiety.18 Numerous tools are used for screening PTSD. Examples include the PCL-M (PTSD checklist, military version) screening tool that is used to assess for symptoms related to stressful military experiences and the PCL-C (PTSD checklist, civilian version). The PCL-C is used to assess for symptoms in response to stressful situations; it can be used for any population.

Formulate multiple nursing diagnoses that are applicable to clients based on assessment.

Signs & symptoms: Previous suicidal attempts, putting affairs in order, giving away prized possessions, suicidal ideation (has plan, ability to carry it out), overt or covert statements regarding killing self, feelings of worthlessness, hopelessness, helplessness Nursing Diagnosis: Risk for Suicide Risk for Self-Mutilation S/s: Lack of judgment, memory difficulty, poor concentration, inaccurate interpretation of environment, negative ruminations, cognitive distortions N/D: Decisional Conflict Impaired Memory Acute Confusion s/s: Difficulty with simple tasks, inability to function at previous level, poor problem solving, poor cognitive functioning, verbalizations of inability to cope n/d: Ineffective Coping Interrupted Family Processes Risk for Impaired Parent/Infant/Child Attachment Ineffective Role Performance s/s: Difficulty making decisions, poor concentration, inability to take action n/d: Decisional Conflict s/s: Feelings of helplessness, hopelessness, powerlessness n/d: Hopelessness s/s: Feelings of inability to make positive change in one's life or have a sense of control over one's destiny n/d: Powerlessness Ineffective Coping s/s: Questioning meaning of life and own existence, inability to participate in usual religious practices, conflict over spiritual beliefs, anger toward spiritual deity or religious representatives n/d: Spiritual Distress Impaired Religiosity Risk for Impaired Religiosity s/s: Feelings of worthlessness, poor self-image, negative sense of self, self-negating verbalizations, feeling of being a failure, expressions of shame or guilt, hypersensitivity to slights or criticism n/d: Chronic Low Self-Esteem Situational Low Self-Esteem s/s: Withdrawal, noncommunicativeness, speech that is only in monosyllables, avoidance of contact with others n/d: Impaired Social Interaction Social Isolation Risk for Loneliness s/s: Vegetative signs of depression: changes in sleeping, eating, grooming and hygiene, elimination, sexual patterns n/d: Self Neglect (bathing/hygiene, dressing/grooming) Imbalanced Nutrition: Less Than Body Requirements Disturbed Sleep Pattern

How is agoraphobia related to panic disorder?

Typically develops in adolescence or early adulthood; about one in three people with panic disorder develops agoraphobia. At times, people with panic disorder may also have agoraphobia. If agoraphobia is present, it is noted as a specifier on a DSM-5 diagnosis.

When does a panic attack typically occur?

Typically, panic attacks occur suddenly (not necessarily in response to stress), are extremely intense, last 1 or 2 minutes (occasionally lasting up to 30 minutes), and then subside. Panic attacks can happen at any time during the day or can occur while sleeping at night, causing the person to wake up terrified. During the intervals between panic attacks, the person may experience low-level constant anxiousness and anticipatory anxiety. It is not uncommon for someone rushed to the emergency department (ED) with all the signs and symptoms of a heart attack (chest pain, difficulty breathing, dizziness, excessive fatigue) to have an extensive medical workup that proves negative for cardiac problems. At that point the person needs to be referred to a counselor for potential diagnosis and treatment of an anxiety disorder.

Why are more women diagnosed with an anxiety disorder?

Women are reported to be more frequently affected than men. Despite the high prevalence of these disorders, they often are unrecognized and untreated. Anxiety disorders are highly comorbid/co-occurring with each other, with major depressive disorders, and with alcohol and/or drug abuse (Martin et al., 2009; Yates, 2011). Major depressive disorder (MDD) co-occurs in approximately up to half of people with anxiety disorders and produces greater impairment and poorer response to treatment. Substance abuse is also frequently present and has a similar negative effect on treatment as well. Anxiety disorders frequently co-occur with many other psychiatric disorders (e.g., eating disorders, bipolar disorders, dysthymia); several studies suggest that up to 90% of people with an anxiety disorder develop another psychiatric disorder during their lifetime. The neurotransmitter serotonin may also play a role in responsiveness to stress and anxiety. Some evidence suggests that the female brain does not process serotonin as quickly as the male brain. Recent research has found that women are more sensitive to low levels of corticotropin-releasing factor (CRF), a hormone that organizes stress responses in mammals, making them twice as vulnerable as men to stress-related disorders. Women are more likely to have a co-occuring condition. Other co-occurring conditions that are medical in nature and have been well documented in the literature include cancer, heart disease, high blood pressure, irritable bowel syndrome, kidney and liver dysfunction, reduced immunity, and others. Chronic anxiety is thought to be associated with increased risk for cardiovascular morbidity and mortality (Yates, 2011). Usually anxiety disorders begin in childhood, adolescence, and early adulthood.

Primary prevention

calmness, promoting safety, self and community effectualness, social connectedness, and optimism—may alleviate the untoward psychologic distress of anxiety and prevent the development of trauma-related anxiety disorders such as posttraumatic stress disorder.

Differentiation from other anxiety disorders Is it psychogenic or biologically mediated?

different anxiety disorders see #1 GAD: This disorder is thought to be primarily due to psychogenic causes that lead to a conditioned response of fear and anxiety. The disorder is chronic, although it responds well to cognitive behavioral therapy (CBT) and SSRI medications to help reduce the anxiety as well as treat the depression. Panic attacks may precede agoraphobia 30% to 50% of the time, depending on the specific source

* la belle indifference * secondary gain * munchausen syndrome

la bellle: inappropriate lack of emotion or concern for the perceptions by others of one's disability, usually seen in persons with conversion hysteria. Munchausen syndrome is a factitious disorder, a mental disorder in which a person repeatedly and deliberately acts as if he or she has a physical or mental illness when he or she is not really sick. Munchausen syndrome is considered a mental illness because it is associated with severe emotional difficulties.

Cognitive

restructure thinking, correct distortions, challenge core beliefs

Behavioral

teach and physical practice of activities to decrease behaviors: Systematic desensitization Thought stopping

functions of the brain

•Frontal cortex: cognitive interpretations (e.g., potential threat) •Hypothalamus: activation of the stress response (fight-or-flight response; refer to Chapter 10) •Hippocampus: associated with memory related to fear responses •Amygdala: fear, especially related to phobic and panic disorders