12918737 Videbeck Psychiatric Nsg Handouts

Anger, Hostility, and Aggression

Anger is a normal human emotion. Hostility and aggression are inappropriate expressions of anger. Anger is a strong, uncomfortable, emotional response to a provocation, either real or perceived. It results when one is frustrated, hurt, or afraid and energizes the body for defense (fight or flight). • Denying or suppressing angry feelings can lead to physical or emotional problems • Anger that is expressed inappropriately can lead to hostility and aggression • Appropriate expression of anger involves assertive communication skills that lead to problem solving or conflict resolution • Venting angry feelings by engaging in safe but aggressive activities (punching bag, yelling) is called catharsis. However, research has shown that catharsis may increase rather than alleviate angry feelings • Clients with depression may have anger attacks when they feel emotionally trapped Hostility and Aggression Hostile and aggressive behavior may occur suddenly without warning, but often stages or phases can be identified: • Triggering • Escalation • Crisis • Recovery • Postcrisis Hostility is an emotion expressed by: • Verbal abuse • Lack of cooperation • Violation of rules or norms • Threatening behavior (verbal aggression) Related Disorders Most psychiatric clients are not aggressive, but some exhibit angry, hostile, or aggressive behavior caused by: • Paranoid delusions • Auditory (command) hallucinations • Dementia, delirium • Head injury • Intoxication with alcohol or drugs • Antisocial and borderline personality disorders Intermittent Explosive Disorder:

Rare psychiatric diagnosis involving discrete episodes of aggressive impulses resulting in serious injury or property damage Episodes are out of proportion to any provocation, and the person is remorseful and embarrassed afterward.

Acting Out An immature defense mechanism in which the person deals with emotional conflict or stress by actions rather than reflection or feelings; the person is trying to feel less powerless or helpless by acting out. Etiology of Hostility and Aggression • Neurobiologic theories: decreased serotonin, increased dopamine and norepinephrine; structural damage to limbic system, damage to frontal or temporal lobes • Psychosocial theories: failure to develop impulse control and ability to delay gratification Cultural Considerations In certain cultures, expressing anger may be seen as rude or disrespectful; some culture-bound syndromes involve aggressive, agitated, or violent behavior. Treatments and Medications Treatment often focuses on treating the underlying or comorbid psychiatric diagnosis such as schizophrenia or bipolar disorder. Aggressive Clients • Lithium for bipolar disorder, conduct disorder, or mental retardation • Carbamazepine (Tegretol) or valproate (Depakote) for dementia, psychosis, or personality disorders • Atypical antipsychotics such as clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa) for dementia, brain injury, mental retardation, and personality disorders • Benzodiazepines for older adults with dementia • Haloperidol (Haldol) and lorazepam (Ativan) for clients with psychoses Application of the Nursing Process Assessment • Early assessment and intervention needed when clients are angry or hostile to avoid physically aggressive episodes • Nurse must assess both individual clients and the therapeutic milieu or environment • Assessment and intervention are based on five phases of aggression Data Analysis Common nursing diagnoses: • Risk for Other-Directed Violence

• Ineffective Coping Outcome Identification The client will: • Not harm self or threaten others • Refrain from intimidating or frightening behaviors • Describe feelings and concerns without aggression • Comply with treatment Intervention Interventions are most effective and least restrictive when implemented early in the cycle of aggression. • Managing the milieu includes: – Having planned activities; informal discussions – Scheduled one-to-one interactions; letting clients know what to expect – Helping clients with conflicts to solve their problems, including expression of angry feelings • Managing aggressive behavior includes: – Triggering phase: • Approach in nonthreatening, calm manner • Convey empathy • Listen • Encourage verbal expression of feelings • Suggest going to a quieter area, or use of PRN medications • Physical activity such as walking – Escalation phase: • Take control • Provide directions in firm, calm voice • Direct client to room or quiet area for time out • Offer medication again • Let client know aggression is unacceptable and nurse or staff will help maintain/regain control if needed • If ineffective to that point, obtain assistance from other staff (show of force) to get client to take time out or take medication – Crisis phase: • Staff must take control of situation as determined by facility or agency policy (trained in techniques for behavioral management) • Use restraint or seclusion only if necessary – Recovery phase as client regains control: • Talk about the situation or trigger • Help client relax or sleep • Explore alternatives to aggressive behavior • Provide documentation of any injuries • Staff debriefing

– Postcrisis phase: • Client is removed from any restraint or seclusion and rejoins the milieu • Calm discussion of behavior; no lecturing or chastising; return to activities, groups, and so forth • Focus is on appropriate expression of feelings, resolution of problems or conflicts in nonaggressive manner

Evaluation • Was the client’s anger defused in an early stage? • Did the angry, hostile, and potentially aggressive client learn to express feelings verbally and safely without threats or harm to others or destruction of property? • Was the client’s anger defused in an early stage? • Did the angry, hostile, and potentially aggressive client learn to express feelings verbally and safely without threats or harm to others or destruction of property? Community-Based Care • Regular follow-up appointments, compliance with prescribed medication, and participation in community support programs help the client to achieve stability • Anger management groups are available to help clients express their feelings and learn problem-solving and conflict-resolution techniques Self-Awareness Issues • How nurse handles own angry feelings • Comfort with expression of anger from others • Ability to be calm, nonjudgmental • Nurse must have assertive communication skills, conflict resolution skills, ability to see that client’s behavior/anger is not personal or a sign of nurse’s failure, and ability to deal with own fear when clients are aggressive or threatening

Abuse and Violence

Abuse is the wrongful use and maltreatment of another person……can be child, spouse, partner, or elder parent Victims of abuse and trauma can have both physical and psychological injuries, including: • Agitation anxiety, silence • Suppressed anger or resentment • Shame and guilt • Feelings of being degraded or dehumanized; low self-esteem • Relationship problems; mistrust of authority figures Characteristics of Violent Families • Social isolation • Power and control by abusive person • Alcohol and other drug abuse • Intergenerational transmission process • Domestic violence occurs in families of all ages and from all ethnic, racial, religious, socioeconomic, and sexual orientation backgrounds • Battered immigrant women face increased legal, social, and economic barriers Spouse or Partner Abuse • Involves the mistreatment of one person by another in the context of an intimate relationship • 90% to 95% of domestic violence victims are women • Pregnancy escalates domestic violence • Abuse can occur in same-sex relationships

Cycle of Abuse and Violence • Initial episode of violence • Honeymoon period: abuser promises it will never happen again, gives gifts and flowers, is affectionate • Tensions begins to build with arguments, silence, complaints • Violence occurs again • This cycle repeats over and over Assessment • It is necessary to identify victims of abuse in all settings, since they often do not seek treatment directly • SAFE questions can be used to assess:

– – – –

Stress/Safety Afraid/Abused Friends/Family Emergency plan

Treatment and Intervention • Domestic violence laws vary among states and are not always followed • Women may stay in abusive relationships for fear of violence to children, fear of increased violence or death, financial dependence • Identifying women in violent situations is a priority. More health care agencies are beginning to ask routine screening questions of all women • Providing women with information about shelters, services, and so forth is essential • The nurse must never indicate that he or she thinks the woman should leave the relationship; need to keep the door open for further communication Child Abuse Child abuse is intentional injury of a child, including: – Physical abuse or injuries – Sexual assault or intrusion – Neglect or failure to prevent harm (failure to provide adequate physical or emotional care or supervision; abandonment) – Psychological abuse All states have mandatory child abuse reporting laws that include nurses. Parents who abuse children: • Have minimal parenting knowledge and skills • Are emotionally immature and needy • Are incapable of meeting their own needs, much less those of a child • Often raise their children the way they were raised, including corporal punishment and abuse • Expect the child to meet all their needs for love and affection

Assessment Suspect child abuse when there are: • Unusual injuries such as scalding and cigarette burns • Delays in seeking treatment, inconsistent history, or illogical explanation for the injuries • Urinary tract infections; red, swollen, or bruised genitalia; tears of vagina or rectum • Old injuries that were not treated • Multiple, unexplained bruises Treatment and Intervention • Getting the child to a safe place once abuse is identified

• • • •

Family therapy Individual therapy for the child Intensive involvement of social service agencies Treatment for parents for any substance abuse or psychiatric issues

Elder Abuse Elder abuse is maltreatment of older adults by family members or caretakers, including: – Physical, sexual, or psychological abuse or neglect – Self-neglect – Financial exploitation – Denial of adequate medical treatment • • • •

60% of perpetrators are spouses, 20% adult children, 20% others People who abuse elders are almost always in a caretaker role Elders are reluctant to report abuse because they fear the alternative (nursing home) Not all states have mandatory elder abuse reporting laws

Assessment Possible indicators of physical abuse: • Malnourished, dehydrated • Rashes, sores, lice • Smell of urine, feces, dirt • Failure to keep needed medical appointments • Untreated medical condition Possible indicators of emotional or psychological abuse: • Reluctance to talk openly • Helplessness • Withdrawal or depression • Anger or agitation Possible indicators of self-neglect: • Inability to manage own finances • Inability to perform activities of daily living • Inadequate clothing • Signs of malnutrition or dehydration • Rashes and sores Possible indicators of financial exploitation: • Inability to manage money • Unusual activity in bank accounts • Different signatures on checks

• Recent changes in will that client could not make • Missing valuables Possible indicators of abuse by caregiver: • Caregiver speaks for the elderly person • Caregiver shows indifference or anger • Caregiver blames elderly person for physical problems • Caregiver shows defensiveness • Caregiver and client give conflicting accounts

Treatment and Intervention Treatment and intervention may involve: • Providing adequate support and respite for the caregivers • Changing caregiving arrangements • Moving the elderly person to a safe environment Rape

Rape is a crime of violence and aggression expressed through sexual means. The act is against the victim’s will or against someone who cannot give consent. • The victim can be any age • Half of rapes are committed by someone known to the victim • Rape is underreported to the police Male rapists have been categorized as: • Sexual sadists aroused by pain of victim • Exploitative predators • Inadequate men • Those who rape as a displaced expression of anger and rage • Same-sex rape can occur between partners but is most common in institutions Physical and psychological trauma to rape victims is severe: • Medical problems: victims are significantly less healthy; pregnancy, STDs, HIV are concerns • Victims may feel frightened, helpless, guilty, humiliated, and embarrassed; may avoid previously pleasurable activities • Relationship problems may occur

Treatment and Intervention • Immediate support to ventilate fear and rage • Care by persons who believe that the rape happened • Coordination of all needed services in one location

• Giving the victim control over choices whenever possible • Prophylactic treatment for STDs • Referral to therapy services; counseling; and groups for longer-term help Community Violence Of great concern are homicides and suicides associated with schools. Solutions emphasize: • Problem-solving skills, anger management, and social skills development • Parenting programs that promote strong bonding between parents and children and conflict management in the home • Mentoring programs for young people A history of violence, victimization, and witnessing of violence can lead to problems with aggression, depression, relationships, achievement, and abuse of drugs and alcohol Psychiatric Disorders Related to Abuse and Violence Two psychiatric disorders are associated with histories of violence and abuse: 1. Posttraumatic stress disorder (PTSD) 2. Dissociative disorders

PTSD Disturbing behavior resulting after a traumatic event at least 3 months after the trauma occurred Up to 60% of persons at risk (combat veterans, victims of violence and natural disasters) develop PTSD. Symptoms of PTSD include: • Persistent nightmares • Memories • Flashbacks • Emotional numbness • Insomnia • Irritability • Hypervigilance • Angry outbursts

Dissociative Disorders Dissociation is a subconscious defense mechanism that helps a person protect the emotional self from recognizing the full impact of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory.

Dissociation can occur both during and after the event and becomes easier with repeated use. Dissociative disorders include: • Amnesia • Fugue • Dissociative identity disorder (formerly multiple personality disorder) • Depersonalization disorder

Treatment and Interventions • Involvement in group and/or individual therapy in the community • Clients with dissociative disorder or PTSD are seen in the acute setting for brief periods when symptoms are severe or there is concern for their safety Application of the Nursing Process Assessment • Includes history of trauma or abuse • Client often appears hyperalert, anxious, or agitated • Mood and affect: client is fearful and anxious; needs large personal space; has a wide range of emotions • Thought processes and content: nightmares, flashbacks, destructive thoughts or impulses • Sensorium and intellectual processes: disorientation (during flashbacks), memory gaps • Judgment and insight: impaired decision-making and problem-solving abilities • Self-concept: client has low self-esteem • Roles and relationships: problems with relationships, work, authority figures • Physiologic considerations: difficulty sleeping, under- or overeating, use of alcohol or drugs for self-medication

Data Analysis Nursing diagnoses include: • Risk for Self-Mutilation • Ineffective Coping • Post-Trauma Response • Chronic Low Self-Esteem • Powerlessness Outcome Identification The client will: • Be physically safe • Distinguish between self-harm ideas and taking action on those ideas • Learn healthy ways to deal with stress • Express emotions nondestructively

• Establish social support network in the community Intervention • Promoting the client’s safety • Helping the client cope with stress and emotions using grounding techniques • Helping to promote the client’s self-esteem • Establishing social support Evaluation Is the patient: • Learning to protecting him- or herself? • Learning to manage stress and emotions? • Able to function in their daily lives? Self-Awareness Issues • Becoming comfortable asking all women about abuse (SAFE questions) • Listening to accounts of abuse from clients and families • Recognizing client’s strengths, not just problems • Working with perpetrators of abuse; dealing with own feelings about abuse and violence

Grief and Loss

Grief refers to the subjective emotions and affect that are a normal response to loss. Grieving, also known as bereavement, is the process of experiencing grief. Anticipatory grief is facing an imminent loss. Mourning is the outward sign of grief. Experiences of grief and loss are essential and normal in the course of life; letting go, relinquishing, and moving on happen as we grow and develop. Grief and loss are uncomfortable. Types of Losses Losses may be planned, expected, or sudden. Loss of a loved one is probably the most devastating type of loss, but there are many other types of losses: • Physiologic (loss of limb, ability to breathe) • Safety (domestic violence, posttraumatic stress disorder, breach of confidentiality) • Security/sense of belonging (relationship loss [death, divorce]) • Self-esteem (ability to work, children leaving home) • Self-actualization (loss of personal goals, such as not going to college, never becoming an artist or dancer) The Grieving Process Nurses must recognize the signs of grieving to understand and support the client through the grieving process. The therapeutic relationship and therapeutic communication skills are paramount when assisting grieving clients. Using these skills, nurses may promote the expression and release of emotional as well as physical pain during grieving. Theories of the Grieving Process Kubler-Ross’s stages of grieving: • Denial (shock and disbelief) • Anger (toward God, relatives, health care providers) • Bargaining (trying to get more time, prolonging the inevitable loss) • Depression (awareness of the loss becomes acute) • Acceptance (person comes to terms with impending death or loss) Bowlby’s phases of grieving:

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Numbness and denial of the loss Emotional yearning for lost loved one and protesting permanence of loss Cognitive disorganization and emotional despair Reorganizing and reintegrating sense of self

John Harvey’s phases of grieving: • Shock, outcry, and denial • Intrusion of thoughts, distractions, and obsessive reviewing of loss • Confiding in others to emote and cognitively restructure Rodebaugh’s stages of grieving: • Reeling • Feelings • Dealing • Healing There are many similarities among theorists about grief. Not all clients follow predictable steps or make steady progress. Tasks of the Grieving Process • Undoing psychosocial bonds to loved one and eventually creating new ties • Adding new roles, skills, and behaviors • Pursuing a healthy lifestyle • Integrating the loss into life Dimensions of Grieving • Cognitive responses to grief – Questioning and trying to make sense of the loss – Attempting to keep the lost one present • Emotional responses to grief • Spiritual responses to grief • Behavioral responses to grief • Physiologic responses to grief Cultural Considerations All cultures grieve for lost loved ones, but the rituals and habits surrounding death vary among cultures, for instance, how shock and sadness are expressed, how long mourning should last, and so forth. Many cultural bereavement rituals have their roots in a major religion. Nurses should be sensitive to cultural differences and ask how the mourners can be assisted.

Nurse’s Role The nurse must encourage clients to discover and use effective and meaningful grieving behaviors: • Praying • Staying with the body • Performing rituals • Attending memorials and public services Disenfranchised Grief or Complicated Grieving

Disenfranchised grief is grief over a loss that is not or cannot be openly acknowledged, mourned publicly, or supported socially: • A relationship has no legitimacy • The loss itself is not recognized • The griever is not recognized Complicated grieving is a response that lies outside the norm of grieving in terms of extended periods of grieving: responses that seem out of proportion or responses that are void of emotion People who are vulnerable to disenfranchised grieving: • Relationships that may be viewed as having no legitimacy: lovers, friends, neighbors, foster parents, colleagues, caregivers, same-sex relationships, cohabitation without marriage, and extramarital affairs • Losses that may not be recognized: prenatal death, abortion, relinquishing a child for adoption, death of a pet, or other losses not involving death such as job loss, separation, divorce, and children leaving home • Grievers who may not be recognized: older adults, children, nurses

People who are vulnerable to complicated grieving include those with: • Low self-esteem • Low trust in others • A previous psychiatric disorder • Previous suicide threats or attempts • Absent or unhelpful family members • An ambivalent, dependent, or insecure attachment to the deceased person Experiences increasing the risk for complicated grieving include: • Death of a spouse or child • Death of a parent (particularly in early childhood or adolescence) • Sudden, unexpected, and untimely death • Multiple deaths • Death by suicide or murder

Complicated Grieving as a Unique and Varied Experience • Physical reactions can include: – Impaired immune system – Increased adrenocortical activity – Increased levels of serum prolactin and growth hormone – Psychosomatic disorders – Increased mortality from heart disease • Emotional responses can include: – Depression – Anxiety or panic disorders – Delayed or inhibited grief – Chronic grief Application of the Nursing Process Assessment • Does the client have adequate perception regarding the loss? – What does the client think and feel about the loss? – How is the loss going to affect the client’s life? – What information does the nurse need to clarify or share with the client? • Does the client have adequate support? • Does the client have adequate coping behaviors?

Data Analysis and Planning • Possible nursing diagnoses: • Grieving • Anticipatory Grieving • Dysfunctional Grieving Outcome Identification Grieving The client will: • Identify the effects of his or her loss • Seek adequate support • Apply effective coping strategies while expressing and assimilating all dimensions of human response to loss in his or her life Anticipatory Grieving The client will: • Identify the meaning of the expected loss in his or her life • Seek adequate support while expressing grief • Develop a plan for coping with the loss as it becomes a reality

Dysfunctional Grieving The client will: • Identify the meaning of his or her loss • Recognize the negative effects of the loss on his or her life • Seek or accept professional assistance to promote the grieving process Intervention • Regarding perception of the loss – Explore perception and meaning of the loss • Regarding adequate support – Help the client reach out and accept what others want to give • Regarding adequate coping behaviors – Shift from an unconscious defense mechanism to conscious coping – Compare and contrast past coping – Encourage the client to care for self Essential communication and interpersonal skills to assist grieving: • Use simple, nonjudgmental statements • Refer to a loved one or object of loss by name (if acceptable in the client’s culture) • Appropriate use of touch indicates caring • Respect the client’s unique process of grieving • Respect the client’s personal beliefs • Be honest, dependable, consistent, and worthy of the client’s trust • Offer a welcoming smile and eye contact

Evaluation Evaluation of progress is based on the goals established for the client. Make an evaluation of the client’s status based on the theoretical tasks phases of grieving.

and

Self-Awareness Issues • Examining one’s own experiences with grief and loss • Taking a self-awareness inventory and reflecting on the results may be helpful.

Level Mild

Moderate

Severe

Panic

Psychological Responses Wide perceptual field Sharpened senses Increased motivation Effective problem solving Increased learning ability Irritability Perceptual field narrowed to immediate task Selectively attentive Cannot connect thoughts or events independently Increased use of automatisms

Perceptual field reduced to one detail or scattered details Cannot complete tasks Cannot solve problems or learn effectively Behavior geared towards anxiety relief and is usually ineffective Doesn’t respond to redirection Feels awe, dread or horror Cries Ritualistic behavior Perceptual filed reduced to focus on self Cannot process any environmental stimuli Distorted perceptions Loss of rational thought Doesn’t recognize potential danger Can’t communicate verbally Possible delusions and hallucination May be suicidal

Physiological Responses Restlessness Fidgeting GI butterflies Difficulty sleeping Hypersensitivity to noise Muscle tension Diaphoresis Pounding pulse Headache Dry mouth High pitch voice Fast rate of speech GI upset Frequent urination Severe headache Nausea, vomiting and diarrhea Trembling Rigid stance Vertigo Pale Tachycardia Chest pain

May bolt and run or Totally immobile and mute Dilated pupils Increased blood pressure and pulse Fight, flight or freeze

Anxiety and Stress-Related Illness Anxiety  vague feeling of dread  unwarranted by the situation  with no identifiable stimulus  accompanied by feelings of uneasiness and apprehension o Fear o there is an identifiable threatening object  has healthy and harmful facets  it is an internal warning device  produces physiologic and emotional changes at each level o mild o moderate o severe o panic WORKING WITH ANXIOUS CLIENTS Mild anxiety o an asset o

o

Moderate anxiety

Severe anxiety

o

client can learn and solve problems effectively

can cause client’s o causes impairment of many attention to wander abilities

o

nurse must redirect client o back to topic

client cannot problem solve

client is receptive to teaching and suggestions

o

nurse must validate that o client has heard and understood

nurse must calm client and focus on lowering anxiety level

CATEGORIES OF ANXIETY DISORDERS Panic, with or without agoraphobia Phobia (social or specific) Obsessive-compulsive disorder (OCD) Posttraumatic stress disorder Acute stress disorder Generalized anxiety disorder Anxiety disorder due to a medical condition Substance-induced anxiety disorder

This chapter focuses on panic disorder, phobic disorder, and OCD.

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INCIDENCE Anxiety disorders are the most common psychiatric disorders in the United States, affecting 15% of adults More prevalent in women More common in divorced and separated persons More common in persons of lower socioeconomic status Onset and clinical course are variable PHYSIOLOGIC AND PSYCHOSOCIAL RESPONSES TO ANXIETY Anxiety can be communicated nonverbally from one person to another. Defense mechanisms are used to reduce anxiety  when overused, they preclude learning more adaptive coping skills. Physiologic responses include:  sympathetic stimulation (fight or flight)  discomfort  difficulty thinking clearly  agitated motor activity  tension headaches ETIOLOGY

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Stress: People handle stress in different ways. Stress is part of everyday life. Selye identified responses to stress on the body in stages:  alarm reaction  resistance  exhaustion Biologic theories: Anxiety may have an inherited component neurotransmitter γ-aminobutyric acid (GABA) Serotonin plays a part in OCD Psychodynamic theories: overuse of defense mechanisms results from problems in interpersonal relationships “learned” behavioral response

CULTURAL CONSIDERATIONS People from Asian cultures often somatize anxiety into expressions of pain in the body. Hispanics may identify illnesses as “hot” or “cold” and eat either “hot” or “cold” foods to counteract them.

TREATMENT

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Effective treatment usually involves a combination of medication (anxiolytics and antidepressants) and therapy. Cognitive-behavioral therapy includes: positive reframing - turning negative messages into positive ones decatastrophizing - making a more realistic appraisal of the situation

Assertiveness training helps the client learn to negotiate interpersonal situations more successfully. PANIC DISORDER o involves 15- to 30-minute episodes of intense, escalating anxiety with emotional fear and physiologic discomfort o 75% have spontaneous attacks of panic with no environmental trigger o Onset peaks: late adolescence and in the mid-30s o Treatment: o Selective serotonin reuptake inhibitors (SSRIs) o cyclic antidepressants o benzodiazepines are used Application of the Nursing Process for Panic Disorder Assessment  Client feels unreal and detached from self during attack.  Fears losing control or going insane  Has temporarily disorganized thought process; feels he or she is dying  Judgment is poor during an attack.  Anticipation of attacks causes the person to limit social activities and may interfere with work, relationships, and family life  Some develop agoraphobia and avoid public places altogether, not leaving their homes  Clients experience: o primary gain (relief of anxiety by staying at home) o secondary gain (attention received from others due to the disorder; relief from daily responsibilities).

Data Analysis Nursing diagnoses include: Risk for Injury Anxiety Fear Social Isolation Situational Low Self-Esteem

Ineffective Coping Powerlessness Ineffective Role Performance Disturbed Sleep Pattern

Outcome Identification The client will: Be free of injury Verbalize feelings Use effective coping techniques Manage own anxiety response Verbalize sense of personal control Sleep at least 6 hours per night Intervention

Promoting safety and comfort Using therapeutic communication Managing anxiety Client and family teaching

PHOBIAS o an illogical, intense, persistent fear of a specific object or social situation o cause extreme distress and interferes with normal life functioning o People with phobias understand that their fear is unusual and irrational but feel powerless to control it. o clients develop anticipatory anxiety when thinking about the possibility of encountering the phobic object o Types of phobia:

Specific phobia is irrational fear of an object or situation, such as fear of a natural phenomenon (for instance, storms, heights), fear of seeing blood or receiving an injection, fear of specific situations (for instance, being in an elevator), or fear of animals Social phobia involves severe anxiety, even panic, when confronted with situations involving people, such as making a speech, having dinner with others, or meeting new people; or fear of eating in public, using public bathrooms, or being the center of attention Specific phobias occur more often in women; social phobias occur in men and women equally; peak onset is childhood and mid-20s.

Etiology Biologic (phobias run in families, hormonal functions, or neurotransmitter activity) Psychodynamic (faulty thinking, belief one doesn’t control the environment, or learned by modeling from parents) Treatment and Prognosis Psychopharmacology: o anxiolytics o SSRI antidepressants o beta blockers to slow heart rate and lower blood pressure Psychotherapy: There are useful approaches, although some people do not seek treatment, especially for specific phobias that do not interfere with daily life. Behavioral therapies include systematic desensitization and flooding. OBSESSIVE-COMPULSIVE DISORDER OCD involves: Obsessions o recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses that cause marked anxiety and interfere with interpersonal, social, or occupational functioning. Compulsions o ritualistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety o Examples: o repeated checking or counting rituals o excessive handwashing o repeating words o touching rituals o symmetry rituals o cleanliness o The person knows the rituals are unreasonable but feels forced to continue them in an attempt to relieve anxiety caused by obsessions. Treatment and Prognosis o behavior therapy o exposure - confronting anxiety-provoking stimuli o response prevention - delaying or avoiding ritual performance o medication o SSRI antidepressants o fluvoxamine [Luvox]

o clomipramine [Anafranil] o buspirone [BuSpar] o clonazepam [Klonopin]) Application of the Nursing Process for OCD Assessment Client assessment focuses on what behaviors or rituals are performed, when and how often, client’s response, and so forth, to discover the pattern of behavior.

Data Analysis

Anxiety Ineffective Coping Fatigue Situational Low Self-Esteem Impaired Skin Integrity (if scrubbing or washing rituals)

Outcome Identification The client will: Complete daily routine within realistic time frame Demonstrate effective use of relaxation techniques Discuss feelings with others Demonstrate effective use of behavior therapy techniques Spend less time performing rituals Intervention

Using therapeutic communication Teaching relaxation and behavioral techniques Completing a daily routine Providing client and family education

Evaluation • Based on established goals • Integrating loss into life GENERALIZED ANXIETY DISORDER Excessive worry and anxiety that is unwarranted more days than not Seen most often by family physicians Treated with SSRI antidepressants and buspirone SELF-AWARENESS ISSUES Stress and anxiety are common experiences for all people.

Persons with anxiety disorders often “look well enough” to control their behavior. Avoid trying to “fix” client’s problems.

ANTIANXIETY DRUGS Indications: anxiety disorders insomnia obsessive-compulsive disorder depression posttraumatic stress disorder alcohol withdrawal Benzodiazepines are the antianxiety agents used most frequently (buspirone [BuSpar] is the only common nonbenzodiazepine in wide use). They moderate the actions of GABA. A wide variety of benzodiazepines are used. They vary in half-life, how they are metabolized, and effectiveness. Some are used primarily for insomnia, due to sedation side effects. Common side effects are drowsiness, sedation, poor coordination, memory impairment, clouded sensorium, and hangover effect in the morning. The biggest problem is psychological dependence: Long-term use can result in overuse or abuse. Client teaching for anxiolytics: Avoid alcohol, and be aware of sedating side effects when driving.

Mood Disorders Everyone has episodes of feeling sad, low, and tired, accompanied by anergia (lack of energy), exhaustion, agitation, noise intolerance, and slowed thinking processes. Work, family, and social responsibilities drive most people to go through their daily routines, knowing that this mood and the feelings will pass. Mood disorders are diagnosed when these alterations in emotions are pervasive and interfere with the person’s ability to live life. CATEGORIES Major depressive disorder: 2 or more weeks of sad mood, lack of interest in life activities, and other symptoms Bipolar disorder (formerly called “manic-depressive illness”): mood cycles of mania and/or depression and normalcy RELATED DISORDERS Dysthymic disorder: sadness and low energy, but not severe enough to be diagnosed as major depressive disorder Cyclothymic disorder: mood swings not severe enough to be diagnosed as bipolar disorder Seasonal affective disorder (SAD) Depressive personality disorder Postpartum or “maternity” blues Postpartum depression Postpartum psychosis ETIOLOGY

Biologic theories include genetics (mood disorders run in families) and neurochemical theories (dysregulation of serotonin and norepinephrine, and neuroendocrine or hormonal fluctuations). Psychodynamic theories tend to “blame” clients and families for illness and have little use today. The exception is Beck, who viewed depression as resulting from specific cognitive distortions in susceptible people—cognitive therapy is used in the treatment of depression.

CULTURAL CONSIDERATIONS • Depression, often masked by other symptoms • Somatic complaints may accompany depression.

MAJOR DEPRESSIVE DISORDER Twice as common in women and more common in single or divorced people Involves 2 or more weeks of sad mood, lack of interest in life activities, and at least four other symptoms, such as anhedonia and changes in weight, sleep, energy, concentration, decision making, self-esteem, and goal setting Untreated, can last 6 to 24 months; recurs in 60% of people Symptoms range from mild to moderate to severe. Treatment and Prognosis Antidepressants Classification Indication Selective serotonin reuptake inhibitors (SSRIs)

Tricyclic antidepressants (TCAs)

mild and moderate depression moderate and severe depression

*effectiveness doesn’t begin for 4-6 weeks

Atypical antidepressants Monoamine oxidase inhibitors (MAOIs)

*Maximum effectiveness takes 6 weeks

Drugs fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) citalopram (Celexa)

Side Effects insomnia weight gain sedation constipation nausea

amitriptyline (Elavil) imipramine (Tofranil) desipramine (Norpramin) nortriptyline (Pamelor) doxepin (Sinequan) venlafaxine (Effexor) bupropion (Wellbutrin) nefazodone (Serzone) (trazodone used for insomnia due to sedation). isocarboxazid (Marplan) tranylcypromine (Parnate) phenelzine (Nardil)

Headache Dizziness Drowsiness Nausea vomiting interaction with tyramine causes hypertensive crisis interact unfavorably with a variety of prescription and overthe-counter drugs lethal in overdose

dry mouth blurred near vision constipation urinary retention sedation weight gain orthostatic hypotension nausea

Electroconvulsive Therapy (ECT)  used when medications are ineffective or side effects are intolerable  After anesthesia and muscle relaxants, a shock is administered via electrodes to produce seizure activity in the brain  administered in a series (for instance, three times a week for 6 weeks)  Care of client before and after ECT is similar to that for any minor surgical procedure  After ECT, there is short-term memory loss, confusion, headache, and drowsiness. Psychotherapy  Psychotherapy in conjunction with medication is considered the most effective treatment  Useful therapies include behavioral, cognitive, interpersonal, and family therapy, depending on client needs. Application of the Nursing Process: Major Depressive Disorder Assessment Must include determination of suicidal ideas, lethality, and client’s perception of the problem Psychomotor retardation or agitation;  feelings of helplessness  anxiety  sadness  guilt  frustration  negativism  pessimism  lack of pleasure  social withdrawal  reduced concentration and decision making

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fatigue and exhaustion low self-esteem and rumination about past bad deeds or failures loss of ability to function in life roles sleep disturbances overeating or undereating lack of attention to hygiene and grooming Depression and rating scales may be used.

Data Analysis Nursing diagnoses may include: Risk for Suicide Imbalanced Nutrition Anxiety Ineffective Coping Hopelessness Ineffective Role Performance Chronic Low Self-Esteem Disturbed Sleep Pattern Impaired Social Interaction Outcomes The client will: Not injure self or others Carry out activities of daily living independently Establish a balance of rest, sleep, and activity Establish a balance of adequate nutrition, hydration, and elimination Evaluate self-attributes realistically Socialize with staff, peers, and family/friends Return to occupation or school activities Comply with medication regimen Verbalize symptoms of recurrence

Intervention

Providing for the client’s safety and the safety of others Promoting a therapeutic relationship Promoting activities of daily living and physical care Using therapeutic communication Managing medications Providing client and family teaching

BIPOLAR DISORDER  Bipolar disorder involves mood swings of depression (same symptoms of major depressive disorder) and mania  Major symptoms of mania: o grandiose mood o Agitation o exaggerated self-esteem o sleeplessness o pressured speech o flight of ideas o being easily distractible o intrusive behavior with lack of personal boundaries o high-risk activities with potentially severe consequences, and poor judgment. Treatment and Prognosis  Treatment may involve medication with lithium  regular monitoring of serum lithium levels is needed  Side effects of lithium therapy: o mild nausea or diarrhea o anorexia o fine hand tremor o fatigue o metallic taste in the mouth o polydipsia o polyuria  Signs of lithium toxicity: o severe nausea o vomiting and diarrhea o severe mental confusion

Anticonvulsant drugs are used for their mood-stabilizing effects:  Tegretol  Depakote  Lamictal  Topamax  Trileptal  Neurontin  Klonopin (a benzodiazepine)

Side effects:  Drowsiness  Sedation  dry mouth  blurred near vision  weight gain Application of the Nursing Process: Bipolar Disorder Assessment General appearance and motor behavior:  Assessing a client in the manic phase may be difficult and based more on observations of the client than on the client’s responses to structured questions  Client jumps from one subject to another  cannot sit still  may wear flamboyant clothing or makeup. Mood and affect:  psychomotor agitation  racing thoughts  pressured speech  ignoring of directions or requests from others  unusual speech patterns Thought processes and content:  starts many grandiose projects but finishes none  careless spending sprees Sensorium and intellectual processes:  loud voice  may be hypersexual Judgment and insight: poor Self-concept:  false, grandiose sense of well-being that covers low self-esteem Roles and relationships:  may be charming and playful, then sarcastic and angry  cannot take “no” for an answer Physiologic and self-care considerations:  inattention to hygiene and groominghunger, or fatigue

Data Analysis Nursing diagnoses may include: Risk for Other-Directed Violence Risk for Injury Imbalanced Nutrition Ineffective Coping

Noncompliance Ineffective Role Performance Chronic Low Self-Esteem Disturbed Sleep Pattern Fatigue Self-Care Deficits

Outcomes The client will:

Intervention

Not injure self or others Establish a balance of rest, sleep, and activity Establish adequate nutrition, hydration, and elimination Participate in self-care activities Evaluate personal qualities realistically Engage in socially appropriate, reality-based interaction Verbalize knowledge of illness and treatment

Providing for safety of client and others Meeting physiologic needs Providing therapeutic communication Promoting appropriate behaviors Managing medications Client and family teaching

Evaluation • Based on client’s mood at “normal” level • Medication compliance is essential. SUICIDE Families need support when a member has committed suicide or is making attempts to do so. They may feel guilty, angry, and ashamed, and they are at increased risk for suicide themselves. Assessment

Outcomes The client will:

Populations at risk Warnings of suicidal intent Risky behaviors Lethality assessment

Be safe from harming self or others Engage in a therapeutic relationship Establish a no-suicide contract Create a list of positive attributes Generate, test, and evaluate realistic plans to address underlying issues Intervention

Using an authoritative role Providing a safe environment Initiating a no-suicide contract Creating a support system list Supervision

SELF-AWARENESS ISSUES Nurses and other staff members need to deal with their own feelings about suicide. Depressed or manic clients can be frustrating and require a lot of energy to care for. Keeping a journal may help deal with feelings; also, talking to colleagues is often helpful.